Tee L. Guidotti

Disasters, by definition, are more than just “large-scale” incidents or events with multiple casualties. They differ qualitatively from routine medical emergencies and public health threats.

This qualitative difference arises from the disruption of normal support systems and saturation of available residual capacity and capability, which is much degraded from normal operations: supply of resources exceeds demands of the disaster. It manifests itself in inaccessibility of routine system dependent resources and impediments to operations such as communication failures. Reliance on routine standard operating procedures becomes counterproductive, yielding highly individualistic on-the-spot innovation and improvisation risks causing confusion, thus making matters worse. Accompanying the disaster is the emergency management equivalent of “the fog of war,” a condition of knowledge privation resulting not only from shortages of information but also from miscommunication, unfamiliar vocabulary (especially in industrial or chemical disasters), distortions, preconceived notions that have not yet been corrected in the event, and the seductive but often misleading tendency to rely on the experience from the most recent similar event.

In a disaster, the strategy of protecting the individual necessarily gives way to that of protecting the population. In other words, medical care gives way in priority to public health, and the system needs the versatility to manage this transition smoothly. To achieve this, occupational medicine (OM), and the occupational health service (OHS) that provides both primary and preventive care, wellness programs, and management services in health, is the pivot point within employer organizations. (See Box 30-1 for a list of acronyms used in this chapter.) Corporations and other large institutions became deeply concerned with continuity of operations and the security of their personnel after 9/11 and have maintained this concern since, reinforced by natural disasters, such as Hurricane Katrina. For effective response to a disaster, responders need to have the appropriate tools and training for the mission. For effective response to the unpredictable and especially the unexpected, responders must be prepared for multiple events, have flexible approaches, be cross-trained, and have the capacity and capability to deal with “all threats” rather than one type of emergency at a time.

Among the responses to these threats has been the idea to strengthen and repurpose the OHS and to increase participation of occupational health professionals, particularly physicians, in the employer’s disaster planning and emergency management response. A management model developed by Jean-Pierre Robin, at Noranda, an aluminum producer, suggests that any organization that creates wealth and adds value cannot rely on routine operations and public services for protection against catastrophic disruption and that sustainability must rest on a foundation that includes special functions designed to assure its security and continuity of operations. The OHS is key to continuity and therefore sustainability, and, to be effective, its functions are integrated with other protective services within the company, in a hierarchical manner. (See Fig. 30-1 for a graphic representation of the model. )

Schema for preserving value and protecting business continuity in a business enterprise, showing the strategic placement of business continuity protection and occupational health, after Jean-Pierre Robin.

(Reprinted with permission from Guidotti TL. Emergency management at the enterprise level. In: Guidotti TL, ed. Occupational Health Services: A Practical Approach , 2nd ed. London, UK: Routledge; 2013, 389–403.)

The imperatives of continuity of operations and disaster response have invigorated and reemphasized the role of OM, one of the oldest recognized medical specialties, in emergency management. In the past and especially during wartime mobilization, physicians were regularly more involved by employers in disaster planning. That ebbed until the present era, stimulated by the threat of terrorism, and this role has now returned as a central function of corporate physicians. The OHS cannot rescue the entire company in the event of catastrophe but that is not its mission. It adds its value in preparedness and planning, and advance networking with community-based public services. Historically, OHSs have always been most active in disaster planning but not the first-line resource in disaster response.

Box 30-2 presents the usual functions of a corporate medical department, provided or supervised by occupational physicians. These functions have traditionally been clustered in a few broad missions: to protect health, to support productivity, to reduce loss and liability, to manage health affairs, and to ensure compliance with regulations and best practice for the industry. These functions have traditionally been viewed as support functions, not part of the business operations of the organization. Indeed, this is why these functions were subject to outsourcing throughout the private and government sectors during the 1980s and 1990s. Disaster management, by its nature, does not lend itself well to outsourcing and so virtually every major employer has some form of emergency management and disaster response plan, contingency, or capacity built into its global operations plan.

