Income

Income level affects all aspects of disasters. Lower-income households may be unable to afford emergency preparedness kits. Single mothers, of whom approximately 33% fall below the poverty line in the United States, may have trouble buying mitigation measures such as hurricane shutters to protect the contents of their homes.³⁸ Those living on fixed incomes have particular difficulties. For example, Hurricane Katrina occurred at the end of August, which meant that social security and disability checks had not yet arrived. Many people were waiting for checks to refill prescriptions. Furthermore, they could not afford gasoline or food to evacuate. Buses that should have been dispatched to evacuate people needing transportation did not arrive. Reluctant to leave a familiar environment and family on which they could depend, a disproportionate number of low-income households remained behind. Extensive damage occurred to many low-income homes located in floodplain areas. For hundreds of families, this meant the loss of a home that had been in their possession for generations and could no longer be replaced due to financial hardship. In a post-disaster context, low-income households face hard choices between recovery and ongoing needs. To survive, they may pawn remaining possessions, relocate to more affordable areas away from familiar healthcare providers, move in with other families, skip meals or eat poorly, delay healthcare, cut medications in half, or not follow through on expensive medical regimens.

Low-income homeowners often face serious rebuilding challenges. Because many are underinsured or cannot afford hazard-specific insurance, they cannot rebuild without assistance. In 2013, maximum federal loans in the United States totaled $31,900. For most low-income households, choices must be made about rebuilding or relocation. Without assistance from volunteer disaster organizations, many cannot return home. Most will enter into a local case management process and await help from faith-based and civic organizations. In addition, the low cost of mobile homes makes it more likely that people living in poverty will rent or buy this type of housing. As a result, when tornados or hurricanes occur, those that are poor are more likely to be harmed when they take cover within their homes.³⁹

Renters encounter similar challenges. After the 1994 Northridge earthquake in California, renters faced extensive displacement due to the time required to rebuild multi-family dwellings and the state of the regional economy.⁴⁰ After Hurricane Katrina, public housing in New Orleans was condemned; the process of rebuilding takes years. Rural-urban divides also produce challenging circumstances. Farm families affected by drought, floods, wildfire, or severe storms may lose their livelihoods or be forced to adapt by taking on new economic roles.

Social networks are especially important to low-income families, particularly in neighborhoods where families have lived for some time. Their neighborhood and familial relationships help sustain them. When disasters force relocation, those social resources diminish and life circumstances become even more difficult. This appears to be particularly true for minority communities, especially those with long-held ties to the land, such as Native American households in the United States.

Race and Ethnicity

Although studies find similarities both within and across racial and ethnic groups, important differences exist.⁴¹ Studies of rapid-onset events illustrating these differences have implications for warning those at risk. For example, in a study of a massive tornado that damaged a neighborhood near Birmingham, Alabama, 80% of white residents heard the warning from television compared with only 67% of African-Americans.⁴² While the influence of social media may change results, historical data show that Hispanics are more likely to get warning information from the radio or from social networks. They are also the largest minority group living in the United States. New Mexico and Texas will likely become Hispanic majority states by the end of the decade.⁴³

Ethnic groups may experience linguistic barriers, such as when warning messages are not distributed in relevant languages.⁴⁴ Translation must also be done correctly. As a tornado approached the small town of Saragosa, Texas, in 1987, efforts failed to translate warnings into Spanish correctly. Rather than learning of an approaching risk, the few listening to the radio heard “news” about a tornado.⁴⁵ Those watching cable television originating far from their location received no warning. Twenty-nine people died and dozens sustained injuries. After any major disaster, companies may hire low-income workers who are recent immigrants and may not receive appropriate training and protective equipment.

Ethnicity has also been associated with income discrimination and segregation patterns that impede abilities to secure adequate housing in areas safer from local hazards.⁴⁶ Lower-income housing tends to fare poorly in areas of high risk. For example, affordable housing is more likely to be located in floodplains and closer to hazardous materials sites. Manufactured housing can fail in the lowest level of tornadoes. In earthquake prone regions, such housing is more likely to lack seismic retrofitting.^22,46 This exposure increases the likelihood of injuries, property loss, and psychological trauma. Minority populations are also less likely to have adequate homeowners’ or rental insurance, as well as being less likely to access aid from federal programs, despite experiencing greater effects from disaster.⁴⁷

Gender

The bulk of published vulnerability research concentrates on gender issues. Much of this research has resulted from a concerted effort by investigators who are linked through the Gender and Disaster Network (www.gdnonline.org). Researchers have documented differential results in survival rates as well as in the methods women and men use to respond to and recover from disasters. The 2004 Indian Ocean Tsunami, for example, resulted in approximately 300,000 deaths and displaced at least 1.6 million people across thirteen nations. More than 80% of the fatalities were women and children.⁴⁸ This differential impact was due to that, in many nations, women waited on the shore with their children for fishermen to arrive with the daily catch, which they would then clean and sell at market.

