key: cord-022075-bbae2nam authors: Gougelet, Robert M. title: Disaster Mitigation date: 2009-05-15 journal: Disaster Medicine DOI: 10.1016/b978-0-323-03253-7.50028-5 sha: doc_id: 22075 cord_uid: bbae2nam nan c h a p t e r 2 1 The definition of mitigation includes a wide variety of measures taken before an event occurs that will prevent illness, injury, and death and limit the loss of property. Mitigation planning commonly includes the following areas: • The ability to maintain function • Building design • Locating buildings outside of hazard zones (e.g., flood plains) • Essential building utilities • Protection of building contents • Insurance • Public education • Surveillance • Warning • Evacuation It is of critical importance that emergency planners incorporate the basic elements of mitigation and have the authority and resources to incorporate these changes into their organization/facility/community. Emergency planners should have a basic idea of the concepts of mitigation through their use in natural disasters over the years. The recent federally mandated transition to the all-hazards approach in disaster emergency response has also given a new perspective on mitigation. Although it is not necessary to redefine mitigation, it is essential to understand how the scope and complexity of mitigation and risk reduction strategies have evolved as the United States adapts to new threats. For example, what measures can be taken in advance to protect the population and infrastructure from an earthquake, flood, ice storm, or terrorist attack? As with each mass casualty event, the answers to this question are location-specific and heavily dependent on the circumstances surrounding the event. However, a common understanding of the goals and concepts of mitigation along with knowledge of its policy history and current practices will help a community develop mitigation plans that are both locally effective and economically sustainable. This chapter illustrates how mitigation strategies have evolved, outlines key historical elements of U.S. mitigation policy, highlights critical current mitigation practices, and describes common pitfalls that can hamper mitigation efforts. The realm of mitigation planning is far reaching and complex, and, therefore, the emphasis of this chapter is on the continuity of medical care during a mass casualty event within a community. In the simplest of terms, mitigation means to lessen the possibility that a mass casualty event can cause harm to people or property. However, this simple definition covers a broad range of possible activities. For example, an effort to ensure that essential utilities, such as electricity and phone service, continue to be available throughout a natural disaster is very different from efforts to minimize the economic damage of postdisaster recovery from a major flood or attempts to educate the public on how to reduce their risk of exposure during a dirtybomb incident. Mitigation strategies can range from focusing exclusively on "hardening" to focusing more on resiliency. Hardening of targets is best described as measures that are taken to physically protect a facility, such as bolting down equipment, securing power and communications lines, installing backup generators, placing blast walls, or physically locking down and securing a facility. Mitigation through hardening has only limited use in systems or facilities such as hospitals where open access to the surrounding community is the hallmark of their operations. In these circumstances, a resilient system capable of flexing to accommodate damage and the ability to maintain or even expand current operations will make that system ultimately more secure. Mitigation through resiliency also has limitations. In many cases, hardening structures is most appropriate, particularly when many citizens may be quickly affected without prior notice or warning. This may include hardening structures in earthquake zones, physically protecting and monitoring the food chain and drinking water systems, and physically securing and protecting nuclear power plants. In these cases, resiliency may come too late to prevent illness and death in large numbers of patients, and planners should target hardening to whatever degree is practically and financially feasible. The threats of nuclear, radiological, chemical, and biological attacks present new challenges for emergency planners. The potentially covert nature of the attack, the wide variety of possible agents (including contagious agents), and soft civilian targets make planning efforts exponentially more difficult than in the past. This complexity has also eroded the distinction between mitigation and response activities. Although it is never possible to mitigate or to plan responses for all contingencies, we do know, however, that there is a basic common response framework. This framework includes coordination, communication to enable inter-agency information sharing, 1 and flexibility to rapidly adapt emergency plans to different sitvations. Traditionally, mitigation in the United States has focused on natural disasters; however, early mitigation planning against manmade disasters included civilian fallout shelters and the evacuation of target cities if a nuclear attack was eminent. The Federal Emergency Management Agency (FEMA) states 2 : Mitigation is the cornerstone of emergency management. It's the ongoing effort to lessen the impact disasters have on people's lives and property through damage prevention and