A Bad Time for Disaster

Legal Requirements for Public Safety and Public Health

In the Commonwealth of Pennsylvania, public agencies have limited options to manage this tension of increasing demand but declining resources under legally mandated requirements. For example, the establishment of police, fire, and emergency medical services (EMS) is authorized by the various municipal codes as a local option. Home rule charters may include specific authorization for these services or leave it to the discretion of the legislative body. Although many municipalities provide police protection through their own departments, contracted services, or intergovernmental compact, approximately 27% of the state’s population (87% of the landmass) relies on patrol and response services of the Pennsylvania State Police (Pennsylvania Governor’s Budget Office, 2010). The provision of fire services is largely through volunteer organizations, supported at least minimally by the municipality with required workers’ compensation insurance. EMS can be provided directly by the municipality within the police or fire departments, a “third service,” volunteer organizations, municipal authorities, or private companies.

The requirement for local emergency management coordinators (LEMC) and emergency operations plans (EOP) is addressed in the Emergency Management Code (Pennsylvania’s Emergency Management Services Code, 1978). The only options available to the municipality are either to provide their own coordinator or to share services through an intergovernmental cooperation agreement.

The responsibility for public health follows two models in Pennsylvania. The Local Health Administration Law of 1951 (Local Health Administration Law, 1951) authorized county and municipal health departments (CMHD) to provide a minimum set of public health services, funded by state grants. The required services include the following:

Currently, there are six county and four municipal health departments in Pennsylvania. The required services in areas without a CMHD are provided by state agencies. Regardless of CMHD status, there are several areas for which the state department of health (Pennsylvania Department of Health [PADOH]) retains responsibility, including hospital and EMS regulation. EMS regulation is administered by regional PADOH contracted nonprofit agencies, which includes ambulance licensure inspections and administration of personnel certification examinations. In areas not covered by a CMHD, other state agencies exercise authority, such as food safety inspection services of the Department of Agriculture.

In larger emergencies or disasters, the Emergency Management Code permits counties and the state to provide material and personnel assistance to an affected municipality. The code does not permit the county or state to reimburse municipalities for response costs. Response costs (emergency protective measures) and repair of qualified municipal and private nonprofit facilities are permitted under a Presidential Declaration of Major Disaster under the Stafford Act (Robert T. Stafford Disaster Relief and Emergency Assistance Act, 1988). Yet, the threshold of loss required to receive a Stafford declaration is high, leaving the municipality to rely on insurance, cost control, or tax increases to pay for the response costs.

Land-use planning also affects public safety and involves primarily local government. Land-use planners and planning commissions can limit buildings to areas outside hazardous areas, but the drive to spur economic development in regions seeking to create jobs may pressure local commissions to permit development in hazardous areas or permit variances that might otherwise be denied. These commissions can also require the use of mitigation techniques to reduce risk (Burby et al., 1999), but these techniques can be cost prohibitive in constrained economic environments. Planners have discretion in the use of management tools (Stevens, 2010), which can be valuable aids in a holistic mitigation effort. The added irony, when planning efforts are circumvented, is that the creation of increased risk from hazardous conditions places additional demands on the traditional public safety and public health agencies. The 10,000 Friends of Pennsylvania (n.d.), an organization that supports local government, states that

without major changes in the structures and laws that govern municipalities and the way they are financed, and unless communities are empowered to work more closely together, their fiscal and physical integrity is at grave risk, and the state’s economy will continue to struggle in the coming decades. (Available from http://10000friends.org/)

On this basis, the group is advocating the integration of collaborative management for scarce resources into their planning process to reduce shared economic and physical risk.

Shrinking Economic Resources Under Fiscal Stress

In further constraint, municipal budgets must be balanced within a tight economy. Pennsylvania’s municipalities, counties, and school districts rely largely on real estate taxes, which are limited by law, political pressures, and practicality. The municipal services are caught between those required by the state and those desired by the residents, and sometimes public safety loses. For example, in August, 2010, the City of Philadelphia, in order to realize a US$3.8 million savings in a much larger budget deficit, implemented the systematic closure of fire stations (“brownouts”) for specific shifts. Specific fire companies are temporarily closed with personnel reassigned to shorter staffed companies or training (City of Philadelphia, Fire Department, 2010). The phenomenon of reducing essential public services to balance municipal budgets is spreading to other cities and counties, placing their respective communities at risk. In Oakland, California, a city with a high crime rate, the City Council voted in 2010 to lay off 90 policemen to meet the requirements of a balanced budget (McKinley & Wollen, 2010).

