Shielding Communities: Public Health Strategies for Natural Hazards

As public health preparedness and response efforts evolved from their initial bioterrorism roots to take on an “all hazards” approach, the public health consequences of natural hazards have come fully into focus for governmental public health entities. The Federal Emergency Management Agency (FEMA) defines natural hazards as “environmental phenomena that have the potential to impact societies and the human environment,” with some examples including hurricanes, earthquakes, tornados, and severe winter storms. FEMA’s 2023 National Preparedness Report highlighted the nation’s marked increase in the frequency, costs, and impacts of natural disasters over the past decade. These increased risks and the social and economic consequences continue to bring natural hazards to the forefront of public consciousness.

Understanding Public Health and Natural Hazards

Yet, when many think of the natural hazards that society may experience, responders and the public do not automatically consider the public health implications of these incidents. Public health factors are important considerations for responders to keep in mind, especially those in the health and medical sectors within the communities they affect. The public health impacts of natural disasters can fall into the following four general categories:

• Direct impact on the population’s health,
• Direct impact on the health care system,
• Indirect effect on the population’s health, and
• Indirect effect on the health care system.

Perhaps the most urgent potential negative influence from an emergency response perspective is the direct impact on the population. Individuals typically experience these public health impacts of natural disasters, including the physical injuries that require a health response. When researching the impact of earthquakes on public health, one January 2023 study found that the injuries typically experienced after natural disasters:

[A]re mainly attributed to the partial or total collapse of buildings, movement of landslide material, generation of post-earthquake fires, physical impact with debris in fast-flowing tsunami water, and spill of hazardous chemicals. [The impacts] vary from minor cuts and bruises to serious fractures, crush injuries and burns. They also include airway obstruction or asphyxiation from the large quantities of dust and debris generated by collapsing buildings.

Additional complications from natural hazards are the potential for infectious diseases to develop and spread. These opportunistic illnesses may have direct or acute impacts, or they may have indirect or long-term effects on the population. The January 2023 study also found that, “although it is impossible to accurately predict which diseases would be transmitted after a certain type of natural hazard, infectious diseases can be categorized as either water-borne, air-borne, or vector-borne diseases,” with primary or secondary causes such as contamination to open injuries.

Unfortunately, the challenges of public health response to these natural disasters can be most attributed to the funding that supports these responses. Public health is used to utilizing the CDC Public Health Emergency Preparedness system to fund its preparedness activities. However, this funding does not specifically call for any capabilities for natural disaster response. While CDC has implemented a Public Health Crisis Response funding mechanism to quickly provide support to state and local jurisdictions during a public health emergency, these natural disasters typically do not rise to a level that would trigger additional public health response funding. This means that public health (as well as health care) must rely on internal funding mechanisms or, in a significant event, funding through the FEMA public assistance program.

Public Health Response

Implementation of effective public health controls after a natural disaster begins with quick and thorough cleanup efforts. Public health controls, coupled with environmental health efforts, can positively impact the population. This includes ensuring access to safe food and drinking water in order to limit known disease vectors (i.e., rodents, insects), and offering appropriate medical interventions for injuries and acute illnesses. If all of these interventions are applied, they can be effective tools to mitigate the longer-term threats to the public’s health.

An additional consideration after a natural disaster is the inherent impact on the delivery of public health and health care services. Power outages or infrastructure damage to facilities may reduce the availability and access to acute treatment at hospitals or urgent care facilities. Flooding that covers or washes away roads or other transit routes may impact the ability of emergency medical services (EMS) or public health officials to respond to locations where their services are needed. These factors may also affect the public health and health care workforce’s connectedness to work sites, further limiting their ability to provide essential services during a post-emergency situation.

Blueprint for Future Success

Planning for the public health implications of natural disasters must factor in the reality that the number of events, and severity of the resulting damage, have been increasing in recent years. The Keck School of Medicine of the University of Southern California suggests the following steps for developing an over-arching game plan: re-connect and retrain local and state-level agencies, develop and train contingency plans, include the new and the [so far] unforeseen events in emergency preparedness training, and understand the differences between sectors.

Re-Connect and Retrain Local and State-Level Agencies

“All disasters are local” in that they begin and end with the local governmental entities. But, as disasters unfold and it becomes apparent that local capabilities and capacities are not enough, the emergency response complexities can rapidly increase exponentially. Intra- and inter-agency coordination is critical for an organized, effective response to a regional or larger disaster. Yet the truth is still that, in practice, many localities may be disconnected from each other (and from the state and federal levels) in their approach to preparedness and response.

This disconnectedness is further complicated in the health sphere, as public health agencies may exist at different levels (e.g., town, city, county, region, state) than emergency management. For example, while municipal and county emergency management may have the authority to manage an emergency response, public health functions may be handled at the county or state level. Additionally, much health care exists within the private sector and typically serves a broader population than a single jurisdiction. Training is critical for emergency management and health workforces to identify weaknesses and teach agencies how to work seamlessly with each other. For example, the infamous failures in New Orleans after Hurricane Katrina could have been mitigated if there had been better inter-agency coordination between local and federal response teams.

Develop and Train Contingency Plans

To quote Mike Tyson, “Everybody has a plan until they get punched in the face.” It is safe to say that many natural disasters can strike like a punch in the face. Ensuring that each level of government produces, maintains, and trains for contingency plans offers a significant advantage in the case of a real disaster if the first response approach does not work. One common scenario seen in the wake of a natural disaster involves:

[T]ransportation lines being broken. Without a contingency plan addressing this risk, many agencies literally stop in their tracks, not knowing how else to proceed. This occurred in 2010, in Haiti, when the main road from the international airport was destroyed after a major earthquake hit.

Include the New and the [So Far] Unforeseen Events in Emergency Preparedness Training

One of the more well-known mantras about emergency planning (compliments of General George Patton) is “train like you fight, and fight like you train.” As the emergency threat landscape continues to change and evolve, preparedness training must provide for new challenges – the “what ifs” of any scenario. The events impacting a specific area of the world can become infinitely more complicated if floodwater, rain, or heat suddenly inundates the region. Contingency planning must anticipate the unexpected and prepare in advance for possible solutions. In addition to what participants generally expect, exercises should cover extreme examples beyond what is probable to include what is possible (e.g., Fukushima).

Understand the Differences Between Sectors

During the COVID-19 response, tension between emergency management and public health officials over roles and responsibilities was reported in multiple settings, which was summarized in this report. The approach by public health was often too slow, too mired in data and analysis, and not responsive to the emergency at hand. On the other hand, emergency management sometimes was seen as not fully understanding the logistics and other realities of a public health emergency response. All parties in a response should explore and understand the cultural differences, response capabilities, and capacity between communities before an incident. While organizational culture is unlikely to have significant shifts, these understandings can help smooth the relationships during a response.

Implementing a Strategy

There is nothing new about natural hazards and the public health risks they present to communities and emergency responders. However, increases in the scale of and needs during these events are new due to increased frequency and larger population sizes. As outlined above, these increases bring with them public health planning and response challenges as well as the potential to implement public health lessons learned from previous natural hazard responses in future responses.

Public health challenges during natural hazards are complex and demand thorough planning, coordination, and response strategies among all disciplines to mitigate their impacts on affected populations. Addressing these challenges calls for public health and emergency management personnel to have a mutual understanding of the risks and hazards associated with natural hazards response, as well as the authorities and the capabilities within and between communities to address them.