OHSs are perhaps most familiar in the manufacturing sector, public safety services, and in the setting of a plant medical clinic. Typically, such services include at least one occupational health nurse (also a professional specialization), an occupational physician (typically on contract), and support staff, all of whom report on a regular basis to a plant manager and are responsible professionally to a corporate medical director, who serves as a traveling troubleshooter, an in-house resource on health issues, and an auditor for health affairs. This physician-led, health-centered team typically is engaged in regular interaction and problem solving in collaboration with an industrial hygienist and safety officer, who are usually oriented more toward process and plant operations, documenting regulatory compliance, and identifying and measuring health hazards. These hazard-oriented professionals usually report through a different manager or directly to the plant manager. This basic pattern was once the norm in industry, but the dramatic reorganization in industry, the management focus on core business, and the rise of the service sector have forged a new pattern, in which services are outsourced to contractors and consultants.

The full-time, physician-led, fully staffed on-site medical facility has been mostly replaced in sectors by a leaner model, in which physicians contract with multiple employers to provide services at various facilities on a part-time basis or send workers out to see designated physicians in the local community. Large employers, with bigger operations and more at risk, are much more likely to have fully staffed OHSs, as well as the capacity and capability to respond during a disaster. However, whichever pattern is followed in a particular enterprise, the essentials are in place in most large operations for a response to protect health in a disaster: a means of monitoring the health of workers, a system for documenting their health, a system for documenting and evaluating hazards, a mechanism for responding to emergencies, and access to a panel of health consultants.

An in-house, corporate, or on-site plant-level OHS usually is already involved within the organization in planning the medical response to emergencies, networking with local hospitals and health agencies, and providing services for casualties who can be helped with available resources, and diverting them away from local hospitals with limited capacity. They also deploy resources for dealing in the first instance (especially triage) with serious injuries and mass casualties, and provide health protection for key personnel (such as diabetic personnel) as required. This existing resource provides the platform that large organizations need to respond to disasters and to protect the security and continuity of operations. Involvement of the OHS in emergency management is a natural extension of the existing mission of the OHS. Disaster medicine involves only an increment of further training and preparation for consequence management and mitigation activities (as described in this textbook), preparedness for a response within the physical plant, and planning for the management of risks inherent to the operation of the specific industrial site and processes.

The most obvious role for the OHS in a disaster mode is as a “poste médicale avancé,” a forward medical position. In an emergency, casualties may be brought for triage; minor wounds treated; the injured stabilized for transport; and the worried may be examined, counseled, and, importantly, kept away from the nearest hospital, which should be reserved for seriously injured casualties. This clinical role is often assumed by managers to be the obvious role for the OHS. In practice, this is usually impractical because of insufficient staffing, although some large companies, especially in manufacturing and industries in which there is a high potential risk of injury, do have this advanced OHS. However, the true value lies elsewhere, and this is where the pivot from medical care to the public health model comes into play.

The value of the OHS is much greater in public health protection, before the response phase (especially periodic health surveillance for the protection of first responders) and in the health management functions of planning and mitigation. These functions apply directly to continuity of operations. The usefulness of a trained, well-informed, prequalified medical resource for dealing with incidents on site is obvious. These may include, but are certainly not limited to, sending infectious material through the mail to company personnel, using company equipment (such as airplanes or, potentially, chemical plants or storage facilities) as instruments of assault, and managing the psychological consequences of an assault. As well, the occupational physician, who is trained in hazard assessment, may assume the responsibility of determining when a site is safe to reenter or a facility to be reopened. This physician may also be responsible, independently or with the employee health service, for managing the psychological consequences of an assault.

Less obvious, but equally valuable, is the role that such occupational physicians may play in both managing the consequences of widespread disruption of business operations due to major threats and protecting the business, the product, and the brand against catastrophe. In time of crisis, the occupational physician may help get the community back on its feet by helping to keep an employer open or critical infrastructure functioning. For example, a little known and almost completely undocumented story of the 9/11 tragedy was how occupational physicians were able to care for vulnerable employees, many older and in ill-health, during the stress and logistical strain of the temporary relocation of the nation’s financial services industry to sites outside Manhattan.