As a leading nongovernmental organization reported after the tsunami, “disasters, however ‘natural’, are profoundly discriminatory. Wherever they hit, pre-existing structures and social conditions determine which members of the community will be less affected, while others pay a higher price. Among the differences that determine how people are affected by such disasters is that of gender.”⁴⁸ The same is true across the Caribbean, where sex differences result in health risks that increase in disasters. These include sexual abuse and violence as well as “malnutrition, anemia, maternal morbidity and mortality, complications in pregnancy, sexually transmitted diseases, and mental and psychological conditions that cause loss of healthy life and wellbeing among women.”⁴⁹

In some contexts, men differentially experience disaster impact. In 1998, Hurricane Mitch generated higher fatalities among Honduran men than women. Gender socialization patterns produced the differential mortality rate, as men felt compelled to remain behind and try to protect livestock and property from storm damage. Hurricane Katrina statistics also demonstrate risks, especially in elderly African-American men, who experienced a disproportionate death rate.³ Post disaster, gender roles can affect continued exposure to hazards, such as after the Chernobyl incident wherein the majority of soldiers and civilians who helped clean up were men.⁵⁰ Gender bias more likely to unequally affect women is evident in other settings. In a shelter environment, for example, women’s needs may include maternity support, privacy for hygienic and religious reasons, nutritional supplements, childcare, trauma counseling, and an environment free from violence. Gender differentiation also occurs when warnings are issued, as women appear more likely to disseminate the warning among others, to respond positively when instructions are given, and to gather the family for evacuation.^51–53 Small businesses and home-based enterprises, which are more likely to be owned by women, tend to sustain higher losses.^54–55 Women also tend to be the family member most likely to access recovery assistance and to link older family members to aid.⁵⁶

Response and recovery organizations have been criticized for their failure to include women.⁵⁶ In Central America, increasing women’s capacities and roles in disaster preparation and aid is strongly recommended. “Women’s societal role is multi-faceted…[T]his is extremely important in the health field where women are often employed and, at the same time, are generally responsible for family health and well-being.”⁵⁷ In the Caribbean, sex-based social capital brings local knowledge, social networks, and critical links to others at risk. Vulnerability can be mitigated by leveraging women’s resources through increased representation, mobilization, education and training, recognition of their needs, and direct involvement in emergency management activities.⁴⁹

Disability

While disaster-related fatalities in the United States have decreased overall, people with disabilities are disproportionately affected.⁵⁸ Historically, individuals with disabilities have been neglected in disaster planning. People with disabilities are less likely to have emergency plans in place, and communities are less likely to have plans that meet the needs of those with disabilities.⁵⁹ One study reported that only 23% of emergency managers have received training on the needs of individuals with disabilities during evacuation.⁶⁰ According to a January 2004 Harris Poll commissioned by the National Organization on Disability (NOD),⁶¹ 66% of people with disabilities did not know who to contact about emergency plans in their communities; 61% of persons with disabilities had not made plans for quickly and safely evacuating their homes; and among those people with disabilities employed full- or part-time, 32% said that no plans had been made to safely evacuate from their workplaces. After Hurricane Katrina, NOD commissioned a task force to examine issues associated with shelter needs for people with disabilities. Known as the SNAKE Report (Special Needs Assessment of Katrina Evacuees), NOD identified several concerns including those related to intake, inappropriate transfers to “special needs” rather than to general population shelters, loss of durable and related medical equipment, inaccessible shelters, and lack of accommodation for sign language and service animals.⁷

Challenges for persons with disabilities exist across all disaster stages including evacuation, sheltering and reentry into the affected community. In a survey conducted in hurricane-prone states 3 years after Hurricane Katrina, 14% of residents in high-risk hurricane areas lived in households in which a person with a chronic illness or disability would require assistance in order to evacuate. Of this group, 43% did not have accessible help, and 17% were not prepared at all for a major hurricane in the next 6 months compared to 9% of households without persons with chronic illnesses or disabilities. They were also less likely to have a 3-week supply of the necessary prescription drugs (39% versus 30%) or to have a first-aid kit (30% versus 20%).⁶¹