flood insurance. Through measures such as; zoning restrictions to prevent building in hazard zones (e.g. Flood plains, earthquake fault lines), engineering buildings and infrastructures to withstand earthquakes: and creating and enforcing effective building codes to protect property from floods, hurricanes and other natural hazards, the impact on lives and communities is lessened. Mitigation begins with local communities assessing their risks from recurring problems and making a plan for creating solutions to these problems and reducing the vulnerability of their citizens and property to risk. 3 However, since the mid-1990s, mitigation planning has become increasingly more complex. Terrorist attacks, industrial accidents, and new or reemerging infectious diseases are just a few of the threats that have started to consume more planning time and resources. The growing scope of threats that must be addressed in mitigation strategies challenges all aspects of planning and response at all levels of government. [4] [5] [6] The importance of sharing intelligence information at the earliest possible stage of a terrorist attack, especially a bioterrorism event, is now recognized in national policy as a critical mitigation asset. Theoretically, if there were the slightest indication of a contagious biological attack occurring within the United States, then early recognition triggered by intelligence alerts followed by appropriate local responses could allow for isolation, treatment, and containment of a potentially widespread event. This intelligence sharing must become a large part of mitigation efforts aimed at limiting the effectiveness of manmade disasters. A similar analogy can be made with the early warning given to the medical community when a surveillance system picks up an unusual cluster of illnesses, long before the initial diagnosis may be made at a physician's office or healthcare facility. The new National Incident Management System (NIMS) states that intelligence must be shared within the incident management structure and states that a sixth functional area, or Incident Command System Section, covering intelligence functions may be established during the time of an emergency. The elevated status of intelligence within NIMS establishes the importance of early and effective intelligence sharing. The challenge is to establish these sharing relationships before the disaster by incorporating them into an ongoing hazard monitoring process and by integrating them into drills, exercises, and day-to-day activities to ensure that this critical resource is operational when needed to mitigate the consequences of a disaster. 7 The Disaster Mitigation Act of 2000 (DMA-2000) elevated the importance of mitigation planning within communities by authorizing the funding of certain mitigation programs and by involving the Office of the President. Under DMA-2000, the president may authorize funds to communities or states that have identified natural disasters within their borders and have demonstrated public-private natural disaster mitigation partnerships. DMA-2000 provides economic incentives through promoting awareness and education to prioritize the following objectives for federal assistance to states, local communities, and Indian tribes: • Forming effective community-based partnerships for hazard mitigation purposes • Implementing effective hazard mitigation measures that reduce the potential damage from natural disasters • Ensuring continued functionality of critical services • Leveraging additional nonfederal resources in meeting natural disaster resistance goals • Making commitments to long-term hazard mitigation efforts to be applied to new and existing structures This important legislation sought to identify and assess the risks to states and local governments (including Indian tribes) from natural disasters. The funding would be used to implement adequate measures to reduce losses from natural disasters and to ensure that the critical services and facilities of communities would continue to function after a natural disaster. 8 Further evidence of the expanding complexity of mitigation efforts can be found in the Terrorism Insurance Risk Act of 2002. This act fills a gap within the insurance industry, which typically does not provide insurance coverage for large-scale terrorist events. The federal government, in the wake of the Sept. 11, 2001, attacks, promptly passed this act, addressing concerns about the potential widespread impact on the economy. The act provides a transparent shared public-private program that compensates insured losses as a result of acts of terrorism. The purpose is to "protect consumers by addressing market disruptions and ensure the continued widespread availability and affordability of property and casualty insurance for terrorism risk; and to allow for a transitional period for the private markets to stabilize, resume pricing of such insurance, and build capacity to absorb any future losses, while preserving State insurance regulation and consumer protections." 9,10 Effective mitigation planning now is expected to include many different aspects of private industry. Private industry is a critical partner; its involvement may range from being a potential risk to the community, such as a chemical plant, to providing assistance in responding to an event. This is especially true in the area of healthcare; most healthcare in the United States is provided by the private sector. It is important to note that the National Fire Protection Association (NFPA) recently released NFPA 1600,Standard on Disaster/Emergency Management and Business Continuity Programs, 2004 edition. This standard establishes a common set of criteria for disaster management, emergency management, and business continuity. Planners may use these criteria to assess or develop programs or to respond to and recover from a disaster. 