Welcome, everybody, to the National Education Curriculum in Public Health Emergency Preparedness and Response, created specifically for preventive medicine residents. It is our privilege to have Dr. Peter Pendergrass, Program Director from University of Texas-Tyler, to deliver the seventh webinar in the series. Just a quick moment of housekeeping before I turn it over to Dr. Pendergrass. This is a pilot webinar series. Feel free to attend the webinars and ask questions to the faculty as you go along. Please pose your questions in the Q&A, and it'll be answered towards the end. We will also be sharing a feedback survey towards the end, and please take a moment to complete this brief survey and help us improve this pilot series of webinars. As you know, resident members have access to this new platform called ACPM Pulse, which is an online discussion forum for members, and please, we encourage you to continue sharing your insights, resources, feedback, and any action items that you may have learned or would like to continue learning on this topic and other topics. This webinar is, of course, being recorded, and we will send you instructions to access the recording. With that, Dr. Pendergrass, I turn it over to you for your introduction. Thank you very much. So, as Anita said, I'm Dr. Peter Pendergrass. I'm the associate professor at the University of Texas at Tyler Health Science Center. We have a relatively new program here, about three years, but I've been engaged in residency education since 2012. I was asked to talk a little bit about myself, but what I thought might be useful is to talk about my experience in emergency preparedness. I did most of my work when I was a regional medical director for the Texas Department of State Health Services in Region 1, which is the panhandle in South Plains area of Texas. In our region, as in every region, we had a very active emergency preparedness response team. We trained using FEMA courses and developed our own courses for incident command, planning chief, operations chief, and finance chief. We did this because FEMA didn't have any courses out at the time. We had many people who could easily step into any of these roles because they were all well-trained. We trained and exercised with local partners on a regular basis, with state partners, with national partners. We even trained with the FBI and NTSB. So I now know how to do a temporary morgue and many other activities. So in my time with Region 1, we responded to many disasters, mostly natural, but some infectious disease. These included things such as tornadoes. When we responded to a tornado, our role was fairly limited. We would go in and we would provide first aid to crews that were cleaning up and doing those kind of activities, make sure they had current tetanus shots when necessary, provide water and other things like that. We did the same thing with straight-line winds, which, interestingly enough, you can't really tell the difference between a tornado and 100-mile-an-hour straight-line winds and the damage they cause. We responded with wildfires, with coastal hurricanes, and H1N1. We always use FEMA's all-hazard disaster approach for disaster planning. We use this also for TB screening clinics, for mass immunization clinics, and even all-staff retreats. So it's a really important tool that you can actually use to plan a birthday party if you wanted to. And so we're going to talk about that for a few minutes. Now, the point of this, as my son would say, is not a humble brag about my training or experience. It's really to make two points. First, since 9-11, emergency preparedness has become a significant role for public health departments. And second, it is to note that my training and experience was not unusual. All the regional medical directors and all the key staff in each region and DSHS in Texas have gone through the exact same training and they continue to do that training. And so my point is, when you go into public health, you're going to need to gain a high degree of knowledge and experience in emergency response. Okay, so let's get started. I have nothing to disclose for this discussion. Unless one of you wants to give me a high-powered, high-priced contract, I might be able to take that. I'm not sure. So the objectives for this talk are really five-fold. We want to identify the 18 natural hazards outlined by FEMA. We want to review FEMA's all-hazard approach to disasters. We want to discuss the epidemiology, economic impact, and human cost of natural disasters, focusing on billion-dollar-plus events. We want to review key information about hurricanes and wildfires, and in this section, we'll go into a lot more depth than we do in the other sections. And then I want to revisit the FEMA phases and just think about what some of the public health response might be for a hurricane situation. And my hope is that this will give you a framework to use when addressing disasters. So I love this quote. I've heard this quote many times. I don't know who the source is of this quote, so I'd say it's unknown. But it says, when you have seen one disaster, you have seen one disaster. And because this is true, I cannot outline step-by-step procedures to deal with a disaster from beginning to end. Each disaster is unique in its presentation and impact. And I could rephrase this and put any disaster type in here. So let's just do it for hurricanes as we're going to talk about that. When you have seen one hurricane, you have seen one hurricane. It's true that hurricanes have characteristics in common, but their true impact is based on so many other factors, such as their intensity, their size, their duration, their proximity, and impact on humans, their proximity and impact on infrastructure, and their impact on the environment, to just name some of the factors. However, the common characteristics are really a starting point. It allows us to plan, and it allows us to begin our response to a disaster. But you always have to keep in mind, as the disaster unfolds, we have to be quick to adapt to changing situations. Okay, so, objective one, we're going to identify the 18 natural hazards outlined by FEMA. This is a list of these natural hazards. You see they range from avalanches to ice storms to winter weather to volcanic activity. I'm