Journal of Urban Health: Bulletin of the New York Academy of Medicine, Vol. 90, No. 5doi:10.1007/s11524-013-9832-9* 2013 The New York Academy of Medicine

Lessons from Hurricane Sandy: a CommunityResponse in Brooklyn, New York

Michael T. Schmeltz, Sonia K. González, Liza Fuentes,Amy Kwan, Anna Ortega-Williams, and Lisa Pilar Cowan

ABSTRACT The frequency and intensity of extreme weather events have increased inrecent decades; one example is Hurricane Sandy. If the frequency and severity continueor increase, adaptation and mitigation efforts are needed to protect vulnerablepopulations and improve daily life under changed weather conditions. This fieldreport examines the devastation due to Hurricane Sandy experienced in Red Hook,Brooklyn, New York, a neighborhood consisting of geographically isolated low-lyingcommercial and residential units, with a concentration of low-income housing, anddisproportionate rates of poverty and poor health outcomes largely experienced byBlack and Latino residents. Multiple sources of data were reviewed, including streetcanvasses, governmental reports, community flyers, and meeting transcripts, as well asfirsthand observations by a local nonprofit Red Hook Initiative (RHI) and communitymembers, and social media accounts of the effects of Sandy and the response to dailyneeds. These data are considered within existing theory, evidence, and practice onprotecting public health during extreme weather events. Firsthand observations showthat a community-based organization in Red Hook, RHI, was at the center of theresponse to disaster relief, despite the lack of staff training in response to events such asHurricane Sandy. Review of these data underscores that adaptation and response toclimate change and likely resultant extreme weather is a dynamic process requiring anofficial coordinated governmental response along with on-the-ground volunteercommunity responders.

KEYWORDS Climate change, Vulnerable populations, Community engagement

INTRODUCTION

In the New York metropolitan area, Hurricane Sandy (Sandy) resulted in 97 deaths;produced major power outages, some lasting weeks; and created billions of dollarsin structural damage.1 Sandy was a reminder that coastal cities are especiallyvulnerable to major storms and rising sea levels. Many major cities, including partsof New York City (NYC), are in hazard-prone areas, either near the coast or in floodplains. Governments are responsible for identifying vulnerabilities of such at-riskurban areas and for applying adaptive measures to increase the resiliency of thesecommunities in order to reduce the damaging effects of weather-related disasters.2,3

Schmeltz, González, Fuentes, and Kwan are with the School of Public Health and Graduate Center,City University of New York, New York, NY, USA; Ortega-Williams is with the Fordham University,New York, NY, USA; Cowan is with the Red Hook Initiative, Brooklyn, NY, USA.

Correspondence: Michael T. Schmeltz, School of Public Health and Graduate Center,City University of New York, New York, NY, USA. (E-mail: mschmeltz@gc.cuny.edu)

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Red Hook, Brooklyn, was vulnerable to Sandy since it lies on a peninsula and isisolated from the remainder of Brooklyn by the Brooklyn–Queens Expressway(BQE).4 It is a densely populated area (pop. 11,069 in 0.82 square miles) with someof the largest public housing complexes in NYC. The community has a 45 %poverty rate and high levels of asthma and diabetes.5,6 When Hurricane Sandylanded on October 29, 2013, the major disaster plans anticipated aftereffects such aselectrical fires, flooding, and displacement of populations residing in evacuationzones. However, these plans, as critics had suspected, did not address extensive andlong-lasting power outages and subsequent lack of key services. Without electricity,heat, or running water for 2 to 3 weeks, garbage collection, or local health clinicalservices, the residents experienced an inability to cook, did not have access to cleandrinking water or have proper sanitation within their homes, as well as experiencedincreased exposure to the elements and limited access to routine medical care.

The focus of this paper is not to critically analyze adaptation strategies but tohighlight the community response to Sandy in one community and to providepotential public health lessons to better inform future adaptation, mitigation, andresponse plans, especially for coastal cities with diverse urban populations, includingvulnerable populations.

BACKGROUND

Given the predicted continuing rise in global temperature, evaluation of the effects ofclimate change should focus on public health needs of vulnerable populations.Vulnerability assessments, public health researchers agree, are a key part of planningto enhance adaptation and response to extreme weather events; they also agree thatidentifying vulnerable subpopulations remains a key issue in plan development.7–13

Such vulnerable populations include the elderly, who are more physiologicallysusceptible, and the poor, who have fewer resources to prepare for and cope withextreme weather events.14 Indeed, some suggested vulnerability assessment strategiesuse a local-level approach (that is, a bottom–up, rather than top–down, planningsystem), which in turn informs adaptation strategies and may build resilience atmultiple community levels through early anticipation and response to problems.15–18

A key feature in the field of vulnerability assessment is “how the adaptive capacityof individuals, households and communities is shaped and constrained by social,political, and economic processes at higher levels.”16 This interaction between localand “higher” levels is thought to be important in developing realistic adaptationplans that serve multifaceted needs. Vulnerability assessments provide the evidenceand build the political will necessary to design, fund, and implement adaptivemeasures that reduce the costs of interventions and responses,19–21 protectvulnerable populations, and save lives during extreme weather events.22 Red Hookis prone to flooding, was in a mandatory evacuation zone, and was severely affectedby Sandy.23,24 It provides an apt case study of response to a weather disaster.

