Democratize Disaster Response Decisions

Without inclusive planning, society's most vulnerable remain most at risk, expert says

World Health Organization workers gear up to go into an old Ebola isolation ward in Lagos, Nigeria.
World Health Organization workers gear up to go into an old Ebola isolation ward in Lagos, Nigeria. Dr. Fink received one of her Pulitzer Prize awards, along with her New York Times colleagues, for coverage of the recent West Africa Ebola crisis. (Courtesy World Health Organization)

Dr. Sheri Fink has won two Pulitzer Prize awards for reporting on health care responses to mass catastrophes, including life-or-death decisions made at New Orleans’ Memorial Hospital following Hurricane Katrina — the basis for her book Five Days at Memorial — and, more recently, the West Africa Ebola crisis. Her first book, War Hospital: A True Story of Surgery and Survival, is about medical professionals under siege during the genocide in Srebrenica, Bosnia-Herzegovina. She previously served as an aid worker in conflict and disaster zones.

So her insight into how health care systems function — or malfunction — during crises is profound.

On July 5, Dr. Fink will join three other health care experts speaking at the 2017 Colloquium, The Health Care of Catastrophes: Innovation Driven by Disaster, sponsored by the Mensa Education & Research Foundation.

She spoke with Bulletin editor Chip Taulbee about developments in health care responses to crises.

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Chip Taulbee: One of the themes that’s come out of your reporting, especially in the post-Katrina coverage, is our health care system’s struggle with the question, “In a crisis, when resources are finite, who should we save?” Do you think our health care institutions and government decision makers are getting any closer to developing a philosophy to answer that question?

Dr. Sheri Fink: There is more attention to that question than there was, say, prior to Hurricane Katrina, which raised the issue in a way that made it salient and that brought widespread attention to it. Other incidents that sparked awareness were the H1N1 flu in 2009 and the SARS epidemic, which you might remember was a very deadly respiratory epidemic that spread by the air and that caused a lot of trouble in Asia and Canada in 2003. In all of these emergencies, there was at least a threat that health care systems, in an acute situation, would not have enough lifesaving resources.

How to deal with resource shortages is a question that requires a nuanced answer. It would be dangerous to have one method for rationing every resource in the health care system. In battlefield triage — acute situations in a war zone, where you have a lot of injured people at once and decisions have to be made about how to prioritize care — one of the most important principles is flexibility, and another important one is reassessment. There’s not a one-size-fits-all solution. The way that you manage your resources may need to change depending on exactly what that crisis is and who it affects and where it hits, whether it’s broadly across the nation or even across the world versus something very localized.

Over the past 10 years, some plans have taken shape, some frameworks to help make these types of decisions in hospitals around the country or in states or in localities. Also, experts have realized that they shouldn’t be the sole architects of prioritization schemes. Every resident of an area has a stake in these questions. People who make rationing policies and who would ultimately make hard decisions in a time of crisis need broadly representative input to guide them.

Can you provide any examples of how these decisions are taking shape?

The epilogue of Five Days at Memorial discusses a project in Maryland and similar projects like it. In Maryland, a group of health care professionals were asked to help craft a policy for the state in case of a future flu pandemic or similar crisis. Experts believe there could be — there likely will be — another very deadly change in the flu virus, and that will cause many people to get critically ill. This happened in 1918.

There will be far more people sick than there are critical care resources, such as ventilators to help people breathe. So there was some planning around how we should prioritize the ventilators. Should it be first-come first-served? Should there be other factors brought into this? Should age be brought into it? Should the likelihood of survival be brought into it? Should the likelihood of survival long-term versus just through this particular crisis be considered? Should health care providers be prioritized so they can be treated and go back to helping people?

In Maryland, the experts decided to not make this decision themselves. They spent two or three years getting input from a diverse group of residents and health care providers through a process of deliberative democracy all around their state. Similar projects are occurring in other localities, where an emphasis is placed on engaging the community and getting widespread input on how to make those choices.

The idea is that even though not everybody would agree on what plans should take shape or who should be prioritized, the process of making those choices can be made more fair and more just and more inclusive. That idea has been embraced more in recent years, I’ve seen.