not going to define each term during this lecture, because I think that would be terribly boring and take up a lot of time. But if you want to go to the reference on this slide, you can get the FEMA definitions for each. But I do want to make a couple of points about this list. First, a primary natural disaster can cause a secondary natural disaster. And what I mean by that is that, for example, lightning can cause or can start a wildfire. Or a hurricane can cause coastal and inland flooding and spin-off tornadoes. And so, you have to keep in mind that these disasters sometimes kind of come in clusters. The second is that what seems like a natural disaster might be a man-made disaster. And as an example, if we have heavy rains, which causes a river to flood, this is a natural disaster. But if, for some reason, a dam breaks, causing the same river to flood, this would be considered a man-made disaster. So the outcomes are the same. You have a river that floods and causes significant damage, but the cause of it is different. And the third, and this may be more a bit of a personal pet peeve, but not every weather event is on this list. For example, thunderstorms are not a specified natural hazard, according to FEMA. However, having grown up in the Thunderstorm Alley in East Texas, I can assure you that thunderstorms can cause significant damage in and of themselves, and they're closely associated with lightning, flooding, strong winds, tornadoes, and hurricanes. And so, maybe this association is what kept them off this list, I'm not sure. So, it's also important to note that FEMA differentiates between natural hazards and natural disasters. A natural hazard and natural disasters are related, but they're not the same. I kind of think of these as potential versus kinetic energy, because a natural hazard is the threat of an event that will likely have negative impact, but a disaster is the actual negative impact. And so, they're related, but slightly different. I think it's important to understand how FEMA defines these two. And just as an example, if you live in the mountains, you're acutely aware of the possibility of an avalanche in winter or a landslide any time, but living with these are just potential hazards is a reality that you have to live with, but they don't become a disaster until the avalanche or the landslide actually occur. Okay, so we're going to move on to review FEMA's all-hazard approach to disasters. So, I know the FEMA all-hazard approach was mentioned in the first lecture. Our goal is to review the concept and expand on this discussion so that when you enter public health, you will understand FEMA's all-hazard approach. The purpose of this approach is to have a standardized process to develop comprehensive strategies to mitigate, prepare, respond, and recovery from a wide range of emergencies that we might see and will likely face in the communities that we live in and we serve. And it standardizes the way that we in public health address a disaster as well as people in law enforcement address a disaster, although we have different areas to focus on, we use the same structure, which makes it very easy to communicate and work together with. And it's important to keep in mind that this whole process is really, has an overarching goal to build resilience in your communities by building capacities and by building capabilities. So, capacities are the quantity or volume that can be handled by a community. And the capabilities are the quality and proficiency of performing a task. So the greater our capabilities are, our capacities increase also. The last thing that I want to point out is that it's called all-hazard approach, but it's important to note that it's an all-hazard, all-agency, all-community approach. No one organization is equipped to meet all the needs in a disaster, so we have to work together and we cannot be successful without community input, support, and participation. If we don't have community buy-in, and we saw some of this through COVID, it's much harder to implement prevention strategies. And I don't know why, but I kind of took that Hillary Clinton phrase, it takes a community to raise a child and it takes a community to respond to a disaster. Okay, so let's go through each of these. Mitigation really involves actions taken to reduce or eliminate the long-term risk of hazards to human life and property prior to a disaster occurring. For example, a hurricane coastal area might erect a seawall to mitigate against storm surge damage. So let's look at a few of these and understand that these are just examples. There's risk assessment, which focuses on identifying potential risk due to a hazard, assessing the impact of that risk, and developing policies to minimize the impact on humans and infrastructure. There's local planning and regulations, and these focus on implementing land-use plans to avoid development in high-risk areas. So say you have an area that is a hundred-year floodplain that you know floods every time a hurricane hits your area, then you want to make sure that you control that and keep people from building in that. Also it can include developing and maintaining green spaces and enforcing building codes so that as the standards for building safe buildings changes, we update and make sure that we build those buildings as structurally sound as we can. Structural projects include such things as building floodwalls and levees, just as an example, are more likely refitting buildings to withstand heavy winds, storms, seismic activity, or other disasters. Natural system protection is very important, and these are protecting and restoring such areas as wetlands or developing and maintaining green spaces. These are important because they're both a buffer to the storm, and they also absorb a lot of floodwater, which does not happen in a city that is full of concrete and asphalt. Another thing that could be in this is vegetation management in forests to prevent wildfires. We do have done in the past controlled burns. The problem with a controlled burn is that they can sometimes become uncontrolled and cause significant damage themselves. But it's the idea of cleaning up the underbrush, which is an easy target for fire to ignite and to spread. And last is education and awareness, which