EDMG541Wk6

Koenig_and_Schultz_s_Disaster_Medicine_Ch_8.pdf

Special Needs Populations

Brenda D. Phillips

OVERVIEW

In studying the impact of disasters, concern has developed regarding populations that demonstrate a greater vulnerability to injury, death, and/or property loss. The term “special needs,” as well as vulnerable populations or populations at risk, has been applied to this group. These terms broadly cover a range of peo- ple who might need particular kinds of assistance in emergencies and disasters. Vulnerable populations include people with dis- abilities, senior citizens, pregnant women, infants and children, single parents, women, low-income families, and racial and eth- nic minorities. Examples of unique interventions for such indi- viduals are specially crafted warnings (in various languages and literacy levels), evacuation and transportation assistance, priority rescue, medical treatment, accessible sheltering, and assistance with rebuilding.

A broad-brush approach to vulnerability has certain ben- efits. First, a wider inclusion means that a given jurisdiction, organization, or community may contextualize the term. In some locations, it may be that the most vulnerable popula- tion includes senior citizens. In another location, it could be recent immigrants. Second, a broad approach captures a more complete list of those potentially at risk. Doing so allows emer- gency managers to understand the complexities of people’s lives and circumstances. Sex, for example, can greatly increase risk in some contexts. Pregnancy may further complicate the abil- ity to escape danger or can, itself, endanger both mother and fetus. Low-income households may lack the resources to afford protective action. If such households include seniors on fixed incomes, additional complications arise including transporta- tion assistance and nutritional and medical support. Because the prevalence of disability increases with age, seniors in these fixed-income households could suffer from mobility or cognitive disorders and require additional support.

The use of broad inclusive terminology generates misclassifi- cations. First, one cannot assume that people have special needs simply because they fall into a given population. For example, a person with a disability can maintain an independent life, make contributions to society, and respond adequately to a disaster

event. Women experience differential vulnerability that is usu- ally tied to income levels or developmental status.

Second, vulnerable populations are dynamic. People move into and out of poverty, experience temporary or new disabil- ities, and immigrate routinely. Local populations can shift and change.

Third, disasters generate new risks. For example, individuals with asthma may manage their condition well on a daily basis and not be considered to have a special need. In a high-rise fire and evacuation, such as occurred on September 11, 2001 in the U.S., that condition may cause significant challenges how- ever. Consider the situation of a Muslim diabetic seeking refuge in a public shelter after Hurricane Katrina. With the only food available being ham and white bread, the evacuee would face a choice of violating religious customs or following medical advice. Rapid deterioration can result. Similar problems result when disasters disrupt access to medications, medical care, and other health-related services. Losing access to dialysis, cancer treat- ment, or to social services such as home healthcare or meals to the homebound can rapidly move someone into life-threatening circumstances. When a disaster strikes at the end of the month, those relatively dependent on social security or disability-related incomes may have to make hard choices between affording med- ications or food and between staying at home and evacuating. People can also sustain major, permanently disabling injuries in disasters. After the 1999 tornado outbreak in Oklahoma and the 1995 bombing of the Murrah Federal Building in Oklahoma City, a number of victims survived, albeit with newly gener- ated mobility and sensory disabilities. The same was true for the attacks on September 11, 2001, particularly for victims sustaining burn injuries and other conditions requiring extensive medical treatment and rehabilitation.

Fourth, a broad view may hide diversity. For example, it may be difficult to identify “people with hidden disabilities, people with serious mental illness, people with intellectual and cogni- tive disabilities, people with a variety of visual, hearing, mobil- ity, emotional and mental disabilities and activity limitations.”1

Similarly, considerable diversity exists within any racial or ethnic group.

113 Koenig and Schultz's Disaster Medicine : Comprehensive Principles and Practices, edited by Kristi L. Koenig, and Carl H. Schultz, Cambridge University Press, 2009. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/apus/detail.action?docID=564432. Created from apus on 2020-02-16 15:42:36.

C op

yr ig

ht ©

2 00

9. C

am br

id ge

U ni

ve rs

ity P

re ss

. A ll

rig ht

s re

se rv

ed .

114 ■ BR E N DA D. PH I L L I P S

Finally, although planners can identify those likely to bear disproportionate risk, issues generated by circumstances and locations must be considered. The type of hazard could create new demands. Lack of preparedness or insight into what people truly require to survive can also produce new unmet needs. To illustrate, consider these examples.

■ A low-income hotel burns to the ground and the local Red Cross opens a shelter. A woman, eight months pregnant, arrives but no one realizes that she is pregnant due to chronic malnutrition.

■ A teenager who is deaf and home alone does not get warning information about an impending hurricane and must wade out through water contaminated with feces, chemicals and petroleum. Over the coming weeks many that waded out through the water develop serious, persistent skin and wound infections.

■ A paraplegic is airlifted to a safe shelter in another state but his wheelchair, which cost nearly $30,000, remains behind. When he arrives at the general population shelter where he could have been independent, he is sent to a medical needs facility that is already overrun and understaffed. His medical records are destroyed by the disaster and his medications have been lost during the storm.

■ A Vietnamese-American family arrives at a shelter that is serving unfamiliar foods. The children, already upset by the events, refuse to eat. When they do begin to eat, several experience intestinal distress.

■ Immigrant workers help to clean dust and debris from homes and offices damaged by a terrorist attack. They are not given protective clothing or equipment. They do not speak much English. Over the next year, they develop a persistent con- dition that comes to be known as the “World Trade Center cough.”

■ Insufficient numbers of accessible, Americans with Disabili- ties Act–compliant Federal Emergency Management Agency (FEMA) trailers are available after a major disaster. A local disability organization sues FEMA to establish a hotline and case management procedures to move people out of hotels and shelters and closer to their healthcare and social service providers.

The magnitude and scope of an event matter as well. In 2005, Hurricane Katrina laid bare the problems of specific populations in the United States. More than 50% of those who died were older than the age of 75.2 A disproportionate percentage of these individuals were racial and ethnic minorities.3 Horrific images linger of people who died due to heat exhaustion, lack of food or water, power losses, poor evacuation planning, transporta- tion failures, and unavailable medications. They died stranded in nursing homes and hospitals, and on rooftops, overpasses, and in places of last refuge. They died in their wheelchairs. These prob- lems were not unexpected.4 Hurricane Katrina revealed deeply embedded problems within the practice of emergency manage- ment, particularly the understanding of how to reduce risks for vulnerable populations.

Recognizing and addressing a group’s increased vulnerability to disasters can achieve significant reductions in risk.

■ In Victoria, Australia, firefighters sought a reduction in the number of fires and subsequent burns among senior cit- izens. Recognizing a pattern in the fires, five firefighters

Figure 8.1. Corpus Christi, Texas, September 9, 2008 – Firefighter assists nursing home evacuees prior to the arrival of Hurricane Ike. Patsy Lynch/FEMA News Photo. See color plate.

learned Turkish, formed a partnership with the local Migrant Resource Center and Islamic schools, and provided informa- tion for Turkish senior citizens and the Turkish media. Fewer fires and injuries resulted.5

■ As Hurricane Gustav neared the U.S. coast in 2008, the U.S. Postal Service released social security and other entitlement checks early to spur evacuation among low-income house- holds and senior citizens across the Gulf Coast. This was especially important for people waiting on checks to refill medications (Figure 8.1).

■ When a shortage of influenza vaccinations occurred in the U.S., public health officials prioritized who should receive immunizations first including the elderly, people living in congregate facilities, children, and people with chronic health conditions and their partners.

■ During Hurricane Katrina, medical needs shelters were over- run by the inappropriate diversion of people with disabilities who did not require medical support to these locations. The Department of Justice issued a set of guidelines to make gen- eral population shelters accessible.

The next section reviews populations at risk and identifies the special needs that each might experience. Personnel with responsibilities for managing disasters should reflect on how each population might be present in their practices or jurisdictions. This chapter then concludes with a consideration of practical strategies and includes recommendations for future research and a resource section.

STATE OF THE ART

A Social Vulnerability Perspective

Social vulnerability theory examines how economic, social, cul- tural, and political conditions foster disproportionate impacts and generate special needs.6,7 Vulnerability theory suggests that special needs arise because of the ways in which society has con- structed social systems. Risk develops as a consequence of failure

Koenig and Schultz's Disaster Medicine : Comprehensive Principles and Practices, edited by Kristi L. Koenig, and Carl H. Schultz, Cambridge University Press, 2009. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/apus/detail.action?docID=564432. Created from apus on 2020-02-16 15:42:36.

C op

yr ig

ht ©

2 00

9. C

am br

id ge

U ni

ve rs

ity P

re ss

. A ll

rig ht

s re

se rv

ed .

SP E C I A L NE E D S PO P U L AT I O N S ■ 115

to collectively address social conditions such as affordable hous- ing and healthcare, prejudice, or interpersonal violence. As a brief example, low-income housing usually sustains more seri- ous damage following a disaster, causing more injuries and deaths and resulting in a significant loss of assets. Remediation for these conditions is deemed necessary at the policy level and requires broad systemic change that tends to occur slowly. As a means to affect change more rapidly, vulnerability theorists advocate for empowering those at risk to participate not only in their own risk reduction, but through informing those responsible for disaster management. The insights of those at risk are deemed valuable and potentially transformative. Therefore, solutions to the chal- lenges of special needs include building capacity among those at risk and establishing partnerships among organizations that link to people with special needs.

Historically, individual attention has been paid to specific demographic groups. In general, knowledge about vulnerable populations has increased as the result of a major event that reveals problems, such as Hurricane Katrina, or as the result of a push forward by lines of academic research or advocacy groups. Researchers have launched multiple lines of literature dedicated to specific demographic groups in an effort to understand and reduce vulnerability. The following sections examine a number of the populations considered vulnerable by generally following the emergence of that literature as it has unfolded over the past few decades. Key citations are included here. Web page links to extensive bibliographies and literature reviews can be found in the resource section.

Age Age clearly relates to vulnerability. Concern has developed

that the very young and the elderly, especially frail elderly, are susceptible to sudden deterioration when placed under adverse conditions. This section looks at both groups and identifies gen- eral areas of concern.