11 Although mitigation planning has become an essential feature of nearly every industry and institution in the wake of Sept. 11, 2001, healthcare settings are disproportionately affected by new challenges and complexities in mitigation. The severe acute respiratory syndrome (SARS) outbreak shook the foundation of mitigation and prevention in healthcare when healthcare workers and first responders in China and Canada died in 2003 after caring for patients with the SARS virus. Access to several Toronto area hospitals was significantly limited for several months because of illness, quarantined staff, and concerns about contamination. The economic costs to the city of Toronto were in the billions of dollars. Hospitals and their communities were thrown into a complex mitigation and prevention crisis. The Association of State and Health Officials (ASTHO) has come out with specific guidelines and checklists to help prepare states and communities prepare for a possible outbreak. 12 Pan-influenza planning closely parallels SARS planning, with considerable effort toward preventive vaccination of the population and emphasis on protecting healthcare workers. 13 Effective strategies were learned during the Toronto SARS outbreak, although it was definitely a "learn-as-you-go-along" situation. The most effective mitigation strategies to prepare for the consequences of an outbreak would be to plan for the home quarantine of patients, establish public information strategies to reduce public concern, to close affected facilities until the knowledge base permitted their safe reopening, plan for a coordinated information and command and control center, and have preestablished protocols and procedures in place to protect the health of healthcare workers and first responders. 14 Vaccination is an essential component of hospital and community mitigation planning. During the fall of 2002, the U.S. government requested that all states prepare for a smallpox attack. The preparations called for each state to present a plan within 10 days to vaccinate all persons within the state, starting with healthcare workers. 15 Each facility and community needs to look at the risk of a disease, the effect of vaccination on healthcare workers, and the ability to maintain continuity of care. If properly informed, healthcare workers could respond and treat patients without risk to themselves or their families. The availability of a vaccination and the ability to mass vaccinate the majority of the population should be considered in all community response plans. The plans for both SARS and paninfluenza now need to address the availability and possible stockpiling of antiviral agents as well as procedures for mass vaccination of the population, if a vaccine were to become available. We have learned much from the many earthquakes, tornadoes, hurricanes, fires, and floods that the United States has experienced, but it is extremely difficult to plan for terrorist and natural events that can quickly overwhelm communities, states, or even the whole nation. These historical events, policy developments, and shifts in public attention have created a very complex planning and operating environment. The next section of this chapter addresses some of the key current practices that mitigation strategists should consider. Current mitigation strategies are as varied as the circumstances in which they are formed. This section illustrates the impact of mitigation through a comparison of responses to two earthquakes that were broadly separated in geography and community preparedness. These examples are followed by a discussion of critical elements of mitigation and risk reduction practice in three broad categories: coordination with other organizations and jurisdictions, hospital concerns, and mitigation strategies based in community health promotion and surveillance. The first step for protecting communities and their critical facilities against earthquakes is a comprehensive risk assessment based on current seismic hazard mapping. This determination of location should also include the assessment of underlying soil conditions, the potential for landslide, and other potential hazards. 15 Communities located on seismic fault lines must also develop and enforce strict building codes. After the Bam, Iran, earthquake, a large section of the city, at first glance, looked like a burned forest with only the bare trees left standing. It soon became clear that these were steel vertical beams standing upright in mounds of concrete rubble. In comparison, after the Northridge, Calif., earthquake many of the buildings were structurally compromised but did not collapse on their occupants. Undoubtedly, this was the result of the strict building codes and enforcement throughout the state of California. To the victims of the Bam earthquake, the most important lifesaving measures may have been the development and enforcement of strict building codes. 16 Building codes are minimum standards that protect people from injury and loss of life from structural collapse. They do not ensure that normal community functioning might continue after a significant event. 