Data and Information Source

An ongoing daily log of observations and recommendations was kept and used as the basis for this field report. Each evening, notes were entered into a smart phone. The process of recording observations and reviewing them during the time of the deployment allowed for identification of themes and points of interest during the response, rather than retrospectively.

Observations

Typhoon Haiyan (known in the Philippines as Yolanda) was a multiple-hazard event that damaged infrastructure and affected social stability. It involved extreme winds, a storm surge which flooded several kilometers inland, and subsequent looting and social disturbances. Residents of Tacloban interviewed during the deployment reported that they had experience with typhoons and had prepared as normal for wind damage (although the predicted severity of this storm was greater than most had experienced previously). However, the storm surge (locally referred to as a tsunami) and looting, not wind damage, overwhelmed community emergency response and medical service capabilities. The vast majority of deaths from Haiyan appeared to have been drownings caused by the unanticipated storm surge. The pharmacies and food stores in the city which were intact despite the winds, were flooded by seawater, and/or were subsequently looted, denying residents access to food and medical supplies. One hundred eighty-one inmates were set free as water rose and threatened the Tacloban City Jail building. As a result, patients presenting to the Hope Force International clinic often reported anxiety about possible criminal attacks.

A number of local disaster planning or response assumptions were found to be in error. First, if there was a loss of local power supply, it was assumed that generators would provide power for hospital and medical sites to keep electronic medical equipment in service. In contrast, it was observed that with hospital roofs and windows damaged from high-velocity winds, flooding had destroyed most generators and electrical equipment (x-ray, computerized tomography, laboratory, computers, and communications) because generators and heavy equipment had been placed in service on ground level floors. Mechanized transportation was disrupted due to damage to roads, which interfered with bringing in relief staff for hospitals and with transport of medical supplies. It was assumed that medical care providers, public safety, and law enforcement entities would still be functioning and that the local government could coordinate relief and security efforts, but the storm disrupted cellular phone services such that key relief personnel could not contact their families and the majority of essential on-duty staff felt compelled to leave work positions to check on and assist family members. Recordkeeping and identifying emergency management/public health trends and concerns had to be done almost entirely on paper. Intensive care, medical, and post-operative in-patients had to be managed with few health care providers and no electrically powered equipment. In addition, security was tenuous in the settings where community members stayed to provide services and relief.

Simultaneous to the health care delivery problems identified above, local residents began approaching hospitals requesting evaluation and treatment for blunt and penetrating traumas suffered during the storm, as well as assistance with pregnancies, blood pressure, diabetes, dialysis, and other usual health care. In the days and weeks after the storm, advanced teams from multiple international relief organizations (such as Doctors Without Borders (New York, New York USA) and the World Health Organization (Geneva, Switzerland)) began arriving to provide needed relief work. However, with the local government essentially inoperable due to complications of the storm, hospital administrators and relief workers were left to make their own decisions regarding which group(s) to form partnerships with, without local, central coordination. Relief relationships were evolving constantly, and most disaster workers were on scene for 3-10 days without developing long-term follow-up or rehabilitation care plans for storm victims.

The themes of relationships, flexibility, and patient-centered attitudes were frequent in the event journal notes. The relationship with a Tacloban business leader was important in providing medical care in the city as well as accessing most of the information gathered for this report. This man owned a chain of restaurants in the province and initially had offered one of the inoperative restaurants as a field clinic site. This site was a few blocks from one of the storm-affected hospitals and would have been an appropriate location to coordinate with the hospital to manage clinic-level acuity patients. After organizing conversations with the hospital administrator, an inoperable, but usable, ground floor wing of the hospital was offered and set up as a field clinic site with coordination of patient care efforts with the foreign medical team which was providing emergency care in the hospital.

It was confirmed that after the typhoon struck, almost all of the on-duty hospital staff had left to attend to their families. Like most modern cities, many employees had a lengthy daily work commute; after the storm hit, they faced walks home of up to 10 hours with roads blocked and vehicles unusable. Hospital staff was not able to return to duty until the shelter, food, and medical needs of their families had stabilized. Two weeks following the storm, the hospital remained dependent on a foreign medical relief team to staff the emergency department and a team of out-of-province Filipino practitioners for surgery and in-patient care. In some circumstances, some hospital employees had been made homeless as a result of the storm and resorted to living in unoccupied hospital rooms. The pattern of need for attention to personal family matters was repeated in other areas of society, with the president of the Philippines stating that 20 of the city’s 290 police officers returned to their posts following the storm. There were similar estimates that 200 of Tacloban’s 2,200 municipal employees were available to work. Locally based, national public health workers were affected to the same extent. Further complicating matters was political strife between city and national political leaders with accusations about adequate support and response from the national government versus poor local planning and preparation.

Analysis and Recommendations

Health care facilities (and police, fire, public health, and emergency management) lost 80%-90% of their personnel for a week or more after the storm. This had an impact on any possible system-wide surge capacity and public safety. The majority of the local workforce was not available as they required time to assure the safety and security of their family and homes. During this period of limited staffing, there was an unmet need to coordinate a wave of national and international responders anxious to help as quickly as possible.

Planning assumptions regarding reserve electrical power (generators), security, and transportation were erroneous, limiting the applicability of any pre-event planned response. Loss of mobile telephone coverage (due to storm damage of cellular towers and loss of electrical power) denied the ability to communicate, resulting in many employees having to leave essential jobs to check upon and attend to family and homes.

There was an influx of aid groups with a variety of levels of expertise and equipment. Optimally, these groups would have been integrated into a coordinated response, but local government was incapacitated. Cooperativeness, flexibility, and open-mindedness were required from all parties to develop effective response relationships.

Keeping a journal during the response provided a log and information that allowed for review of observations relative to the event. Keeping a journal also served as a stress reduction technique, as well as a means to step back from positive and negative daily experiences, to examine those situations objectively later, after recovery from personal stress and emotional reactions related to being a responder.