THE ELDERLY

Two general divergent points of view have emerged regarding seniors. The first is that disasters disproportionately deprive the elderly relative to younger counterparts, causing them to sustain greater losses.8 The second perspective is that they demonstrate some degree of resilience by virtue of knowledge gained through prior life experiences.9,10 In other words, they are somewhat inoculated against disaster adversity based on what they have learned. Evidence supports both perspectives to varying degrees. Hurricane Katrina, for example, resulted in a significantly higher rate of mortality among the elderly, with at least 50% of the fatalities being older than the age of 75. The relative deprivation hypothesis would direct attention to the lack of resources for transportation and evacuation, a higher prevalence of disabili- ties that required additional evacuation support, and a reduced ability to withstand the high heat and humidity during rescue operations. It is also true, however, that the elderly can and will respond when directed to do so. For example, warning and evac- uation compliance is fairly high when the messages are received and resources are made available.11 Furthermore, psychologi- cal researchers have found that “the significance of the event becomes relative to a lifetime of circumstances experienced by the individual.”12 The inoculation hypothesis thus holds some merit.

The recovery period also presents challenges for the elderly. Seniors appear to be reluctant to access relief and other recovery

programs. Part of the problem apparently stems from fear of institutionalization if it is assumed they cannot meet their own needs. Resistance may also result from pride, self-reliance, and an unwillingness to accept charity. Burdensome paperwork that challenges and fatigues some seniors has also been blamed. Elders who are socially isolated are at particular risk for not accessing disaster resources.13 In addition, the digital divide (Internet, text messaging, pagers often used for warning messages, and online aid applications) may increasingly segregate elders. The online FEMA application times out for security purposes, a problem for those with slower responses or who are unfamiliar with the Internet, cannot type, and have limited eyesight or cognitive challenges.

Vulnerability theory suggests building capacity and estab- lishing partnerships as a remedy. These solutions were embraced by the Baylor College of Medicine and the American Medical Association. Together, they produced a set of recommendations for assisting elderly disaster victims.14

■ Involve gerontologists, geriatricians, geriatric nurse practi- tioners, and others in emergency operations planning.

■ Conduct predisaster planning with local social services, pub- lic health services, and other key organizations, especially aging organizations, senior centers, and faith-based organi- zations.

■ Offer specific training to those who interact with elderly disaster victims, including transportation personnel, shelter staff, and case managers.

■ Protect seniors from abuse and fraud. Adult Protective Ser- vices can be a partner in this activity.

■ Plan carefully for the frail elderly, the homebound, and those in nursing homes.

CHILDREN

Children’s reactions to disasters vary by age. Younger chil- dren react well to being physically comforted after a frightening experience. Reactions of older children depend on how adults behave.9,10,14 Because children lack a referential framework for behavior, they tend to look to trusted parents, childcare work- ers, and significant others for behavioral cues. If parents react with inappropriate actions or acute distress, children are likely to respond similarly. Children home alone at the time of a dis- aster may experience greater challenges than those in the pres- ence of adults unless they have been trained for the anticipated hazard.15

Behavioral responses that are typical for younger children and usually diminish with time include being upset over losses (blankets, toys, and pets), loudness or aggression, fear of sleep- ing alone, nightmares, fear of similar events (wind, rain, and storms), crying, enuresis, thumb sucking, and psychosomatic responses including headaches, gastrointestinal distress, and even fevers.9,10,15 Older children and adolescents may experi- ence more difficulty coping with the disaster because of their enhanced capacity to grasp the meaning of the event. Psycho- logical treatment, school programs, and even volunteer work are typically recommended as intervention strategies for older children.

Psychological responses are also affected by exposure to cer- tain stimuli, particularly personal injuries or harm to others around them, loss of loved ones, and the ways in which par- ents or guardians handle psychological trauma. Extreme events,

C op

yr ig

ht ©

2 00

9. C

am br

id ge

U ni

ve rs

ity P

re ss

. A ll

rig ht

s re

se rv

ed .

116 ■ BR E N DA D. PH I L L I P S

such as the attacks on September 11, 2001, or Hurricane Katrina in the U.S., are likely to create a more complex range of prob- lems including school disruption, displacement, separation from families during evacuation, and living in temporary locations as well as loss of medical records, medications, and familiar health- care providers. These difficulties may be particularly acute for children in households experiencing domestic violence pre- or postdisaster. Recommendations typically include reestablishing routines, reintegrating children into school, and providing men- tal health support at shelters and other temporary locations.16 By getting children back into a routine, a “ripple effect” is believed to occur that moves through families, households, and into the broader community to generate recovery.16

Support from trusted adults, including parents, teachers, childcare workers, disaster volunteers, and shelter workers, is key to helping children.17 Mental health providers may need to offer a range of services to children. After the bombing in Oklahoma City, for example, trauma counselors created “Project Heart- land” that trained teachers and others to recognize and manage signs of long-term trauma. Over 60,000 students received inter- ventions.18 Services to teachers and students included counseling and training for stressor identification and coping mechanisms. Researchers examining the attacks of September 11, 2001 found that approximately 10% of all children in New York City received counseling.19 Schools served as the most common setting (44%) followed by professional treatment (36%) or spiritual care/other (20%). Children were more likely to receive counseling if parents also experienced traumatic reactions.19

Health concerns for children depend on the type of event. Concern for dissemination of severe illnesses erupts in refugee camps and mass evacuation locations, particularly in develop- ing nations. In the Philippines, for example, mothers express concern over the potential for epidemics in unsanitary evacua- tion centers, where “children are exposed to . . . lack of food and clean drinking water, unsanitary shelter, closed schools and poor health services . . . they face hunger and epidemics, perhaps even death.”20 In an event such as Hurricane Katrina, concerns arose over toxic contamination of schools, homes, and playgrounds.17

The dust from the World Trade Center has prompted concern for long-term effects on all ages including pregnant women, new- borns, and people with both existing and newly appearing related respiratory conditions.21

Recovery proves especially challenging for some families with children. FEMA disbursements in the U.S., for example, have been critiqued for their “one size fits all” approach in which a single mother with several children will receive the same funds as an adult man without any children.16 Living in cramped, tempo- rary housing is also difficult for any family. For larger families or for single parents, the situation may create extra stress. Families in trailers often refer to themselves as “spam in a can” and few disaster trailer parks can establish amenities like playgrounds or after school programs.

Yet similar to the elderly, children can also prove to be resilient. Children developed coping skills after Hurricane Katrina while living in shelters and formed strong bonds with shelter workers.17 Children in the Philippines are consid- ered “indispensable helpers . . . the potential of elder children could . . . be developed and maximized through community day- care and other collective activities.”20 Structured environments, play and therapeutic activities, and effective role modeling appear valuable in helping children cope with disasters.

Income Income level impacts all aspects of disasters. Lower-income

households cannot afford to purchase or create emergency pre- paredness kits. Single mothers, of whom approximately 33% fall below the poverty line in the U.S., cannot purchase mitigation measures such as hurricane shutters to protect the contents of their homes.22 Those living on fixed incomes have particular dif- ficulties. 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. Reluc- tant to leave a familiar environment and family on which they could depend, a disproportionate number of low-income house- holds remained behind. Extensive damage occurred to many low-income homes that were 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 postdisaster con- text, low-income households face hard choices between recovery and ongoing needs. To survive, they may pawn remaining pos- sessions, 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 chal- lenges. Because many are underinsured or cannot afford hazard- specific insurance, they cannot rebuild without assistance. At the time of this writing, maximum federal loans in the U.S. totaled only $28,800. For most low-income households, choices must be made about rebuilding or relocation. Without assis- tance 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.

Renters encounter similar challenges. After the 1994 North- ridge earthquake in California, renters faced extensive displace- ment due to the time required to rebuild multifamily dwellings and the state of the regional economy.23 After Hurricane Katrina, public housing in New Orleans was condemned; the process of rebuilding will take years. Protests have erupted, with concern that a new design integrating mixed-incomes into the rebuild- ing plans will displace low-income residents. The U.S. Housing and Urban Development agency has offered relocation for low- income households across the U.S., often far from Gulf Coast states. 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 com- munities, especially those with long-held ties to the land such as Native American households.

Race and Ethnicity Although studies find similarities both within and across

racial and ethnic groups, important differences exist.24 Studies of rapid-onset events demonstrate those differences with clear implications for warning those at risk. For example, in a study of a massive tornado that damaged a neighborhood near Birming- ham, Alabama, 80% of white residents heard the warning from

C op

yr ig

ht ©

2 00

9. C

am br

id ge

U ni

ve rs

ity P

re ss

. A ll

rig ht

s re

se rv

ed .

SP E C I A L NE E D S PO P U L AT I O N S ■ 117

television compared with only 67% of African Americans.25 His- panics appear more likely to get warning information from the radio or from social networks.

The consequences of not receiving warning information can be significant. Ethnic groups may experience cultural barriers, such as when warning messages are not distributed in relevant languages.11 Translation must also be done correctly. As a tor- nado approached the small town of Saragosa, Texas in 1987, efforts failed to translate warnings into the correct Spanish words. Rather than learning of an approaching risk, the few listening to the radio heard “news” about a tornado.26 Those watching cable television originating far away from their location received no warning. Twenty-nine people died and dozens sustained injuries. After the 1989 Loma Prieta earthquake in California, local Lati- nos alleged discrimination due to a lack of information and other concerns in the city of Watsonville.27 The U.S. Department of Justice investigated and, although finding no overt discrim- ination, suggested some changes. As a result, the city hired an ombudsperson to liaise with Latinos and Latino organizations. One year later, a unity parade was held.

Ethnicity has also been associated with income discrimina- tion and segregation patterns that impede abilities to secure ade- quate housing in areas safer from local hazards.28 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. In earthquake prone regions, such housing is more likely to lack seismic retrofitting.11,28 Such exposure increases the likelihood of injuries, property loss, and psychological trauma.