includes public education campaigns for individuals, families, and communities to prepare them to survive disasters. They can be workshops for families. They can be public service messages, or you could go as far as having community meetings with community members and elected officials on hazard mitigation techniques. So preparedness is really getting ready for emergencies before they happen. You focus on planning and preparing for potential emergencies to ensure an effective response. One of the examples of this could be emergency planning, where you focus on developing emergency operations plans that outline roles, responsibilities, and procedures to be followed. In public health, we have many disease-specific plans that have been developed. It helps us understand how we're going to respond to a particular disease, such as the class A biohazards, or the biohazards that might be used in an attack on a country. And so these are very important because they help us think through the process, understand the science behind what we're doing, and have plans in place to respond rapidly. Then we have training and exercise, which focuses on conducting drills and exercise to test our plans, and then more importantly, after it's tested, improve our response capabilities through things like after-action reports, which lead to revisions of our processes. Another responsibility is resource management. We focus on acquiring and assuring the availability and accessibility of necessary resources and equipment. And just as an example, in Texas, and my experience is from Texas, so the examples you hear will be from here, one of the issues that we addressed was how we would help people who need dialysis. And so in every region, we have stockpiles of machines that can perform dialysis that we can easily move to areas that are uninfected and move those patients to that area also so that they can continue their dialysis. It's interesting how they were implemented across all regions. In our region, we actually had agreements with hospitals to take the units and to use the units, but they also had the responsibility to keep them up and then to replace those units when they would be available to us when we needed them. So others just kind of kept them in a warehouse until needed. So the approach can be very different, how you store and utilize that equipment. The last that I put in here was public awareness campaigns. These can focus on educating the public on emergency procedures and preparedness measures, such as evacuation plans. And so that's always very important. Response activities address the immediate effect of a disaster, focusing on saving lives, protecting property, and meeting basic human needs. And I've just listed four examples here. One is deployment of emergency services. The second is evacuation and sheltering. The third is medical and public health services. And the fourth is public information. So during a response, emergency services must be activated. This includes deploying police, fire, medical, and other emergency services, such as search and rescue teams. We can deploy teams of public health physicians or public health employees, including nurses, to provide immunizations or to provide first aid. So we have teams of public health people that are easily deployed. We are getting engaged with evacuation and sheltering of high-risk individuals or the evacuation of high-risk facilities, such as nursing homes with very sick individuals who are in the eye of a hurricane or in the direct path of a hurricane. And I just want to mention also that it's very important to make plans not only for humans but for their pets so that they can be sheltered safely. And I don't know if it would surprise you, but it surprised me many years ago when we were doing evacuations, and people would not leave because we didn't have plans to evacuate their animals. And so it's very important. Animals become family members, and people will not leave family members. And so any sheltering process that we did after that time, our veterinarian was involved, and we set up essentially a mock clinic where we could keep the pets. We had crates for storage for the pets. We had techs who could take care of the pets when needed. So it's a very important thing to consider also. It's important, public health provides a lot of medical oversight for evacuations. We provide medical care at shelters. We provide first aid and medical transportation for search and rescue activities. Now this may not come from a local, it may come from a state level or a federal level, but that's really some of the roles that we do in public health also. And then public information includes updating people on the status of the emergency response and steps to remain safe during and after a disaster. Okay, so let's move on to recovery. Recovery involves restoring the affected area to its previous state or even better. This focuses on rebuilding and revitalizing communities. And some of the examples of this would be that during the recovery phase, instead of doing a risk assessment, you're doing a damage assessment, which focuses on evaluating the extent of damage and identifying recovery needs. This could include financial assistance, probably not at the local level, maybe not at the state level, but at the federal level, FEMA certainly, helps individuals and businesses and communities to rebuild. And then it's the actual rebuilding process of a reconstruction that is critical. And then last part is really, at this point, you want to do long-term planning and you want to focus on improving your preparedness response, which reduces future risk and improves community resilience. Because as I said, the overarching goal is to have a community that is resilient and can respond to a disaster and recover quickly. Okay, so we're going to move on to our third objective, which is to discuss the epidemiology, economic impact, and human cost of disasters, focusing on billion-dollar-plus events. And this data is from 2023, and that's the last full year of data that we have. In that year, there were 28 billion-dollar-plus natural disasters that cost $92.9 billion and caused 492 fatalities. The types that occurred were severe weather, 17 severe weather, 4 flooding events, 2 tropical cyclones or hurricanes, 2 