Similarly, the occupational physician is now regularly called upon to manage the corporate response to serious health-related issues, such as travel to areas in which SARS and other emerging infections were a risk, rapid investigation of suspicious outbreaks of disease, following exposure to potential hazards, and determining when reentry and reoccupancy is possible in contaminated facilities, such as post office facilities contaminated with anthrax. Several companies, including Cathay Pacific, participated in an informal monitoring network during the SARS epidemic, to share observed trends and experience when the information they needed was not forthcoming from conventional sources. Procter and Gamble, alerted to the emerging problem by its own corporate medical leader for China, instituted SARS precautions a month before any official warnings were advised.

The occupational physician also has an important place at the table as an active member of the management team, interacting with local prehospital care providers and hospitals on the Local Emergency Preparedness Committee (LEPC). LEPCs are charged, under the 1986 Emergency Planning and Community Right-to-Know Act (EPCRA), with developing emergency response plans, reviewing them annually, and providing information about chemicals in the community at the request of citizens (which obviously needs balance against the threat of terrorism). They bring together first responders (police, fire, and emergency medical technicians), civil defense and emergency management, facility and agency heads and key managers, public health authorities, media, and community representatives. The community emergency response plans have several required elements, each of which has obvious implications for employers, the workforce, and occupational health protection (adapted from the Environmental Protection Agency) :

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  Identification of facilities holding and transportation routes for the movement of extremely hazardous substances

  
  
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  Descriptions of emergency response procedures, on and off a given site

  
  
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  Designation of a community coordinator and facility emergency coordinator(s) to implement the plan

  
  
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  Outline of emergency notification procedures

  
  
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  Description of the method by which the probable area and population affected by releases will be determined (e.g., air modeling)

  
  
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  Inventory and description of local emergency equipment and facilities and the persons responsible for them

  
  
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  Evacuation plans

  
  
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  Training plan for emergency responders (including schedules)

  
  
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  Simulation and drill schedules for exercising emergency response plans

These functions build on the traditional involvement of occupational physicians in disaster planning, as well as health protection for employees. The occupational physician has usually assumed responsibility within the organization for planning the medical response to emergencies, identifying facilities and resources for dealing with serious injuries and mass casualties, and providing health protection for key personnel if required. Although outsourcing has reduced the direct involvement of the occupational physician in planning emergency management in many organizations, particularly in the service sector, this function has not been completely replaced by external consultants because it requires a practitioner with intimate knowledge of the operations, hazards, workforce, and policies of the organization.

The well-supported occupational physician can add value to the management of catastrophic consequences in other ways. These include the following:

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  Survival of key personnel in a catastrophic event

  
  
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  Continuity of business following a catastrophic event

  
  
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  Instant connectivity to resources for assistance in a health-related emergency

  
  
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  Surveillance of the workforce and the early detection of an outbreak

  
  
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  Integration of emergency response with public health agencies

  
  
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  Surge capacity and capability as a resource when a local event requires mobilization of all available medical resources

  
  
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  Vaccination programs and other protective measures

  
  
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  Establishing on-site consequence management and mitigation programs

  
  
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  Developing decontamination plans

  
  
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  Providing specialized, sector-specific expertise to emergency mangers

  
  
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  Participation in teams evaluating and assessing imminent hazards: chemical, biological, physical, mechanical, and psychological

  
  
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  Advising on effective personal protective equipment (PPE)

  
  
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  Liaison with the LEPC, prehospital care, and hospitals

  
  
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  Continuing education and training on site and in the community of indigenous risks inherent to the operation

  
  
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  Access to SDS (safety data sheet) information on chemical hazards

  
  
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  Lead any after-action discussion to effect process and system improvement

  
  
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  Fitness-for-duty evaluation of key response personnel in advance of deployment, to ensure readiness and safety (see Chapter 31 )

  
  
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  Respirator fitness testing (conforming to regulations of the Occupational Safety and Health Administration) in advance of deployment, for response personnel facing an airborne hazard (see Chapter 31 ).

To perform these duties effectively requires committed time for preparedness activities and an OHS that is structured and whose providers are trained to play such a role in time of crisis. However, it is costly and inefficient, even for large corporations, to dedicate a full staff and support structure for the management of an event that may or may not materialize. This is why adaptation of the existing OHS makes sense for many employers, especially those in critical or hazardous industries.