Gender The bulk of published vulnerability research concentrates on

gender issues. This body of research has resulted from a con- certed effort by investigators often linked through the Gender and Disaster Network (www.gdnonline.org). Researchers have demonstrated differential results in survival rates as well as in the methods women and men use to respond and recover from disasters. The 2004 Indian Ocean Tsunami, for example, resulted in approximately 300,000 deaths and displaced at least 1.6 mil- lion people across 13 nations. More than 80% of the fatalities were women and children.29 This was due in part to the fact that, in many nations, women waited on the shore 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 dis- criminatory. Wherever they hit, pre-existing structures and social conditions determine that some members of the community will be less affected while others pay a higher price. Among the differ- ences that determine how people are affected by such disasters is that of gender.”29 The same is true across the Caribbean, where sex differences result in health risks that increase in disasters, such as sexual abuse and violence as well as “malnutrition, ane- mia, maternal morbidity and mortality, complications in preg- nancy, sexually transmitted diseases, and mental and psychologi- cal conditions that cause loss of healthy life and wellbeing among women.”30

In some contexts, men experience similar difficulties. Hur- ricane Mitch generated higher fatalities among Honduran men than women. Sex 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 for elderly African American men who experienced a death rate dispropor- tionate to their population.3

Other disaster dimensions demonstrate sex bias as well and unequally affect women. In a shelter environment, for exam- ple, women’s needs may include maternity support, privacy for hygienic and religious reasons, nutritional supplements, child care, trauma counseling, and an environment free from vio- lence. Sex 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.31–33 Small businesses and home-based enterprises, which are more likely to be owned by women, tend to sustain higher losses.34,35 Women also tend to be the family member most likely to access recovery assistance and to link older family members to aid.36

Response and recovery organizations have been critiqued for failure to include women.36 In Central America, increas- ing women’s capacities and roles in disaster preparation and aid is strongly recommended. “Women’s societal role is multi- faceted . . . this 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.”37 In the Caribbean, sex-based social capital brings local knowledge, social networks, and critical links to others at risk. Vulnerability can be miti- gated by leveraging women’s resources through increased repre- sentation, mobilization, education and training, recognition of their needs, and direct involvement in emergency management activities.30

Disability Research exploring the relationship between disability and

disaster has lagged behind studies of other vulnerable popula- tions in all dimensions. Recently, experts in disability evacuation reported that “faced with a significant lack of data, professionals are unable to suggest alternatives.”38 Part of the difficulty stems from how disabilities are perceived and, consequently, how they are addressed. In a book on earthquake hazards and disabilities in California, three approaches to disabilities and disasters were discerned: the medical, economic, and sociopolitical models.39 In the first two models, attention is focused on the individual. The medical model, for example, views disability as a “physiological or mental condition caused by an illness, impairment or other factor.”39 The medical approach addresses the problem at the individual level through treatment, prostheses, assistive devices, and/or rehabilitation. The economic model views the disability as a work limitation and defines the individual in terms of per- ceived abilities. The individual approach for the economic model uses rehabilitation for “gainful employment.”39

Although researchers acknowledge the appropriateness of providing medical and economic support to those in need, they express concern that these models are blinded to the social dimensions of disability. A social perspective requires exam- ining the way in which society circumscribes and “shapes the life chances of disabled individuals.”39 The sociopolitical model looks at how disability results not from physical limitations but from barriers that limit possibilities. In the U.S. for example, the Americans with Disabilities Act directly targeted the dis- tinctions between the individual and social perspectives through an emphasis on accessibility and reasonable accommodations.

C op

yr ig

ht ©

2 00

9. C

am br

id ge

U ni

ve rs

ity P

re ss

. A ll

rig ht

s re

se rv

ed .

118 ■ BR E N DA D. PH I L L I P S

Since then, disability organizations and advocates have worked to apply those standards to disaster contexts. The bulk of progress has occurred after major events such as the World Trade Center bombing on September 11, 2001 and Hurricane Katrina.

After the terrorist attacks in 2001, the National Organiza- tion on Disability (NOD) launched an Emergency Prepared- ness Initiative. Initially, they conducted surveys asking people with disabilities if plans were in place at work for evacuation. In 2001, 50% of the respondents said “yes” followed by a decline to 34% in 2005.40 Subsequently, NOD crafted a booklet of rec- ommendations for emergency managers and posted download- able disability-specific preparedness brochures on their website (see resource list at end of chapter). After Hurricane Katrina, NOD commissioned a task force to examine shelter concerns for people with disabilities. Known as the SNAKE report (Special Needs Assessment of Katrina Evacuees), NOD identified these concerns.1

■ Problems with the intake process at shelters. Procedures did not identify disability, medical, or nutritional issues suffi- ciently

■ Inappropriate transfer of people with disabilities to special needs and medical shelters

■ Failure to evacuate people with durable medical equipment, assistive devices, and service animals

■ Lack of accessible transportation and equipment at general population shelters

■ Not using the skill and expertise of support organizations ■ Inability to provide adequate interpretation services ■ Lack of accommodation of service animals at shelters

Many people with disabilities are, or can be, independent in a disaster context. Thus, from a sociopolitical perspective, prob- lems 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 take people with disabilities into consideration and “increase the rate of participation of people with disabilities in emergency planning . . . preparedness, response and recovery drills and exercises.” Since then, a number of new policies have emerged to address gaps in planning and preparedness (for exam- ple, see Department of Justice shelter protocol in an upcoming section). The emphasis is on building capacity among those with disabilities and bringing people with disabilities, disability orga- nizations, and knowledgeable advocates into the planning pro- cess. Partnerships are the key. Disaster resilience can be increased and new insights generated by strengthening individuals through personal preparedness planning and inviting disability organiza- tions to the broader planning table. As with other populations, 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 water quality to pandemic announce- ments. Within most nations, this kind of information is usually disseminated 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 in sign language.

Low levels of literacy can impede the capability to under- stand and respond as directed. Written materials present obvi-

ous problems. The manner in which communication occurs can also impact response. The National Hurricane Center in the U.S. has struggled with providing understandable information to the public as well as to emergency managers.41 Because hurricanes vary and can change quickly, 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 mak- ing a decision to evacuate, understanding those risks is crucial. During recovery, the federal aid application 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.

Sign language varies across geographical areas and nations and must be adapted to incorporate cultural differences. As noted in a breakthrough study, warnings fail to reach people who are deaf or hard of hearing.42 Although U.S. Federal Communica- tions Commission policy dictates that closed-captioning must occur during emergency time periods, few stations can afford this service and frequently fail to provide closed-captioning dur- ing rapid-onset events. Meteorologists tend to turn their backs or their sides to the camera during on-air coverage and graph- ics often scroll across closed-captioning. Few schools of mete- orology offer instruction regarding vulnerable populations or prepare students to work with the deaf.41 Thus the problem is not individual culpability, but one reflecting larger societal prob- lems. Although technologies address some warning distribution issues, the cost of those devices can be prohibitive for some.

Increasing diversity within the U.S. has prompted the inte- gration of pre-event messages and interpreters into emergency operations plans. In the San Francisco, California area alone, at least 112 languages are spoken.43 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. A hostel fire that occurred in Queensland, Australia during the year 2000 caused the deaths of 15 backpackers from six nations. Agencies devel- oped a fire safety brochure in multiple languages to address this communication issue.5 Pictorial brochures can be offered in place of written materials, with the added benefit of spanning both literacy and language issues.

Congregate Facilities Special needs exist also for those in congregate facilities.

These situations include assisted living, nursing homes, adult daycare centers, schools for students who are blind or deaf, and facilities for veterans or adults with cognitive disabilities. Very little empirical work has been performed on any of these popu- lations in a disaster context.

More is known about nursing homes than other facilities. Transferring such populations to other facilities carries risk even though evacuation may be the safest choice overall. Nursing home administrators make the decision to evacuate and failure to do so, as seen after Hurricane Katrina, may have fatal con- sequences. 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 chal- lenges in identifying these populations, determining their needs, and providing for and coordinating their transportation.” Those challenges include finding transportation resources, contractors

C op

yr ig

ht ©

2 00

9. C

am br

id ge

U ni

ve rs

ity P

re ss

. A ll

rig ht

s re

se rv

ed .

SP E C I A L NE E D S PO P U L AT I O N S ■ 119

Figure 8.2. Caddo County, Oklahoma, August 20, 2007 – Damage to a nursing home as a result of a tropical storm. There were no injuries. Patricia Brach/FEMA News Photo. See color plate.

to drive the vehicles, and staff to escort patients. It is likely that in a major disaster, the “local demand for transportation would exceed supply” of vehicles.44

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 24 patients perished. Nursing homes most likely to evacuate belong to chains 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 (Fig- ure 8.2). 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 medica- tion protocols. Facilities face challenges for ensuring that support systems remain in place during evacuation, including transfer of medical records.45,46 Efforts that were effective during the evac- uation for Hurricane Katrina included actions by emergency managers working closely with home healthcare agencies, doc- tors, and other community organizations to disseminate mes- sages about the impending disaster, transportation options, and shelters.44 Studies also recommend that families and patients remain together to provide social support and lessen transfer trauma.46

Medical facilities that offer outpatient care can also sus- tain damage during an event, altering the availability of cru- cial services to vulnerable populations. Disruption in treatment can occur for patients receiving dialysis, cancer therapy, and human immunodeficiency virus (HIV)/acquired immunodefi- ciency syndrome–related interventions as well as those with sig- nificant respiratory conditions who require assistance. In addi- tion, the loss of facilities that provide critical resources such as oxygen and tube feeding prompt concern for rapid restoration of such services.

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 than in their native country when they begin their studies at a new university. They will need to acquire new skills to survive an event. Similarly, recent immi- grants will require outreach to teach them about local risks and appropriate protective actions. Because immigrants may include extended family members, those 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, putting that person at acute risk during an event. Outreach to people who are new to, or unfa- miliar with, an area is crucial. These individuals include tourists, convention-goers, exchange students, or medical mission teams. The type of event can make a difference as well, for example, American Muslims experienced violent retributions and height- ened fears after the events of September 11, 2001, putting them at considerable risk in some locations.47

After Hurricane Andrew in 1992, U.S. officials removed the name “federal” from FEMA signs to reduce fear of deportation among local immigrants. After the Loma Prieta earthquake in San Francisco in 1989, Central American immigrants relocated to a makeshift tent city as a result of fear of the National Guard presence at a formal Red Cross shelter. For these recent immi- grants, the uniformed presence signified “death squad.” 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 lan- guage, 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. Their efforts included utilizing 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,

C op

yr ig

ht ©

2 00

9. C

am br

id ge

U ni

ve rs

ity P

re ss

. A ll

rig ht

s re

se rv

ed .

120 ■ BR E N DA D. PH I L L I P S

religious, and health procedures.5 As with other groups, involve- ment of the “at risk” population in addressing the issues can provide crucial resources.

Intersected Vulnerabilities As experienced researchers have delineated, it is empirically

challenging to separate demographics and specify that only sex, income, or age creates a vulnerable condition. In reality, demo- graphic conditions and the broader social, economic, cultural, and even political conditions in which people live create “entan- gling effects” that foster and exacerbate vulnerability.48

Although specific circumstances and/or conditions may gen- erate vulnerabilities and special needs, it is likely that overlapping conditions also contribute and will require attention. For exam- ple, greater susceptibility to health issues such as osteoporosis means that women in general may be 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 context and merits a more comprehensive range of intervention strategies.