SETTING

The New York City Housing Authority (NYCHA) buildings, Red Hook East andRed Hook West (known as the Red Hook Houses), were completed in 1955 andprovided much needed low-income housing in the area with a total of 2,878apartments, some as high as 14 floors.25 The Red Hook Houses are the secondlargest public housing complexes in New York State and among the largest in the

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country.26 Beyond the public housing residents, Red Hook includes a range ofstakeholders including small business owners, churches, primary schools, public andprivate home residents and retail giants new to the area (e.g., IKEA and FairwayMarket).27

Despite many community strengths, Red Hook has numerous vulnerabilities. RedHook has a higher percentage of people living in poverty, lower percentage of adultswith a high school diploma or higher, and a higher concentration of residents under18 years of age compared to NYC as a whole (see Table 1).5 In Red Hook, 85 % ofresidents are Black or Latino; data indicate they are more likely to be exposed tosocial risk factors, increased barriers to health care, and compounded stressors thannon-White residents.28,29 In 2009, a health assessment survey for the residents of theRed Hook Houses was conducted to explore how sharing the 11231 zip code withan adjacent affluent neighborhood might mask health disparities.6 Their findingshighlight the following health disparities: 18 % of Red Hook Houses respondentshad been diagnosed with diabetes versus 6 % in the 11231 zip code and 9 % in allof New York City. Twenty-six percent of respondents had been diagnosed withasthma compared to 8 % in the 11231 zip code and 5 % in all of New York City.While 89 % of Red Hook Houses respondents had health insurance, nearly 80 % ofthose uninsured earned less than $20,000.6 Specifically, 49 % of respondents whodid not have health insurance earned less than $10,000 while 29 % earned between$10,000 and $20,0000.6

EXISTING ADAPTATION AND MITIGATION PLANS FOR NYC

Studies projecting risks posed to NYC by climate change state that sea level rise,coastal storms, and extreme heat events will continue to affect the city.30–32 Whilethere are many vulnerability assessments and adaptation plans for NYC in theacademic literature that seek to identify vulnerable geographical areas andpopulations,33–35 there are few official government assessments for adaptation toclimate change in NYC. For example, the New York City Hazard Mitigation Plan,

TABLE 1 Demographics of NYC and Red Hook, Brooklyn

NYCa Red Hook, Brooklynb

Total population 8,244,910 11,069Under 18 years (%) 22 % 31 %Female (%) 53 % 56 %Race/ethnicityBlack (%) 26 % 38 %Hispanic or Latino origin (%) 29 % 47 %White, not Hispanic (%) 33 % 13 %

EducationHigh school degree or equivalent (%, 25 years and older) 25 % 14 %Bachelor’s degree (%, 25 years and older) 20 % 10 %

IncomeMedian household income $51,270 $40,026Persons below poverty level (%) 19 % 45 %

a2010 US Censusb2009 American Community Survey for census tracts 0085, 0057, 0059. Source: US Census: American

Community Survey5

LESSONS FROM HURRICANE SANDY: A COMMUNITY RESPONSE IN BROOKLYN 801

produced by the NYC Office of Emergency Management (NYCOEM), and PlaNYCfrom the Office of the Mayor are official assessments incorporating human healthaspects into adaptation and mitigation planning.26,36 The Federal EmergencyManagement Agency (FEMA) provides training for community emergency responseteams (CERT) to assist in disaster recovery by linking community members and localgovernments.37 However, to successfully implement a CERT, coordination betweenFEMA, local emergency management officials, and on-the-ground communitygroups is needed. Unfortunately, neither of the NYC plans lists the involvement ofCERTs in their adaptation and mitigation efforts.

Critics of PlaNYC claim there has been limited and disorganized communityengagement to inform this particular official response plan.38–41 While PlaNYCmentioned a continued engagement of vulnerable populations, there are nomethodological agenda stated in the plan for this outreach and engagement.PlaNYC’s main focus is sustainability by improving mitigation efforts to combatthe negative effects of climate change by reducing greenhouse gases (e.g., throughtransportation alternatives, increased green spaces). The NYC Hazard Mitigationplan provides only a broad spatial and secondary data analysis to identifyvulnerable populations without actively engaging communities.6,23,36 Both plansfail to incorporate community-level adaptation capabilities for dealing with climatechange at the local level; nor is health data indicative of the health vulnerability ofindividual NYC communities addressed in the aforementioned adaptation plans.

DATA SOURCES

This field report describes on-the-ground response efforts in Red Hook, primarilyfrom the perspective of several board members and staff from Red Hook Initiative(RHI), a nonprofit organization whose mission focuses on creating social changethrough youth development and leadership. RHI served as an information andservice anchor in the aftermath of Sandy. Data sources for this report include twoseparate firsthand accounts from a RHI staff person and a board member who wereon the ground during the event and well known in the community before Sandy. Inaddition, to triangulate data, the following were reviewed: minutes from fourcommunity meetings before utilities were restored in Red Hook, personal textswhich provided a timeline of events, and finally, social media including the Twitterfeeds and Facebook posts of the Red Hook Initiative and a New York City Councilmember.

