Editor’s note: Vivian Reyes, MD, is an emergency room physician at Kaiser Permanente San Francisco Medical Center. She led a team of Kaiser Permanente caregivers on the ground in the Philippines in the wake of Typhoon Haiyan, which killed at least 4,000 people and left millions homeless. Reyes and her team were in the Philippines at the request of Relief International. She filed this dispatch upon her return to San Francisco.
Jan. 5, 2014
When we enter the New Year we often look at the previous year’s successes and failures. We ask what we learned, what we will bring forward, and what we will change. Returning home from a disaster response is similar. Now that I am back in the United States, having just celebrated the holidays, I can look back at my experience during the Kaiser Permanente/Relief International Philippines typhoon response and see the lessons learned.
At the start of our medical response, I spent most of my time assessing the medical needs in various affected areas. The damage was unimaginable, both in intensity and expanse of its destruction. Initially, I thought the extent of damage was due to the poor quality of home construction, as we saw many “shanty” structures. It took only a day or so before I realized that the shanty structures were new and that they were built on top of what once was a well- constructed building. But still, it was only after seeing hill after hill littered with coconut trees that were literally snapped in half as a result of the 200 mph winds that I stopped thinking, “This kind of destruction would never happen in the U.S.” Memories of the destruction sustained in Hurricane Katrina in 2005 brought me back to reality – natural disasters know no boundaries. And thus, the first lesson is 1) Don’t ever think this can’t happen to you. Who ever would have predicted that Japan would suffer through an earthquake, tsunami, and nuclear event all at once? Yet it happened.
Once we accept the first lesson, we must consider how the public is notified about an impending disaster. In California, where earthquakes remain our greatest vulnerability, warnings will not be possible like they were for Typhoon Haiyan. In the areas of Tacloban City where we worked, a lot of the severe damage was caused by the “storm surge. Prior to this response, I did not truly understand what storm surge meant.
Patients told us that Typhoon Haiyan not only brought 200 mph winds, but also a series of large ocean waves – 18 to 20 feet high in Tacloban City, The multiple waves fed into each other’s turbulence, creating large whirlpools strong enough to crumble concrete homes, office buildings, and warehouses. When I first arrived in Tacloban City, I wondered why no one evacuated to higher ground. Why would sea-level communities stay home once a storm surge was predicted? A few days later one of the community leaders answered my question: The locals, just like me, didn’t really understand what a “storm surge” was.
After the 9/11 attacks in 2001, the United States adopted the NIMS (National Incident Management System). This is now the basis for emergency management in our country and is practiced in most, if not all, U.S. hospitals. Under NIMS, code words and ambiguity were retired and replaced by plain English. Communication is the key to a good warning system, and it must be delivered in a way that its recipients can understand. Again and again, I thought to myself how many people would still be alive if the warnings described a typhoon with a ‘tsunami-like wave.’ Sure, the terminology is not scientifically correct, but doesn’t the point come across more clearly? I’m not sure what the right answer to this dilemma is, but the second lesson is 2) Effectively communicate warnings about impending disasters, using simple and plain English that allows recipients to truly understand what the impending disaster may bring.
Warnings and preparedness don’t prevent disaster, they only mitigate damage. After the inevitable happens, the community still needs to respond to the damage and to those injured by it. The early hours after a disaster only have local responders. International medical teams cannot help. The Typhoon Haiyan response was particularly difficult. The typhoon struck multiple islands, making transportation nearly impossible. At the same time, it knocked out internet and cell towers, in some cases for days to weeks. Together these factors led to prolonged assessment and response times.
In the United States we use the “96-hour rule” for hospitals, meaning a hospital should be self-sufficient for 96 hours following a disaster. This rule is based on the fact that it generally takes medical teams 96 hours to become fully functional, taking into account “out-the-door” transport, staging, and set up times. After Typhoon Haiyan, the medical response time was closer to a week. This means that the first responders were locals, medically trained or not. By the time our KP/Relief International team arrived, most of the typhoon- related injuries had already been addressed by the local community.
So, if you learned the first lesson and believe this can happen to you, then the third lesson is 3) The best way to increase your community’s survival rate is to undergo some basic training in disaster response because you will be your community’s first responder; trained responders will generally arrive too late.
Once the medical response team is underway, they need to be coordinated. While disaster relief often seems chaotic, there is a formal national (NIMS) and international (throughout the United Nations) coordination process. I realized in the Philippines how few people, including disaster responders from the United States, know about this system of coordinating clusters of disaster responders. While I will not describe it here, the fourth lesson is simply that 4) A coordinated disaster response system exists and all responders should strive to work within the system to prevent duplication of effort and response.
The last lesson is the simplest to understand, yet the hardest to follow. 5) Allow communities to recover.
This seems insultingly obvious, yet this is the most difficult lesson for responders, including myself, to grasp. When we respond to disasters that happen outside of our communities, we bring with us our cultural beliefs, tendencies, judgments, and ways of doing things. Recovery may mean different things to us as responders than it does to members of the affected community. The Philippines typhoon response and the Haiti earthquake response in 2010 provided aid to cultures very different from our own. We need to recognize this, and remember that we are not there to change culture, but to help communities return to a new normal that will work within their cultural framework.
Imagine if the tables were turned. If we had European medical teams come to our aid after a severe disaster, they may question the fee-for-service model used in much of the United States. This same dilemma arose in the Philippines. As Kaiser Permanente employees, we are not accustomed to witnessing how fee-for-service works. But in the Philippines, few patients receive “charity care”, and EMTALA (Emergency Medical Treatment and Labor Act) does not exist. While fee-for-service practices were postponed for most of our time spent in the Philippines, as recovery furthered, fee-for-service practices resurfaced. With so many people still down on their luck, it seemed unfair to me for them to pay for health care services. However, this, too, is a step to recovery. How will health workers earn a living if they cannot bring in revenue from working? What will drive them to work month after month if they cannot earn money? I do not have the answers to these questions but it is something to consider early during any disaster, so that it does not come as a surprise later.
And so, as we move forward into the New Year, and as I continue to process my experience during the Typhoon Haiyan medical response, I resolve to make the Kaiser Permanente health care organization, as well as our members and staff, more prepared to confront, survive, and recover from a disaster. As my friends and colleagues have supported me on this response to the Philippines, I hope they will also support me on my mission toward better organizational resiliency.
Thank you again to all who have read my updates. And, thank you again to all who have supported my endeavors in disaster response, as well as emergency management. I feel lucky to be supported in doing what I love to do.
Manigong Bagong Taon!
Happy New Year!