Elderly men are more likely to live in socially isolated condi- tions, away from important relationships and networks that may provide buffers against the consequences of disasters. In addi- tion, their disability risk increases with age. Fifty percent of those older than 75 have some type of chronic condition and 75% of those older than 80 have “at least one significant disability.”46

Because disability is associated with lower wages, technologi- cal devices such as text messaging may not be affordable for a low-income individual with a disability or even appropriate for a senior citizen. To summarize, one “condition” or population demographic is insufficient to understand vulnerability. Rather, a complex set of conditions, circumstances, and contexts inter- act to produce vulnerability. Using a simple checklist of possibly affected population groups is a starting point. Understanding the intersected nature of vulnerability and the concerted efforts that must be made to address that complexity is necessary for real vulnerability reduction.

The Life Cycle of Emergency Management and Special Needs

Both emergency managers and disaster researchers tend to group the practice and knowledge relating to disasters into a “life cycle” of emergency management. Most nations organize their disas- ter activities around 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 U.S., the National Gov- ernor’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 will address special needs con- cerns within each phase. Each subsection will first define and illustrate the phase of emergency management and connect it to the topic of special needs. Ideas and practical strategies will then follow for each phase to generate reflection and practical solutions.

Preparedness Preparedness is defined as “actions undertaken before dis-

aster impact that enable social units to respond actively when disaster does strike.”48 Actions should be taken at the individual,

household, organization, and community levels as well as within local, state, and federal governments. Activities might include building partnerships, development and dissemination of edu- cational materials, training for specific tasks such as sheltering or triage, evacuation planning, the creation of special needs reg- istries, writing emergency operations plans, and holding exer- cises. This section examines key areas starting with the advice most frequently given by emergency managers and social service providers to know the community.

Know the Community Before any serious effort can be made to address special

needs, emergency managers must first learn as much as possi- ble about the demographic groups present in a community as well as the organizations with which partnerships can be built. The U.S. census provides data of local populations with gen- eral overviews. The census occurs every 10 years with more fre- quent 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, sex and age distributions, disabilities, and income levels. The problem with 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 (Table 8.1).

The second step in knowing the community is identifying the range of local community-based organizations. From these groups, it is possible to then 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 those who are homeless. Faith-based organizations extend ser- vices to new immigrants and may offer personnel who speak relevant languages. A key organization with which to link is the local emergency management agency. An increasing trend among emergency managers is to establish a Special Needs Advi- sory Panel. Becoming part of this partnership provides links to organizations with expertise including disability and rehabilita- tion agencies, health organizations, and senior networks.

Medical personnel represent a marginally tapped disaster management resource in many communities. Typically, hospi- tals and medical staff remain in a stationary location waiting to receive patients. Conversely, outreach by medical personnel into the existing or emerging partnerships that address special needs can make a considerable difference. Expertise on disabili- ties, 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 medical staff played an important role in identifying patients who needed transporta- tion during Hurricane Katrina. A stronger link among indi- viduals, the medical community, and emergency managers can make a measurable difference in reducing risks. Medical per- sonnel 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 person- nel frequently on emergency procedures. By getting acquainted and working with a broad array of partners, special needs can be identified pre-event for planning and building partner- ships.

C op

yr ig

ht ©

2 00

9. C

am br

id ge

U ni

ve rs

ity P

re ss

. A ll

rig ht

s re

se rv

ed .

SP E C I A L NE E D S PO P U L AT I O N S ■ 121

Table 8.1: Representative U.S. Census Data Depicting the Size of Various Vulnerable Populations∗

General Disabled Minority Below the Location Population Age >5 y Groups Age >65 y Poverty Level

Bradenton, FL 49,504 11,365 5,574 Hispanics

7,481 African American

12,589 6,572

Denton, TX 80,537 11,298 9,025 foreign born; 13,188

Hispanic, 14,081 speak a language other than English at home

6,364 11,776

San Francisco, CA 776,733 150,131 239,565 Asian

109,504 Hispanic

60,515 African American

3,844 Hawaiian/Pacific Islander

3,458 American Indian/Alaska Native

106,111 86,586

∗ The groups represented here may vary considerably in number across communities.

Source: U.S. Census, 2000.

Training and Education It is not sufficient to read a single chapter on special needs

issues. Continuing education is necessary, particularly as policies and procedures are rapidly evolving within the U.S. alone. To obtain more information, these resources may be useful.

■ Universities and colleges have developed programs across the U.S. and in some other nations that include opportu- nities for stand-alone courses, certificates, or degrees. Many offer courses available on the Internet for distance learn- ing. Links to programs can be found at the FEMA Higher Education Project website (http://www.training.fema.gov/ EMIweb/edu/collegelist/, accessed January 12, 2009).

■ FEMA offers an interactive course at their Independent Study (IS) website. IS197 concerns special needs (http:// training.fema.gov/EMIWeb/IS/is197SP.asp, accessed January 12, 2009).

■ Professional emergency management conferences, such as the National Hurricane Conference or the International Association of Emergency Managers, offer topical work- shops and Continuing Education Unit credits for special needs courses. Specialized conferences appear on list serves for emergency management such as the 2008 conference on special needs held by FEMA Region II in New York City. 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 list serves (the latter is available free at www.colorado.edu/hazards/).

■ Scholarly journals are increasingly publishing special needs research. Top journals that should be scanned for recent arti- cles include the Natural Hazards Review, the International Journal of Mass Emergencies and Disasters, Environmental Hazards, Natural Hazards, Disaster Prevention and Manage- ment, Disasters, and the Journal of Emergency Management.

Further sources of information and training stem from local, state, federal, and international emergency management agencies. Such entities routinely hold tabletop exercises and com- munity drills. Participation is recommended. Training should include all personnel in a medical setting from those who

dispose of biohazards or push wheelchairs to the top admin- istrators.

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 careful credentialing before assistance can be rendered.

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 partner- ship likely paid other dividends as well across the community by demonstrating the value of cross-cultural and interorganiza- tional linkages. The medical community can work with expe- rienced disaster providers to offer training. Shelter managers can benefit from specialized instruction offered by the medi- cal 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.

Public Education One of the foremost tasks in the preparedness phase is edu-

cating those at risk about approaches to reduce their own vul- nerabilities. Medical personnel can play an important role in this by extending information to their patients.

■ Place informational brochures in waiting rooms. Free, disability-specific brochures can be downloaded from the National Organization on Disability (NOD) at www.nod.org (select Emergency Preparedness Initiative). Care should be taken to provide materials in multiple formats for various languages and literacy levels as well as for people with vary- ing degrees of visual limitations. Offices may also consider purchasing communication boards that include specific lan- guages, pictures, and situations (i.e., bleeding or pain).

C op

yr ig

ht ©

2 00

9. C

am br

id ge

U ni

ve rs

ity P

re ss

. A ll

rig ht

s re

se rv

ed .

122 ■ BR E N DA D. PH I L L I P S

■ Include individual and household risk assessments during medical histories and annual examinations. Disaster check- lists can be obtained at www.ready.gov, www.fema.gov, and www.preparenow.org. Histories can concentrate on the level of individual or household preparedness for an event such as an evacuation. Long-term psychological trauma tends to be more likely among those with previous trauma. By assessing for such trauma (e.g., war injuries, interpersonal violence, prior disaster or severe injuries) it may be possible to iden- tify pre-event those at risk and offer advice and counsel- ing resources to strengthen patients’ ability to respond with resilience.9,10

■ Advise patients that they should establish an emergency bag or “go kit” (Table 8.2). 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, communications information and preferences, nutritional needs, insurance and Medicaid/Medicare papers, and contact information for healthcare and pharmacy providers, family, guardians, or caretakers.

■ Alert patients to opportunities for obtaining emergency bag items or other information, especially low-income patients and U.S. 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.

■ Explain to patients how general populations and special needs shelters operate. 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 and encourage evacuation.49

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

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

■ 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 hos- pital 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 appropri- ate protective actions in a disaster. For example, how can a family member move an individual with new mobility limi- tations without injury? Where can the family member obtain assistance in such a situation?

■ Support domestic violence shelters with outreach to indi- viduals experiencing intimate partner violence. Because it appears that domestic violence may increase after disasters, those known to be at risk require additional attention. Medi- cal personnel can provide information and escape options and support the efforts of domestic violence prevention staff.50

Registries Special needs registries are often considered a useful pre-

paredness strategy. Registries are lists of people who might require assistance in an emergency, such as a person who is blind

Table 8.2: Suggested Items for a “Go Kit” to Use in an Emergency

General items (based in part on www.ready.gov) ■ Radio and batteries for 3 days ■ Water, 1 gallon per person per day for at least 3 days ■ Flashlight and extra batteries ■ Whistle to signal for help ■ Cell phone or communication device with extra batteries ■ Clothes and bedding in case of an overnight stay including in a

vehicle ■ First aid kit ■ Medications and medical records ■ Identification papers ■ Dust mask or t-shirt to use as an air filter ■ Toilet paper, paper towels ■ Disinfectant, hand gel, antibacterial towelettes ■ Appropriate food for each person for 3 days ■ Can opener to open cans; plates, utensils, cups ■ Communications plan to stay in touch with the family ■ Maps

Additional items for senior citizens (based in part on www.redcross .org, www.ready.gov) ■ Extra medications, medical records, prescriptions ■ Assistive devices that may be needed ■ Denture needs ■ Pillows or other items that provide comfort or support

Additional items for people with disabilities (based in part on www.nod.org) ■ Dark glasses for those sensitive to light ■ Assistive devices; folding cane ■ Paper to write notes ■ Medical records ■ Communications devices ■ Extra battery packs for anything requiring power; recharging devices ■ Patch kit for tire repair ■ Heavy gloves to move debris or use with a wheelchair ■ Whistle to signal for help

Additional items for parents of young children (based in part on http://www.ready.gov/kids/step1/index.html and www.redcross.org) ■ A special and familiar toy or blanket ■ Familiar food appropriate for medical and nutritional needs

including infant formula; bottles; powdered milk ■ Diapers ■ A familiar pillow to aid the child in sleeping ■ Activities to keep the child busy, especially those that do not need

batteries ■ Clothing and bedding appropriate for weather variations

Pets and Service Animals (see also www.hsus.org and www.nod.org) ■ Veterinary records; first aid kit ■ Food, medications, water; can opener ■ Vests and identification for service animals ■ Muzzles, leashes, collars, identification on the pet ■ A crate to use in a shelter environment ■ A toy ■ Litter, pan, scoop; newspaper for bedding to litter ■ Paper towels, plastic bags ■ Stakes or tie downs

or someone with limited transportation options. Such listings have been touted as a possible solution to identifying those at risk and providing adequate resources. Registries vary and might be extremely comprehensive, including everyone who lacks trans- portation. In comparison, others might focus on just those

C op

yr ig

ht ©

2 00

9. C

am br

id ge

U ni

ve rs

ity P

re ss

. A ll

rig ht

s re

se rv

ed .