HURRICANE SANDY EVENTS AND PUBLIC HEALTHIMPLICATIONS IN RED HOOK

Despite a mandatory evacuation order for Red Hook, many residents did not leavesince Hurricane Irene’s minimal impact, the year prior, provided a false sense ofsecurity. Additionally, residents conveyed they feared, “they may not be allowedback in once they were evacuated.”42 Despite posted mandatory evacuation flyerson all building floors, with instructions to residents when they should evacuate andby what means, with transportation to shelters provided, many preferred to stay intheir apartments and homes. This sentiment was similar to that of residents of publichousing in New Orleans during Hurricane Katrina.43

The timeline shown in Fig. 1 presents an overview of the events in Red Hook inthe weeks after Hurricane Sandy. As there were multiple players on the ground

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during a rapidly changing situation, this timeline serves as one of many possibleillustrations of key events that occurred. The only health clinic in the neighborhoodwas flooded; clinic staff, nurses, and doctors were evacuated. A local resident, amedical student, assembled a lay and professional team of medics to canvass theneighborhood using a basic medical intake form he created. The team targetedsenior citizens and other homebound individuals, particularly those who wererunning out of vital medications or were on life-assisting devices in public housing.44

In the first week, the team saw an estimated 250 to 300 patients. Nearly 2 weeksafter the storm, the clinic reopened largely due to volunteer groups’ ability to obtaingenerators and recruit volunteers for rapid cleanup efforts.

Running water, electricity, and heat were restored at different periods in RedHook. After 11 days, running water was restored, during which time, residents hadto leave their homes for food and drinking water and could not flush their toilets.Electricity was not fully restored to most of the Red Hook Houses until 3 weeksafter Sandy landed, including the period when NYCHA preemptively shut downelectricity before Sandy made landfall to prevent additional damage and thepossibility of fires when the storm arrived.45 Some residents experienced intermittentelectrical outages through the remainder of the year. Volunteers and RHI staffcanvassed the Red Hook Houses to tabulate where utilities were restored.Occasionally, this information conflicted with the official NYC estimation broad-casted by local news media. The lack of communication about utilities and progressto restore them was frustrating to residents, some of whom voiced their despair atcommunity meetings with public officials.

There was no heat for Red Hook Houses residents for 17 days, between October30 and November 15, during which time the city faced average temperatures in themid-40s (degrees Fahrenheit)46 and a winter Nor’easter a week after Sandy.Exposure to cold temperatures for long periods of time can lead to hypothermia

Oct 27: NYCHA begins shutting down elevators, boilers, electrical systems

Nov 15: Heat begins to be restored for RH Houses (Day 17)

Oct 29: Hurricane Sandy hits NYCOct 30:

RHI opens as warming/charging center, serves breakfast, and by end of day was a food pantry.Volunteers start reaching out.Medic team (“Medic Matt”) and his team conduct neighborhood canvassing.Addaboo, the one neighborhood clinic is flooded

Oct 31: Restaurants do a cook out. Occupy Sandy begins coordinating clean up.RHI assesses what community partners are open andfunctional.Nov 1:

National Guard on groundFood delivery from RHI coordinated for homebound

Nov 4: RHI space heater distribution in NYCHA parking lot with NYCHA police support and social work escorts

Nov 6: Election Day – Obama re-elected

Nov 7: Snow Day – no heatThree NYU doctors with “medic team”to help withreferrals to primary care + needs assessment300 residents already visited and supportedBrooklyn Hospital sends van + 2 doctors

Nov 5: Community meeting held

Nov 11: Community meeting heldNov 12:

Power back on for most RH HousesNYCHA, for first time, does canvass of elderly, sick and shut in127 people treated and brought to hospital

Nov 14: Community meeting held

Nov 8: Portable lights in streetsPorta potties arriveRunning water back“Medic team”moves from RHI to Addabo that has temporary generators running

FIGURE 1. Timeline of events in Red Hook, New York, during and after Hurricane Sandy.

LESSONS FROM HURRICANE SANDY: A COMMUNITY RESPONSE IN BROOKLYN 803

and can increase the risk of a heart attack and pneumonia. For a community withhigh asthma rates and other underlying medical conditions, this was a potential riskfactor for upper respiratory infections (URIs). Water damage can aid mold growthand in turn exacerbate respiratory ailments such as asthma, chronic obstructivepulmonary disorder, bronchitis, and other respiratory infections, the rates of whichincreased among people affected by flooding due to Hurricane Katrina.47–49 Oneexample of a URI, potentially among many, was the story of a young person whocontracted pneumonia after a few weeks of engaging in relief work and living in theRed Hook Houses. In addition to health concerns from disease and sanitation issues,there were security concerns due to the darkness that covered the neighborhood forweeks. Although there was no reported or documented crime of communitymembers within the area, there was a feeling of unease.