Volunteer fire departments represent most of the more than 2,000 fire departments in Pennsylvania. Although many volunteer departments rely on fundraising and donations, some receive direct stipends from the municipality. All recognized departments receive a per capita–based distribution of a statewide 2% tax on foreign fire insurance policies (“relief fund”). Career departments use relief funds to meet retirement obligations, and volunteer departments use the funding for personnel safety equipment and training. Departments are eligible for federal Assistance to Firefighters Grants and the state Volunteer Loan Assistance Program. With the large number of volunteer fire departments, some financial savings have been realized with consolidation, but there are cases in which consolidation is not warranted. The replacement of a paid fire department with volunteers requires a referendum.

Police departments are funded through the general fund, supplemented by enforcement revenues (fines, fees, etc.) and various federal grants, mostly from the U.S. Department of Justice. With the options available for police coverage, some municipalities have reduced police departments in force or shift coverage, consolidated or contracted with other municipalities, or disbanded their police departments completely. Those without local police protection rely on the State Police in increasing numbers to the point that legislation has been proposed, though unsuccessful to date, that would allow the state to impose per capita fees for patrol services to municipalities that require specific levels of service.

EMS, the newest of the public safety services, has seen consolidation and privatization efforts since its modern inception in the 1970s. EMS funding relied heavily on federal highway safety and preventive health block grants until the 1980s, when the state implemented an EMS Operating Fund (EMSOF) through an additional fee on certain vehicle code violations. The EMSOF fee has not been increased since its imposition, and most of the funds are now used for the administration of the EMS Act rather than the provision of street-level emergency care. Although EMS agencies can bill private medical insurance, complete cost recovery remains elusive to many providers. Strategies of insurance billing, as well as fees for false alarms, have been imposed in some municipalities to recoup costs of fire and vehicle rescue services, with varying degrees of success.

Fiscal stress further erodes the already limited services in public health at the county and municipal level. The governmental public health service directly controls relatively few resources. The health care providers are largely employed by private and nonprofit health care systems, including hospitals, clinics, and private practices. In time of emergencies or disasters, these nongovernmental providers make up the response system. In areas such as Pittsburgh, practitioners, their facilities, and supplies provide a strong capacity for response that other areas of the state may lack. A sudden increase in patient demand, referred to as surge, may tax even larger systems. The state received a US$350,000,000 federal grant to develop supplies and equipment to support surge events. Additional personnel are being recruited though the Emergency System for Advance Registration of Volunteer Health Professionals and the Medical Reserve Corps (MRC).

Planning in Pennsylvania is distributed between the counties and the municipalities. Of the 67 counties in Pennsylvania, 62 (92.5%) have a planning commission. This high number shows a consistency of planning at the county level, but on the more vital municipal level, only 59.6% of the municipalities have a planning commission (Pennsylvania Department of Community and Economic Development, 2010). There are 10 multicounty planning commissions, which may work better for economic development, but lack the granularity in planning and training needed for many types of hazards.

Individual and household preparedness is also constrained by limited economic conditions. In households where one or more persons are unemployed, savings are consumed in meeting daily demands, and there are no reserves for preparedness measures or sudden, unexpected events. The strain is particularly harsh on households of low socioeconomic status. In Hurricane Katrina, those who did not have the funds available could not leave (Elder et al., 2007). Reduced individual preparedness, in turn, increases resource demands on the response organizations. Low-income residents of New Orleans, unable to leave the city, were crowded into the Superdome for shelter and required airlifts to transport them to Houston and other cities for safety (U.S. House of Representatives, 2006).

The decrease in resources has affected the nonprofit sector as well as government. In 2009, total charitable contributions have decreased US$303.75 billion (3.6%), the first decline since 1987 (USA Today, 2010). Government funding for preparedness and training is also declining. The Department of Homeland Security (DHS) request to Congress for preparedness funding through the State and Regional Preparedness Program, Metropolitan Statistical Area (MSA) Preparedness Program and Training, and Measurement and Exercise program has decreased by US$313.7 million (13.33%) according to the International Association of Emergency Managers (2012). Funding to states for Hospital Preparedness decreased US$1,733,871 (21.58%) from 2004 to 2010 (ASPR, 2010).

