Jeffrey Upperman, MD, surgeon-in-chief at Monroe Carell Jr. Children’s Hospital at Vanderbilt, talks about why the U.S. needs a coordinated initiative to emphasize the impact of disasters on children to improve both future crisis responses and the care of children in the immediate aftermath and as they develop.
Upperman, a national leader in pediatric trauma and disaster preparedness, is among the authors of the Pediatric Disaster Science Series from the National Academy of Medicine that published in late September as scenes of Hurricane Helene’s devastation emerged across the Southeast, underscoring the need to formalize response, research and care efforts.
“Many of us in the field felt we needed to make strong statements on what we believe are responsible frameworks for filling gaps in the work around disasters at large. It’s not just about a pandemic or natural disasters; it’s about understanding what a framework would look like for understanding these problems in a prospective way, particularly around children. They are often left out of the planning because they are hard to study, spanning from zero to 21 years of age, each bringing different dynamics to the table. There’s clearly not going to be a one-size-fits-all approach,” said Upperman.
What’s the goal of pediatric disaster science?
Since we’re at Vanderbilt, let’s put it in pandemic terms. I would say we’ve got to cut down on the amount of time from when we know we have a problem to when we have a developed vaccine. Then we need to shorten the amount of time it takes to get that vaccine into the arms of children.
What we’re trying to push is this concept that reactions, responses and planning — the whole disaster cycle — is not just a just-in-time activity. There should be, and sometimes there are, well-thought-out hypotheses and approaches that are being tested, sometimes in a controlled way. It’s obvious we’re not going to test pediatric disaster science responses in a standard randomized controlled trial for ethical reasons. But there are metrics, parameters and concepts that are well known and have been tested in some controlled areas in other disciplines. You see coordination and metrics, for instance, when they pop up on the back end of a hurricane and hurricane damage.
We know disasters, pandemics, tornadoes, hurricanes, you name it are going to happen. So the reality is we’re going to have to have some hard conversations because we can’t “what if” ourselves to death by not having an approach.
The thing is though, we know what we have to do in children’s hospitals — we have to take care of this kid. That’s what was on our mind in these discussions — we know there are big questions that people will want to go back and forth on — but we’ve got to do the right thing. We have to take care of kids who get put at risk in disasters.
What spurred the work to start now?
As a citizen who happens to be a researcher and clinician, I think that part of the catalyst is the narrative during and after the pandemic, about whether people really trust science. There needs to be a dialogue that connects the immediate response to a disaster not only to the rebuilding but to the impact on children’s health — and in the bigger picture, public health. Are we capturing and analyzing data, so we can help better, or are we just responding?
As a volunteer on this work with the National Academy of Medicine, our role was to promote a platform for dialogue with research scientists across the country who have been studying these areas and identified gaps in how one prepares for or reacts to a crisis. There has been great work done in areas that people may not understand. For example, I learned about something called exposome. In this concept, in the communities impacted by this hurricane, for instance, where people are walking in water up to their waist and exposed to contaminated water, this exposure can lead to immediate health issues like diarrhea or more insidious long-term effects. This changing environment is impactful on a person. It becomes a marker in a person’s exposome and can help us understand the ecological or biological phenomena impacting humans.
The Centers for Disease Control and Prevention defines exposome as “the measure of all the exposures of an individual in a lifetime and how those exposures relate to health. An individual’s exposure begins before birth and includes insults from environmental and occupational sources.”
For instance, the recent blast in Georgia raised questions about the environmental impact of the plume on surrounding communities. Experts in hazmat suits are probably measuring the immediate effects, but the long-term impact on groundwater and the environment needs to be studied. This science helps us prepare better and provide more guidance to citizens, which is what we were trying to get at.
The exposome is an interesting lens, especially with the current emergent situations, to use regarding the longer-term changes to the environment from events and how those are going to interact with children’s development. How does this shift how disaster response and public health officials think about the symbiotic relationship between the physical world and children’s development?