COMMUNITY PARTICIPATION AND NEEDFOR COORDINATED RESPONSE

One benefit of geographic isolation is the opportunity for community stakeholdersto establish and maintain strong social networks and have a profound understand-ing of the inner workings of the community. High social capital within theneighborhood that might not be replicable in other vulnerable communitiescontributed to Red Hook’s resiliency in the weeks after Hurricane Sandy landed.Individual groups including volunteers from outside of Red Hook, residents, andlocal community-based organizations (CBOs) had important resources they wereable to bring to bear on the problems that emerged. Their efforts were coordinatedto provide hot meals, resource and information distribution, and limited access toelectricity. To address the lack of refrigeration and gas to cook meals, RHI and othervolunteers coordinated efforts to deliver food, medicine, and ice for medication tothe homebound. This service began as early as the day after the storm and continuedover a 3-week period. Activist groups used online registry tools (e.g., typically usedfor wedding registry) to collect donations for NYC and then triage them to high-need areas. RHI also utilized social media to communicate beyond Red Hook whenfood, supplies, and volunteers were needed for specific tasks. This approachtranslated into 300 contributors per day for 3 weeks. It was not until governmentofficials arrived that public health needs were addressed. The government providedporter potties, generated powered floodlights for public safety, and coordinatedstreet sanitation pickup and transportation to and from shower facilities. This casestudy demonstrated how Red Hook, an urban environment without running water,heat, and electricity, was exposed to potential for disease transmission (e.g.,diarrheal disease) and exacerbation of underlying medical conditions (e.g., upperrespiratory infections).50–52

LIMITATIONS

The primary limitation of this report is that it is written from the perspective ofindividuals closely affiliated with a single CBO in Red Hook, RHI. The authorsrecommend that a full case study be undertaken to provide a more inclusive lens ofthe Red Hook experience. Another suggestion is to undertake a comparative casestudy to allow researchers to examine how other geographically vulnerableneighborhoods fared during this period to learn about the strengths and weaknesses

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of the existing adaptation and mitigation plans. Despite these limitations, weprovide recommendations based on the experiences described above.

CONCLUSION AND RECOMMENDATIONS

We document the community response to unfolding challenges, coordination oflocal efforts, and emerging liaison with government entities and then argued forfuture vulnerability assessments that encourage input from local communities onplanning and response. This case study revealed that the current process for gettingcity-, state-, and federal-level help in responding to emergency weather situationshighlighted a lack of coordinated government response and that the immediateresponse relied on individuals and CBOs. A tenet of public health is to first, do noharm. While having local CBOs, churches, other community groups, and volunteerscollaborate as first responders was encouraging, this highlighted a lack ofcoordinated disaster planning and response. Collaborations between governmentand on-the-ground volunteer responders, including CBO staff and other volunteers,should be formalized in adaptation and mitigation plans.

We argue that future plans need to include meaningful community input todevelop a bottom–up and realistic approach to planning for the next naturaldisaster. While RHI, a social service agency with no disaster response training, wasable to assemble a response and relief effort akin to a CERT program, there shouldbe an officially trained front-line team organized by government officials capable ofresponding to emergency situations. Preparedness efforts should include engagingorganizations from vulnerable communities prior to extreme weather events, torecruit and train individuals who can serve on these teams in an official capacity.Government agencies have the resources and organizational infrastructure toquickly and efficiently respond to public health needs of affected communities,while local organizations and communities can provide networks and communityknowledge to identify vulnerable populations and direct recovery implementation.One key example of this type of collaboration during Sandy recovery efforts camefrom FEMA reaching out to CBOs for direction on where to deliver 4,000 blankets.

Is it possible that measures in the form of generators or additional power andwater alternatives taken near low-lying areas prior to the storm could improverecovery and relieve the stress placed on this and other geographically vulnerablecommunities? Are there particular measures and resources that can be madeavailable in public housing to protect low-income residents? These are questions thatshould be posed to community members, utility companies, and most importantly,to government officials. Similarly, understanding that the only clinic in Red Hookwas vital to the community’s routine medical care is another issue that needs to beaddressed prior to a disaster. An alternative to primary care and chronic illnessmaintenance is critical so as not to drain key emergency services during immediaterecovery. Mandatory evacuation as a policy needs to be reanalyzed as well. Forexample, will transportation be provided? Will special needs populations havesufficient care at shelters? How long can a shelter maintain a displaced population?What is needed to encourage relocation and reintegration? Communities that arerequired to evacuate and use shelters should have their needs heard and addressed tofacilitate and support evacuation efforts. Vulnerability assessment theory andpractice literature postulate that improving bottom–up approaches to adaptationcan help in building resilience in vulnerable populations and reducing the negativeeffects from extreme weather events caused by climate change.15,16,53 As presented

LESSONS FROM HURRICANE SANDY: A COMMUNITY RESPONSE IN BROOKLYN 805

in this paper, the community members that make up Red Hook had comprehensiveknowledge about its strengths and weaknesses during an extreme weather event.Future adaptation efforts should stem from this foundation.

