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What Sandy Teaches Us About Harvey

Eric Toner, MD, August 28,2017

The historic, catastrophic, ongoing flooding from Hurricane Harvey is battering Houston and other areas of east Texas, including the health sectors in those areas. Important lessons can be learned from the experiences of those who were involved in the response to Hurricane Sandy in New York and New Jersey nearly 5 years ago. My colleagues and I from the Johns Hopkins Center for Health Security, along with collaborators from the CDC, spent nearly 2 years studying the impact of Sandy on the health sectors of those affected areas and, from the research, developed a practical checklist of actions to improve the resilience to natural disasters of health sectors of other communities. The full report and checklist is available at Our previous study on the impact of hospital evacuation caused by Sandy on the receiving hospitals is available at

Health Sector Resilience

The health sector is broader than just hospitals, emergency medical services (EMS), and public health agencies that are normally included in emergency preparedness and response. It also includes healthcare providers, outpatient clinics, long-term care facilities, home health providers, behavioral health providers, and correctional health services. In addition, it involves community-based organizations that support these entities and represent patients. We define health sector resilience very broadly as well, including all factors that preserve public health and healthcare delivery under extreme stress and contribute to the rapid restoration of normal or improved health sector functioning after a disaster.


Key Findings Most Immediately Relevant to Hurricane Harvey

Some of our findings and recommendations refer to strategic actions that take years to implement; however, others can be implemented now and have immediate impact on the response to and recovery from Harvey:

  • Most of the healthcare visits after the storm will not be people injured or sickened directly but rather people with chronic health conditions who have been displaced from their normal source of health care.
  • Disruption of outpatient, community-, and home-based care adversely affects patients not only directly but also indirectly by placing an extraordinary burden on hospitals that are ill-prepared for both the volume of patients and the types of problems that these patients experience. For example, hospital emergency departments are not equipped to provide care for more than a handful of patients needing dialysis or methadone maintenance.
  • Nonhospital residential facilities are usually less prepared and, therefore, inherently less resilient than hospitals.
  • The storm can easily splinter the already fragile support systems on which many vulnerable people (eg, elderly, young, chronically ill, addicted, poor, and non–English speaking people) rely, such as home-based care, public clinics, just-in-time medications, and public transportation. 
  • Special needs and medical shelters must have a large capacity with a well-considered mission, staffing, and concept of operation. 
  • With the aftermath of the storm lasting weeks or months, patients’ access to health care may be disrupted for extended periods, resulting in prolonged burdens on the healthcare facilities that remain open.
  • External support and relief will be desperately needed to handle the surge in patients and to backfill local personnel who are unable to report for work or who need respite after days and weeks of sustained work with little sleep.
  • The loss of readily available vehicle fuel, electricity, electronic communications, and transportation threaten people with chronic health needs and greatly hinder the ability of healthcare facilities to respond.
  • Mobile health units of various types can be very useful. A number of health-related entities, including pharmacies, hospitals, medical clinics, and substance abuse programs, own or have access to mobile units that they use for routine activities.
  • Normal procedures and standards of care may need to be adjusted in order to do the most good for the greatest number.
  • Political leaders play an important but not always constructive role. Having high-level support from elected officials for emergency managers and public health officials is essential to response efforts; however, conflicts between political leaders and ad hoc decisions by leaders that are not consistent with response plans or strategies can create confusion and complicate the response.

The Checklist

The checklist includes cross-cutting actions that many different health sector organizations can implement to foster resilience. In addition to this general checklist, supplemental checklists are included that are specific to individual components of the health sector: hospitals, long-term care facilities, outpatient medical facilities, behavioral health providers, pharmacies, correctional health facilities, public health departments, patient transport providers, home- and community-based care providers, elected officials and jurisdictions, as well as patients and families.

A Conceptual Map of Health Sector Resilience

We developed a conceptual map of how the various parts of the health sector interrelate in the context of a disaster such as a major hurricane, which we have summarized in the following infographic and also in a YouTube video intended for a lay audience:



We believe that there is much to be learned from the lived experience of those who played a role in preparing for, responding to, and recovering from a recent disaster. Our evidence-informed checklist that outlines action steps for medical and public health authorities, in partnership with nongovernmental organizations and private industry, can strengthen the resilience of communities’ health sectors in the face of the current and future disasters. 


  1. Toner E., McGinty M, Schoch-Spana M, et al. A community checklist for health sector resilience informed by Hurricane Sandy. Health Security 2017;15(1):53-69.
  2. Adalja A, Watson M, Bouri N, Minton K, Morhard R, Toner E. Absorbing citywide patient surge during Hurricane Sandy: a case study in accommodating multiple hospital evacuations. Ann Emerg Med 2014;64(1):66-73.