Disaster Response 2.0: Noncommunicable Disease Essential Needs Still Unmet.

Globally and in the United States, 2017 was the most expensive year for disasters ever recorded. Disasters caused more than $337 billion in economic losses worldwide.[1] In the United States, the federal government provided nearly $100 billion in emergency supplemental funding to respond to and recover from recent hurricanes, wildfires, and other disasters.

The recent experiences of Hurricanes Harvey, Irma, and Maria devastated large swaths of the United States and US territories, but their effects are, unfortunately, not new. In 2005, Hurricane Katrina flooded approximately 80% of New Orleans, Louisiana, and decimated the health infrastructure, destroying hospitals, clinics, dialysis centers, and other critical health infrastructure for weeks. A critical problem in the resulting health crisis was "the inability of the displaced population to manage their chronic diseases."[2](p1546) The Center for Disease Control and Prevention (CDC) reported that chronic, noncommunicable diseases (NCDs) accounted for five of the six most commonly reported conditions after Hurricane Katrina.[3] More than 45% of evacuees did not bring their daily medications with them, and so more than two thirds of all medications provided during the response were for the treatment of chronic diseases.[4]

Hurricane Katrina made it clear that NCDs were a critical health gap after a disaster. Aging populations and urbanization, along with changes in environment, lifestyle, and treatment modalities are demonstrated contributors to these growing risks and the vulnerability of large populations. There have been improvements: the Department of Health and Human Services' Assistant Secretary for Preparedness and Response (ASPR), the CDC, and the Centers for Medicare and Medicaid (CMS) have established programs to improve readiness and response. Examples include the ASPR emPOWER initiative, which uses CMS billing records to identify people with high-risk health needs before an event and provide health services after; the CDC created reference site Disaster Information for People with Chronic Conditions and Disabilities (https://www.cdc.gov/disasters/chronic.html); and the CMS created fact sheets for special-needs populations, such as those on dialysis. Many states have joined these efforts by improving their special-needs shelter capacities and creating resources such as the Kentucky Department for Public Health and the University of Louisville Hospital's Disaster Preparedness for Persons With Chronic Disease patient resource manual.

Specific global interventions have also emerged. For example, since 2011, the World Health Organization's (WHO's) Interagency Emergency Health Kit (IEHK) includes psychiatric medications. In 2017, WHO revised the kit to include medications for diabetes, seizures, hypertension, and other cardiovascular diseases.[[5]]

Unfortunately, the 2017 hurricane season demonstrated that there still remain significant gaps in disaster planning and preparedness for chronic diseases. Perhaps the greatest example of our fragile NCD response was the death of 12 patients in a nursing home in Hollywood, Florida, after Hurricane Irma. Moreover, first-person interviews with Hurricane Harvey first responders in Texas and others instrumental in shaping medical response in last year's hurricane season clearly also demonstrated that we have not come far enough. (We conducted telephone interviews with several first responders, including Jennifer McQuade, MD, MS, MA; Regina Troxell, MD; Christina Propst, MD; Kevin Schulz, MD; Ashley Saucier, MD; Bo Brice, MD; and Margie Gerena Lewis, MD.) The interviews described how critical needs were often addressed on the fly, including (1) long-term acute care for assisted living patients requiring nonurgent but life-sustaining interventions such as chronic oxygen therapy, (2) the needs of patients with end-stage renal disease and those who would need to be transported out for dialysis, and (3) triage and care for the more than 10 000 people that arrived at the George R. Brown Convention Center--a shelter that was meant to hold roughly 5000.

Interviewees also indicated that the most common medical needs were for medications for chronic illnesses such as high blood pressure, diabetes, asthma, psychiatric diseases, seizure disorders, narcotic withdrawal, and skin conditions. Many patients did not have their medications or medical supplies, and too many did not know the names of their illnesses or medications or how to access the information. Even when patients did know the names of their medications, the medications were often unavailable in the shelter: insulin arrived only after a social media call to local providers; there were no neuroleptic medications for four days; and albuterol was scarce but used for both acute exacerbations of asthma and hyperkalemia in patients with end-stage renal disease without access to dialysis. In attempting to treat the medical needs of the victims, the first responders had to create census and medical records; track prevalence of diseases and treatments; catalogue medication needs and resources; treat with few resources; and, at the same time, seek more staff, equipment, and resources.

Similar challenges in managing chronic illnesses were mirrored in the aftermath of Hurricane Maria in Puerto Rico and Hurricane Irma in Florida.

There are many unique challenges to improving management of chronic diseases during disasters. High priorities include the following.

• 1. A focus on personal preparedness for those with NCDs. Providers and insurers need to assist patients with personal preparedness plans that include access to resources and kits that include medication lists, medical histories, and emergency stockpiles of medications and durable medical equipment.
• 2. Improved informatics and availability of health care records. (a) Information-sharing platforms need to be strengthened for access to electronic medical records, medication lists, medication allergies, and locations of high-risk patients. Programs like emPOWER can be used to identify and evacuate vulnerable populations before an event or rescue them quickly after. (b) Enhanced smart devices can be used to educate and monitor those with NCDs to prevent an exacerbation of their illness. Uniquely in Houston, the Emergency TeleHealth and Navigation program uses telemedicine to connect emergency physicians with fire and emergency medical service providers to perform a medical screening examination to reduce unnecessary emergency medical services, transportation, and emergency department use.

• 3. Improved access to pharmaceuticals, durable medical goods, and medical records in the aftermath of a disaster. This includes preassembled resource kits, such as the proposed Supplementary Unit for Chronic Diseases presented to the WHO in 2010 which could be deployed within hours of the disaster.
• 4. Establishment of standardized treatment plans, including protocols, decision charts, and data-collection forms to document morbidity, mortality, health needs, and resources.
• 5. First responder and health care professional training modules that are used preemptively and are accessible when needed.

It is critical that these resources be available and accessible within the first few hours of disaster response.

• 6. Expanding special-needs shelter capacity, resources, and budget allocation to prevent those with NCDs from decompensating in the aftermath of a disaster. There is equal value in providing these preventive services at a patient's first point of contact as there is in staffing acute care hospitals for the seriously ill. Keeping a patient out of acute care hospitals by simply providing oxygen, for example, prevents the unnecessary use of higher acuity resources.

Strides have been made in the management of chronic diseases after a disaster; however, there is much more that can be done. The focus needs to be on reducing demand through a focus on personal preparedness for those with chronic disease and improved informatics and availability of health care records, as well as increasing capacity through improved access to pharmaceuticals, durable medical goods, and medical records; establishing standardized treatment plans; developing first responder and health care professional training modules; and expanding special-needs shelter capacity, resources, and budget allocations. With increasing disaster frequency and severity and an increasing prevalence of NCDs and disabilities, struggling to anticipate and actualize prevention of the morbidity and mortality of NCDs in disaster preparedness and response will prove increasingly costly. If not now, when?

We thank Russell Jaffe, MD, PhD; Jennifer McQuade, MD, MS, MA; Regina Troxell, MD; Kevin Schulz, MD; Christina Propst, MD; Ashley Saucier, MD; Alison Schroth Hayward, MD, MPH; May Nour, MD; Bo Brice, MD; and Margie Gerena Lewis, MD, for their contributions to this work and their passion to take care of people in need.

Note. The views expressed here are those of the authors and do not reflect the official policy or position of the Uniformed Services University of the Health Sciences, the US Department of Defense, or the US government.