tornado outbreaks, 1 drought and health heatwave event, 1 wildfire event, and 1 winter storm event. Now if we look at these billion-dollar disasters by decade, starting in 1980, and this is, I think this is when they first started collecting this data, we see that there's an increasing number of billion-dollar disasters since 1980 and an increasing number of fatalities by decade during that same time. And between 1980 to 2000, 75 percent of all disaster-related costs were due to these billion-dollar disasters. But by 2023, we saw this continually increase until over 85 percent of all disasters-related costs are due to these major events. And it's, the reason that this is happening is speculated that over the years, the density population on people living and building houses in forests is going up, building nice homes on coastal areas is going up, the number of people that are living in those areas are going up, and the valuation of those properties have certainly gone up. If any of you guys are buying houses right now, I can tell you that in the last few years, valuations have gone up tremendously. And so that all plays into it. But we've also seen an increase, I'm probably getting ahead of myself, but increase in more severe hurricanes, not necessarily in more hurricanes, but more severe hurricanes. And so some of these storm events, experts say that it is due, in part, to climate change. Okay, so I want to just take a minute and look at data that looks at billion-dollar natural disasters by type. And this is from 1980 to November 1, 2024. This data is a little different than previous data because it is much more, it goes into November of this year. Overall, during this time, there were 400 billion-dollar-plus disasters, costing over $2,799,000,000,000 and causing 16,768 fatalities. The most common type are severe storms, as we mentioned, with 203 events. These cost $512 billion and caused 2,145 deaths. Probably the most costly, not as frequent, but most costly are the tropical cyclones. And that, again, are the hurricanes. The second was 66 events, and it cost over $1,425,000,000,000 in losses. And it caused 7,201 fatalities. And so, as you can see, natural disasters have a high toll on life and on infrastructure in the United States. I'll let y'all read the rest of that data at your leisure at another time. Okay, so I want to move on and spend a little more time looking at key information about hurricanes and then key information about wildfires. This is Objective 4, but I called it 4A and 4B. So Part A of this is looking at hurricanes. So a hurricane is a tropical cyclone or localized low-pressure weather system that has organized thunderstorms but no front. A front is a boundary separating two air masses of different density and maximum sustained winds of at least 74 miles per hour. Now, a hurricane begins as a low-pressure system that is moving over warm water. The water has to be at least 80 degrees Fahrenheit or higher. If it's 79 degrees, they say a hurricane cannot form. So that's why we see hurricanes in the summer moving into fall time, because that's when the water is the warmest. As the warm water heats the air, the air rises. As the air rises, it begins to cool and moisture from the cooling air condenses, forming clouds initially and then thunderstorms. To fill the vacuum caused by the rising air, air rushes in from the side, potentially creating strong winds. And last, the rotation of the earth creates a force that causes the rushing air coming in from the sides to spin. In the northern hemisphere, it spins counterclockwise, and in the southern hemisphere, it spins clockwise. And so as the storm intensifies, and that's defined by increasing wind speeds and increasing cyclonic circulation, it moves from a low-pressure area to a tropical disturbance, to a tropical depression, to a tropical storm, to a tropical hurricane. And as I said, these are really defined based on wind speed and how organized that cyclonic spin is. But it's important to note when a tropical hurricane occurs, that they have winds greater than 74 miles per hour, they have well-defined cyclonic spin, they have a well-defined eye and eye wall, and they have spiral rain bands that are coming off of the hurricane. And these drop a lot of rain. So, the epidemiology kind of economics and fatalities associated with hurricanes, well, this data is between 1980 and 2019, so it's over four decades. The U.S. experienced 46 billion dollar hurricanes. These hurricanes cost $1,142,000,000,000 and caused 6,508 deaths. So, as we saw previously, with overall trends in billion-dollar disasters, that we're seeing an upward trend in cost to infrastructure that's lost, and more importantly, the cost to human lives from hurricanes. Okay, so how are hurricanes classified? Well, in the United States, we use the Sapphire-Simpson Hurricane Scale, which places hurricanes into categories based on wind speed and magnitude of impact. And that is projected flooding and structural damage. And really, that's based on the wind speed. As wind speed increases, potential storm surge increases, and degree of potential destruction increases. Category 1 hurricanes are considered minimal, with wind speeds between 74 and 95 mph, and storm surge of 4 to 5 feet. This will cause power outages, flooding, and damage, particularly to poorly made homes. And so, like mobile homes, which are not well attached to the ground, tend to be homes that are significantly damaged in even a Category 1 hurricane. If we skip over to and look at Category 3, these hurricanes are considered to produce extensive damage, with wind speeds between 110 and 130 mph, and storm surges of 9 to 12 feet. These, at this level, we're likely getting a lot of inland flooding. We're getting irreparable damage to buildings and homes, especially with weaker foundations. Now, let's look at Category 5. We'll skip over Category 4 and just go to Category 5. These storms are considered to produce catastrophic damage, with wind speeds in excess of 156 mph, and storm surge greater than 18 feet. These storms cause roofs to collapse, buildings to be demolished, and extensive coastal flooding requiring evacuations. Not that you wouldn't necessarily evacuate in Category 4, 3, or 2 storms, depending on the characteristic of them. So, hurricanes