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All disasters have a health aspect, and all disasters, exercises, responses, and recoveries are deeply dependent on technology and communications. Two large-scale disasters affecting much of the United States – Hurricanes Katrina (2005) and Sandy (2012) – provide vast amounts of documentation on the significant technological challenges that arose. In 2017, the country experienced one of the worst hurricane seasons and one of the worst California wildfire seasons until that point in its history. A common practice for response officials and emergency planners is to conduct after-action reviews following a disaster to identify successes and failures. Although these reviews aim to prioritize failures for immediate improvement and analyze successes for continued enhancement, many of the same issues continue to plague all phases of emergency management, especially responses. By identifying common technical difficulties impacting public health during four disasters from 2005 to 2017, this information may help improve future preparedness, mitigation, response, and recovery procedures.
Technological Problems in Disaster Response
The after-action reviews of Katrina and Sandy identified many problems that directly affected healthcare systems and public health. Despite significant technological advancements over the seven years between storms, and even after substantial technological improvements, similar issues plagued both storms. Hurricane Maria and the Thomas Wildfire encountered similar problems. Emergency preparedness professionals responsible for planning, higher education, research, training, exercises, technology, standards, and accreditations are challenged to implement change. Closer working relationships and partnerships between preparedness and response leaders may enhance practical improvements that can save lives.
This article shows how communities managed when power outages, communication failures, and healthcare concerns emerged after four disasters.
The Select Bipartisan Committee to Investigate the Preparation for and Response to Hurricane Katrina found that nearly all issues during the response to the storm arose from information gaps. Numerous communication failures and information-sharing gaps may have led to leaders failing to act in timely ways at all levels. When they did act, they did so blindly, without adequate intelligence and analysis. In addition, after the hurricane made landfall, much of the communication infrastructure was damaged, and backup systems were unavailable.
A compounded effect of the communication difficulties was the evacuation and transportation of medical patients. During Hurricane Katrina, 65 hospitals across the country took in evacuated patients. However, many facilities lacked electronic health records, and sending patients with paper records was inefficient and unworkable. As a result, many patients arrived at new locations with incomplete medical records. Additionally, coordination and planning to use private and military transport vehicles and aircraft were complex and challenging due to widespread communication failures. Many planes and other vehicles consequently went unused during the evacuation process.
During Hurricane Sandy, the most common problems were power loss and communication issues due to the resulting flooding. These problems impacted hospitals, long-term care facilities, primary care offices, clinics, and emergency medical services, directly affecting healthcare providers’ ability to communicate with their patients. It also caused difficulties in communication between state and federal response officials. In addition, there were concerns about the power supply for medication refrigeration and other medical devices. Flooding prevented many people from traveling and resulted in worker shortages. Patients could also not travel, and doctors had to visit critically ill patients in their homes.
Secondary consequences included flooding of facilities and roadways and supply chain disruptions. Flooded roads prevented deliveries and medical workers from getting to work. The supply chain disruptions were far-reaching, affecting everything from fuel for vehicles and generators to food, water, and medical supplies. Power outages and a lack of generator fuel resulted in the inability of heating and life support systems to operate. Heating loss caused residents to run their gas stoves as a heat source. This practice and the incorrect use of generators resulted in at least eight deaths from carbon monoxide poisoning. Finally, the long-term impacts of mold from flooded locations were a concern. Many people had to return to their homes even though they may not have been adequately cleaned and renovated from the flood waters.
Like Katrina, the storm damaged much of the communication infrastructure. Several power station transformers had to be shut down before being inundated with floodwaters. These preemptive shutdowns saved the equipment but resulted in widespread power outages and further communication difficulties. Before, during, and after the hurricane, it is estimated that hospitals evacuated over 6,400 patients in New York City alone. With each patient requiring transportation to another facility, the drastic increase in transportation needs stressed medical transportation systems and receiving facilities. Power outage issues also could have impacted electronic health records for these transitioning patients.
Likewise, the response to Maria was troubled by communication and supply chain issues from the start. Due to the significant number of severe storms that year, the Federal Emergency Management Agency (FEMA) moved response supplies and personnel from warehouses on the island to other locations. As a result, the response to the incredible amount of damage from Maria was weak. Local authorities were similarly unprepared. Instead of practicing self-resilience, they chose to rely on federal authorities, leaving themselves unable to assist their citizens in the storm’s aftermath.