Finally, contingency plans must be in place, especially in large housingdevelopments like the Red Hook Houses, and accessible to the community toquickly and efficiently address critical infrastructure issues. Transporting portablefacilities 9 days after Sandy landed is far too long to leave any urban populationwithout access to proper sanitation. Closure of the only clinic in Red Hookhighlights a need for clinics to have emergency preparedness plans. These planscould include: staff assignments, generators on site to support community recoveryfor routine nonemergency medical needs, and identifying alternate locations if clinicsare in low-lying areas. With some effort, response to extreme weather events willresemble other rapid responses from emergency services, such as EMTs and the firedepartment the public have come to rely on.

The authors of this article are hopeful that the government will provide a safetynet for those who are most vulnerable by investing in plans to improve responseefforts to extreme weather events—plans that actively engage the community,respond to needs with appropriate resources, and collaborate with and draw fromthe knowledge base that exists within the various low-lying neighborhoodsthroughout the country.

ACKNOWLEDGMENTS

This piece is written with deep gratitude and appreciation to the Red Hook Initiativeand broader Red Hook community. We are in your debt for lessons about thehuman spirit in the aftermath of Hurricane Sandy.

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This document is a companion document to the Emergency Responder Health Monitoring and Surveillance, National Response Team Technical Assistance Document found at: ERHMS.nrt.org

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A high priority of the National Response Team (NRT) is the preparation of emergency responders and decision makers for planning and conducting effective response and recovery activities while maintaining high standards of responder safety and health. The Emergency Responder Health Monitoring and Surveillance (ERHMS) NRT Technical Assistance Document (TAD) is designed to provide the response community with a comprehensive framework for collecting important elements of responder safety and health in an organized, systematic manner and to utilize this data to optimize the health and safety of emergency responders and recovery workers prior to, during, and after their response to man-made or natural incidents. It is also intended for use by emergency response planners developing local and regional response plans in the context of the U.S. National Response Framework, the National Incident Management System, and other federal and state guidance that has been issued in recent years.

In an effort to provide a concise and practical overview of the ERHMS system for the supervisory personnel involved in emergency response planning and execution, this “Guide for Key Decision Makers” was written to serve as a companion to the complete technical assistance document. It provides a step by step summary of the components of the ERHMS system, its primary data requirements, primary recommendations, and key decision points, and it outlines the type of health and safety reports that the ERHMS system can provide to decision makers. To function optimally, the ERHMS system requires the support and involvement of senior response personnel. This companion piece will help supervisory personnel understand how they can facilitate the implementation of the ERHMS system, anticipate its safety and health data requirements, and utilize ERHMS recommendations to optimize the safety and health of emergency responders under their command.

Target AudiencesThis document is intended for those organizations and individuals responsible for planning and executing an incident response that optimizes the health and safety of response, remediation and recovery workers. The intended audience is decision makers at the local, regional, state, tribal, and federal levels who are responsible for decisions affecting the occupational safety and health of responders. These decision makers include:

• Elected and appointed officials• Incident commanders• Planners across disciplines that support emergency response• Leaders of emergency-response departments• Managers of healthcare/public safety organizations• Voluntary organizations active in disasters

Key Emergency Responder Protection PrinciplesWhen disaster strikes, the nation depends on emergency response workers who are prepared and trained to respond effectively. Response work can range from well-contained, localized efforts to massive, diffuse mobilizations and involves a broad array of activities including search, rescue, investigation, assessment, recovery, cleanup and restoration. Such work is carried out by individuals from emergency management, fire service, law enforcement, emergency medical services, public health, construction and other skilled support, disaster relief, mental health, and volunteer organizations. To ensure that emergency workers can meet the challenges of disasters, every effort must be made to protect them from the safety and health risks inherent in their work. Concerns about worker safety and health are apparent in nearly every type of response, and an effective framework of health monitoring and surveillance of workers is necessary to recognize possible health issues and bring these potentially devastating hazardous situations under control.

Previous emergency events have demonstrated that despite analyzing and applying ‘lessons learned’, significant gaps continue to exist in emergency response workers health monitoring and surveillance. These gaps were documented in the Government Accounting Office and Rand reports prepared following the World Trade Center response, but these problems have persisted and, despite improvements, were observed again in Hurricane Katrina and Deepwater Horizon responses.

The persistence of these gaps in emergency responder health monitoring and surveillance, despite considerable attempts to anticipate and correct them, emphasizes that there remains a need for a coherent, comprehensive

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approach to protecting emergency response workers and a need for detailed, practical guidance on how to implement such an approach. Any effort to meet this need must incorporate a variety of measures, including the following:

• Medical screening that focuses on assessment of readiness and ability to safely and effectively deploy on a response

• Training regarding hazards to be anticipated and protective measures to mitigate them • Approaches to centralized tracking or rostering of responders • Surveillance and monitoring for exposures and adverse health effects, including supporting efforts in

environmental monitoring and assessment • Out-processing assessments on completion of response duties and deployments • Follow-up including long-term surveillance or monitoring for potential delayed or long-term adverse effects

of the deployment experience The guidelines, recommendations, and procedures utilized to implement these protections are designed to be fully compatible with and function within the National Incident Management System (NIMS), which has been adopted as the accepted standard organizational focus for emergency response at all levels (local, state and federal) and for all incident sizes and types. Before a response occurs, it is crucial that the ERHMS system is well understood and incorporated into planning and procedures by Incident Command leadership, as well as health, safety, and medical personnel.