A study of Hurricane Katrina survivors sheltered just after the disaster found that 38% of the individuals interviewed reported that they did not evacuate because they were physically unable to leave or that they were caring for someone physically unable to evacuate.⁶² According to the Committee on Disaster Research in the Social Sciences: Future Challenges and Opportunities and National Research Council, “Major failures occurred in the provision of evacuation assistance by both governmental and nongovernmental organizations to citizens with limited capacity to evacuate on their own prior to Hurricane Katrina.”⁶³ In addition to the evacuation of persons with disabilities, evacuation plans need to make allowances for transporting and reuniting special equipment, mobility devices, and assistance animals with users.

People with disabilities report difficulties during and after disasters when shelters, shelter restrooms and showers, and other temporary housing are not accessible to them.⁶⁴ People with disabilities may be physically unable to enter or clean up their properties, while the assistive services that they require may be lost along with other community infrastructure. In addition, many voluntary organizations may be unfamiliar with effective ways to assist individuals with disabilities or unaware of organizations that provide disability-related assistance.

Workplaces are of similar concern. After the terrorist attacks in 2001, NOD launched an Emergency Preparedness Initiative. Initially, it conducted surveys asking people with disabilities whether evacuation plans were in place at work. In 2001, 50% of the respondents said “yes” followed by a decline to 34% in 2005.⁶⁵ Subsequently, NOD crafted a booklet of recommendations for emergency managers and posted downloadable disability-specific preparedness brochures on its website (see Resources list).

From a sociopolitical perspective, many of these problems emanate from a societal failure to structure emergency and disaster procedures with accessibility in mind. U.S. Presidential Executive Order 13347 established that emergency preparedness measures must consider people with disabilities and “increase the rate of participation of people with disabilities in emergency planning…preparedness, response and recovery drills and exercises.”⁶⁶ Since then, a number of new policies have emerged to address gaps in planning and preparedness (for example, the U.S. Department of Justice shelter protocol and the U.S. National Response Framework).⁶⁷ The emphasis is on building capacity among those with disabilities and including people with disabilities, disability organizations, and knowledgeable advocates in the planning process. Better practices encourage independence and provide for equal access, trained staff, appropriate food and equipment support, proper communications, and assistance in keeping people together with their families and service animals.⁶⁸

Partnerships are the key. Disaster resilience can be increased and new insights generated by strengthening individuals through personal preparedness planning and by including disability organizations in the planning process. Risk reduction requires active participation and involvement by those individuals believed to be vulnerable.

Language and Literacy

Language influences the ability to obtain information of all kinds, from warnings on rapid-onset events to the problems of lingering heat waves. Within most nations, this kind of information is usually disseminated primarily in the most commonly spoken language. Efforts to translate information must be made to reach the full population, from people with low levels of literacy to people fluent only in sign language. In addition, weather information language may not be user-friendly to the public as it is intended primarily for other users such as emergency managers. Few weather stations include live interpretation. Scrolls and weather maps may be difficult to understand and meteorologists sometimes obscure closed-captioning. For people who became deaf in later life, following the scroll or understanding sign language may be next to impossible.

Low literacy levels can inhibit proper understanding and response to public health messages. Written materials present obvious problems. The manner in which communication occurs can also impact response. The National Hurricane Center in the United States strives to provide understandable information to the public as well as to emergency managers.⁶⁹ Because hurricanes can be unpredictable, forecasts must be issued in terms of probabilities and risks. Understanding probabilities and how they apply to one’s personal risks can be challenging. When making a decision to evacuate, understanding those risks is crucial.

During recovery, applying for federal aid requires the ability to understand and complete multiple forms. Social workers and case managers report that low-literacy applicants denied benefits tend not to challenge the decision without encouragement and assistance. Benefit loss among low-literacy applicants appears to be higher as a result, with increases in stress and related illnesses. Similarly, individuals with disabilities often need support in negotiating the post-disaster recovery system and benefit from support from case managers with expertise in supporting people with disabilities.⁷⁰

Sign language varies across geographical areas and nations and must be adapted to incorporate these linguistic differences. As noted in a breakthrough study, warnings often fail to reach people who are deaf or hard of hearing.⁷¹ Although U.S. Federal Communications Commission policy dictates that closed-captioning must occur during emergency news broadcasts, stations frequently fail to provide closed-captioning during rapid-onset events. Meteorologists often turn their backs or their sides to the camera during on-air coverage, which precludes lip-reading, and graphics often scroll across closed-captioning. Few schools of meteorology offer instruction regarding vulnerable populations or prepare students to work with the deaf.⁷¹ Thus the problem is not individual culpability, but one reflecting a larger societal problem. Although technologies address some warning distribution issues, the cost of those devices can be prohibitive.