There’s literature out there and some reports suggesting that post-Katrina, with all the mold that built up in those structures, many of which had to be destroyed, there was a concern about an excess amount of asthma exacerbations or other pulmonary or mold-related diseases. A group went in to look, and although they didn’t pick up a signal, the thinking was important because of the unfortunate natural experiment. They went in really trying to understand if we needed to do something differently for this population of kids and others with regard to asthma because of this environmental disaster.
We really need that data to be able to inform not only public policy, but also public health policy — and maybe even public health reactions. Without that information, it’s speculative. It just becomes sort of an anecdote where the community pediatrician kind of gets the sense that, ‘Man, it seems like I’m writing a prescription for a lot of inhalers these days.’
It just becomes a curiosity to them as opposed to a system put in place to understand what’s going on. Someone needs to say, ‘We’ve been looking for a model that would help us understand what an unexpected exposure could be to a child. And here’s this. It’s unfortunate, but here it is.’ We need to be able to carefully look at the situation and track it to ensure that we understand really what’s going on. But that type of framework doesn’t really exist in a reasonable way today.
Does a framework exist elsewhere that could be imported to establish pediatric disaster science?
On the global public health side, we know the CDC sends environmental control officers overseas to track viruses and all these things. But do we have a robust framework in the domestic United States looking at some of these disasters to do it?
I think we have some systems and there’s some grants available, but in general, some of the institutes don’t fully fund these types of activities. The National Science Foundation does, largely around engineering things; I don’t know what their current portfolio looks like. But in general, the scientific establishment is not necessarily set up to do this just-in-time exploration as rapidly as many of us in the field think it should be done.
What this brings to mind is the need for a legion of responders like the storm chasers who go out to collect and submit data. Just-in-time exploration would be complex orchestration of the disaster community.
I don’t know if the disaster community has enough of those human sensors, so to speak, in the field, because we have to be agnostic to the disaster. Human sensors are out there to observe and collect data. We’re thinking about any type of disaster — man-made or natural — but each one brings its own set of responders, right? You’ve got tornado chasers. They may not be interested in hurricanes or wildfires. You’ve got the wildfire crew, and so on.
How do you utilize communities like that in a safe and ethical way to have data that is very reliable? Me? I’d be very interested in their dataset because I have a bias that I’ll take the data from anywhere as long as it’s gathered appropriately.
An important consideration in setting up a framework is the need to responsibly conduct research on the back end of a disaster. We need to speed up all those approvals and have funding that comes within days or weeks, not six months later, to understand how a hurricane ravages the Southeast United States. This would allow research teams, as soon as it’s safe enough, to start collecting information that would be useful — not just for the people now, but for future advice to that community or others facing similar disasters.
For example, about the built environment: If an engineering crew went in and found that structures on Main Street had certain building codes while those off Main Street did not, and saw that the structures on Main Street survived better, they could advise that having uniform building codes might have saved more structures and lives. This has to be done quickly however because once the dump trucks and bulldozers come in, they’re focused on cleanup, not on gathering detailed data.
This kind of timely research could apply to a whole host of things from zoning and engineering to understanding longer-term health impacts associated with these crises.
But we have to be on the ball so we can let the communities get on with the important work rebuilding quickly. We don’t need to impose data collection when they’re just trying to rebuild their lives.
What’s next?
The good thing about this work is it was not in a silo. We had most of the major health-related agencies involved at the table contributing to this work or at the symposium that we had. So there’s an awareness. I hope, as a citizen and as a volunteer in this effort, that each of these agencies picks this document up and really combs through how it could impact their strategy; their short- and long-term plans for supporting these types of efforts. I hope that our well-known agencies that supply funding for health-related activities in the research space would look to add, I’ll just say generically, pediatric disaster-focused projects to these things. I hope they see the need to put it in their funding strategic plans and get these things funded.