Since Hurricane Katrina, how has our health care system become better prepared to deal with mass catastrophes?

There has been more of a realization that preparedness is important and should be a priority. After Hurricane Katrina, disaster preparedness in health care institutions, particularly hospitals, saw some additional federal money to support local efforts. However, that money’s been chipped away at in recent years.

There is also a new federal rule from the Centers for Medicare and Medicaid Services. Seventeen different types of health care facilities — from hospitals and nursing homes to outpatient dialysis centers to residential homes for people with intellectual disabilities, all different kinds of facilities that have a health care mission — they are now required, if they receive funding from Medicare or Medicaid, to adhere to some basic standards of emergency preparedness. This is the first time that there’s been something like that. The idea was first proposed after Hurricane Katrina and the tragic problems that emerged in health care institutions. It took many years to get through all the bureaucratic processes and the objections and the negotiations and finally become a reality.

I don’t know how much data there are in terms of the likelihood those standards will make those institutions more prepared. But what I think the new rule has done, for sure, is to put health executives on alert to make it a priority.

What areas of our health care system remain vulnerable?

As a country, our health care system is highly vulnerable to disasters and emergencies. On the one hand, the better an organization functions on a daily basis, the better it should be in an emergency. So a stronger health system should tend to be more resilient. But we’re also incredibly dependent on — here’s one example — technology. And technology relies on power, electrical power. We have seen many, many examples when power goes out. We have an aging electrical infrastructure, and the backup power systems, when they do exist in our health care institutions, are not always very robust. That’s one point of vulnerability for our health care system, and there are others.

Emergency preparedness is not a one-time investment; it’s something you have to work on over and over again.

The other thing I would say is there are multiple layers of responsibility from federal to state to local to the private institutions, whether for-profit or not-for-profit, and I hear over and over when I speak with people who are in charge of that job of emergency preparedness in their health care institutions or in their localities that they are working with not a lot of resources, not a lot of priority from their institutions.

Emergency preparedness is not a one-time investment; it’s something you have to work on over and over again. Just like if you’re thinking about a sports team going out on game day, they need to practice and develop that muscle memory to be able to perform in that moment. It’s the same thing with emergencies. The ideal is to invest in it in a way that strengthens your everyday operations as well, and it’s really another form of triage, right? We don’t have unlimited resources in our health care system, so how do we prioritize these, and how much should we invest in preparedness for rare but potentially catastrophic incidents and ones that are predictable. Only when you know what the consequences are of not preparing can you make a more informed decision about that.

In thinking about the United States’ responses to catastrophes, what keeps you up at night?

Many places are not well prepared for a range of different disasters. What keeps you up at night, in terms of the specific so-called hazard, which would be the specific catastrophe, would vary from place to place in terms of what is most likely, and I think there are many candidates on that list. Even for a while the federal government would keep a list of something like its top-10 priorities for investment in preparedness.

Medical personnel aboard the USS Bataan care for an injured Haitian man during a mass medical evacuation.
In the wake of the devastating 2010 earthquake in Haiti, medical personnel aboard the USS Bataan care for an injured Haitian man during a mass medical evacuation from various areas around Port-au-Prince. (Courtesy Kristopher Wilson/U.S. Navy)

More globally, what I worry about is these situations related to the availability of resources. When resources become scarce, it tends to be the same groups of people who suffer more. So the people who are vulnerable on a day-to-day basis are equally or more vulnerable in times of disaster. It is important to focus on the preparedness of those communities. That would include people who don’t have as much income or who live in places where the infrastructure isn’t as good or where older, poorly maintained infrastructure could fail. People with disabilities are often not included in preparedness efforts and tend to be particularly vulnerable in disasters but also have developed daily coping strategies that preparedness experts could do well to learn from.

There have even been a few lawsuits around the country, in New York where I live and in California, for example, where people with disabilities have sued their local governments to do better planning around their communities for disasters. It’s a very important and sometimes overlooked issue — people who are older, people who live at home and have medical issues. Many more people are able to stay at home, and it seems to be an important goal to live at home as long as possible. But what that also means in times of disaster is that people need to know how will I get my medications, how will I get my health care needs met if I’m displaced or if the power goes out? These are some of the most important issues.