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Preface From the moment of impact through the years it takes for communities to recover and rebuild, disasters have complex and far-reaching health impacts, extending beyond an assessment of mortality only. Exacerbating the toll of lives lost are serious morbidities, including not only direct physical injuries, but also trauma and stress-induced mental health effects, disaster-induced interrupted treatment aggravating underlying conditions and, in some instances, exposures to environmental contaminants. Disadvantaged and underserved communities are in most cases disproportionately impacted by disasters; hence any comprehensive disaster impact assessment must also take into account the social determinants of health. Congress mandated this study in 2018 as part of the Disaster Recovery Reform Act, following the publication of significant discrepancies regarding the numbers of deaths caused by Hurricane Maria in Puerto Rico in September 2017, which brought to the forefront pointed questions about how estimates of total disaster-related mortality ought to be derived. Yet, the assessment of disaster-related health impacts is a complicated and multifaceted endeavor, requiring the coordination of diverse stakeholders within a nationwide patchwork of systems responsible for recording and reporting health and mortality data. Over the course of the committeeâs deliberations, we sought to pinpoint the most important challenges that undercut the ability of practitioners to gather, report and use mortality and morbidity data to save lives and protect health. It became clear that responsibilities and practices across multiple stakeholders were fragmented and inconsistent, making it difficult if not impossible to compare and learn across disasters. Thus, while it may be possible to answer the narrow question, âWhat is the best way to calculate the total mortality from a particular disaster in a given population over a given time frame?,â any functional system for regularly assessing disaster-related mortality and serious morbidity will require sustained efforts to integrate disparate systems, harmonize and standardize definitions and practices, and cultivate the commitment of stakeholders to assess, report, and make data accessible and usable as a fundamental component of the disaster management enterprise. To realize this transformation, the committee strove to develop recommendations that are actionable and that provide a practical roadmap to overcome persistent barriers to achieving real, sustainable change that bolsters community resilience. The committeeâs deliberations occurred during an unprecedented time; just as our term of appointment was about to wrap up, a novel infectious disease grew into a pandemic with enormous impacts on health and society. The original charge to the committee did not focus heavily on disasters related to infectious diseases, but this exclusion was reconsidered as the COVID-19 pandemic gathered momentum worldwide in early 2020. Following the Stafford PREPUBLICATION COPY: UNCORRECTED PROOFS P-1
P-2 A Framework for Assessing Mortality and Morbidity Disaster Relief and Emergency Assistance Act declaration for all states in March 2020 and the escalating spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) within the United States, many of the challenges already identified by the committee became starkly evident in real-time, as early attempts to assess COVID-19-related mortality and morbidity were scientifically challenging and fraught with methodologic, logistical, philosophical and even political controversy. In May 2020 the study sponsor, the Federal Emergency Management Administration, approved the committeeâs request to include considerations related to the COVID-19 pandemic in the final report. The committeeâs intent for this inclusion is to provide practical context for the core recommendations set forth in the report, not to adjudicate the relative merits of current estimates of pandemic-related mortality nor to comprehensively assess the impacts of the COVID-19 pandemic. We also did not want consideration of issues related to data on pandemics to become the focus of the report, which has much broader implications for disasters of all types. Therefore, at several places in the report we offer examples drawn from the ongoing pandemic that highlight administrative, logistical, and methodological challenges in assessing mortality and morbidity common to large-scale disasters of any provenance, and to illustrate how the committeeâs framework could be applied in practice to help overcome those barriers. While the report focuses on the approaches and systems needed to accurately estimate disaster-related mortality and morbidity, the value of these data extends far beyond these estimates. For practitioners and policy makers, an integrated, holistic data system should inform targeted investments in response and recovery to strengthen community resilience between disasters. For individuals and communities, these data hold deep emotional significance and they can help survivors and their loved ones in a community in memorializing what has been lost. For society and at a global level, these data can even be used to prevent some disasters, by helping to shape decisions in the context of the changing global climate as to where and how people live and whether to rebuild or retreat from geographic areas subject to frequent flooding, high temperatures, or wildland fires. An area of critical significance, which the committee was not able to cover in great depth due to the narrowness of the Statement of Task, is the role of social determinants in disaster- related morbidity and mortality and how these factors relate to community resilience. It is well established that disasters affect populations inequitably: disparities in socioeconomic factors and other environmental, geographic, political, and biological dimensions heighten vulnerabilities and amplify the risks of death and morbidities for certain groups during and after a disaster. It is the committeeâs perspective that these issues are of fundamental importance. We strongly advocate for further study about how social determinants of health affect disaster-related health consequences, as well as how mortality and morbidity data can be contextualized and enriched by multidimensional data to develop and use more effective strategies to protect vulnerable groups and promote community resilience. Lastly, although the committeeâs recommendations are targeted at the assessment of mortality and morbidity related to âlarge-scaleâ disasters (see the definition in Chapter 1), our plan of action, presented in Chapter 5, is intended to be read and adopted more broadly to develop stronger, more nimble systems that are primed and ready to respond to events of any magnitude or origin. This report is being released at a time of great uncertainty, with much remaining unknown about the health impacts of the as-of-yet unrelenting COVID-19 pandemic, and the next disaster that could occur at any time. It is the committeeâs hope that our PREPUBLICATION COPY: UNCORRECTED PROOFS
PREFACE P-3 recommendations will strengthen the nationâs resolve and ability to save lives and protect health in the wake of this disaster and the nextâwhenever or wherever it strikes. Ellen J. MacKenzie, Chair Committee on Best Practices for Assessing Mortality and Significant Morbidity Following Large-Scale Disasters PREPUBLICATION COPY: UNCORRECTED PROOFS