Emergency Preparedness and Accountability for Vulnerable Populations: A Literature Review

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In emergency situations, the most vulnerable people suffer disproportionately. As climate change accelerates, natural disasters are expected to occur with increasing frequency and with greater intensity. Under these conditions, preparing for special-needs populations has never been timelier. In this paper, I’ll review the literature relevant to emergency preparedness and special needs populations, focusing on natural disasters, and using Hurricanes Sandy and Katrina as useful case-studies. I hope to provide a clear picture of the existing emergency-preparedness infrastructure in relation to these populations, paying special attention to existing problems and potential solutions. I’ll analyze the existing literature on this subject in three parts: (1) defining vulnerable populations and relevant agencies, (2) problems with existing infrastructure and preparedness, (3) solutions and obstacles to implementation.

Defining Vulnerable Populations and Relevant Agencies

In this section, I’ll discuss the definition of disability and the scope of “vulnerability,” distinguish institutional needs from non-institutional needs and discuss the agencies involved in emergency preparedness. To better understand the definition of disability, we turn to the ADA Amendments Act of 2008 (ADAAA). Under the ADAAA, disability is defined as “a physical or mental impairment that substantially limits one or more major life activities” (U.S. Equal Employment Opportunity Commission, 2009). Though disabilities play a central role in vulnerability, other populations need to be taken into consideration as well. Non-English speakers, individuals without access to transportation, pregnant women, children, and the elderly must be accounted for in emergency situations. Many of these groups have little in common. These differences must be considered separately rather than grouped under the umbrella term of “special needs” (Kailes, 2005). A need for language services must be distinguished from a need for medical services, which must be distinguished further from a need for supervision.

After classifying individuals by their type of limitation – and hence, the type of service needed in an emergency – agencies must distinguish institutionalized individuals from non-institutionalized individuals. Institutions may include nursing homes, hospitals, and mental health facilities. These institutions must plan for a variety of disasters – natural, biological, or chemical – providing training for evacuation, the mass movement of patients, and the overwhelming of normal capacities. At present, most hospitals plan thoroughly for adult populations but may devote less attention to special populations such as children (Niska & Shimizu, 2011). Accounting for non-institutionalized individuals is more complicated and requires more resources. Non-institutionalized individuals with disabilities (including senior citizens) make up 19.3% percent of the total population in the United States and have a wide variety of impairment-specific needs. Amongst older adults, the percentage rises to 30 or 40% (Milford, 2013). Impairments may affect mobility, vision, hearing, mental abilities, or other bodily systems. Many of these people require special equipment (e.g. wheelchairs, walking sticks) or medication (e.g. insulin, immunosuppressants, antipsychotics, and so forth).

Agencies accountable for emergency management range from local hospitals and fire departments to state emergency management organizations to national and international institutions. On a national level, the department of transportation is involved in evacuating populations with special needs (Department of Transportation, 2009). The Department of Homeland Security (DHS) works with the Federal Emergency Management Agency (FEMA) to coordinate emergency preparedness and disaster response (Federal Emergency Management Agency, 2011). Following the devastation caused by Hurricane Katrina, the Emergency Management Reform Act was passed in 2006, reforming the FEMA’s emergency management capabilities (Department of Homeland Security, 2012). In 2007, the “new” FEMA released more stringent guidelines on emergency planning and persons with disabilities (Kuiper, 2009). In certain types of emergencies (e.g. “infectious, occupational, or environmental incidents”), the Centers for Disease Control (CDC) works with state and local governments to respond to the threat (Centers for Disease Control, 2012). On an international level, the World Health Organization (WHO) monitors threats to public health and safety, responding to serious threats in member countries (World Health Organization, 2012).

Problems with Existing Infrastructure and Preparedness

The three main shortcomings of existing emergency infrastructure are (1) inadequate risk communication, (2) inadequate evacuation procedures, and (3) inadequate continuity of services. Problems with risk communication can be divided into two types: lack of access and inadequate content. When emergencies occur, citywide announcements may not reach the blind or deaf because these warnings are rarely available in large print, braille, or closed captioning (Nick, Savoia, Elqura, Crowther, Cohen, Leary, Wright, Auerbach, & Koh, 2009). Non-English speakers may have trouble interpreting public announcements, and those who are mentally impaired may have trouble understanding the announcements in the first place (Department of Transportation, 2009). Each of these problems may affect vulnerable populations before, during, and after a disaster.