have associated hazards, and it's important to know these. The predominant hazard for any given hurricane is not always predictable. Damage is dependent on where the storm makes landfall, and is dependent on the degree of infrastructure that is vulnerable, and the population characteristics. The four major hazards with hurricanes are storm surge, flooding, high winds, and tornadoes. Now, this shows where the majority of the fatalities come from hurricanes. This is data from 1963 to 2012, and as you can see, storm surge is the primary source, followed by floods, winds, and then tornadoes. So, storm surge is often the deadliest aspect of hurricanes, as it can lead to rapid and severe flooding in coastal areas. Just as an example, Hurricane Katrina in 2005 caused over 1,800 deaths that were preliminary due to storm surge. Heavy rains from hurricanes can cause rivers and streams to overflow, leading to widespread inland flooding. And we saw this with a recent hurricane that went into the Kentucky area. Back in 2017, Hurricane Harvey caused catastrophic flooding in Texas, leading directly to 68 deaths. Winds are also another source of significant damage. They cause significant structural damage, leading to fatalities. For instance, Hurricane Andrew in 1992 caused 65 deaths, many due to wind-related incidents. And then the last one I'm going to talk about are tornadoes, which are spawned off of hurricanes. These add to the destruction and fatalities associated with hurricanes. And just as an example, Hurricane Ivan in 2004 produced 117 tornadoes, which is just kind of mind-boggling. So overall, hurricanes have been responsible for thousands of deaths over the past few decades, with each storm presenting unique challenges and dangers. Okay, let me talk about the other ones real quickly. A storm surge is a wall of water pushed onshore by the winds of a hurricane. So the more severe a storm, the stronger the winds and the greater the potential surge. Historically, it is the primary factor, as we said, in loss of life. However, as hurricane predictions have improved, i.e. both the path of the storm and the timing of landfall, our ability to mitigate through evacuations have caused a dramatic drop in loss of life due to storm surge. Other things that have helped is retrofitting of buildings and better building codes. So, in the northern hemisphere, as we said, hurricanes rotate counterclockwise. This makes the right front quadrant of the storm and landfall the area with the greatest surge. Areas left of the eye have winds blowing toward the ocean, reducing the storm surge. And also, the time of impact matters. If it's at high tide, the surge will be much deeper and more severe than at low tide. And the slope of the seafloor also matters. If the seafloor has a gradual slope, the surge is likely to be much more severe. If the seafloor has a natural shelf, which you see in some places, this helps block the surge, reducing its size. This is much like a man-made seawall. And then the last point I want to make is that water weighs about 1,700 pounds per cubic yard. So you can see why the water from a storm surge is highly destructive and can level many, many buildings. So, flooding occurs due to massive rains that fall inland because of a hurricane. Flooding can cause secondary disasters such as mudslides. It can uproot trees, which can take out power lines. And recently, inland flooding has become the primary cause of loss of life from a hurricane. High winds are significant because they blow out windows, especially in high-rise structures. They destroy residents, causing trees to fall and cut critical power lines. Tornadoes often form in the right-front quadrant, as we said. But they can occur from any rain band that's associated with the hurricane. And these tornadoes have winds from 100 to 300 miles per hour, so they can definitely cause significant destruction on their own part. It's also important to think about the spread of infectious disease. As people are evacuated and more and more people are sheltered together, the risk of disease outbreak increases. We also have to think about zoonotic diseases. In a hurricane that I've been blanking on the name the last few days, we actually saw large populations of mosquitoes blown en masse to different areas. And so, we had vector control issues that we had to deal with in areas that weren't normally that full of mosquitoes. So, it's really kind of fascinating how this works. So, let's go on to Objective 4 and see if I can speed up a tad bit on this part and look at wildfires. So, a wildfire is defined as an unplanned fire burning in nature or wildland areas, such as forests, shrublands, grasslands, or prairies. They're caused by lightning. So, wildfires are part of natural maintenance of the ecosystem, and these kind of fires are caused by lightning. But in our current society, the majority of fires are man-made, either from carelessness from campers and other people out in the forest, or due to arson. And it's important to remember that risk factors that drive fires include significant vegetation, high winds, and periods of dry weather. This is why South Plains and Pandan will have a lot of wildfires, because we get 19 inches of rain a year whether we need it or not, and we have winds that just howl at night and day and have the right kind of shrub vegetation that really can spread a fire. Okay, so wildfires are a common occurrence in the United States. The average number of fires per year between 2014 and 2023 was 62,277 fires, with a high of over 71,000 in 2017 and a low of just over 50,000 in 2019. During the same time period, the average acres burned annually was over 7 million acres, with a high of 10 million acres in 2015 and a low of 2,600,000 in 2023. The average acres burned in any given year is greater than the acreage of Rhode Island, Delaware, and Connecticut combined. And to reach the 10 million acre mark, you have to add a Y to this list. The cost is quite significant. Over a 10-year period from 2014 to 2023, the average annual federal cost just for the Department of Interior and Forest Services was over $2,500,000,000. Keep in mind that there are state firefighters and there are local firefighters who are all engaged in this, and these costs are not in debt. And in 