17 Structural protection of facilities requires the active role of qualified and experienced structural engineers during planning, construction, remodeling, and retrofitting. The immediate response of a structural engineer after a disaster is to assess building damage and to assist in determining the need for evacuation and the measures needed to ensure continuity of function. Extensive analysis of seismic data taken during an earthquake that are compared with subsequent building damage has given structural engineers valuable information on structural failures of buildings. This information allows communities to rebuild with better and stronger facilities. 18 The following measures to protect the structural integrity of a facility should be in place before an incident 19 : • A contract with a structural engineering firm to participate in planning, construction, retrofitting, and remodeling • A contractual agreement guaranteeing the response, after an event, of a structural engineer (with appropriate redundancy) to ensure structural stability, to assess the need for evacuation, and to take additional measures to ensure the continuity of essential functions • Inventory and classify all buildings • Conduct a vulnerability assessment • Ensure code compliance • Determine public safety risks • Determine structural reinforcement needs, and prioritize them • Prepare lists of vulnerable structures for use in evacuation and damage assessment Extensive resources and technical assistance for structural earthquake protection are available on the Internet. FEMA's Web site itemizes these resources into three major categories: earthquake engineering research centers and National Earthquake Hazards Reduction Program-funded centers, earthquake engineering and architectural organizations, and codes and standards organizations. 20 FEMA has released the Risk Management Series publications, which provide very specific guidance to architects and engineers about protecting buildings against terrorist attacks. 21 The Institute for Business and Home Safety is also an excellent source of incident-specific information for both businesses and homes. 22 The protection of facilities from earthquake damage also involves protecting the facility's nonstructural elements. These nonstructural elements do not comprise the fundamental structure of the building (Box 21-1). Primary damage to nonstructural elements may be the result of overturning, swaying, sliding, falling, deforming, and internal vibration of sensitive instruments. Relatively simple measures, which do not require a structural engineer, may be taken to prevent damage to or from nonstructural elements. These measures may include fastening loose items and structures, anchoring top-heavy items, tethering large equipment, or using spring mounts. Other elements, such as stabilizing a generator from vibration damage by placing it on spring mounts or from sliding damage by having slack in attached fuel and power lines, may require the assistance of an engineer. Hospitals and other medical care facilities are especially vulnerable to damage from nonstructural elements. Consider the placement of routine medical care items such as intravenous poles, monitors/defibrillators, and pharmaceutical agents and medical supplies on shelves. Loss of emergency power to key services, such as computed tomography scanners, laboratory equipment, and dialysis units, may also significantly affect the continuity of medical care (E. Aur der Heide, personal communication, February 2005). 23 Loss of generator power may be due to failure of crossover switches, loss of cooling, or loss of connection of power and fuels lines. A process for the continual review of the power needs of new and critical equipment should be a part of a hospital's emergency planning process. Cooperating with the federal government and understanding the resources, structure, and timeframe in which the federal resources are available are critical to appropriate mitigation planning. 24 NIMS and the National Response Plan are described elsewhere in this book. Each document describes in detail the organizational structure and response authority of the federal government in the time of a disaster. 25, 26 Healthcare organizations, communities, and states are mandated to ensure that their strategies for mitigation, response, and recovery are developed in coordination with these national models. Presidential Decision Directive Homeland Security Presidential Directive (HSPD) #5 mandates that by fiscal year 2005,"the Secretary shall develop standards and guidelines for determining whether a State or Local entity has adopted the NIMS, " 27 and all mitigation and risk reductions strategies should be designed accordingly. In addition to efforts to coordinate with federal plans, mitigation strategists must also build functional partnerships within communities and across jurisdictional lines. This point has been emphasized in several recently published planning guides. 17, [28] [29] [30] These guides help hospitals and their communities plan for mass casualty events by incorporating key features of planning, risk assessment, exercises, communications, and command and control issues into functional and operational programs. Hospitals also present special challenges. Presidential Decision Directive HSPD #8 specifies that hospitals qualify as first responders. 