Problems with evacuation procedures may involve a lack of transportation, a lack of coordination between facilities, or problems with the route design for the impaired. A report issued in 2003 discussed the aftermath of September 11th for vulnerable populations. According to this report, “Emergency workers believed the buildings had all been evacuated, but disabled people who were unable to leave their apartments were left behind with no electricity...no running water, and no information about what was happening and what they should do” (O’Brien, 2003, 2). Hundreds of people with disabilities or other impairments were neglected for days. In other types of disasters, accessible shelters may be unavailable or inadequately publicized. When elevators go out of service, those with mobility impairments may become stranded, as stairs are not a feasible exit route. Evacuation transport vehicles are rarely equipped to carry mobility devices (Nick et al., 2009), and amongst hospitals, less than half are equipped to accommodate the needs of children and persons with disabilities during a public health emergency (Niska & Shimizu, 2011).

Problems with continuity of service may involve inadequate access to food and water supplies or inadequate access to medical treatment. Research conducted in 2011 demonstrated that “Although over one-half of hospitals had staged epidemic drills, only one-third included mass vaccination or medication distribution” (Niska & Shimizu, 2011, 1). Earlier research demonstrated that individuals reliant upon regular medication, treatment, or supervisory care are especially vulnerable during public health crises (Fernandez, Byard, Lin, Benson, & Barbera, 2002). Problems with continuity of service plagued the emergency-response teams involved in Hurricanes Sandy and Katrina. Following Hurricane Katrina, 29% of those who were taking prescription drugs said they had trouble getting those prescriptions filled (Aldrich & Benson, 2008). Aldrich and Benson estimate that 200,000 people with chronic medical conditions lacked access to medications or their usual sources of care. New York was similarly unprepared for Hurricane Sandy. In the wake of the hurricane, a New York court found that the city had violated the Americans with Disabilities Act by “not adequately protecting the vulnerable disabled population during that disaster” (Milford, 2013). Establishing plans for continuity of service should be an essential facet of emergency management.

Solutions and Obstacles to Implementation

I’ll analyze means of improving emergency response systems in four parts: (1) special needs registries, accessible shelters, and the evacuation of vulnerable populations, (2) education and training of personnel, adequacy of response systems, (3) increased coordination amongst responsible agencies, and (4) teaching disaster preparedness to vulnerable individuals and their caretakers. I’ll then briefly turn to the obstacles facing the implementation of these potential solutions. The first solution, the use of special needs registries, involves the voluntary listing of special needs individuals with relevant agencies. People who sign up may receive personalized alerts, check-ups, accessible transportation during evacuation, and placement inaccessible shelter facilities (Chavkin, 2013). Accessible shelters and evacuation routes should be publicized well in advance (Nick et al., 2009). Each community should have access to accessible evacuation vehicles (Department of Transportation, 2009).

Responders must be provided with advanced education and training, especially when assigned to relocation efforts (Nick et al, 2009). The information available to mobile healthcare first responders should be detailed and meaningful (Wang & Barrett, 2011), perhaps drawing from databases compiled by special needs registries. Doctors, pharmacies, and hospitals should coordinate with emergency response agencies to prepare for disasters. Because the inability to refill prescription medications is often a critical problem (due to the closure of pharmacies and doctors’ offices as well as the inability to get pharmacies to pick up medications), agencies should set up a system through which they can provide emergency prescription refills (O’Brien, 2003). While many of these solutions have been implemented on an ad hoc basis, they have not achieved the widespread usage that they deserve.