SP E C I A L NE E D S PO P U L AT I O N S ■ 123

who require paratransit vehicles for people using wheelchairs. Registries have never been studied empirically, although it is clear that they do have benefits as well as limitations. After the 2003 wildfires in California, the Independent Living Council conducted an assessment. Although a registry existed identify- ing those needing assistance, problems occurred when emer- gency personnel could not access the confidential registry due to security measures.51 Other challenges with registries include the possibility that registrants fear self-disclosure of personal information, costs associated with maintenance, physical loca- tion, and the means for storing and backing up the list (paper, database, or web based).

Typical groups who work together to maintain registries include emergency managers, home health and related social service agencies, aging organizations, disability organizations, disaster organizations such as the American Red Cross, fire departments, emergency transportation and medical units, para- transit resources, the health department, veterans affairs per- sonnel, disability and rehabilitation services, and interpreters. Issues of confidentiality and access typically arise because of the myriad organizations and agencies that might participate. A single organization, such as the fire department or emergency telecommunications office, might manage the list. Each agency or organization may maintain their own respective list to facil- itate contacting clients. Maintenance of registry lists appears to be particularly challenging. A well-funded effort in Alabama for a nearby chemical weapons facility faced annual challenges in updating registrant contact information.52 Registries, although certainly a practical strategy, also represent a considerable challenge.

Evacuation There are many reasons why evacuation is problematic. The

main reason that so many people were stranded or died after Hur- ricane Katrina was due to lack of transportation. A study done on Hurricanes Floyd and Dennis discovered that people with disabil- ities might have assumed that shelters were not prepared for them and they would not evacuate.49 When someone identified as an evacuation “buddy” is unavailable, escape is not possible. There is no standardized system in place to evacuate massive numbers of people from congregate facilities. Specific locations face par- ticular challenges. As an example, a domestic violence shelter in New Orleans could not purchase bus tickets when officials closed the bus station during the Hurricane Katrina evacuation. The shelter director eventually found keys to a van and drove the residents to safety in Baton Rouge.53 The last bus of evacuees to leave Plaquemines Parish below New Orleans was populated with Vietnamese-American men who were attempting to protect their economic livelihoods and family possessions until the last possible minute.

The large-scale evacuation of New Orleans revealed sev- eral issues. To move people quickly and without accessi- ble transportation, those assisting people with disabilities left wheelchairs, assistive devices, and other necessary items behind. The Louisiana Department of Rehabilitation spent 6 months trying to retrieve items and return them to their owners. Some wheelchairs that cost up to $30,000 were irreplaceable. Paramedics in Texas, Oklahoma, and other locations reported serious problems when patients arrived at shelters. Buses had sometimes driven for 12 hours straight through, resulting in not only deteriorating conditions for medical patients on board but also a hazardous waste situation for first responders. The goal of

evacuation is to conduct pre-event planning and activate appro- priate resources for those at risk. Prior to the approach of Hur- ricane Ike on the Texas Coast in 2008, emergency management officials put such plans into place for congregate populations and special needs residents.

Because medical professionals represent trusted, credible individuals, it is valuable for them to become involved in evac- uation and transportation planning and the issuing of warning messages. Medical personnel can also engage in the following activities.

■ Participate in evacuation planning and provide insights on how to transport people with particular conditions in a safe and healthy manner. Ensure that medical records, medica- tions, and support staff stay with those at risk. This includes those who may appear healthy but could deteriorate under conditions of stress, heat, or severe cold.

■ Assist with training evacuation personnel in methods for transporting individuals with a specific condition, from someone relying on a ventilator to a patient with a bariatric disorder.

■ Contact patients who might not receive warning, evacua- tion, and transportation messages, including the deaf, hear- ing impaired, blind, aged, and those with low levels of literacy or who are non-English speaking. Conducting out- reach through health clinics and other facilities that serve low-income individuals and families can help to disseminate information through credible sources. Advocate for these groups by encouraging local officials to do the same.

■ Advise patients and local authorities to develop plans for pet evacuation. Seniors seem more likely to evacuate if pets accompany them. Such planning also benefits service animals.

■ Encourage local officials to search widely for accessible trans- portation resources. The best efforts to use nongovernmental resources require advance negotiation for liability and reim- bursement.44

■ Ensure that receiving personnel are well trained and orga- nized to manage a variety of conditions when patients or vulnerable groups arrive. These range from medical prob- lems and interpersonal violence to children separated from their parents.

■ Join local officials in planning and advertising local general population and special needs shelters. Ensure that those in need of such facilities realize that arrangements have been made for their mobility, nutritional, and other needs as well as for their service animals.

■ Request that local officials keep evacuees with their durable medical equipment, assistive devices, and service animals. Help patients and officials develop personal evacuation plans, protective actions, and communication strategies that keep families, guardians, and caretakers together. Suggest a buddy system, with multiple backups, for those in need of personal transportation assistance. A checklist to determine if some- one needs a buddy can be found at www.preparenow.org.

Response The emergency response phase focuses on saving lives and

reducing damage from an impending or ongoing event. Efforts are made “to reduce casualties, damage and disruption and to respond to the immediate needs of disaster victims.”48 Response activities are likely to include: implementing an emergency

C op

yr ig

ht ©

2 00

9. C

am br

id ge

U ni

ve rs

ity P

re ss

. A ll

rig ht

s re

se rv

ed .

124 ■ BR E N DA D. PH I L L I P S

response plan and requesting support personnel; initiating search and rescue activity; first aid and emergency medical intervention; opening special needs and medical shelters; and measures such as sandbagging, implementing a plan to operate generators, or opening a distribution center for medications.

Shelters Two kinds of shelters begin operations after a disaster. The

first is a general population or mass care shelter open to every- one. Traditionally, the American Red Cross operates this facility in the U.S., although in most disasters, others such as faith-based organizations may also open shelters. In developing nations, non- governmental organizations may establish relief centers. General population shelters are supposed to accept people with disabil- ities and their service animals, but that is not always the case. During Hurricane Katrina, for example, some general popula- tion shelters turned away people with disabilities who could have remained independent. The massive evacuation also complicated the situation for people who lost or were forcibly separated from assistive devices and durable medical equipment. Children, peo- ple with acute medical needs, seniors, and people with disabilities were also separated from friends, family, guardians, and caretak- ers. This meant that these individuals were routed to the second type of shelter, usually referred to as a special needs or medical shelter.

Ideally, it is desirable to accommodate as many people as possible, given their condition, in a general population shelter to maintain independence and reduce impact on staff in both types of relief centers. Keeping evacuees with their own equipment (e.g., medical, communications), key social support systems, medical records, and medications during evacuation increases the probability they will actually leave the area. The U.S. Depart- ment of Justice offers an Americans with Disabilities toolkit for state and local governments on their website specific to shelters. Key recommendations for shelters include

■ Plan ahead; “a person’s health will be jeopardized without access to life-sustaining medication that must be refriger- ated.”

■ Individuals with disabilities, including “those with disability related needs for some medical care, medication equipment, and supportive services” should use general population shel- ters with family, friends, and others.

■ Provide trained staff to medical shelters and keep families together in such locations.

■ Modify kitchens to allow people with medical conditions, such as diabetes, to have immediate access to food and med- ications.

■ Provide a variety of means to communicate. ■ Safeguard residents from further injury by assessing the envi-

ronment, especially considering individuals with mobility or sensory disabilities such as low vision or blindness.

■ Offer a “low-stress” location, which may be particularly valu- able to children and adults with cognitive disabilities.

■ Invite people with disabilities to specify their needs and par- ticipate in problem solving as they can provide relevant, use- ful insights.

■ Stockpile durable medical equipment and medications for shelter use.

As another step toward proper facility use, general pop- ulation shelters should establish intake procedures to identify

specific needs and ascertain if an evacuee requires further sup- port. Generally, shelters distinguish between those who require minor assistance and can remain in a general population center (e.g., those with asthma or require tube feeding) and those who require enhanced care such as a continuous intravenous infusion. Other issues to assess include mobility, language and communi- cation preferences, literacy levels, presence and needs of service animals, and availability of a family member or translator. If most of these needs are met, the individual can remain in the general population shelter; however, the facility should remain cognizant of the continual needs of the evacuee. Other confiden- tial questions might be asked in a private setting to encourage disclosure and to design appropriate support or intervention.54

For example, a patient with HIV may fear disclosure; however, if that patient were separated from medications required to control the disease, the information regarding HIV infection would be crucial to obtain. A similar situation exists with a family mem- ber at risk for domestic violence. Intake staff should be trained to establish a trusting environment to secure crucial healthcare information. The intake process also allows for consideration of potential transfer to a special needs shelter.

Special needs shelters represent a last-resort outpatient facil- ity where those with extensive medical requirements can receive care. Such locations are reserved for those not acutely ill and admission should be based solely on medical eligibility. Special needs shelters require extensive pre-event planning for staffing, supplies, facility selection, transportation, logistical support, intake, and discharge. Medical supervision is mandatory in a spe- cial needs shelter and should be coupled with adequate staffing and resources including reliable sources of power, water, heat, air conditioning, proper nutrition, and supplies. Where possible, it is far more desirable to place patients in an existing facility.

In both general populations and special needs shelters, dis- charge planning is required. Those in charge must consider whether the evacuee is able to travel home. Issues to consider include 1) debris removal from the roads and inside the home, 2) restoration of utilities to minimum levels, 3) transportation of the evacuee home and proper support to sustain basic needs while residing in the home, 4) the evacuee’s needs to return home including transportation, medical care, family support, and power, 5) the evacuee’s loss of critical resources that need replacement, including a wheelchair, and 6) the needs of the evacuee’s service animal. By identifying the problems that must be addressed, a list of possible support organizations can be cre- ated including disability and aging organizations, veterans facil- ities, home health agencies, veterinarians, rehabilitation centers, medical supply companies, and others familiar with the transi- tion from shelter or hospital to home.54

Continuity of Care Disasters disrupt multiple community functions, including

a wide range of medical services needed by vulnerable popula- tions. Post-Hurricane Katrina reports indicate that not only did hospitals close, but other facilities including clinics, mobile out- reach units, dental offices, dialysis centers, and cancer treatment facilities ceased operations. Vulnerable populations suffered sig- nificant disruptions in healthcare services, particularly seniors and people with disabilities. Although a situation as extensive as Hurricane Katrina occurs rarely in the U.S., it is clear that continuity of care to low-income households suffered. To ensure that vulnerable populations sustain continuity of medical care, it is necessary to

C op

yr ig

ht ©

2 00

9. C

am br

id ge

U ni

ve rs

ity P

re ss

. A ll

rig ht

s re

se rv

ed .