Increasing diversity within the United States has prompted the integration of pre-event messages and interpreters into emergency operations plans. In the San Francisco, California area alone, at least 112 languages are spoken.⁷² The most frequently spoken languages include English, Spanish, Chinese (various dialects), Portuguese, and Punjabi. Issues with language and literacy can be addressed. As an example, FEMA issued informational brochures in dozens of languages after September 11, 2001. FEMA then increased its capacities after Superstorm Sandy in 2012. FEMA’s Limited English Proficiency (LEP) department conducted outreach in twenty-five different languages and distributed over 900,000 flyers, fact sheets, and other materials. The FEMA telephone registration line was staffed by personnel who could identify languages and then route the caller to the proper staff member. Within 3 months, more than 11,300 people had called and received assistance in 35 different languages. Interpreters also went to nearly sixty community meetings and provided 25 language interpreters at Disaster Recovery Centers in the affected area.

Congregate Facilities

Functional and access needs also exist for those who live in congregate facilities. Such facilities include assisted living, nursing homes, adult day care centers, schools for students who are blind or deaf, and facilities for veterans or adults with cognitive disabilities. However, very little empirical work has been performed on any of these populations in a disaster context.

More is known about nursing homes than other facilities. Transferring such populations to other facilities carries risk; however, failure to evacuate can have fatal consequences, as seen in Japan after the Fukushima radiation disaster and in the United States after Hurricanes Katrina and Rita. The U.S. Government Accountability Office found additional problems. There is no national system to evacuate patients in nursing homes and “states and localities face challenges in identifying these populations, determining their needs, and providing for and coordinating their transportation.” Those challenges include identifying transportation resources (vehicles and drivers) and escort staff. It is likely that in a major disaster, the “local demand for transportation would exceed supply” of vehicles.⁷³

Hurricane Rita, which occurred shortly after Katrina, prompted massive evacuations and resulted in gridlock on Texas highways. In the worst tragedy of the evacuation, a nursing home bus caught fire and twenty-four patients died. Unlike hurricanes that have some warning, rapid-onset events may not allow for movement to safe rooms, or facilities may lack such shelters. In 2011, a massive, violent tornado tore the roof off a local nursing home in Joplin, Missouri. Sixteen residents and a caregiver died as medical staff tried to protect, cover, and hold on to their patients.

Nursing homes that are most likely to evacuate, particularly in the case of slow-onset events, belong to systems that are capable of providing patient care at alternate facilities. Independent facilities are less likely to evacuate, to have adequate transportation assets to do so, and to have the staff necessary to travel with patients. The evacuation itself can be associated with increased morbidity, including what appears to be a higher potential for death, a reaction called “transfer trauma.” Other challenges include the patient’s ability for adapting to changes in heat or cold or obtaining proper nutrition, especially in relation to medication protocols. In addition older adults may experience physical challenges that limit their abilities to evacuate or shelter during events like earthquakes or tornados. Statistics indicate that approximately 32% of American adults aged 70 or older report difficulty walking.⁷⁴ In addition, facilities face challenges for ensuring that support systems remain in place during evacuation, including transfer of medical records.^75,76 Actions by emergency managers working closely with home healthcare agencies, doctors, and other community organizations to disseminate messages about the impending disaster, transportation options, and shelters were effective during the evacuation for Hurricane Katrina.⁷³ Studies also recommend that families and patients remain together to provide social support and lessen transfer trauma.⁷⁶

Medical facilities that offer outpatient care can also sustain damage during an event, reducing the availability of crucial services to vulnerable populations. Disruption in treatment can occur for patients receiving dialysis, cancer therapy, and HIV/AIDS–related interventions, as well as for those with significant respiratory conditions who require assistance. In addition, the loss of facilities that provide critical resources such as oxygen and tube feeding highlights the need for rapid restoration of such services. An important factor for those living in congregate care is that caregiver and medical supports are available to provide continuity of care during a disaster event.⁷⁷ Similarly, employers who provide supported work environments must consider needs of their employees with disabilities should a disaster occur. In both congregate housing and work environments, designing a disability-accessible area for sheltering-in-place is important.⁷⁸