The development of strong relationships between public health agencies is essential in coordinating response services during a crisis (Aldrich & Benson, 2008). Establishing partnerships between these agencies ensures that each organization knows who will be responsible for which aspects of each program. Emergency medical services, public health organizations, and community leaders must create a coordinated citywide emergency plan (Nick et al., 2009) before disaster strikes. In doing so, one organization may take the lead in such an effort, providing representatives to serve older and disabled populations. These representatives may serve as consultants to other agencies and oversee the system through which these organizations pool their resources. Through this approach, “the lead organization would appoint a contact person to serve as the liaison to FEMA, the Red Cross, the Area Agency on Aging, the Salvation Army, the police and fire departments, and other emergency organizations” (O’Brien, 2003, 2). This ensures that no details of a citywide emergency plan are left unaccounted for.

Teaching special-needs individuals and their caregivers disaster preparedness is also essential. Educational programs may enable vulnerable people to have more control over what happens to them when emergencies occur. These programs could be carried out through federal, state, or local organizations, and would teach vulnerable people and their caregivers how to help themselves during a disaster (O’Brien, 2003). Through these programs, people with disabilities and other functional needs should prepare emergency kits that include necessary medications, emergency contact info sheets, blankets, food, and water (Federal Emergency Management Agency, 2011). Establishing relationships between vulnerable populations and emergency management agencies before a disaster is crucial to these programs’ success.

Obstacles to implementation include inadequate awareness, inadequate funding, geographical barriers, and the difficulty of identifying and reaching vulnerable groups. Those in charge of emergency management efforts are often unaware of the needs of vulnerable populations. In the United States, only 20% of emergency managers report having disability guidelines in place, and 66% of counties report “no intention of modifying their guidelines to accommodate the needs of persons with disability impairments” due to costs, lack of awareness, or limited staffing (Fox et al., 2007, 196). Funding for training, supplies, and infrastructure is woefully inadequate in many communities (Federal Emergency Management Agency, 2012). Inadequate funding means that not all agencies and departments have what they need, even when they are aware of the vulnerabilities of special-needs populations. Geographical barriers further complicate evacuation efforts. In rural areas, special-needs individuals may be difficult to identify, locate, and reach (Nick et al., 2009). Developing solutions that recognize and respond to these obstacles is essential for successful emergency management.

Concluding Thoughts

In emergency situations, the most vulnerable people are at the greatest risk. In this paper, I’ve reviewed the literature relevant to emergency preparedness and special needs populations, focusing on natural disasters in particular, but recognizing that the same emergency response framework applies to other types of disasters as well (chemical disasters, biological disasters, nuclear disasters, etc.). I’ve analyzed the existing literature on this subject in three parts: (1) defining vulnerable populations and relevant agencies, (2) problems with existing infrastructure and preparedness, (3) solutions and obstacles to implementation. In the first section, I defined the scope of disability and vulnerability, distinguished institutional needs from non-institutional needs, and discussed the agencies responsible for emergency preparedness. In the second section, I discussed the inadequacies of risk communication, evacuation procedures, and continuity of services. In section three, I suggested several solutions to these inadequacies, focusing on care for the vulnerable during a crisis, education and training, coordination between agencies, and the teaching of disaster preparedness. I then turned briefly to the obstacles that these agencies face in implementing potential solutions. Taken together, this information is foundational for further research into these subjects.


Aldrich, N. and Benson, W. F. (2008). Disaster preparedness and the chronic disease needs of vulnerable older adults. Preventing Chronic Disease: Public Health Research, Practice, and Policy, 5(1), 1-7.

Centers for Disease Control. (2012). Office of Public Health Preparedness and Response. Retrieved from http://www.cdc.gov/phpr/

Chavkin, S. (2013). Special needs registries saved lives during Sandy, but not in NYC. The New York World. Retrieved from http://www.thenewyorkworld.com/2013/01/16/disaster-registries/

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O’Brien, N. (2003). Emergency preparedness for older people. International Longevity Center Issue Briefs. Retrieved from http://www.ctaa.org/webmodules/webarticles/articlefiles/Emergency_Preparedness_for_Older_People.pdf

U.S. Equal Employment Opportunity Commission. (2009). Questions and answers on the final rule implementing the ADA Amendments Act of 2008. Retrieved from http://www.eeoc.gov/laws/statutes/adaaa_info.cfm

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