Cutbacks in Personnel

In public safety, limited personnel services are often hidden through creative record keeping. In some cases, the LEMC is another municipal official, such as the fire or police chief, or an appointed volunteer. In other cases, individual public safety personnel may play multiple roles, but in a major event, can feasibly play only one role, leaving the other roles unfilled. For example, if the local chief of a volunteer fire department also serves as the local EMS chief, the public safety roster for the community will list him as filling both positions (known as a “double hatter”), meeting the legal requirements of the EOP. In practice, in an urgent event, the “double hatter” can fill only one role effectively, leaving the municipality seriously understaffed.

Although a legal framework for the design and delivery of public health services exists in Pennsylvania, cutbacks in personnel have seriously limited the capacity to deliver public health services in a systematic way. Over the past 30 years, for example, the Allegheny County Health Department has been downsized from a department of approximately 1,000 personnel to its current level of 300 personnel, a reduction of 70%. The Department’s US$6.4 million biosafety Level 3 laboratory, intended to house the H1N1 testing equipment, was reported behind schedule and well over budget (Pittsburgh Tribune-Review, 2009). The laboratory, set to open in August of 2009, failed its August inspections, and while it opened in 2010, the laboratory still only functions at Level 2 (T. Gaglierd, personal communication, December 2, 2010). Efforts are continuing to become Level 3, but the certification remains elusive. Consequently, the only public health laboratory licensed to operate in Southwestern Pennsylvania did not have the capacity to provide this critical service during the outbreak of H1N1 flu in late April-May, 2009. The H1N1 outbreak in the Pittsburgh Metropolitan Region in 2009 proved milder than many observers initially anticipated, but the cutback in personnel and laboratory capacity revealed the limited services that local agencies responsible for public health monitoring and testing for H1N1 cases were able to provide in a situation of potentially high risk.

Increasingly Vulnerable Communities

The three factors named above interact not only with each other but also with the external conditions of severe weather conditions, aging infrastructure, high unemployment rates, and an increasing number of people who, having lost their jobs, are also losing their savings and capacity to withstand any unexpected set of demands that would require sudden expenditures. The limited fiscal capacity of the communities also limits their capacity to provide even basic services to an increasing number of people who need them.

Agenda Setting

As advocated by John Kingdon (1996), the critical task is to get the policy makers’ attention and design a set of policy options that can be moved forward at precisely the most opportune time to generate sufficient consensus to initiate change in public support for funding increases. This approach assumes that other items on the public agenda will need to move down, as public safety and public health move up, in terms of a limited model for achieving a desired set of goals, in this case, capacity for managing risk to communities. Criticized by Zahariadis (2007) as politically manipulative, this approach falls short of meeting the requirements for sustainable management of increasing risk to communities across demographic, geographic, and climatological conditions. It encompasses, instead, a high risk of loss and missed capacity to respond to critical but infrequent events.

Nested Sets

The concept of “nested sets” captures the interdependence among levels of government in ways that illustrate the dynamic effects of action by one level of government upon another and the ricocheting consequences of action or inaction taken in response. The concept has been used by several theorists in different fields. Ernst Haas (1990) referred to “nested sets” in his characterization of international organizations that were composed of nation states that, in turn, encompassed substate structures ordered in declining scale. For example, nations encompassed states or provinces that were subdivided into counties, which, in turn, included municipalities and districts (Haas, 1990). Elinor Ostrom (2005) also used the concept of nested sets in presenting her Institutional Analysis and Development framework. The merit of the concept is its recognition of the effects of interaction on all participants. Acting in reference to any given condition creates a reciprocal response that may or may not have been anticipated and may significantly alter the interactions among the participants. The concept is integral to the wider theory of complex adaptive systems.

Intergovernmental relations in emergency management (EM) and public health function in practice like nested sets. The federal system in the United States operates as a general framework for governance, with states acting as subsystems within that framework, counties acting as sub-subsystems within states, and municipalities acting as sub-sub-subsystems within counties. Although the legal structure of governmental organization in this multijurisdictional system is hierarchical by design, in practice the performance of interacting governments functions most effectively through informed choice. Actions taken at one level of government constrain the choices made at the next level, and choices made at that level further constrain the next set of choices made at the first. The process is interactive, with exchanges made, unmade, and remade in a continuing effort to find the best “fit” of resources to demands, using the skills and technologies available to the actors. The strength of this approach is at once its weakness. Given a largely voluntary commitment to emergency preparedness in public safety and public health, this approach relies on a timely, informed process of information exchange. In turn, the capacity for information exchange depends on creating a valid, current knowledge base for the region at risk that can be shared by all participating actors in event of a major threat. Without such a knowledge base in place before the threat occurs and a consequent level of awareness for public and officials responsible for guiding the interactions, the system is vulnerable to error, misjudgment, and, worse, inaction.