As Maria battered the island, power outages became widespread and affected all aspects of healthcare. Electrical infrastructure damage resulted in the largest power outage ever in the United States. Many locations on the island went without power for 11 months. Before the storm, the island did not have enough generators. After the storm, shipping disruptions caused delays in providing portable generators. Compounding effects of a power outage, such as life support and electronic health record access, were slow, if even available. Illness and disease were likely without proper food storage and preparation or water sanitization.
In the Thomas fire’s after-action report, the county emergency managers identified several areas that needed improvement for future disaster response. However, although the area experienced a power outage, communication issues were not deficiencies. A strength of that response was the ability of separate agencies to share information in the joint information center. The rapid information exchange resulted in timely public health warnings, including air quality measurements, hazardous materials identification, animal safety messages, and evacuation notices. The county established a call center early on that was highly effective at distributing and receiving information. For example, citizens’ calls and texts to the center for up-to-the-minute details evolved into a behavioral health support network for citizens affected by the fire and responders. This communication technology worked well and was cited in the after-action report as a success.
Failure to Improve Technological Problems
It seems apparent that communication issues and information-sharing have continued to be problems during disaster response for most incidents. Communication and information-sharing were cited issues during Hurricane Katrina and still proved difficult years later. In 2005, during Katrina, cell phones were not as widespread as they are now. Most emergency communication occurred through radios and landline systems. Communication technology improved rapidly afterward. However, communication difficulties remained present even with increased cell phone capabilities and availability during Hurricanes Sandy and Maria. The cell phone infrastructure, such as cell towers, added another layer of vulnerability without adequate protection. On the other hand, California appears to have addressed communications during disaster scenarios well.
While electronic health records were rare in 2005 during Katrina, they were more common in 2012 when Sandy hit. Then, in 2014, they became mandatory for all healthcare organizations in the United States. Even so, there were still difficulties ensuring proper patient transport and care for evacuated individuals. Power outages impeded the ability to access electronic records during Sandy and Maria. When medical providers could access them, there were, at times, compatibility errors between systems. Supply chain issues were present in all disaster responses. After Katrina, supply issues were blamed on the unprecedented scale of the damage, resulting in too few supplies being pre-staged for use. For Sandy, transportation difficulties led to the shortage. Like Katrina, supply shortages during Hurricane Maria were blamed on the many disasters that occurred previously in the year. There was a failure to stock enough supplies for worst-case scenarios. Instead, jurisdictions were only prepared for a minimal response effort assuming the other entity would cover any gaps.
Disaster planning since 2012 continues to vary among communities. Emergency preparedness professionals learn from past experiences and continue improving response efforts. Unfortunately, many of the same problems continue to plague response efforts in 2022.
Recommendations to Prevent Issues
The primary recommendation to prevent technological issues is to study the past. New technologies must be built with the intent of disaster planning, preparedness, resilience, mitigation, and prevention. The infrastructure and supporting elements must be hardened and prepared to withstand all types of disasters, especially with heavy reliance on advanced technologies, where system failures have widespread, devastating consequences.
As part of preparedness planning, it is a best practice for facilities of all types to have access to a generator or other form of emergency power supply. However, at a minimum, healthcare facilities with an on-site patient population should be required to have a generator with at least 72 hours of runtime capability – because many facility evacuations were due to a lack of backup power supply. States could ensure the implementation of these mandates through public health inspections like those done with elevators.
Hurricane Irene, which came ashore the year before Sandy, gave the region a false sense of security. Many health facilities and other organizations felt prepared since they fared well during Irene. As a result, they did little to increase their preparedness, and many failed to take the threat of Sandy seriously. In contrast, the utility companies in Connecticut were unprepared for Irene and spent the next year conducting mitigation activities. As a result, power loss was significantly reduced in the state when Sandy hit in 2012. Even though there were fewer power outages, healthcare facilities still experienced difficulties with communications, patient tracking, and maintaining standards of care due to staff shortages. This examination shows that complacency can be fatal and that continual upgrades are vital.
It is critical to study and learn from history. Every disaster offers an opportunity to learn from what went well and what did not. These lessons provide the information needed to enhance the preparedness level of facilities, organizations, and communities and then put into action by updating plans, policies, and exercises.
Further, individuals and organizations of all sizes must accept responsibility for their resilience by preparing for the unexpected. Although the federal government provides resources, it must not be the only source. The federal government provides immediate resources and support, state governments manage disaster recovery, and local governments implement those recoveries. Self-reliance increases survival. Technology continues to evolve but will not always result in enhanced safety or security. Everyone must prepare their homes and families to survive a disaster and practice vigorous preparedness, mitigation, and response activities. Failure to do so will continue to result in potentially escalating consequences.