Adaptation of the OHS also lends itself to an “all-threats” approach, since the occupational health staff is already intimately involved with hazards in the community. Focusing too narrowly on one particular threat degrades the quality of response to all threats. This degradation in capacity and capability due to over-emphasis was one of the chief concerns among the public health community in the years immediately following 2001, when emergency management was focused too narrowly on terrorism preparedness and the nation’s public health capacity and capability was still grossly underfunded and its infrastructure overly centralized and dependent on the Centers for Disease Control and Prevention. Later in the decade, a spate of natural disasters featuring the incompetent response to Hurricane Katrina in 2005 made the wisdom of an all-threats approach to emergency management abundantly clear.

It should also be noted that focusing narrowly on one particular threat also degrades the quality of response to the threat getting the most attention. A historical example is the response to bioterrorism, which consumed the nation’s attention from about 1999 to 2004, for good reason but, not to minimize the tragedy of those that occurred, with very few actual incidents. A purpose-built system to detect and deal with a bioterror threat, alone and in isolation, was the initial knee-jerk response, but such an approach would have almost certainly been doomed to failure. Timely and fluent response requires practice and unexpected and unpredictable tests of the system. Bioterrorism events are very rare, but a public health department responds weekly and (in large communities) daily to outbreaks of infectious disease of one type or another, from simple food poisoning to urgent events that simulate plausible scenarios for a bioterror attack because they resemble scenarios following intentional introduction of a pathogen: the SARS epidemic of 2002, the West Nile Virus outbreak of 2002-2003, the H1N1 pandemic influenza epidemic of 2009, and current outbreaks and numerous serious outbreaks on a local level, such as dengue in Florida. It is now realized and accepted in government and homeland security circles, not just in the public health community, that a competent response to bioterrorism, an extremely rare event, requires competence in responding to these other infectious disease outbreaks. Further, development of this broader competence has led to greater capacity to plan and capability to respond to much more likely threats, such as pandemic influenza. As true as this demonstrably was for infectious threats, it is equally true for chemical hazards, radiation threats, and physical hazards, all of which are already in the mandate of the OHS and within the documented competencies of OM as a field.

Incorporating emergency management into the mission of the OHS builds the efficiencies and redundancies required for a proper community response. The same resources used for tracking employees’ health can be used for surveillance to detect potential disease outbreaks due to bioterrorism. The technology of hazard identification and measurement can be applied to detect chemical or radiation threats. The medical staff on duty primarily to monitor health and to provide timely clinical care can provide surge capability in time of crisis. Health protection for senior executives, and the personal knowledge that entails, can provide the detailed knowledge of health needs required to keep key personnel on the job and safe, especially when they are moved to new locations or are operating under conditions of stress and potential risk. The skills that are normally applied to ensure a safe workplace can be used to determine when it is acceptable to return to work or to venture into a facility that has been contaminated or damaged. Planning for foreseeable industrial disasters can inform and refine the response to unforeseen threats, given that sophisticated disaster planning is a matter of identifying resources and contingencies, not deriving detailed plans for single-threat incidents.

Perhaps most attractive to cost-conscious managers, investment in expanding the emergency management capacity within an OHS is not “lost” if an event never occurs. The same health management systems that support the traditional OHSs that industry and government employers require will be enhanced and available for use in emergencies. This may lead to cost savings, increased productivity, and reduced liability as added value. Conscious of their responsibility, and aware of their own position on the firing line along with the employees and executives they protect, OPs have been preparing themselves for an expanded role in emergency management. The principal specialty organization, the American College of Occupational and Environmental Medicine (ACOEM), has for some time offered training in topics relevant to emergency management. In 1999, the ACOEM began providing continuing education on the characteristics of weapons of mass destruction. Offerings have included emerging infections (particularly using the model of SARS), tabletop exercises to train participants in emergency management, health protection of first responders, and consequence management for disasters and mass casualties. Immediately following the tragedy of 9/11, an ACOEM task force produced a guide to the management of mental health issues among survivors of mass assaults, disseminated it to all members and posted it on the college website: all within four days. This achievement was unique and widely admired at the time among medical specialty organizations.

Informational Sharing and Analysis Centers (ISACs, previously “Information Sharing And Coordination”) are organizations set up and managed outside the government by the owners, operators, key employers and institutions in industries and sectors recognized as critical infrastructure for continuity of essential services, vital supplies, and the national economy. ISACs have official status with the Department of Homeland Security and are intended to coordinate the planning response of critical sectors of the U.S. economy and society. They have been formed, for example, in industry sectors such as critical utilities (such as water supply), finance, health care, and transportation.