2023, there were 4,318 structures that were destroyed by fire. Most of these were houses. So wildfire has a significant human impact. There are heat illnesses, which include heat cramps, heat exhaustion, and heat stroke. And I'm not going to go through those today, but those would be good things to look up, particularly for the boards. There are burn injuries obviously associated with fire, and these are particularly in the firefighters and the people supporting the firefighters. But sometimes you get people who just won't leave their house. They're going to use their garden hose and try to save their house with it, and they also have issues. Dehydration is a major factor and plays into heat illnesses, and the one we're going to really focus on is smoke injuries. Because in the short run, smoke injuries, particularly some of the substances in smoke, can cause significant issues. And remember that smoke travels a long way away from the fire, so it encompasses a much larger part of the population. So, I just want to talk for a minute about air quality. How do we measure it? Well, it's really fairly easy with the EPA's Air Quality Index. It's a tool the EPA uses to communicate air quality to the public. It measures the purity of air from communities on a specific day, and it covers the five major pollutants regulated by the Clean Air Act. These are ground-level ozone particle pollutions, which are particulate matter either fine or larger. There's carbon monoxide, sulfur dioxide, and nitrogen dioxide. We're not going to go through each of these, but I do want to spend a minute on particulates, because those are particularly concerning. But this is just a map of the quality index summary. If you're between zero and 50, there's no risk, and that's notified by a green color. If you go up to, say, 150 to 200, this is unhealthy for everybody, particularly serious for sensitive groups. It's a red. And if you get to the maroon area, which is 301 to 500, it's hazardous to everyone, and the entire population is affected. So let's talk a bit about particulate matter. I just mentioned that smoke travels significant distances, and one of the things that it carries with it are the particulate matters. Particulate matters can either be fine particles, which are less than or equal to 2.5 micrometers. They're not just from wildfires or wood stoves. They're from other things such as power plants and industrial processes and vehicle tailpipes, but it's something we see significantly in wood stoves and fireplaces. There's also more coarse, which is greater than 2.5 to 10 micrometers, and this is from crushing and grinding operations, like when they take large rocks and they grind them into materials for roads, roll dust off of that, and some agricultural operations also produce the coarse particles. So sensitive groups to this population are individuals with heart disease, lung disease, older adults, children, and teenagers. I did not know this until I started working on this, but it's because their lungs are still developing, which I didn't know that for childhood. They breathe more air per pound of body weight than adults, so they can take in more particulate matter. It's also a high-risk group for pregnant women and outdoor workers. And it's important that this is important because for these high-risk groups, you want to make sure that they have air filters in their houses. You want to make sure that they have, stay indoors, and then if they have wood fireplaces, they don't burn those during these events. Okay, so this is just a quick look at what the AQI looks like. This is from my hometown, and if you look at the footnote, airnowgov, you can go there and look it up for your city. Okay, the last thing I want to do, and I'm sorry, I know I'm running a little bit longer than I should have, is just look at examples of public health response to a hurricane. I just give you these to remind you of the four categories. And so, if you think about it from the public health perspective, we're still going to perform a health risk assessment, but it's going to be based on previous events, focusing on health, identifying what the major health issues are, identifying the people that may need to be evacuated, mapping this out on maps so that we know what people are vulnerable, what facilities we may need to evacuate, so that we have all this ready to go before an event occurs. We want to help people with family disaster preparedness. It's always good to have your go kit. It's always good to have your medicines available. It's good to have important documents. It's good to have food and water, particularly food that does not require cooking in that go kit. And then we can advocate for infrastructure improvements. We don't have a lot of money, so we can't really fund these, but these really can be funded through probably more state and federal sources. So, preparedness activities, as we said, develops emergency response plans, but we don't necessarily do this for police or crowd control or things like that. We do it for things that, we do it for health risk. So we might have a plan to address a novel virus. We might have a plan to help evacuate a nursing home, things like that. And then we obviously train and exercise these emergency health plans. And we also do a lot of stockpiling of medical supplies. And the last thing we do is we really educate people on preparing family emergency kits and community communication plans. Response activities are establishing emergency services, setting up shelters and medical shelters and working these shelters. We provide basic first aid for evacuations or for search and rescue. We do, again, public education. And then recovery is establishing public health services back as quickly as we can. And we help healthcare services reestablish also. We continue to do surveillance. We've talked about, we begin that in response, but we continue to do that. And then we keep people informed about disease outbreaks and how to stay healthy during this time. The last thing I wanna share with you is, I wanna close with this quote from Dr. C. Everett Koop. He was the Surgeon General during the AIDS epidemic. And he states that, healthcare is vital to all of us some of the time, but public health is vital to all of us all of the time. And I