Disaster preparedness

Disaster preparedness in the book is measured not by whether a plan exists but by whether people, equipment, authority, and reliable information can be brought together when ordinary systems fail. The response to Hurricane Katrina shows how foreseeable hazards became a crisis through gaps in evacuation, infrastructure, and coordination. The contrasting experience of Charity Hospital demonstrates that preparation also depends on practical routines and decisions about whose lives to prioritize.

Preparedness Beyond the Plan

Preparedness begins with anticipating what a disaster will demand, but it must extend to the circumstances of those expected to respond. When Ray Nagin ordered New Orleans evacuated, residents without cars depended on transportation plans that had significant gaps, including insufficient drivers. The New Orleans Superdome was designated a last-resort shelter, and Nagin directed people with medical conditions toward it without specifying what assistance would be available there. People could be told to leave while lacking the means to do so; patients and others dependent on care faced a further problem of how to travel safely.

The strain was visible in the transport system. Dispatchers at Acadian Ambulance were overwhelmed by requests from hospitals, nursing homes, and homes. Many of the roughly two dozen ambulances made available were stuck in traffic, and some began taking patients to the Superdome rather than out of the city. In one hospital’s case, administrators considered moving nine of their sickest patients to western Louisiana, but clogged roads made the journey dangerously prolonged unless an urgent airlift could be arranged. These were not interchangeable logistical inconveniences: the delays fell hardest on people whose medical needs made independent evacuation impossible.

Known Hazards, Unfunded Protections

The book presents the vulnerability of New Orleans as a risk known well before the storm. The city’s flood-control system had recognized weaknesses, while loss of wetlands had diminished a natural buffer. The Hurricane Pam exercise had modeled a catastrophic hurricane and the presence of more than two thousand hospital patients in the city, yet officials had not worked out how to move so many patients to safety. On the day before Katrina made landfall, federal emergency officials were told that all but two New Orleans hospitals had generators, electrical switches, or both at ground level.

At Memorial Medical Center, the danger had been documented in concrete terms. After Hurricane Ivan’s near miss, plant operations director Eric Yancovich studied storm-surge models with the US Army Corps of Engineers. Memorial sat three feet below sea level, and the models suggested that a major storm could bring twelve to fifteen feet of water around it. Yancovich sketched the elevations of hospital entrances and outdoor equipment on lined paper; his calculations showed that less than four feet of street flooding could send water over the loading dock. Although the generators themselves were on the second floor, parts of the emergency power distribution system were at or below ground level. He warned that comparatively little water could disable most of the medical center and anticipated that patients might need to be moved to the newer Clara Wing.

Some protections were installed, including floodgates and a raised vent for underground diesel tanks, but recommended work on transfer switches and pumps supplying medical air and vacuum suction was not completed. A partial bid for the electrical work exceeded a quarter of a million dollars, and Yancovich recorded that a lack of capital made approval unlikely at the time. Preparedness therefore involved more than recognizing a hazard: it required funding the connections and supporting systems on which clinical care depended. The failure to make those investments left a known weakness in place.

When Infrastructure Fails in Sequence

Memorial’s generators were expected to support the hospital for at least three days, though they were designed and tested for much shorter periods of backup operation. The three 750-kilowatt units had already been running for two days when problems escalated. On-site electricians and engineers were not generator mechanics. After an engine overheated, staff added water and restarted it; later, low oil pressure and other failures led workers to bring diesel and try to restore power.

The generators were only one part of a larger electrical system. When one failed, workers tried to transfer some of its load to another. They went through knee-deep water to reach electrical equipment and used a bypass handle to connect the circuits. A gauge then indicated that the working generator was drawing too much current, raising concern about a short circuit. With some transfer switches and distribution panels apparently submerged, staff shut off circuits and attempted repairs without spare parts. After two hours of effort, at about two in the morning on August 31, the last generator surged and stopped.

That sequence illustrates why a backup device cannot be treated as a complete backup system. Power depended on generators, fuel, transfer switches, distribution panels, and related equipment remaining usable together. Floodwater threatened components that connected the generators to hospital operations, and the loss of power then constrained patient care. At Memorial, some patients were ventilated by hand with Ambu bags after the outage. The crisis was thus not an unforeseeable failure of a single machine; it was a cascade through infrastructure whose weak points had already been identified.

Charity Hospital as a Contrast

Charity Hospital faced severe conditions of its own. It flooded and lost power, functioning plumbing, computers, telephones, and elevators; it had no helipad, and transferring all patients took until the afternoon of September 2. The hospital had about twice as many patients across its two campuses as Memorial, with fewer staff relative to patients. Yet fewer than ten patients died. The comparison does not make the circumstances equivalent, but it draws attention to choices and capacities that shaped care within them.

Charity had drilled for a Category Three hurricane and levee failure. With federal preparedness funds made available after the September 11 attacks, it purchased portable generators, oxygen-powered ventilators, and a ham radio system, and provided disaster training for security officers. During the crisis, workers siphoned gasoline from cars to run ten small generators, powering ventilators and cardiac monitors in intensive-care units, including equipment supporting a very premature baby. This differed from Memorial, where two similar generators were later used to power lights and fans in common areas and at the helipad, rather than medical equipment.

The contrast also involved organization, not just equipment. Charity leaders held meetings every four hours for staff ranging from doctors to janitorial workers. Staff maintained routines, including therapy services, shifts, and regular sleep schedules; they also tried to limit rumors by insisting that reports be based on what workers had seen. Most consequentially, leaders did not designate a category of patients as too ill to rescue: the sickest were evacuated first, rather than last. These practices helped sustain a degree of coordination and continuity amid conditions that could otherwise have magnified panic and uncertainty.

Unequal Capacity and Lessons Revisited

The book connects institutional readiness to the unequal ability of people to reach safety. The city’s evacuation order could not supply cars, drivers, or ambulances that were not available, and a shelter designation could not by itself ensure medical support. Even within a hospital, a patient’s dependence on oxygen, suction, or other equipment made the condition of power systems part of the evacuation problem. During the boat evacuation at Memorial, a neighborhood resident waded to the hospital because he was overdue for dialysis; a separate outpatient arrived for a scheduled chemotherapy appointment despite the emergency around the hospital. Such episodes show how people may continue to seek essential care without having an accurate picture of how much the surrounding system has deteriorated.

Preparedness also appears as a matter of institutional coordination and learning. The book describes years of warnings and planning exercises, alongside failures to turn known scenarios into workable patient-transport plans and resilient infrastructure. In its later account of preparations for Hurricane Sandy, a nonprofit hospital parent company had a local command center and offered proactive assistance to its hospitals and others in the region—support the book contrasts with the assistance provided by Tenet and LifeCare headquarters during Katrina. Yet some staff still had not planned for a complete loss of power, the failure of the backup to the backup. The comparison keeps preparedness from becoming a story of simple progress: better coordination can coexist with unresolved assumptions about how systems fail.

Across these episodes, disaster preparedness means building capacity before an emergency and preserving judgment during it. It encompasses evacuation routes and drivers, power systems and the components connecting them, communication and staff routines, and triage decisions that determine who is moved first. The book’s central distinction is between plans that acknowledge danger and arrangements capable of protecting people when the danger arrives. Where the latter are absent, the costs are not borne evenly; they accumulate among patients, older people, and residents without independent means of escape.