ACOEM also participated in a number of initiatives related to the interface between critical industries and the Department of Homeland Security. In 2003, leaders within the college developed the Occupational Health Coordinating Group (OH-CG) within what became the Healthcare and Public Health Coordinating Center. The OH-CG was the first health sector element to be created within the health sector’s ISAC and was, for over a year, the only functioning ISAC component in the entire health sector. Because occupational health is cross-cutting across industries, the vision was for OH-CG to serve as a resource for other critical sectors rather than to focus on the health sector itself. However this proved to be nearly impossible because the OH-CG was embedded in an ISAC interested in acute delivery of health care and the supply chain, not protection for workers across critical sectors. As a result, from the beginning, the OH-CG was effectively marginalized, and it lacked the mandate or leverage to reach out to other critical sectors. Eventually, the OH-GC became unsustainable, although ACOEM itself continues to have contact with the ISAC.

The OH-CG, while it was in operation, sponsored the development of the Occupational Health Disaster and Emergency Network (OHDEN), a prototype platform for supporting worker protection during a disaster-scale emergency. It was initiated in 2004, and its efforts were supported for several years directly by ACOEM. OHDEN was a web-based system for sharing information and templates for employee tracking, disaster response, and hazard information. Its mission was to provide occupational health professionals with what they need when they need it in time of crisis, through channels that do not depend on any one mode of communication. OHDEN’s first “proof of concept” came before it was really ready, when it briefly “went live” immediately following Hurricane Katrina in 2005 and was able to broker the timely sharing of information on guidelines for fitness-for-duty and return to work for employees in disaster-struck areas. A second test came in 2006 when its open website (now taken down) disseminated best practices in corporate policies related to pandemic influenza. Both “dry runs” were judged successful at the time, with evidence that the information was actually used. Unfortunately, despite efforts, no external funding to support OHDEN was forthcoming, and it was too large a project to be financed by ACOEM acting alone. Although OHDEN no longer exists, it demonstrated clearly that such a platform was feasible; it could be made efficient and cost-effective and would add value to disaster management.

Lacking a large-scale network providing a platform and templates for operationalizing worker protection in disaster management, employers have to build their capacity individually. How might an organization prepare its occupational health department to respond to a disaster? The first requirement is a well-organized and effective occupational health team. Teamwork in an emergency comes from training and planning before the event, but also from regular personal contact, trust, and practiced cooperation. A team that functions well in the complex duties of an OHS, and one that already knows the operations, workforce, and facilities is more likely to function well in an emergency, compared with an outside provider who may not be around in a crisis and probably has other clients and obligations.

Another part of the answer is to build redundant information and communication systems that can quickly retrieve critical information on hazards, disease or injury patterns, and individual health records in an adverse environment. Occupational health systems may require upgrading to do this effectively, but the technology is readily available. Partnerships within the LEPC, local industry, and other similar facilities not only reduce the initial and ongoing cost but also enable more efficient planning, training, and response.

Acquiring the necessary expertise is an obvious first step. The occupational health staff may require special training to take on the additional functions, but this is not much of a stretch from current duties. County emergency managers are eager to share training opportunities through grants and other programs within the public domain. On-site training and response in coordination with local prehospital care utilizing strategies of consequence management and mitigation, education, decontamination, and PPE will support efforts by the Occupational Safety and Health Administration (OSHA) to protect workers and may reduce liability exposure fur the organization’s insurers. The expense for preparedness may be justified by potential reductions in insurance premiums, as well as reduction of loss in the event of an emergency.

Establishing networks and agreements for mutual assistance may be critical. Here the occupational health staff can coordinate arrangements with local hospitals, specialist practitioners, public health agencies, and first responders in advance and maintain personal relationships required for smooth operation in the event of a crisis. The first step is to forge an active participant’s role in the LEPC. Some counties have a more active, dynamic, and responsive LEPC than others. An OHS for a large organization has the opportunity to lead and to become the backbone of emergency management in the community.