SP E C I A L NE E D S PO P U L AT I O N S ■ 125

■ Ensure that medical records can be easily transferred. This requires a system for protecting and duplicating medical records that can survive the disaster itself.

■ Develop a crisis plan to expedite prescription refills, some- times at significant distances.

■ Store extra supplies including prescription medications in an easy-to-access location for distribution to low-income households, especially senior citizens on fixed incomes. When people must evacuate, it may be useful to help them reestablish contact with a pharmacy and/or pharmaceutical company assistance program.

■ Establish and participate in networks among healthcare organizations, public health agencies, and community-based organizations that connect to vulnerable populations. These include groups who are non-English speaking, homeless, and newly arrived immigrants.

■ Contact congregate or similar facilities that may need sup- port due to staff reductions or disruption of supplies. Solicit volunteers (best done through pre-disaster memoranda of understanding or mutual aid agreements) to serve at veter- ans’ centers, state schools, centers for people with cognitive disabilities, farm worker rest centers, domestic violence cen- ters, adult daycare, senior centers, nursing homes, and similar locations. Offer free screening or testing for basic healthcare needs.

■ If healthcare facilities are established during a disaster (including points of distribution for medications for patients exposed to bioterrorism agents or influenza prevention), be sure that locations are accessible to people with disabilities, seniors, and others. Offer childcare to encourage single par- ents to present for medical care.

■ Work with and train shelter staff to identify and assist people experiencing a disruption in healthcare services, including those requiring dialysis, cancer treatment, or HIV manage- ment. Plan how to assist these shelter residents prior to the event, particularly those distant from their usual healthcare providers.

■ Be aware that most donations and acts of volunteerism occur during the response period. The bulk of human needs occur through the extended recovery period.

Recovery Recovery is a process that involves “putting a disaster-stricken

community back together.”55 Activities that might occur during this period include: 1) discharging individuals from special needs or general population shelters, 2) ensuring that persons with disabilities can navigate their damaged living environment when they return home, 3) restoration of utilities and healthcare access, 4) debris removal with adequate safeguards for health risks, 5) major reconstruction of the built environment including roads, ports, bridges, transit, and paratransit systems, and 6) providing both temporary and permanent homes that are acces- sible. In this section, a few of the key areas are examined in which medical personnel can have a significant impact.

Recovery Planning Although predisaster recovery planning is ideal, most loca-

tions fail to accomplish this task. Consequently, postdisaster recovery planning is the norm. Such planning typically sets out guidelines and goals for rebuilding the community. In many loca- tions, a recovery planning task force is convened. The broader public may be periodically informed of progress or invited to

actively participate. Regardless, medical professionals bring a special kind of asset, called structural social capital, to the plan- ning process. This kind of social capital emanates from the status attributed to medical professionals.56,57 They bring capital from this status into events such as a recovery planning process. The capital can include insights, ideas, suggestions, procedures, and perspectives that can impact the recovery plan. Because medical professionals also benefit from the respect of the broader com- munity, they are viewed authoritatively and their opinions have a great deal of credibility. Their participation is important, in part because they can advocate for those lacking a presence on the recovery planning team. Seniors may be unable to travel to a recovery meeting. People with disabilities may be working to reestablish basic household, work and healthcare routines and not have time to attend. New immigrants may not even learn of the meeting or be unfamiliar with how such a process is conducted.

Medical personnel can thus be advocates for those lacking a voice though actions including the following.

■ Emphasize a need for paratransit resources and accessible roads, curbs, bridges and neighborhoods during the rebuild- ing process.

■ Encourage recovery planners to reach out to and include non-English speaking residents.

■ Request that recovery meetings are accessible for a wide vari- ety of participants.

■ Suggest that recovery meetings be held in accessible locations including senior centers, homeless missions, farm worker labor camps, independent living centers, and public housing units.

■ Discuss the value of integrating a holistic recovery design that connects people to the locations they need to visit such as the pharmacy, grocery store, and healthcare or fitness center. Ensure that environmental quality is included in the recovery plan so that future generations are not affected by debris management, pollution, or loss of habitat.58

■ Advocate that a percentage of all new construction fall into the affordable range for the affected community.

■ Help maintain a wide range of economic opportunities so that people can earn a living from home-based to small busi- nesses to large-scale industries. Specify that rebuilt businesses must safeguard those at risk with appropriate mitigation strategies.

Debris Disasters can generate massive amounts of debris that must

be handled according to appropriate environmental controls. After Hurricane Hugo in 1989, North Carolina officials sought alternatives to burning massive amounts of green waste due to concern over air quality and ozone pollution, which could unduly affect those with chronic respiratory conditions.59 Their solution was to convert the downed trees into mulch and firewood. The attacks on September 11, 2001, represented multiple and differ- ent kinds of challenges. Monitoring of both short and long-term health conditions continue due to inhalation of contaminated air at the World Trade Center.21,60–62 Increased rates of asthma and a condition known as the “World Trade Center cough” have emerged as the key concerns, especially among specific groups such as firefighters, truck drivers, and other debris workers.

Vulnerable populations that bore increased potential risk included workers cleaning adjacent locations. A mobile medical

C op

yr ig

ht ©

2 00

9. C

am br

id ge

U ni

ve rs

ity P

re ss

. A ll

rig ht

s re

se rv

ed .

126 ■ BR E N DA D. PH I L L I P S

screening project reached out to Hispanic workers who did not speak English and lacked health insurance. Furthermore, these workers did not receive personal protective equipment or training for hazardous waste contact. Medical staff found per- sistent symptoms that lingered after discontinuing the work that included irritated airways, fatigue, headaches, difficulty sleeping, and dizzy spells.63 One study of expectant mothers found a pos- sible incidence of lower birth rates and shorter pregnancies.21 To support vulnerable populations in disasters that generate debris, the following are suggested.

■ Question patients about their exposure to any element of debris including dust that settles inside a home, mold that grows from floodwaters, and exposure to hazardous house- hold chemicals or more serious toxic waste. Monitor patients appropriately.

■ Ask patients to identify their occupation and note any poten- tial exposure to debris. Be sure to screen for temporary work assignments and volunteer activities.

■ Identify specific work crews that handle debris and establish a procedure to follow their health and record symptoms for an appropriate duration of time. Pay particular attention to those who lack training and may be hired as day laborers.

■ Demand protective equipment and training for all debris workers and contact state and federal authorities to provide oversight at work sites.

■ Work with medical epidemiologists to gather and analyze debris effects. Include a census of people living, working, or traveling in or through the affected area. Identify populations that may bear disproportionate risk due to exposure and provide appropriate medical intervention.

■ Support healthcare and other organizations that attend to those without routine access to medical care who may have been exposed to hazardous substances, including undocu- mented workers or the pre-disaster homeless.

■ The World Trade Center Health Registry will continue to monitor 8,148 individuals exposed to the debris and other effects after the terrorist attacks for 20 years. Medical providers should remain informed about the longitudinal consequences of debris exposure. (See: http://nyc.gov/html/ doh/wtc/html/registry/registry.shtml, accessed January 12, 2009).

■ Provide healthcare information in relevant local languages and at varying literacy levels (Figure 8.3).

Psychological Although it may seem counterintuitive, most people fare

well psychologically after disasters. In a massive meta-analysis of 60,000 disaster victims, the most commonly appearing symp- toms were depression and anxiety.9,10 Posttraumatic stress dis- order, a form of anxiety, was relatively low. Nonetheless, it was also clear that certain conditions increased vulnerability to psy- chological symptoms. Prior trauma has been linked to the devel- opment of posttraumatic stress disorder. Some studies link sex, race, and ethnicity to higher rates, although it is also believed that severity of exposure exacerbates posttraumatic stress disor- der. People living in inferior housing, which is more prevalent among some populations such as female-headed households, will experience higher levels of exposure to damage and injuries. Predisaster trauma can also increase the potential for postdisaster trauma, such as prior exposure to interpersonal violence. Massive collective loss is also associated with higher rates of trauma, such

Figure 8.3. Biloxi, Mississippi, September 27, 2005 – Vietnamese res- idents of Biloxi, Mississippi are assisted by a FEMA community rela- tions representative. Mark Wolfe/FEMA News Photo. See color plate.

as when an entire community must relocate or suffers significant losses.64

More common psychological responses include trouble sleeping and the potential for increased use of alcohol, drugs, and smoking. Increase of the use of these substances tends to be asso- ciated with predisaster use. What may mediate these responses are strong interpersonal relationships, having obtained counsel- ing for prior trauma, being embedded in a secure social net- work, and remaining optimistic about the situation. Medical personnel can screen patients for risk (alcohol and drug abuse, nicotine addiction, and domestic violence history) and offer information and referrals to local counseling and crisis inter- vention. In the U.S., FEMA funds crisis counseling for disaster survivors.

Reestablishing Medical Facilities When the Indian Ocean tsunami struck the community of

Nagapattinam in the State of Tamil Nadu in 2004, a local hos- pital with 56 buildings and 300 patients lay in its path. As local villagers raced into the compound with cries of “water, water,” staff and family scrambled to carry patients to higher floors. The waves burst through the neonatal unit, surged into most of the buildings above the height of patient beds, and destroyed valu- able medical equipment. This represented a significant loss for an impoverished community. Yet not a single patient or staff mem- ber died. Medical staff then moved quickly to try and resuscitate the victims outside the facility. The futility of this effort, however, soon became clear. Victims either lived or died; there was little middle ground. Just a few months earlier, the staff had expe- rienced disaster training albeit not for a tsunami. The training transferred to the new context.

As the waters receded, remaining mud and debris damaged the buildings further. Over the following year, medical staff worked with UNICEF and other nongovernmental organiza- tions to secure funds and rebuild the hospital farther inland. The new hospital required water treatment facilities, a new kitchen, new beds, x-ray and surgical equipment, and offices. Restoration of services was urgent because the hospital was the only medical facility for hundreds of miles.

Hurricane Katrina caused similar damage to healthcare facil- ities including the loss of Charity Hospital in New Orleans, a facility for indigent patients that will not reopen. Although some

C op

yr ig

ht ©

2 00

9. C

am br

id ge

U ni

ve rs

ity P

re ss

. A ll

rig ht

s re

se rv

ed .