Concise Overview for Incident CommandersThe ERHMS system is designed to provide real time data and recommendations on health and safety issues that arise among the responders involved in an emergency response. For example, it could potentially provide incident command with:

• A complete roster of responders involved in the response to date (including spontaneous volunteers) • A summary of data regarding responder readiness (health status, incoming training level, receipt of on-site

training, certifications, and credentials)• A summary of occupational health and safety issues that have occurred among responders to date, with

recommendations for reducing concerning trends• Identification of responders or responder groups who have experienced hazardous exposures during the

response, with recommendations for tracking of their health after the event for future health effectsTo ensure that the valuable information produced by the ERHMS system is made readily available to Incident Command, the Incident Commander should identify a component of the ICS structure that will be given the responsibility for implementing ERHMS, ideally soon after the ICS command has been identified. We recommend that this function be assigned to the Safety command within the ICS structure and should act in cooperation with the medical assets involved in the response. The lead members of this “ERHMS Unit” will have several responsibilities, which include:

• Ensuring that all safety officers are given the knowledge and tools they need to carry out ERHMS functions• Serving as the central point for the collection of data that is necessary to allow ERHMS to fulfill all its

functions (A software system is being designed by NIOSH to facilitate this process.)• Assigning qualified personnel for the analysis and interpretation of the data, and the production of updates,

reports, and recommendations based on these reports The complete ERHMS technical assistance document is designed to prepare and assist the ERHMS Unit by providing them with the knowledge and tools they will need to implement the full range of functions within the ERHMS system. The following is a brief overview of these key functions and responsibilities, the key deliverable items that the Incident Command can expect to receive from the ERHMS Unit, and the steps that the Incident Command should take to help facilitate the functioning of ERHMS.

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Summary of ERHMS Functions, Decision Points, and DeliverablesPre-deployment: There are a number of key activities that should ideally be conducted by a responder organization before they deploy their responders to an emergent event, such as medical screening, credentialing, and safety training. The responder organization should document these activities either in electronic or written format, and the data from these records should then be made available to the ERHMS Unit for utilization during and after a response. If these activities were not completed prior to the response or the data is not readily available, then such functions can be carried out, for example, through the use of responder surveys near the outset of the response.

The following is a brief overview of the pre-deployment activities that should ideally be conducted by responder organizations and the deliverables that the Incident Command can expect to receive based on these data:

Rostering and Credentialing:A basic tenet of safety and health in emergency response is to maintain accountability for all emergency responders. The registration and credentialing system of emergency response and recovery workers should be designed to support four interdependent, interoperable functions: (1) registration (records basic and credential information on each worker); (2) emergency credentialing (assigning a credential level based on responder certifications and education); (3) re-verification (periodically verifies responder information); and (4) emergency badging (assigning an identification badge in accordance with the credential level). Since the information requirements of each function are interdependent, these four functions should ideally be integrated within a single database.

Health Screening: Within the framework of an ERHMS system, pre-deployment health screening is intended to establish a baseline physical and emotional health status. Such information may be obtained from an entrance physical examination to determine fitness for duty, or from subsequent medical examinations. This baseline information allows for more informed interpretation of possible post-deployment adverse health effects and is particularly valuable when exposure information is difficult to obtain, interpret, or is completely absent. Baseline health status should address not only the responder’s physical health status but also emotional health status and immunization status.

In addition to providing baseline health information, the pre-deployment screening can serve as an opportunity to assess whether the responder has the appropriate education, training, and experience to perform assigned response duties.

Deliverable: Each participating response organization should develop a complete roster of their responders that includes data on each responder’s credentials.

Decision Point: A key initial task of the ICS command structure is to determine if the activities required for ERHMS in the pre-deployment phase have in fact been completed by participating responder organizations and that the data from these activities is made available to the ERHMS Unit. If not, they should facilitate the procurement of such data by direct survey of participating responders.

Deliverable: Each response organization’s roster should include the designation of “fit for response duty” for each responder listed, as appropriate. Data related to this determination may later be needed for analysis purposes.

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Training: Training is critical for the preparedness of the responder. The responder is required to be fully certified to perform duty-specific tasks, which may have federal, state or locally mandated training requirements. In addition, the ability of the responder to recognize and avoid possible health and safety risks will affect the responder’s performance, survivability and resilience during and after the disaster response. Regardless of the training a responder has received prior to a disaster, there will be a need for additional training focused on site-specific hazards, operating procedures, and available resources. This training is sometimes referred to as “orientation,” “just-in-time (JIT),” and “toolbox or tailgate talks” during the disaster but will be referred to as “site-specific training” in this document. The ERHMS system could provide insight into areas that may be responsive to increased responder training or require adjustment to reduce possible injuries or near misses. Additionally, the ERHMS system could provide a valuable source of post-disaster data to evaluate the impact that responder training had on minimizing responder illness and injury. The ERHMS system may be used as an evaluation tool to determine the effectiveness of preparedness training, as well as the impact of site-specific training on specific types of injuries or accidents.

