“Everybody has a plan until they get punched in the mouth.” —Mike Tyson, Boxing Heavyweight Champion
This article derives from an extended interview with Dr. Rajko Anic. As a physician during the 1992-1995 Yugoslav war and an accomplished mixed martial arts fighter, Anic explained that – when in a fight and the opponent seems to be countering every move – “If Plan A doesn’t work out for you, then try B, C, or even D.”
In the opening chapters of the celebrated book, “Five Days at Memorial,” the author Sheri Fink recounted in detail the horrifying facts of “life and death in a storm-ravaged hospital” following Hurricane Katrina in 2005. She described a major medical center without electricity, clean water, wastewater treatment, and ventilation, as well as only limited communications, supplies, and transportation. Patients, deprived of lifesaving technology, lingered and then died in the heat.
Of the 16 U.S. critical infrastructure sectors, Healthcare and Public Health is particularly important in the immediate response and recovery phase of a disaster. The populations served – critically ill, injured, and hospitalized patients – are vulnerable segments of society. The Healthcare and Public Health sector is also one of increasing complexity that relies on a combination of support from the other sectors, especially the power grid, and increasingly on moment-to-moment connectivity with information technology (IT) and the internet.
Lessons From Bosnia Dr. Rajko Anic’s firsthand knowledge and recollections of what it was like for a European country to devolve quickly into chaos – and the need for healthcare providers to continue providing care – are instructive. He and his family lived in Bosnia during the first half of the war, until they were able to escape to Germany via a series of refugee camps, leaving their former lives (and extended family) behind. Beginning in March 2016, Anic was interviewed several times in Colorado Springs, Colorado, about what it was like to practice medicine, or attempt to, without reliable electricity or supplies for approximately one year.
Although this interview describes Anic’s experience in a conflict zone – sometimes referred to as a “complex humanitarian emergency” – conclusions can be drawn from his experience in the former Yugoslavia and applied to a prolonged power outage in the United States. The fact that a prolonged power outage would affect all critical infrastructure sectors is especially worrisome because of the “interconnectedness” of these sectors. Anic described how the long-term power outages affected the various sectors and, therefore, healthcare responsibilities.
Hospitals, Physicians & Surgeons Within 3-5 days, hospitals needed to adapt to the new normal – without electricity. The military was called in to provide support to hospitals, as many of the injured were also soldiers. The military medical units stayed intact with their own chain of command but supplemented and worked alongside the staff of the civilian hospitals. Throughout the war, hospital supplies were mostly provided by the military, but also by international humanitarian aid agencies. Depending on location, there was intermittent electrical power, perhaps a few hours per day. Central Bosnia was fortunate to have some of its power supplied by hydroelectric dams and their power stations.
Shelling structurally damaged hospitals, which markedly increased the difficulty of providing care. Eventually these hospitals were abandoned and “buildings of opportunity” were set up to function as field hospitals. One of the best and most capable was located underground. Although the civilian medical staff was initially motivated to “come to work,” as their patriotic duty, the continued shelling of cities (and hospitals) changed this motivation over time.
Anic was able to go home at night to see his family, but others were not so fortunate. He was able to continue to take care of patients as long as there were supplies trickling in. Later in the war, confusion at the front lines made it difficult to distinguish friendly from enemy casualties, but casualties from all sides were treated at his hospital. Unless medical staff members were reassured that their families were taken care of, there was a steady loss of doctors and nursing staff over time.
Surprisingly, Anic stated that, “Surgeons continued to perform life- and limb-saving surgery even under very austere circumstances.” Trauma surgery outside the chest cavity and orthopedic injury were the most likely cases to be undertaken. However, not surprising, he stated, “the post-surgical infection rate increased and the mortality rates increased accordingly,” given the difficult conditions – for example, operating rooms without glass or even screens in the windows.
In many cases, “anesthesia needed to be provided by an anesthesia tech or even with OJT (on the job training) for a medical assistant.” The ability to use an injectable anesthetic or even ether by a drip method, although extremely dangerous, was a useful skill to have. Unlike in the United States where a pack of sterile items is opened to use once and the rest discarded, he said that healthcare workers would, “plan on sterilization and re-use of single use items.”
Logistics, Barter & Exchange “Elevators no longer worked. Stairs became the only access to upper floors in hospitals,” Anic said. Therefore, “there was an increased need for physical manpower to move patients up/down stairs.” This need for additional physical labor was also apparent in the aftermath of Katrina, which was highlighted in Fink’s book. Related to that event, in the urban environment, multi-story buildings presented a special hazard. “Patients or the elderly stuck several floors up in an apartment block were in real trouble unless there was a coordinated effort to assist them.” Because of lack of communications, transportation, a means of exchange, and means of local production, everything became harder. “Taxi drivers became ‘kings’ or ‘generals’ for a variety of reasons: local knowledge, contacts, transportation, and communications,” he said.
Anic’s comments followed exactly with a book about the Yugoslavian War, “Lie in the Dark” by Foreign Correspondent Dan Fesperman. Anic further commented that, “Hard currency, preferably in large denomination notes (i.e., 100DM or US$100) were still the best means of exchange.” Obviously, credit or debit cards did not work. Anic explained that, “coins were essentially useless; gold, jewelry, other similar tangibles did not work very well for trading either. Tobacco, cigarettes, alcohol, and coffee were always welcome in trade.” For a variety of uses, especially for radios and flashlights, batteries of standard types were also very welcome in trade.