SP E C I A L NE E D S PO P U L AT I O N S ■ 127

hospital and treatment facilities have opened in the damaged areas, low-income healthcare remains disrupted. Reports of lim- ited service to people with disabilities continued 4 years later. To maintain services to vulnerable populations, it is recommen- ded to

■ Develop business continuity plans for a medical facility or office.

■ Determine the additional number of disaster survivors who can be added to a patient load (surge capacity) and the costs of those services. Consider a sliding fee or take a tax contri- bution for those services.

■ Develop mutual aid agreements with comparable facilities, including cross credentialing of staff, so they may work at multiple hospitals.

■ Prepare memoranda of understanding with area shelters, congregate facilities, and others to provide continuity of care to these locations.

■ Plan medical mission teams with stored supplies and funds prior to the event.

■ Develop a staff release plan to send medical personnel to affected areas.

■ Join international and national efforts like the Disaster Med- ical Assistance Team program before disaster strikes; acquire training and plans for deployment.

■ Support local emergency management efforts to reduce risks through mitigation planning and implementation of risk reduction measures.

Mitigation Mitigation is defined as “sustained action taken to reduce or

eliminate the risk to human life and property from hazards.”65

Mitigation can be divided into two main types, structural and nonstructural mitigation. Structural mitigation measures target the built environment and might include shatter-resistant glass in nursing homes, elevating homes above anticipated flood lev- els, securing bookcases and filing cabinets to the wall to avoid injuries during an earthquake, and safe rooms. Nonstructural mitigation measures include land-use management that disal- lows development in floodplains or building codes that increase roof resistance to high-velocity winds. Medical offices should create protective action plans for the range of local hazards that could affect patients and staff.

Medical facilities can be hardened to withstand local hazards and ensure continuity of care. By working with architects and engineers, additional strengthening can be added to secure roofs, retrofit walls for local risks, and prevent projectiles and debris from penetrating windows and doors. To reduce risks to life safety, FEMA recommends that facilities prevent loss of power through purchasing and locating generators in areas safe from hazards and by developing a generator operations plan. In short, by securing medical facilities, the possibilities for assisting vulnerable populations and preserving critical services increases. Nonstructural mitigation measures would include code compliance, purchasing hazard-specific insurance, and identifying alternate locations for continuing operations should a disaster affect offices and facilities. Avoiding downtime for the facility and reducing the costs of displacement can protect a medical business.

Medical professionals can also support local efforts to safe- guard those at higher risk. Few trailer parks, which usually house

low-income households, offer congregate safe room locations from tornados. Other congregate settings fare poorly as well, a situation that can be remedied through supporting new build- ing codes and local land-use planning. In 2008, FEMA funded a grant to the Association for Retarded Citizens of Baldwin County (Georgia, U.S.) for construction of the first congregate safe room for people with special needs. The Hazard Mitigation Grant Pro- gram provided $3.2 million USD for the facility, which will shelter 430 people. In addition, the grant provides funds to retrofit the Laundry and Life Skills Training Center to increase the capacity of the roof to withstand 320-kph winds. This structural mitiga- tion project will safeguard a previously at risk population and should be duplicated widely.

Other locations can benefit from mitigation measures that alert people to danger. Sirens, alarms, lighted strobes, vibrating devices, pagers, wireless devices, tactile signs, and evacuation devices can be installed in any workplace including a medical office, home health agency, dialysis center, hospital, or personal home. Physical barriers can be removed to allow for egress by those in wheelchairs and evacuation devices can be purchased and placed pre-event for use (an extensive list of disability- specific devices can be seen at the Job Accommodation Network, www.jan.wvu.edu, accessed October 15, 2008). Medical associ- ations should consider partnering with civic organizations to secure funding for placement of such devices in private homes and congregate facilities.

Finally, the time period immediately after a disaster is usually referred to by emergency managers as the “window of opportu- nity.” This phrase means that the opportunity exists to intro- duce measures that reduce further risk during this period. After the 2004 Indian Ocean tsunami, for example, many nations expressed concern about massive epidemics from the number of deceased. Although most researchers suggest that such outbreaks are extremely unlikely, the concern prompted an opportunity. Across the affected area within India, both governmental and nongovernmental organizations vaccinated tens of thousands of survivors against cholera, typhoid, hepatitis A, and dysentery.

Emerging Policies and Practices

Several policies and practices have emerged since Hurricane Katrina in the U.S., although some remain in draft status. The U.S. Department of Transportation will develop plans for high- way evacuation. The Federal Highway Administration is produc- ing guidance for transportation of people with disabilities that provides advice for evacuation of congregate facilities where such individuals reside. FEMA, following a lawsuit (Brou v. FEMA), is continuing to integrate people with disabilities and disability organizations into their policies and programs to make tempo- rary housing accessible. The National Disaster Housing Strategy and Plan (in draft status in early 2009) acknowledges the valuable partnership that can occur with disability organizations, espe- cially at the state level. The National Council on Disability in recent years has investigated emergency preparedness issues and reports through minutes of its quarterly meetings available on its website (www.ncd.gov, accessed October 15, 2008).

RECOMMENDATIONS FOR FURTHER RESEARCH

Extensive research remains necessary on vulnerable popula- tions. More specifically, a number of research questions carry

C op

yr ig

ht ©

2 00

9. C

am br

id ge

U ni

ve rs

ity P

re ss

. A ll

rig ht

s re

se rv

ed .

128 ■ BR E N DA D. PH I L L I P S

implications for medical professionals. Future research might focus on

■ How various jurisdictions develop, use, and share registries, including the challenges of maintenance and confidentiality.

■ Medical support during the evacuation of residents using general transportation resources including buses, paratransit vehicles, and caravans.

■ The development of checklists and forms usable during life histories to assess risk and document disaster-related health issues.

■ The most effective strategies for keeping families, guardians, and caretakers together during evacuation, sheltering, and return to the home.

■ Loss of healthcare facilities for low-income households, how they regain access, and how communities restore such ser- vices.

■ The type of medical outreach services most commonly needed for marginalized populations after a disaster and the duration of time those services must be provided (from rou- tine procedures like annual examinations to more detailed care).

■ Analysis of communication tools for a full range of vulnerable populations as used by medical professionals.

■ The critical role of home health agencies in reaching the homebound with disaster information.

■ The assessment of special needs and medical shelters, from intake procedures to discharge, and all dimensions of service from routine patient care to medical emergencies, staffing, and logistics.

■ The most expedient routes for provision of healthcare access to immigrant populations after disasters, as well as the kinds of healthcare concerns that most commonly arise.

■ Improving knowledge about some racial and ethnic groups in disasters, such as Native Americans. Within the Native American population, additional issues may surface such as how elders fare in disasters and whether the impact of prox- imity to hazardous wastes, newly appearing diseases such as the Hanta virus, or long-term exposure to occupational hazards has an effect.

■ Comprehensive examinations that span the life cycle of dis- asters: preparedness, response, recovery and mitigation such as ■ Case studies of effective partnerships that span vulnerable

populations, engage the broader community, and lever- age resources to address unmet healthcare needs after disasters.

■ Examination of intake and discharge procedures from general populations and special needs shelters.

■ Psychological effects of disasters on medical personnel including secondary trauma or compassion fatigue that may result from working with survivors.

■ Mitigation success stories for a full range of medical faci- lities.

CONCLUSION

Whether interested in public education, emergency response, long-term recovery, or risk reduction, the medical commu- nity can support efforts to aid vulnerable populations. From a social vulnerability perspective, risk reduction requires more

than healthcare, accessible shelters, or construction assistance. As international disaster humanitarian Fred Cuny66 wrote, “Vulnerability reduction is ultimately a social problem that requires a lifetime commitment.” Civic involvement is necessary to address continuing problems including a lack of affordable and safe housing, domestic violence, pollution and environmental degradation, access to jobs, language prejudice, racial discrimi- nation, and exclusionary practices. Such involvement will ulti- mately reduce risks. By participating in efforts that address public housing issues, promote literacy, reduce partner abuse, increase healthcare access, conserve floodplains, retrofit low- income housing, and reach out to new immigrants, society can create more disaster-resilient communities. In the interim, those interested in special needs populations can educate patients and providers, secure important facilities, design outreach efforts, partner with other community and advocacy organizations, and be part of the cadre of people dedicated to increasing life safety for all.

Resources (all websites were accessed January 12, 2009)

■ FEMA offers a variety of training materials, including free online courses (downloadable and interactive) and on- campus courses at its Emergency Management Institute (EMI) location. A list of courses can be obtained from www.fema.gov. From the independent study (IS) course list, select the FEMA IS197 course.

■ The NOD offers downloadable resources at its Emergency Preparedness Initiative page at www.nod.gov.

■ The National Council on Disability is currently generating a series of reviews on all phases of emergency management. The site at www.ncd.gov contains updates and copies of min- utes from the quarterly meetings.

■ The Gender and Disaster Network provides extensive materials including those that apply worldwide at www. gdnonline.org.

■ FEMA and the Humane Society offer tips for protecting pets and service animals at www.fema.gov and www.hsus.org.

■ FEMA for Kids provides games and downloadable materials. The American Red Cross offers a “Master of Disaster” cur- riculum that is tied to school content at www.redcross.org.

■ Buddy assessments and emergency kit information can be secured in multiple languages at www.preparenow.org.

■ A set of papers that include content on vulnerable popula- tions is available at http://understandingkatrina.ssrc.org/.

■ A large bibliography on social vulnerability can be found along with college course materials at the FEMA Higher Education Website available from http://www.training .fema.gov/EMIweb/edu/collegelist/. Once there, select the free college courses and the Social Vulnerability course. These materials will be produced in an edited book titled Social Vulnerability to Disasters (August 2009), edited by Brenda Phillips, Deborah Thomas, Alice Fothergill and Lynn Blinn- Pike.

■ AHCA forms and checklists for Home Health Agencies (Florida) and Adult Daycare facilities, assisted living facilities, ambulatory surgical care centers, hospice centers, hospitals per Florida statute.

■ Educational materials for seniors and people with disabilities can be viewed at www.eadassociates.com. These materials are in the form of “wheels” that can be dialed to reveal hazard- specific preparedness information.

C op

yr ig

ht ©

2 00

9. C

am br

id ge

U ni

ve rs

ity P

re ss

. A ll

rig ht

s re

se rv

ed .

SP E C I A L NE E D S PO P U L AT I O N S ■ 129

■ An extensive bibliography on Hurricane Katrina can be accessed at http://lamar.colostate.edu/∼loripeek/ KatrinaBibliography.pdf.