During deployment: Over the course of an emergency response, there are various health and safety functions that should be conducted by various components of the Incident Command, including the Safety, Planning, and Logistics sections. Such functions include on-site training, exposure assessment, development of health and safety plans, and surveillance for injuries and illnesses occurring to responders. The ERHMS Unit must be able to collaborate and work closely with the various command components responsible for these functions in order to obtain all the necessary data that is crucial to the functioning of the ERHMS system.

The following are the list of functions that the ERHMS system recommends be conducted during a response (and their subsequent data made available to the ERHMS Unit), the deliverables that the Incident Command can expect to receive, and the considerations that the Incident Command should take to help facilitate the functioning of ERHMS during the response.

On-site Rostering: The process of personnel identification, accountability, and tracking can be referred to as the responder roster. Whenever the level of response is greater than what the first tier of local responders can handle, a roster should be used to log everyone who reports to the disaster area and is engaged in response or remediation work. The Logistics Section is responsible for collecting this information into a comprehensive rostering system, but components of accountability also include parallel and linkable procedures conducted by Planning (example–demobilization) and by Command (Safety Officer). Site-specific training (SST) should be performed prior to responders entering a designated disaster control zone and is required under 29 CFR 1910.120. Strategies for implementing SST should be pre-planned to the extent feasible with consideration given to different training materials necessary to meet expected and unexpected health and safety hazards on site. A variety of PPE may be needed by response workers and volunteers, and for many workers, this equipment will be issued to them during their SST training or during check-in procedures as they arrive at the response scene and are placed on the response roster. This central function or location for issuing PPE to responders serves as an opportunity for recording the amount, type, and condition of the PPE that is issued, allowing for documentation of these data within the ERHMS system.

Deliverable: Each response organization’s roster should include a listing of key training courses completed by each responder.

Decision Point: Soon after an ICS Command has been identified for a given response, the command should appoint an ERHMS Unit in charge of collecting and analyzing the responder safety and health data that is required by the ERHMS system. The command should facilitate collaboration and sharing of data between this unit and other key sections of the ICS command, such as Safety, Planning, and Logistics.

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Health Monitoring and Surveillance: Health monitoring and surveillance are two different but complementary methods to protect the health and safety of incident responders during an emergency operation. Monitoring refers to the ongoing and systematic collection, analysis, interpretation, and dissemination of data related to an individual incident responder’s injury and illness and exposures status. This allows for the evaluation of the occurrence of an exposure, determination of the level of exposure an individual responder might experience during duties, and assessment of how that exposure is affecting the individual responder. Surveillance refers to the ongoing and systematic collection, analysis, interpretation, and dissemination of illness and injury data related to an event’s emergency responder population as a whole. This allows for the tracking of emergency responder health (illness and injury) trends within a defined population during response and recovery. A mechanism to allow surveillance should be an integral part of the response to any event.

Response Activity Documentation and Safety Controls Documentation: Response workers and volunteers may be exposed to many different chemical and environmental hazards in the course of their work. Obtaining accurate and useful worker exposure information is a crucial element in ensuring exposures are correctly characterized, risk is communicated appropriately, and sufficient information is available for making evidence-based decisions (i.e., PPE and work practice controls) to protect the health and safety of response workers. The exposures addressed in this document include chemical and physical hazards, as well as “psychological toxins”, fatigue, and the factors contributing to and increasing fatigue. Psychological toxins include sights and smells of death, exposure to the wounded, and risk of becoming a casualty. There are three risk management decisions, as described later in this document that safety officers, industrial hygienists and other public health professionals ascertain from the assessment process: acceptability of exposures, unacceptability of exposures and uncertainty of exposures (which requires further information gathering).

Decision Point: The Incident Command should facilitate on-site rostering by leveraging opportunities from other command functions, such as check-in procedures, badging procedures, or on-site training events.

Deliverable: The ERHMS Unit will compile an on-site roster of all responders who are physically present at the response event.

Decision Point: The Incident Command should facilitate the acquisition of injury and illness data from a variety of sources, including safety records, on-site medical facilities, state and local emergency departments and clinics, and federal medical resources assigned to the event.

Deliverable: The ERHMS Unit will compile and assess available data regarding injuries and illnesses that occur to responders over the course of the response, as well as compile and assess any health monitoring data available for those responders whose health and safety are being closely monitored.

Decision Point: The Incident Command should facilitate the documentation of responder activities by leveraging various sources of data, including daily safety plans, check-in and out logs, and pay records

Deliverable: The ERHMS Unit will compile available data regarding responder activities, their use of personal protective equipment, fatigue risk factors, and pertinent data from the Health and Safety Plan.

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Communication of Exposure and Health Monitoring and Surveillance Data during an Emergency Response: Communication is critical throughout the course of an emergency response. There are multiple components to communications during an emergency response, including psychology (phase-dependent), messaging (content, timing), audiences, and spokespersons. The collection of environmental exposure data and individual health and safety monitoring data, along with aggregate surveillance data, are relevant to protecting all the responders involved in an event both in the short-term and long-term, but it is not an end unto itself. This information must be communicated to workers, intra-organizationally, inter-organizationally, and inside and outside the ICS structure. Although it is common for organizations to track and report data they are collecting within their own operational structures, the need for tracking and communicating more broadly than a single organization is key to informing responders (e.g., workers, contractors, volunteers) about proactive steps they can take to protect themselves from hazardous exposures while attempting to protect the environment, identify survivors, or recover those who have died.