According to Anic, “Some trade happened with weapons and ammunition; ammo was cheap and widely available but also heavy to carry in quantity.” Hospitals and physicians (and perhaps patients who require chronic lifesaving medication) should, “stockpile medications and medical supplies in advance, if possible.” Anic stated that they did not, “worry too much about expiration dates,” since most prescription medications are still safe and effective for some period beyond the expiration dates when kept in controlled environments. “Narcotics or illicit drugs were not exchanged in trade, as it was not a part of the culture,” he said. Finally, he stated with encouragement for any incident, “Remember this, somewhere, perhaps a long distance away, someone will have the resources you need. You just have to locate them.”
Communication, Transportation & Migration The need for improved communications is the most frequently mentioned “after action” de-briefing item in disaster after disaster. The same was true in the former Yugoslavia. Anic stated, “AM and FM broadcasts continued throughout the war. HAM (amateur) radios were very helpful.” In fact, HAM radio links could be used to connect the local telephone system outside the conflict area, to pass messages to loved ones in another country.
In other communications, Anic said, “word of mouth information (rumors) passed amazingly fast, but it was not always accurate.” Because Anic was in the Bosnian military, he had access to the military communication systems. “The military always had communications and was one of the best sources of outside information, if you could access it.” There was some civilian use of handheld radios for local communications, but this was not always reliable. “Public safety and emergency services communications were severely stretched,” he said.
“Early on, there was mass migration of the population. Anyone who could get out early, did so.” For those left behind, just getting around was a major effort. “Roads were controlled by the military. You had to have documentation to travel.” For persons who still had access to automobiles, “all the gas stations were empty; gasoline/diesel was a very critical and very scarce resource.” As such, gasoline was one of the most sought after items of trade because any gasoline remaining in underground tanks was inaccessible unless electricity was available to run the pumps.
Particular to this conflict, “migration within Yugoslavia was for alignment by race, religion, and culture.” Throughout the conflict, there was still trading between the opposing factions. However, two groups moved in and out of the conflict area transporting people. First, “transportation for refugees provided by the United Nations (UN) was a Godsend but rare.” Second, “human smugglers were in high demand and became rich as a result of their services.”
Public Health & Wellbeing Although few did it, “stockpiling of nonperishable food in advance turned out to be important,” Anic said. Food was either consumed quickly or used in trade, so lack of food caused people to migrate from one area to another. However, despite a few specific nutritional deficiencies, Anic saw no signs of obvious starvation. A complex disaster such as war still brings about some predictable patterns of disease. For example, he said that, “Water borne and food borne illnesses were frequently on the rise. The elderly, pregnant women, and children were hit especially hard. Communicable disease increased in relationship to the duration of the emergency.” In contrast to some scenarios, “disposal of corpses turned out not to be such a risk for spread of infectious diseases, although the smell was horrific.” Many families had to bury their own. In addition, clean water was always in short supply, so those who did not have their own wells (with pump handles) had to “plan on carrying water some distance, each day.”
Anic is an amazingly resilient person. He was able to reflect back on some of his feelings during his time in the war zone, and experienced symptoms similar to post-traumatic stress disorder. He said that, “in a state of constant stress, you remain alert for possible threats,” yet “street smart (as opposed to book smart) people were much more resilient and better able to survive.” Unfortunately, those who were “nice, civilized people did not remain that way for very long.”
Weapons were ubiquitous in the former Yugoslavia, so snipers on the hillsides kept everyone in a constant state of fear. Surprisingly, people adapted and changed their patterns of behavior to accommodate that risk. Unfortunately, “weapons were equal to law” and “people were willing to use them for personal benefit.” Even this many years later, Anic said that it is still difficult for him to completely relax and is always in a semi-alarm or increased alert state.
Anic dealt with many life-and-death decisions during his time in the conflict zone. “Physicians and others did the very best they could for their patients, with what was at hand. There were many hard choices to be made.” Patients in severe pain without hope of survival posed particularly difficult scenarios. As humanitarian assistance medicine has become increasingly professionalized since the 2005 tsunami/earthquake in Indonesia and the 2010 earthquake in Haiti, disaster responders must abide by the “highest possible” standards of medical care. This assumes the possibility of re-supply of pharmaceuticals and other consumables, as well as free movement of healthcare workers into and out of the “conflict zone.” In the former Yugoslavia, this was not the case (re-supply or free movement) for prolonged periods.
Call to Action Although the experience that Anic and his family had was extreme and not as likely to occur in the United States, numerous other scenarios could result in an extended loss of power over a large geographic area. When that happens, hospitals will be especially vulnerable under current requirements, which include having only a limited number of days of fuel for the emergency electrical generation system. For example, during Hurricane Sandy in 2012, at least one large hospital lost power and had to close and evacuate its patients, so such requirements are being reviewed and updated as needed.
Education about the vulnerability of the power grid – especially for emergency planners and other policy makers – is essential. In addition, a continued call for preparedness at a variety of levels (individual, family, community, medical staff, and other hospital staff) would save many lives. In general, the concept of resilience – that is, to be able to “take a punch in the mouth and still remain standing,” to paraphrase Mike Tyson – is essential for healthcare institutions that plan to continue to provide healthcare during and after a disaster.
James Terbush, MD, MPH, belongs to an FBI sponsored organization Infragard EMP-SIG, which is focused on several specific threats such as a prolonged and widespread power outage. He was previously (2012-2014) the medical lead for Innovation and Experimentation, Science and Technology Directorate, North American Aerospace Defense Command (NORAD), and United States North Command. His particular area of interest is in protection of public health and healthcare critical infrastructure. https://www.linkedin.com/in/jamesterbushmdmph, https://www.