Immigrants and International Visitors

People who have recently arrived in a new location are among the last to receive disaster information. International students, for example, face different hazards from those in their native country and need to acquire new survival skills. Similarly, recent immigrants require education about local risks and training on appropriate protective actions. Because immigrants may include extended family members, materials should be distributed in multiple languages and with consideration of literacy levels in those languages. An elderly immigrant may never learn the locally or nationally spoken language. Outreach to people who are new to, or unfamiliar with, an area is crucial. These individuals include tourists, convention-goers, exchange students, or medical mission team members. The type of event can make a difference as well. For example, American Muslims experienced violent retributions after the events of September 11, 2001, putting them at considerable risk in some locations.⁷⁹

After the 2013 tornadoes in Oklahoma, recent immigrants who had lost their documents in the storms feared requesting government aid because of a perceived risk of deportation. To address this concern, faith-based organizations provided services where people felt comfortable accessing aid. In 1999, Darwin officials in Australia hosted over 1,800 evacuees from East Timor. Local officials worked with members of the existing East Timorese/Portuguese community out of concern for potential negative consequences resulting from language, religious, and sex differences. Together, they established the Police Ethnic Advisory Group to operate a reception center. For more than 2 years, local fire, police, and Timorese leaders worked as partners to receive evacuees. They used local Timorese representatives to meet new arrivals and use their native language. Their “fellow country” people helped to establish and explain appropriate food preparation, sleeping, religious, and health procedures.¹¹ As with other groups, involving the “at-risk” population in addressing issues provides crucial resources.

An estimated 11.3 million undocumented immigrants live in the United States, many of whom are Hispanic.⁸⁰ After the Southern California wildfires of 2007, reports of mistreatment and discrimination against undocumented individuals included instances of police officers who circulated through shelters, woke up families, asked for identification, and escorted those with no papers out of the shelters.⁸¹ Understandably, these actions dissuaded families without documentation to seek shelter and support during this disaster. Navarrette⁸⁰ later reported that at least “half a dozen charred bodies have been uncovered in the ashes-bodies that authorities believe are those of illegal immigrants who did not get out of harm’s way fast enough.”⁸²

People in Rural Areas

Although the population of the United States has become increasingly urban, over 20% of households are located in rural areas. Rural communities can be more vulnerable than their urban counterparts as they confront unique challenges that affect how they are able to prevent, serve, and respond to the public’s needs during disasters.⁸³ For example, the Bastrop County Complex wildfire occurred in a wildland urban interface area where homesteads and ranches were established in a piney forest. When drought struck Texas in 2011, pine needle drop, lack of moisture, and high winds led to a multiple wildfires that converged and consumed nearly 1,700 homes. Rural residents had to quickly evacuate and many lost livestock and ranching infrastructure in addition to their homes.

Rural communities frequently lack disaster resources and sufficient formal governmental structures that facilitate effective mitigation, preparedness, response, and recovery.^84,85 Additionally, rural areas must plan for a trio of considerations that include common disasters, unique local threats, and urban populations fleeing densely populated areas to the perceived safety of rural America.⁸⁵

Intersected Vulnerabilities

It is difficult to separate demographics and specify that only gender, income, or age create a vulnerable condition. In reality, demographic conditions and the broader social, economic, cultural, and even political conditions in which people live create “entangling effects” that foster and exacerbate vulnerability.⁸⁶

Although specific circumstances and/or conditions may generate vulnerabilities and support needs, overlapping conditions occurring together create vulnerabilities. For example, greater susceptibility to health issues such as osteoporosis means that women may be generally more likely to sustain injuries. Women’s vulnerability is further exacerbated by age, which can be aggravated by disability. An elderly woman with a mobility, sensory, or cognitive disability bears disproportionate risk in a disaster and merits a more comprehensive range of intervention strategies.

As another example, elderly men are more likely to live in socially isolated conditions, away from relationships and networks that may provide buffers against the consequences of disasters. In addition, their disability risk increases with age. In the United States, one in five people have a disability, a situation that increases with age.⁷⁶ Gender may complicate the intersection of age and disability. For example, older men may receive delayed evacuation information and have difficulty accessing supports that facilitate timely evacuation.

To summarize, one “condition” or population demographic is insufficient to understand vulnerability. Rather, a complex set of conditions, circumstances, and contexts interact to produce vulnerability. Using a simple checklist of possibly affected population groups is a starting point. Understanding the intersected nature of vulnerability informs the concerted efforts needed to address vulnerability reduction.