Facilities planning may be required, taking into account the characteristics of the site, for evacuation, securing the premises but preserving access for ambulances and first responders, defining areas of the plant for operational response (e.g., for staging rescue operations, triage, stabilizing casualties, decontamination, and “incident command” activities). Even locations without special hazards may benefit from such contingency planning in the event of an external threat. For example, the first anthrax assault was in the office of a newspaper, not normally a high-risk location but a logical target for an attack on media, and one that placed workers at risk in their workplace setting, as did the subsequent assaults on television media and congressional offices.

Surge capability may be provided under various contingencies, whether to call in help for managing mass casualties on sites (especially if local hospitals are not functioning or cannot be reached), to assist other units in a mutual assistance pact, or to perform services such as mass immunizations. On-site decontamination may have to be continued at the hospital or a second alternate care location away from the industrial incident. Surge capability operations may be created away from the hospital under the direction of the LEPC, county emergency manager or hospital. This may include separate health care mutual aid agreements specific for the incident, secondary triage and treatment, through the use of vendor agreements or prepositioned equipment and supplies, met by trained physicians and other health care providers. This strategy will enable the hospital and community health care delivery system to operate at near standard operations during the industrial incident. Any facility that has potable water, electricity, and shelter may serve. Preexisting arrangements for accessing these sites should be spelled out under mutual aid agreements, vendor contracts, memoranda of understanding, or special circumstances agreements negotiated in advance between the County Emergency Management Office, the hospital or the local employer. Documentation of expenditures is a critical function, just as it is in the incident command structure, in order to reimburse all nonvolunteers and contracts executed in the response.

Certain routine functions can be anticipated and planned, for example, if anthrax or some other threat is suspected in the mailroom, procedures can be put in place in advance to protect employees, limit disruption and rapidly evaluate evolving situations. In the case of anthrax, these are quite simple and can be accomplished in a proactive manner, as was done by DST Output, the nation’s largest direct mail operation, on the advice of its medical director. This last function is particularly important to deter inevitable hoaxes and to prevent disruptions to business from ill-defined or unknown hazards. For example, the common scenario of an unknown “white powder” appearing on a loading dock or in an office can shut down operations for a day or more until a toxic substance is ruled out. Having the capability on hand to show that it is harmless saves time and anxiety.

Confronted with a true emergency, most people behave in an adaptive, rational manner that helps them to get through the crisis and to mitigate personal damage or injury. Some are capable of helping others in an emergency. This response appears to be shaped at least in part by whether the emergency arises from a natural disaster or a “technological” event (an incident arising from human agency). The perception of an intentional assault may also shape the psychological response for some people. Some people in situations of perceived catastrophic risk behave irrationally, however, and demonstrate psychogenic symptoms and maladaptive behavior. Dealing with anxiety-promoting perceptions and psychogenic symptoms among employees that arise from rumors or incidental illness occurring at the worksite requires skill in rapid assessment and in risk communication, but it can save an enterprise from devastating loss of confidence and the potential loss from employees who may refuse to come to work. Distinguishing between human drama and a true emergency arising from a nonobvious cause is also a challenge requiring specialized expertise that is within the scope of the occupational physician.

An enterprise may be in a position to control its liability and potential loss from claims following a disaster by developing a flexible, effective emergency management capability within its OHS. In addition to reducing actual loss through planning and effective consequence management, which is most important, such an enterprise would also be able to show after the fact that it had done its due diligence in anticipating and preparing for plausible threats. This could reduce its exposure for punitive awards or claims based on negligence or omission. Legal opinions on this may vary, but it seems reasonable that a company that is seen to be prepared is less likely to be accused after the fact of ignoring a foreseeable threat.

In the classic business model followed during times of business as usual, the priorities of corporate management are shareholder value and profitability, continuity of production and operations, and loss control and risk management, in that order. For government agencies, there is a similar set of priorities with the mission of the agency coming first. However, in times of crisis, survival of the enterprise and protection of people take precedence. In the past, OM and OHSs have always been perceived as support functions, facilitating management priorities, but not as a core business priority. In the new era of threats to survival and business continuity, the OHS and the physicians in them may play a role in the survival of the enterprise and its people. A wise organization, faced with an extraordinary threat, may look within to build its salvation on a functioning system that is already serving its interests.