Post-deployment: Although listed as post-deployment in nature, the following activities of the ERHMS system should be initiated while the response is ongoing. The first function assigned to this phase of ERHMS is the out-processing assessment, which captures data from the individual responder as they are completing their time spent at the response. Data and information obtained from departing responders can, on an ongoing basis, be included in analyses that might lead to identification of responders that would benefit from post-event tracking of their health. This determination may be made for certain groups of responders before the overall response has finished, and thus is really a function that begins during the event, though often may be delayed until complete exposure assessment and environmental analysis becomes available. The following is a summary of the “post-deployment” activities of the ERHMS system and the deliverables that the Incident Command can expect to receive. The ERHMS Unit conducts these functions during the timeframe of the response and may then hand off this function to appropriate authorities who are officially assigned such duties in the formal post-response phase.

Out-processing Assessment: The out-processing assessment is the minimum post-deployment evaluation that should be conducted for responders. Out-processing assessments are conducted to determine the extent, if any, to which individual responders have been adversely affected by their work during deployment and to assess trends within the population of workers for the purpose of identifying potential risks to others. Responders often encounter complex, uncontrolled environments which can involve multiple or mixed chemical exposures, hazardous substances, microbial agents, physical agents (temperature, noise, etc.), long work shifts, or stressful experiences. Therefore, all responders should receive an out-processing assessment as part of the demobilization process or as soon as possible after demobilization. Out-processing assessment should be simple, concise, and standardized. Ideally, the out-processing assessment would be a face-to-face interview in the field as responders are preparing to depart back to their routine duty station; however, other good options could include different formats (paper, website, or phone interview) or conducting the assessment 1 to 2 weeks before or after demobilization.

Decision Point: The Incident Command should assist in the development of a Communications plan early in a response that will include and accommodate the findings and recommendations arising from the ERHMS system.

Deliverable: The ERHMS Unit will provide the Incident Command with periodic reports on the health and safety of the responders involved in the event and work with the Liaison and Information Officers to develop appropriate messaging for other stakeholders and the general public.

Decision Point: The Incident Command should facilitate the participation of all responders in an out-processing assessment. The assessment can be conducted using a variety of formats, including paper forms, oral surveys, and online surveys. Employing a combination of formats will likely lead to increased participation.

Deliverable: The ERHMS Unit will create an out-processing assessment survey that is conducted for all responders at or near the completion of their duties for the event.

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Tracking of Emergency Responder Health and Function: Because of potential health and safety risks inherent in emergency response work, post-event tracking of responder health may be appropriate. The goal is to identify adverse health or functional consequences potentially associated with response work (e.g., exposure, illness, injury, or disability–including emotional trauma), to intervene early to maximize the chances for recovery, and to stop further exposure for workers remaining on-scene (i.e., through exposure control or medical treatment). The decision to opt for further tracking should be based on a wide variety of factors, including information regarding the responders’ hazardous work exposures, hazardous work activities, concerns expressed by the responder or safety and health personnel, the adequacy of control measures (and adherence), and injuries and illnesses incurred during their deployment. Such information should be viewed in the context of the workers’ prior physical and mental health status and the extent of their prior knowledge and experience with disaster work. Post-event tracking of health may be difficult or costly to conduct on a case-by-case basis, and it is often more suitable for such decisions to be made for categories of responders with similar exposure histories. High-priority worker groups for post-event health tracking would include those most likely to have exposures to hazardous agents or conditions and those reporting similar adverse health outcomes.

Lessons-learned and After-action Assessments: At the conclusion of an event, there is a need to assess how the emergency response has been conducted through the pre-deployment, deployment, and post-deployment phases and try to identify ways to improve during each of these periods. This ensures that best practices are used and that mistakes are identified and measures taken so that they are not repeated the next time. Often this is accomplished through a document called an After-Action Report (AAR). It is essential that ERHMS be included in the general after action report or similar document. Practices such as identifying deficiencies in communications of safety and health protocols; examining when and where there were exposures; and noting any difficulties involved in compiling a complete, accurate, and timely roster; all help organizers improve the safety environment and better protect emergency responder safety and health during the next emergency.

Decision Point: The Incident Command should assist in identifying the most appropriate organiza-tion for implementing post-event health tracking recommended by the ERHMS Unit. Note that this tracking recommendation may range from short, informal health surveys mailed to responders to long-term intensive monitoring of responder health under the supervision of a physician.

Deliverable: The ERHMS Unit will identify those responders or responder groups whose health would benefit from periodic tracking after the event, make recommendations regarding the most suitable method of tracking, and suggest an appropriate duration for health tracking.

Decision Point: The Incident Command should incorporate the After-Action Report from the ERHMS Unit into the overall After-Action Report that is developed for the response as a whole.

Deliverable: The ERHMS Unit will compile an After-Action Report for ICS leadership that should be made available to all responder organizations involved in the response, so they can benefit from these insights.