A Resilience Perspective

In contrast to the concept of vulnerability, scholars and practitioners have endorsed the idea of “resilience.” Defined generally as the ability of individuals and communities to recover from adverse circumstances, resilience has been used to describe not only psychosocial hardiness but also the time it takes for a community to reestablish essential services and commerce post-disaster. Medical personnel can facilitate resilience on the individual level by providing psychological treatment resources to disaster survivors. With respect to community resilience, medical personnel can support disaster preparedness of hospitals and clinics. Post-disaster, they are instrumental in providing care and restoring needed medical services. Key actions should focus on mitigation and preparedness, at both the individual and community levels.⁸⁷

Resilient communities take deliberate, meaningful, collective action in response to disasters. An emphasis is placed on connection and caring among community members and organizations.⁸⁸ These communities are able to minimize the effects of, and recover quickly from, disasters. A community is only as prepared and protected as its most vulnerable members. The health and safety of traditionally vulnerable populations can be considered an indicator of overall community resilience.

The Life Cycle of Emergency Management

Emergency managers and disaster researchers describe a “life cycle” of emergency management. Most nations organize their disaster activities around the categories described in this cycle. In New Zealand, for example, they are known as the Four R’s: readiness, response, recovery, and reduction. In the United States, the National Governor’s Association first organized the phases into preparedness, response, recovery, and mitigation activities. Regardless of the terms, the phases have influenced both practice and research. The remainder of this chapter addresses relevant issues and connects each disaster phase to vulnerability. Practical strategies that promote resilience are discussed. To emphasize the importance of these phases, this section begins by addressing legal mandates for emergency managers.

Preparedness

Preparedness is defined as “actions undertaken before disaster impact that enable social units to respond actively when disaster does strike.”⁸⁶ Actions should be taken at the individual, household, organizational, and community levels as well as within local, state, and federal governments. Activities might include building partnerships, developing and disseminating educational materials, training for specific tasks such as sheltering or triage, evacuation planning, the creation of functional and access needs registries, writing emergency operations plans, and holding exercises. This section examines key areas.

Know the Community

Before addressing specific population needs, emergency managers must become familiar with community demographic groups and potential partnership organizations. The U.S. census is a good source of local population data. The census occurs every 10 years with more frequent assessments made through random sampling conducted by the American Community Survey. Both can be accessed at www.census.gov. General information gleaned by geographical location includes overviews of race, ethnicity, languages, gender and age distributions, disabilities, and income levels. A limitation of the census is that it misses key population descriptors, such as recent immigration, literacy levels, and homelessness. Thus the census is only the first step in assessing localized and special needs. For developing nations, census data may be incomplete or never collected. Capturing a sense of the community requires familiarity with the population. Interacting with local organizations provides valuable data.

Thus, the second step in knowing the community is identifying the range of local community-based organizations. From these groups, it is possible to learn more about those present in the community. Agricultural areas in southern Florida and parts of California, for example, have health and advocacy organizations dedicated to both migratory and resident farm workers. Urban locations usually host missions and other places dedicated to the homeless. Faith-based organizations extend services to new immigrants and may offer personnel who speak relevant languages. The local emergency management agency is another key organization. An increasing trend among emergency managers is to establish a “Functional and Access Needs Advisory Panel” or to generate an approach based on the notion of the “Whole Community.” Developed by FEMA in the United States, “Whole Community” means that everyone is invited to participate in planning and preparedness, including community, civic, and faith-based organizations. Becoming part of this partnership provides links to organizations with expertise. Relevant groups include disability and rehabilitation agencies, health organizations, and senior networks, as well as other higher-risk populations.

Medical personnel represent a marginally tapped disaster management resource in many communities. Typically, medical staff remain in stationary hospital locations waiting to receive patients. Conversely, outreach by medical personnel into existing or emerging partnerships that address special needs can make a considerable difference. Expertise on disabilities, movement of fragile patients or frail elderly, and insights into child and partner abuse can help emergency managers and other organizations to reduce risks. According to the U.S. Government Accountability Office, physicians and other medical staff played an important role in identifying patients who needed transportation during Hurricane Katrina. A stronger link among individuals, the medical community, and emergency managers can mitigate bad outcomes. Medical personnel who provide services to nursing homes, assisted living facilities, settings for people with cognitive disabilities, and other similar locations can encourage those facilities to train personnel frequently on emergency procedures. By getting acquainted and working with a broad array of partners, special needs can be identified pre-event.