think this is no more, I think this is true all the time, but I think it's no more true than during a disaster when people are most vulnerable and most vulnerable. And most in need. So I wanna thank each of you for choosing what is truly a noble specialty within medicine. And I'm sorry, I know I took too much time, but I'll answer any questions if I can. Thank you again. Back to you, Anita. Of course, thank you again so much, Dr. Pendergrass. What an incredible, incredibly informative lecture. So we do have a couple of questions, one question that's come in. More than one question, actually. So we'll go ahead with the questions. The first question is in the chat. Today, Northern California issued a tsunami warning following a 7.0 magnitude earthquake. Fortunately, the warning has been lifted. You mentioned the cost of a natural disaster. Suppose a tsunami did occur and the emergency managers are in the process of creating a sit trap to assess the damage. 24 to 48 hours after the disaster. What tools are available to determine the economic costs of damage, particularly for impacts that are not immediately visible? For impact that's not immediately visible. I would think with a tsunami that there'd be, most of the impact would be pretty obvious. You wouldn't necessarily know about all the loss of life because a tsunami can literally wash people away. But if they wash buildings away, I think you would notice that. I think the biggest damage to me that is not gonna be obvious is the psychological impact of something like that on individuals. And I had it as a note in one of my slides, but realized I was kind of running behind a bit. So I skipped over some of that. But one of the things that we do in public health is that we're not psychologists or we're not psychiatrists, but we do a lot of crisis intervention, kind of psychiatric crisis intervention to assessing where people are and what their needs are and providing a forum for them to kind of talk about it and work through that. So I would think that might be the most important thing you could do because I've never lived through a tsunami, but when I've seen recent ones and seen the impact, it's devastating to me just to think about what those people are going through. And so I can't imagine what the impact is if you actually lived through it. I don't know if that answers the question, but those are my thoughts about it. Thank you, Dr. Pendergrass. A couple of more questions have come in. Dr. Odak asks, what is the most important lesson you have learned from the past disasters that you've been a part of that you wish you knew sooner? Well, let me answer that in a couple of ways. When I was involved with my first, disaster, I let everything else get in the way. It took me a while to understand that if it wasn't directly in my lane to just ignore it. For instance, if a building was on fire, I can't go put that fire off, but it would consume my thoughts. And to some degree, probably appropriately, because you'd have to transport people. But I had to learn from a practical standpoint how to pick and choose what pieces of that disaster I focused on, and it was based on what might kind of stay in my lane. I think the other thing is that disaster response is a team approach. I will tell you, the last hurricane I responded to, I was not the incident commander. My preparedness guy was incident commander, and I was used by other groups to do things. So like, I was sent to a hospital in Galveston, no, I'm sorry, in Houston, to assess it for a federal emergency department to come in. Now, I'm driving there talking to a federal guy who's telling me what to look for, because I've never done that. And so, it taught me a couple things, and that one was, you never know what you're gonna have to do, but you gotta be ready to do it. And you can't put your ego in this. My emergency prep guy was far better than me, and he was, you know, I wanted him in the incident command position. And I really felt like I filled that kind of specialty niche well when he was in charge, because I didn't have to worry about what was going on. And the other thing about that is stay flexible, because, you know, I will honestly tell you that we had three-inch binders on single-item disasters, and when that disaster would happen, we never pulled them off the shelf. We didn't have time to read that and respond, but what it did for us is that we remembered a lot of what we wrote, and it made us think through the process, and so we had the skillsets to think through each disaster as we did that. And so, I would say those were things that I've learned about it. The other thing is self-care. It can be devastating. I drove down to Boulevard Island after a hurricane. I did some crazy things, like the health director in Galveston wanted people standing behind him during the press conference, so I was the state representative standing behind him for public health. Drove down there for two hours, drove back for two hours, didn't say a word, I was just standing there in solidarity. Did it make a difference? I don't know, but it made a difference for this guy. But while I was down there, I drove down to this little island called Boulevard Island that was this beautiful place with very expensive houses on poles, and all you saw were the poles that were snapped off. Some were three feet high, some were six feet high. There was no sign of any house there. And those people refused to evacuate, which meant they were in the middle of the ocean somewhere, and they were probably all dead. And so, you have to learn to process when you are doing these disasters, because this stuff, I can tell you, I'm already getting kind of, you know, that feeling in my, that stressed feeling just talking about it. But you gotta learn how to process through those things, and you gotta have ways to do that and people to process with, because some of this stuff can be just devastating, what you see. So, we have a couple of more questions. It is 8.01, but do you mind staying back to answer just a couple of them? Oh, I'm happy to, if we can. Well, absolutely, absolutely. The next question came in, what can we do as preventive medicine physicians to ensure support and funding for emergency preparedness, especially given the progressively increasing costs of