REFERENCES

1. National Organization on Disability. Special Needs Assessment for Katrina Evacuees. Washington, DC: National Organization on Disability; 2005.

2. American Medical Association. Nearly 1,000 People Killed by Hurricane Katrina in Louisiana. Available at: http://www.ama- assn.org/ama/pub/category/print/20035.html. Accessed Jan- uary 10, 2009.

3. Sharkey P. Survival and death in New Orleans: an empirical look at the human impact of Katrina. J Black Studies. 2007;37(4):482– 501.

4. Laska S. What if Hurricane Ivan had not missed New Orleans? Natural Hazards Observer. 2004;1.

5. Mitchell L. Guidelines for emergency managers working with culturally and linguistically diverse communities. Aust J Emerg Manage. 2003;18(1):13–18.

6. Enarson E. Social Vulnerability Course. http://www.fema.gov. Accessed September 30, 2008.

7. Wisner B. Development of Vulnerability Analysis. http://www .fema.gov. Accessed September 30, 2008.

8. Friedsam H. Older persons as disaster casualties. J Health Hum Behav. 1970;1(4):269–273.

9. Norris F, Friedman M, Watson P. 60,000 disaster victims speak: part II. Psychiatry. 2002;65(3):240–260.

10. Norris F, Friedman M, Watson P, Byrne C, Diaz E, Kaniasty K. 60,000 disaster victims speak: Part I. Psychiatry. 2002;65(3):207– 239.

11. Lindell MK, Perry RW. Communicating Risk in Multiethnic Com- munities. Thousand Oaks, CA: Sage; 2004.

12. Prince-Embury S, Rooney JF. Psychological symptoms of res- idents in the aftermath of the Three Mile Island accident and restart. J Soc Psychol. 1988;128(6):779–790.

13. Poulshock S, Cohen E. The elderly in the aftermath of disaster. Gerontologist. 1975;15(4):357–361.

14. Baylor College of Medicine, American Medical Association. Rec- ommendations for Best Practices in the Management of Elderly Disaster Victims. Baylor College of Medicine; 2006.

15. Phillips B, Hewett P. Home alone: disasters, mass emergencies and children in self-care. J Emerg Manage. 2005;3(2):31–35.

16. Peek L, Fothergill A. Reconstructing Childhood: An Exploratory Study of Children in Hurricane Katrina. Boulder, CO: Natural Hazards Center; 2006.

17. Fothergill A, Peek L. Surviving catastrophe: a study of chil- dren in hurricane Katrina. In: Center NH, ed. Learning from Catastrophe. Boulder, CO: Natural Hazards Center; 2006:97– 129.

18. Pfefferbaum B, Call J, Sconzo G. Mental health services for children in the first two years after the 1995 Oklahoma City terrorist bombing. Psychiatry Serv. 1999;50(7):956–958.

19. Fairbrother G, Stuber J, Galea S, Pfefferbaum B, Fleischman A. Unmet need for counseling services by children in New York City after the September 11th attacks on the World Trade Cen- ter: implications for pediatricians. Pediatrics. 2004;113(5):1367– 1374.

20. Delica ZG. Balancing vulnerability and capacity: women and children in the Philippines. In: Enarson E, Morrow BH, eds. The Gendered Terrain of Disaster. Miami, FL: International Hurricane Center; 2000:109–113.

21. Landrigan P. Health and environmental consequences of the World Trade Center disaster. Environ Health Perspect. 2004;112(6):731–739.

22. Heinz Center. Human Links to Coastal Disasters. Washington, DC: The Heinz Center; 2002.

23. Comerio M. The Impact of Housing Losses in the Northridge Earthquake: Recovery and Reconstruction Issues. Berkeley, CA: Institute of Urban and Regional Development, University of California-Berkeley; 1996.

24. Fothergill A, Maestas EGM, Darlington JD. Race, ethnicity and disasters in the United States: a review of the literature. Disasters. 1999;23(2):156–173.

25. Legates DR, Biddle MD. Warning Response and Risk Behavior in the Oak Grove-Birmingham, Alabama Tornado of 8 April 1998. Boulder, CO: Natural Hazards Center; 1999.

26. Aguirre BE, Anderson WA, Balandran S, Peters BE, White HM. Saragosa, Texas, Tornado May 22, 1987: An Evaluation of the Warning System. Washington, DC: National Academies Press; 1991.

27. Phillips B. Cultural diversity in disaster situations. Intl J Mass Emerg Disasters. 1993;11:99–110.

28. Cutter S. The geography of social vulnerability: race, class and catastrophe. Available at: http://understandingkatrina .ssrc.org/Cutter/printable.html. Accessed January 11, 2009.

29. Oxfam. The Tsunami’s Impact on Women. London: Oxfam Inter- national; 2001.

30. Noel G. The role of women in health-related aspects of emer- gency management: a Caribbean perspective. In: Enarson E, Morrow BH, eds. The Gendered Terrain of Disaster. Miami: Inter- national Hurricane Center; 2000:213–219.

31. Enarson E, Morrow BH. Why gender? Why women? An intro- duction to women and disaster. In: Enarson E, Morrow B, eds. The Gendered Terrain of Disaster. Miami: International Hurri- cane Center; 2000:1–9.

32. Enarson E, Phillips B. Invitation to a new feminist disaster soci- ology. In: Phillips B, Morrow B, eds. Women and Disasters: From Theory to Practice. Philadelphia: Xlibris, International Research Committee on Disasters; 2008:41–74.

33. Phillips B, Morrow BH. What’s gender got to do with it? In: Phillips B, Morrow B, eds. Women and Disasters: From Theory to Practice. Philadelphia: Xlibris, International Research Commit- tee on Disasters; 2008:27–40.

34. Enarson E. What women do: gendered labor in the Red River Valley flood. Environ Hazards. 2001;3:1–18.

35. Webb G, Tierney K, Dahlhamer J. Businesses and disasters. Natural Hazards Rev. 2000;1(3):83–90.

36. Enarson E, Morrow B. A gendered perspective: the voices of women. In: Peacock W, Morrow B, Gladwin H, eds. Hurri- cane Andrew. Miami: International Hurricane Center; 2000:116– 140.

37. Toscani L. Women’s roles in natural disaster preparation and aid: a Central American view. In: Enarson E, Morrow BH, eds. The Gendered Terrain of Disaster. Miami: International Hurricane Center; 2000:207–211.

38. Christiansen K, Blair M, Holt J. The built environment, evacu- ation and individuals with disabilities. Rev Disabil Policy Stud. 2007;17(4):249–254.

39. Tierney KJ, Petak WJ, Hahn H. Disabled Persons and Earthquake Hazards. Boulder, CO: Institute of Behavioral Science; 1988.

40. National Organization on Disability. Harris Survey Data. Available at: http://nod.citysoft.org/index.cfm?fuseaction= page.viewPage&PageID=1565&C:\CFusion8\verity\Data\ dummy.txt. Accessed January 11, 2009.

41. Phillips B, Morrow B. Social vulnerability, forecasts and warn- ings. Natural Hazards Rev. 2007;8(3):61–68.

C op

yr ig

ht ©

2 00

9. C

am br

id ge

U ni

ve rs

ity P

re ss

. A ll

rig ht

s re

se rv

ed .

130 ■ BR E N DA D. PH I L L I P S

42. Wood V, Weisman R. A hole in the weather warning system. Am Meteorol Soc. 2003;84(2):187–194.

43. Hendricks T. Bay Area report: 112 languages spoken in diverse region. San Francisco Chronicle, March 14, 2005.

44. Government Accountability Office. Transportation-Disadvan- taged Populations. Washington, DC: GAO; 2003.

45. Eldar R. The needs of elderly persons in natural disasters. Dis- asters. 2007;16(4):355–358.

46. Fernandez L, Byard D, Lin C-C, Benson S, Barbera J. Frail elderly as disaster victims. Prehosp Disaster Med. 2002;17(2):76–74.

47. Peek L. Becoming Muslim. Sociol Religion. 2005;66(3):215–242. 48. Tierney KJ, Lindell MK, Perry RW. Facing the Unexpected: Dis-

aster Preparedness and Response in the U.S. Washington, DC: Joseph Henry Press; 2001.

49. Willigen MV. Riding out the storm. Natural Hazards Rev. 2002;3(3):98–106.

50. Enarson E. Violence against women in disasters. Violence Against Women. 1999;5(7):742–768.

51. California State Independent Living Council. The Impact of Southern California Wildfires on People with Disabilities. Sacra- mento, CA: California State Independent Living Council; 2004.

52. Metz W, Hewett P, Muzzarelli J, Tanzman E. Identifying Special Needs Households that Need Assistance for Emergency Plan- ning. Intl J Mass Emerg Disasters. 2002;20(2):255–281.

53. Jenkins P, Phillips BD. Battered women, catastrophe and the context of safety. NWSA J. 2008;20(3):49–68.

54. Florida Department of Health. Resource Guide for Special Needs Shelters. Tallahassee, FL; 2006.

55. Mileti D. Disasters by Design. Washington, DC: Joseph Henry Press; 1999.

56. Nakagawa Y, Shaw R. Social capital: a missing link to disaster recovery. Intl J Mass Emerg Disasters. 2004;22(1):5–34.

57. Uphoff N. Understanding Social Capital. Washington, DC: The World Bank; 2000.

58. Natural Hazards Center. Holistic Disaster Recovery. Boulder, CO: Natural Hazards Center; 2001.

59. Steuteville R. Hugo sets an example. BioCycle. 1992;33:1030– 1033.

60. Centers for Disease Control. Self-reported increase in asthma severity after the September 11 attacks on the World Trade Cen- ter. MMWR. 2002;51:781–784.

61. Lin S. Respiratory symptoms and other health effects among residents living near the World Trade Center. Am J Epidemiol. 2005;162(16):499–507.

62. Szema A. Clinical deterioration in pediatric asthmatic patients after September 11, 2001. J Allerg Clin Immunol. 2004;113:420– 426.

63. Malievskaya E. Assessing the health of immigrant workers near ground zero. Am J Indust Med. 2002;42(6):548–549.

64. Erikson K. Everything in its Path. New York: Simon and Schuster; 1976.

65. Godschalk DR. Mitigation. In: Waugh W, Tierney K, eds. Emer- gency Management: Practice and Principles for Local Government. 2nd ed. Washington DC: ICMA Press; 2007:89–112.

66. Cuny F. Disasters and Development. Dallas, TX: Intertech; 1983.

C op

yr ig

ht ©

2 00

9. C

am br

id ge

U ni

ve rs

ity P

re ss

. A ll

rig ht

s re

se rv

ed .