Training and Education

Ongoing education about vulnerable populations is necessary, particularly as policies and procedures are rapidly evolving within the United States alone. The following are useful resources:

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  Universities and colleges have developed programs across the United States and in some other nations that include opportunities for stand-alone courses, certificates, or degrees. Many offer distance learning courses available on the Internet. Links to programs can be found at the FEMA Higher Education Project website: http://www.training.fema.gov/EMIweb/edu/collegelist.

  
  
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  Many states and communities have developed robust Medical Reserve Corps with volunteers from the medical sector.⁹³ They respond on an as-needed basis when disasters occur and assist with a range of issues including pandemics, shelters, and annual immunizations. For more information, visit www.citizencorps.gov.

  
  
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  FEMA offers an interactive course at their Independent Study (IS) website. IS197 concerns functional and access needs. See http://training.fema.gov/EMIWeb/IS/is197SP.asp.

  
  
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  States offer instructor-led functional and access needs training courses. Course materials may be obtained from FEMA at https://training.fema.gov/EMIWeb/pub/register.asp.

  
  
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  Professional emergency management conferences, such as the National Hurricane Conference or the International Association of Emergency Managers, offer topical workshops and continuing education credits for special needs courses. Organizations such as the International Association of Emergency Managers, the National Emergency Management Association, or the Natural Hazards Center at the University of Colorado-Boulder provide listserves. The latter is available at www.colorado.edu/hazards.

  
  
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  FEMA hired disability coordinators at their ten regional offices. Contacting them may lead to the initiation or furtherance of important partnerships. FEMA’s Office of Disability Integration offers additional information at http://www.fema.gov/office-disability-integration-coordination/office-disability-integration-coordination/office-1.

  
  
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  Scholarly journals are increasingly publishing research on populations at risk. Key sources include the Natural Hazards Review, the International Journal of Mass Emergencies and Disasters, Environmental Hazards, Natural Hazards, Disaster Prevention and Management, Disasters, and the Journal of Emergency Management.

Further information and training resources are available from local, state, federal, and international emergency management agencies. Such entities routinely hold tabletop exercises and community drills. Training should include all levels of personnel working in a medical setting.

Finally and perhaps most importantly, healthcare personnel should engage in cross-training with disaster organizations. The American Red Cross trains shelter managers and provides other disaster courses. For professionals in psychology and psychiatry, the Red Cross requires credentialing before participation in actual disaster response.

U.S. FEMA “Getting Real” Conference Public Education Initiatives

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  Educating those at risk about approaches to reduce their own vulnerabilities is essential for preparedness. Medical personnel play an important role in this by providing information to their patients.

  
  
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  Place informational brochures in waiting rooms. Free, disability-specific brochures can be downloaded from NOD at www.nod.org (select “Emergency Preparedness Initiative”). Provide materials in multiple formats for various languages and literacy levels as well as for people with varying degrees of visual limitations. Offices should also consider purchasing communication boards that include specific languages, pictures, and situations (i.e., denoting bleeding or pain).

  
  
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  Include individual and household risk assessments during medical histories and annual examinations. Disaster checklists can be obtained at www.ready.gov, www.fema.gov, and similar sites. Focus history taking on the level of individual and household preparedness for an event such as an evacuation. PTSD is more likely among those with previous trauma such as war injuries, interpersonal violence, prior disaster, or severe injuries. Assessment for a history of trauma helps pre-event identification of populations who may benefit from advice and counseling resources.^9,10

  
  
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  Advise patients that they should establish an emergency bag or “go kit.” Materials that should be included are identified at www.ready.gov and www.redcross.org. Within this kit, it is particularly important that patients include medications, lists of medical routines, a medical history, communication information and preferences, nutritional needs, insurance papers, and contact information for healthcare and pharmacy providers, family, guardians, and caregivers.

  
  
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  Alert patients to opportunities for obtaining emergency bag items or other information, especially low-income patients and, in the United States, seniors on Medicare Part D (particularly those that are experiencing gap coverage). This might include assisting patients with pharmaceutical programs that provide free or reduced medications.

  
  
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  Assist families with transitions into assisted living facilities. Immediately orient new residents to emergency procedures and establish a clear means of communication with families about what will happen, how, and under what circumstances.

  
  
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  Support practices and legislation that mandate safe rooms in schools, day cares, and other locations where large numbers of children may need rapid sheltering.

  
  
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  Explain to patients the resources that will be available in evacuation shelters. Because individuals with disabilities may be reluctant to evacuate due to the belief that shelters will not be ready, it can be valuable to provide that information to encourage evacuation.⁵⁰

  
  
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  Send new parents home from the hospital with checklists for emergency procedures in a disaster. Provide emergency bags (formula, diapers, and other key items).