31 As such, they have important mitigation activities to consider. What does mitigation mean for a hospital? In the current threat environment, it means minimizing the impact of an event on the institution and ensuring continuity of care. Accessibility to the public 24-hours a day, seven days a week has been a hallmark of hospital emergency care. However, one of the most important mitigation strategies a hospital can adopt is the ability to limit and control access to patients and families during the time of a mass casualty or a hazardous materials event. Additionally, facilities must have plans and the ability to decontaminate patients, protect essential staff and their families, handle a surge of patients with complimentary plans for the forward movement of patients to surrounding areas, set up alternative treatment facilities within the community, to train staff in early recognition and treatment of illness or injury related to weapons of mass destruction, and ensure continuity of care and financial stability during and after an event. Although hospitals will always form the cornerstone for medical treatment of patients during mass casualty events, best practices for hospitals must now also incorporate healthcare resources within the community. 32 Hospitals will have to work with other first responders within the community to conduct drills and exercises that realistically test the whole hospital's ability to respond to a mass casualty event. 33 Hospitals also will have to ensure that staff members have the proper training to complete hazard vulnerability assessments 34 and to set up and staff outpatient treatment facilities to ensure continuity of care. 35, 36 Even with very careful planning, most communities will be overwhelmed for the first minutes to hours or possibly days after a massive event, until an effective and prolonged response can occur. Communities must also look at the continuity of medical care as a communitywide issue and not just emphasize the hospital or emergency medical services aspects of medical care. The loss of community-based clinics, private medical offices, nursing homes, dialysis units, pharmacies, and visiting nurse services can significantly increase the number of patients seeking care at hospitals during a mass casualty event. Risk communication and education, specifically aimed at protecting the affected population, can help prevent surges of medical patients. 1 Hospitals now have enormous community responsibilities in terms of preparing for and mitigating mass casualty events. Hospitals in hurricane, flood, earthquake, and tornado zones have prepared for many years against these threats. However, a pattern of repeated systems failures within hospitals continues and includes communications and power loss, with additional physical damage to the facility. 37 To prevent such failures, hospitals need to recognize that mitigation and risk reduction planning must approach the level of detail and logistical support that parallels military planning. Surveillance is another key mitigation strategy for health emergencies. Early recognition of sentinel cases in biological events can significantly affect the outcome, particularly in contagious events. States are funded and required to participate in the surveillance programs mandated in CDC and Health Resources and Services Administration guidelines. 38, 39 The earlier an event is recognized, especially if it involves a contagious disease, the earlier treatment can begin and preventive measures can be taken to prevent the spread of illness to healthcare workers and responders, as well as the rest of the community. Public health departments are critical to establishing relationships between local providers and their communities. Local, state, and federal public health agencies must ensure that effective surveillance at the community level occurs. These agencies can also assist in awareness-level and personal protection training for hospital staff, emergency medical service employees, and law enforcement first responders. Motivating healthcare facilities to take part in mitigation is one of the largest challenges in disaster medicine. It is always best to take measures beforehand to minimize property damage and prevent injury and death. In the case of hospitals, some preliminary research indicates that four factors affect an institution's motivation to mitigate: influence of legislation and regulation, economic considerations, the role of "champions" within the institution, and the impact of disasters and imminent threats on agenda-setting and policy making. It was discovered during this research that "mitigation measures were found to be most common when proactive mitigation measures were mandated by regulatory agencies and legislation." 40 Tax incentives, government assistance grants, and building code and insurance requirements may also serve to motivate administrators and decision makers to put the necessary time and effort into mitigation planning. 17 Extensive mitigation activities are a necessary prerequisite for the response and recovery activities that must follow a large-scale mass casualty event. We have never seen the number of casualties in the United States we are preparing for today. We do have the threat of an enemy who will strike within the United States with the purpose of inflicting mass numbers of casualties on the civilian population. We must maintain the perspective that even the smallest chance of such an incredibly devastating event, whether manmade or natural, warrants our full attention. 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