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During Hurricane Maria, Gloria Amador said, staff members held an emergency room door shut for four hours straight.
“They knew that if they opened the door, it would destroy the emergency room,” said Amador, chief executive officer of Salud Integral en la Montaña (SIM), a Puerto Rican health center.
Amador is proud that SIM’s emergency rooms stayed open throughout the 2017 hurricane. But providing emergency care as Maria decimated the island around them turned out to be just the beginning.
People began flocking to the health center, many of them needing the vital medicines to manage their chronic conditions. SIM didn’t have power, but that didn’t stop healthcare providers from doing their jobs. “Without electricity, we were providing meds to the patients with flashlights and lanterns,” Amador said.
And food, clean water, and basic supplies were hard to come by. SIM began to distribute them throughout the community, assessing individual families’ needs and then working to meet them. Six months after Hurricane Maria, the health center had provided medical services or donations to nearly 12,000 patients.
Working to bring services to people affected by Maria, Amador said, staff members realized something: “We have been changing our vision on how to provide primary care services,” she said. SIM is “not only waiting for patients to come to the clinic. We have to go to the community to serve them.”
It’s a familiar story. As natural disasters like fires, floods, and hurricanes become an increasingly prominent – and catastrophic – part of their patients’ lives, community health centers are rapidly adapting.
They’re installing solar power and backup generators that they never needed before, so they can stay open, protect medications, and access medical records. Wading through dirty water to distribute supplies. Driving dangerous roads to get medicines and equipment to immobile patients. Staffing evacuation centers for the first time.
In short, health centers are seeing themselves as a fundamental part of a community’s disaster response.
A Growing Need
It doesn’t seem, at first glance, like a natural pairing.
Beginning in the 1960s, community health centers were designed to provide primary and preventative care to vulnerable populations. Although they’ve adapted to serve the changing, complex needs of their patients, they fundamentally focus on providing ongoing primary care – not crisis response.
However, according to Amy Simmons Farber, the communications director for the National Association of Community Health Centers, responding to the needs of their communities – whether ongoing or acute – is a fundamental part of health centers’ role.
“What health centers have always done has been to address social determinants of health, the environmental factors that make people sick,” she explained.
Over the past few decades, that’s meant an increasing emphasis on behavioral health and integrative care, for example. It’s meant a focus on overcoming nonmedical barriers like a lack of access to healthy food, reliable housing, and even child care.
And now, it means navigating the increasingly prominent role that disasters play in the vulnerable communities they serve. Just as disease is more likely to affect underserved populations, so are disasters.
Even federal regulations reflect the essential role that health centers can play in their communities.
In 2016, the Centers for Medicare and Medicaid Services introduced an “Emergency Preparedness Final Rule,” which required providers receiving funding from either program to have a disaster plan, work with government emergency responders, and prepare to meet increased needs for health care. (A supplementary rule was introduced in September of this year.)
According to Simmons Farber, this attitude first evolved in response to Hurricane Katrina.
The hurricane and its aftermath devastated large swathes of the Gulf Coast in 2005, killing hundreds of people (estimates of the death count vary) and leaving many stranded without medical help.
“One of the things that we found…is that the most overwhelming need after Hurricane Katrina was not so much triage but primary health care needs,” including for chronic conditions and mental health issues, Simmons Farber said.
Since Katrina, major storms, along with devastating wildfires have grown more common. But the overwhelming need for primary care in the days and weeks after a disaster remains.
Health care organizations and doctor’s offices are frequently forced to close just when patients are most in need of medical care. That, in turn, can put pressure on overstressed emergency departments.
For a patient who requires care after a disaster, “the current system is that that person is put in an ambulance and sent to the emergency room,” said Tina Wright, the director of emergency management at the Massachusetts League of Community Health Centers. In all likelihood, that person “does not need to sit a long time…in an overcrowded emergency room to get basic care.”
An Evolving Role
That’s where health centers can come in. In the wake of a disaster, they can provide vital primary care, whether that’s within the walls of a clinic, in patients’ homes, or in the one place where many of their patients are most likely to show up: an evacuation shelter.
Doctors, nurse practitioners, and other staff members at Santa Rosa Community Health found themselves providing medical care in a local shelter – even as the Kincade Fire threatened the health center’s facilities.
It’s up to local jurisdictions if they’re going to provide medical services in the aftermath of an emergency, Wright explained. In this case, Sonoma County’s public health officer asked the health center if they could provide care in the shelter.
“We’d never been asked to be in that position before,” said Dr. Lisa Ward, Santa Rosa Community Health’s chief medical officer.
On the one hand, the ailments were nothing new. “We’re familiar with treating colds and PTSD,” Dr. Ward said. But “in the shelter, we had to go back a few steps.”
Patients needed medications, along with specialized equipment like oxygen tanks and nebulizers. (“We basically pilfered our own clinic stocks,” along with using donations and county resources, Dr. Ward said.) Health care providers had to find a simple, reliable way to keep and transfer patient notes.
In addition, Dr. Ward was struck by vulnerability of the shelter’s occupants, many of whom were elderly or had serious health issues. A disaster like the Kincade Fire “reveals the underbelly of medical fragility that people live with every day.”
Medical staff quickly adapted, finding a reliable way to keep records and developing a box of essential supplies – like felt-tip pens and paper – to bring to a shelter for the next emergency.
“It is a new role for community health center clinicians to play in the setting of disasters,” Dr. Ward said.
Learning on the Fly
Health care’s changes aren’t just due to disasters – from telehealth to community paramedicine to mobile clinics, medicine is increasingly moving outside clinic walls. “The model’s growing to accept other modalities,” Wright said.
But when it comes to disasters, health centers are learning on the fly.
“When you look back on it in hindsight, we tried to just be available to the community and it took on many different looks,” said Dena Hughes, CEO of TAN Healthcare in Texas. TAN’s patient population was heavily affected first by Hurricane Harvey in 2017, then by flooding from Tropical Storm Imelda earlier this year.
That meant receiving and distributing supplies like food and baby care items in Harvey’s wake, and, in one case, even driving over flooded roads to bring medication to a stranded patient.
While TAN provided primary health care in the immediate aftermath of the storm, Hughes said that it was primarily supplies, not medical attention, that was needed.
She elected to do things differently when Imelda hit, leaving supply distribution to first responders and focusing on the inevitable increase in medical need.
“This go-around, let’s be that steady arm. Let’s stay out of the way of people doing more first responding…and let’s be ready” when people get sick after the storm, she decided.
That means having mobile vans – purchased and outfitted with Direct Relief’s support – at the ready, to hold mobile clinics and reach patients in hard-to-access areas.
It also means working with other fixtures in the community – like churches, community centers, and food banks – to create post-disaster “one-stop shops” where patients can get everything from food to FEMA resources.
And it means being ready both before and after the storms to help patients get medications and receive essential care.
“We’re not holding the net. We are the net that keeps people from falling between the cracks,” Hughes said. “So our weave has to be super tight.”