  
  
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  Target people with disabilities and seniors for special attention. Provide information through both direct contact and accessible-format materials. Medical personnel tend to have high levels of credibility when disseminating information, so these efforts can have considerable impact.

  
  
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  Link with home healthcare agencies and encourage them to provide disaster information to patients, particularly those in transition from hospital to home. A family leaving the hospital with someone using an oxygen tank for the first time may need special training not only on the medical equipment but also on how to help the family member take appropriate protective actions in a disaster. For example, how a family member can move an individual with mobility limitations without injury.

  
  
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  Support domestic violence shelters with outreach to individuals experiencing intimate partner violence. Because it appears that domestic violence may increase after disasters, those known to be at risk require additional attention. Medical personnel can provide information and escape options and support the efforts of domestic violence prevention staff.⁵¹

Other organizations can benefit from cross-training as well. For example, after the 1989 Loma Prieta earthquake in San Francisco, a Latino healthcare organization called Salud Para La Gente cross-trained with the American Red Cross. The benefits were significant. Salud Para la Gente developed an emergency response healthcare plan and the Red Cross expanded its network of providers for the Spanish-speaking community. This partnership likely led to other benefits across the community by demonstrating the value of cross-cultural and interorganizational linkages. The medical community can work with experienced disaster providers to offer training. Shelter managers can benefit from specialized instruction offered by the medical community to help identify evacuees who appear stable, but could deteriorate due to unseen medical conditions, nutritional requirements, and other circumstances. Medical associations can partner with veterinary organizations to deliver joint assistance to people using service animals.

Since 2010, FEMA has organized several “Getting Real” conferences, which have brought together emergency managers, first responders, state emergency planners, and members of disability organizations to discuss factors that place individuals with disabilities or functional and access needs at risk. As part of these conferences, FEMA has provided cross-training for disability content experts on the structure of emergency management, while concurrently providing disability awareness training for emergency management personnel. State and regional partnerships established at these conferences have led to increased dialog between emergency management and disability groups, as well as the inclusion of people with disabilities and their advocates in disaster planning. Medical personnel associated with

Registries⁹⁴

The whole community approach to emergency management requires an informed and shared understanding of a community’s risks, needs, and capabilities. Communities often consider using Emergency Assistance Registries as a strategy for gaining such an understanding of their populations with communications, medical, independence, support, or transportation access or functional dependencies. An emergency assistance registry is a specified list or set of lists of identifiable individuals used by a community to plan for and provide emergency services to its enrollees.¹ The U.S. Department of Justice recommends using such registries as a step toward meeting Americans with Disability Act requirements for providing “same access” to emergency services.² The State of Florida has made county use of registries a statutory requirement.³ A 2009 NOD report indicated that 63% of emergency management agencies and 54% of disability organizations maintain emergency assistance registries.⁴

Emergency assistance registries can vary by purpose and by how registry operators collect and store enrollee information. Some registries focus on meeting a single response-related need such as providing evacuation transportation to carless individuals. Others are very comprehensive, collecting information that leads to the community providing a complex mix of preparedness and response support to enrollees. Still others focus on only collecting information to help with community emergency planning efforts. Most registries collect their information by return-mail questionnaires (e.g., postcards, forms), online registration, or from organizations that provide services to people with disabilities and access or functional needs. There are issues with each collection method. Using return-mail questionnaires can be expensive because of postage. The target population’s access to computers ― which tends to be 75–90% less than the general population for people with disabilities⁵ ― affects the rate of online registration. The ability to obtain information from service providers is often constrained by privacy laws such as the Healthcare Insurance Portability and Accountability Act (HIPAA). Registries take the form of indexed card decks, tables, spreadsheets, electronic databases, and complex geographic information systems.

Existing studies reveal that registries have benefits as well as limitations. One major benefit of registries is the building of relationships among the groups that work together to maintain them and provide services. They include a wide array of partners from across the community. Limitations and concerns include issues of high operational and staffing costs, difficulties with responder access, and enrollee privacy. One rural Alabama county estimated the cost to operate a registry at between $194 and $199 per enrollee, with predicted operating costs of $123,000 per annum.⁶

Used with permission from Paul Hewett, Argonne National Laboratory.

References

1.Hewett P. Organizational networks and emergence during disaster preparedness: The case of an emergency assistance registry. Doctoral dissertation. Stillwater, Oklahoma State University, 2013.

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