damage related to climate change? Well, I think, you know, I am, I'm in no way an expert on climate change. I'm probably a bit of an outlier for public health, because I see 100,000 years ago when there were very few people in this world, and we had, still had, extreme heating periods and extreme cold periods. So, I know man has an impact on it, but I'm not yet convinced that we can do it. Not yet convinced that it's that great. And so, you know, right there, you might discount everything I have to say about climate change. So, I think the reason that the costs are increasing so much is because we all want to live in the forest and the mountains, or we all want to live on the seashore, and we're all building more and more expensive properties. And every day, the valuation of these properties are going up, and the number of people in that area are going up. So, we're seeing more people killed by it, as well as greater valuation of the properties so that the overall cost is going up. I think that has a lot to do with it. I think climate change may impact the fact that we've seen more category four and five storms. And I think it probably impacts the severity, the severe weather storms that we have. But I don't know if it plays a role in all of it. I think, and this is probably an unpopular opinion too, but we've had some pretty crazy forest management techniques that have been put in the last 20 or 30 years. And I think that has driven some of the wildfires also. When you leave all the underbrush in a forest without managing it, you have just instant fuel there for a fire. And so, y'all don't yell at me because I'm not quite as big a believer in the climate and the role of climate change in all of this, but I think there are just a lot of factors. I think some of it is the federal policies that have been in effect, like the forest management, things like that also. So does that answer it at all? No, I think it's a wonderful, it's an important perspective you're presenting, Dr. Pendergrass. But as a follow-up, do your residents or do you engage in advocating for funding for emergency preparedness particularly, regardless of- We don't advocate for funding, but what we do is we actively engage with groups that are tasked with responding. So our residents will help plan medical plans, they'll help plan exercises, they'll participate in exercises, they'll participate in post-event, post-exercises, debriefings, where we analyze it and come to conclusions about how we did and whether we can do better and what that looks like. And then once a year, we go to a live exercise where they actually engage in medical care of indigent people in an exercise. So my interest is not as much on the funding advocacy side as it is assuring that my residents can step into public health and be active participants in disaster responses or disaster preparation and responses. I think there've been enough disasters that it still has the ear of Congress and for funding. It's kind of like TB. We did such a good job with TB that in the 80s, they started cutting funding. About the same time we saw HIV, which made TB worse. And so we had increase in TB and then it caught people's attention again. I think there are enough disasters going on that we don't really have to keep the politicians and funding sources necessarily engaged in funding that because they see the impact of that on their citizens. My final question, I wanna be respectful of people's time. There has been a lot of news about the large telecom hack. Have you had to deal with these systems going down before during your response? Say that one more time. There has been a lot of news about large telecommunications hack, people hacking telecommunication systems. So have you had to deal with any of these systems going down, especially during disaster response? So I haven't dealt with any hacks like that or major systems going down. The things that we've had to deal with have been significant, but much on a smaller scale. And for instance, in my region when I was there, we had different communication systems between counties and they could not talk to each other. And so we had worked through the process of building a communication system in every county where at least they had one radio or one mechanism to communicate. We built, and that took quite a bit of time. And it was quite a shocker the first time we realized that we couldn't reach a county because they were on different frequencies and their machines wouldn't pick up the frequencies that we had. You know, we learn a lot of this by seat of the pants. You do it and you see an issue and you go and you try to do your best to fix it. So those are the things that I've had to deal with. I can't imagine a large scale telecommunication failure that it would certainly make the whole process much harder. Well, thank you so much, Dr. Pendergrass. If you can move to one additional slide forward or perhaps- Yes ma'am, sorry. No problem. We appreciate truly for all the residents for staying back nine minutes past hour. Thank you again for a fantastic lecture and for answering the questions in detail. Again, as a reminder, you can continue asking these questions and engaging with one another through ACPM Pulse. And next week we have our final webinar for this year, 2024. Dr. Miriam Alexander will be talking about exposures and you'll once again have an opportunity to interact with Dr. Alexander and ask her questions and learn more. So with that- I don't know how to do this, but if you want to send out my email to this group, I'm happy to try to answer questions. Absolutely. I can't quite figure it out. I'm a Teams guy, I'm not a Zoom guy. So I can't quite figure out how to put it in there. Of course. No, not a problem at all. We're happy to share your contact information so residents can continue interacting with you to ask any additional questions and clarification. Sure. With that, we end this webinar. Thank you all, everybody, and have a wonderful evening. Thank you all. Bye-bye.

Public Health Emergency Preparedness

Disaster Response Training

Multidisciplinary Collaboration

FEMA All-Hazard Approach

Natural Disasters

Hurricanes

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Saffir-Simpson Scale

Emergency Resilience

Preventive Medicine Residents