Distributed Cognition

A key insight into the performance of complex systems is that no single agency or individual possesses all the information, skills, or resources needed to manage large-scale threats alone. Instead, effective interorganizational response involves a detailed effort to exchange timely, valid information among a range of actors, each of which has different skills, expertise, and resources that are essential for resolving the problem. Coordinated action among multiple actors, agencies, and jurisdictions then depends on the capacity of the set of actors to create a shared knowledge base, or in the vernacular of emergency services personnel, a “common operating picture,” as the basis for action.

Edwin Hutchins (1995) added a set of key perspectives that inform his broader concept of cognition. Cognition is essentially a process of structuring information to aid comprehension of the context for action, and it evolves as the product of interactions among participants in a wider system. Consequently, it can be designed to focus on a desired goal and to enhance preferred outcomes. Design, guided by intent, shapes actions and generates a learning process, as the act itself stimulates information processing that creates a memory trace and influences future actions. Such action differs from unguided evolutionary processes as it can be traced systematically and compared at successive steps to the intended outcome, although Hutchins acknowledges that interactions lead to reciprocal adjustments among the participants. The conduct of design involves specifying the key tasks that each actor performs in the complex set of interactions undertaken, the sequence in which these tasks are performed, the instruments and methods that are used in producing the information shared for decision making by the participants in the system, as well as identification of error and revisions that occurred in producing the actual outcome. Distributed cognition (Hutchins, 1995) creates new mental structures among the participants that search, store, access, and exchange information about tasks and performance. Importantly, shared task performance builds a common base of knowledge and enhances the capacity to learn among the participants in the system. Examining this process of collaborative learning requires exploring the logical relationships among environmental conditions, participants, methods and instruments used in task performance, and interactions among agents over time in dynamic environments.

These three theoretical approaches contribute to a better understanding of risk and the kinds of actions that public agencies may take to avoid disaster. Missing, however, is a means of calibrating the decline in capacity among organizations and jurisdictions as the threat of a given hazard, or the interaction among a set of diminished resources, increases. Balancing the risk of disaster against capacity for timely response becomes the primary task of public managers, public officials, and community organizations and residents.

Increased Adoption and Use of Information Technology

This strategy reflected the innovative adaptation of a set of emergency services and public health managers in a small, rural county that faced limited resources in a region with health care facilities and emergency services distributed geographically over sizable distances. Faced with limited personnel in all agencies and relying largely on volunteer fire departments and emergency services, the LEMC turned to information technology to link his office with other offices electronically. This pattern was strengthened by a strong program at the local hospital to connect with the research hospitals in the region to access advanced medical consultation in areas of medicine that the hospital’s medical staff could not provide. The pattern was further reinforced by the staff nurse at the District Office of the PADOH, who, alone in her office, needed to connect with the state office some 300 miles away on a regular basis. Using information technology in innovative ways, this small group of experienced emergency and public health managers likely multiplied their effective service to their community many fold over standard practices of face-to-face group meetings.

Increased Isolation From Community Participation and Preparedness

A second strategy, readily observable in another semirural county was increased isolation and withdrawal from community-wide efforts to prepare and practice for extreme events. The organizations in this category were operating at maximum capacity, trying to meet demands for daily services. Limited personnel, for example, a nurse on duty 1 day per week at the District Office of PADOH, simply could not respond to requests to participate in county-wide preparedness meetings. When and if public health threats occurred, response actions were organized by the more experienced EM personnel, with public health staff providing the medical knowledge and expertise. In a county with a high proportion of elderly residents and frequent exposure to extreme weather conditions, this strategy, while barely maintaining daily demands, leaves almost no reserve for extreme events.

Increased Reliance on Organizations With More Experience and Funding

A third strategy that has evolved in recent years is an increasing reliance of smaller organizations or organizations without resources on larger organizations that do have resources and funding for preparedness exercises, and more experienced personnel. This pattern is especially evident in the changing relationship between public health and EM organizations. Although public health organizations—hospitals, health departments, and EMS—are theoretically actors in a “public health system (PHS),” these organizations often do not recognize themselves as members of a distinct PHS and rather identify with their closest counterparts, in many cases, the EM system of the county. This pattern tends to vary in relation to risk, with agencies exposed to risk minimizing the likelihood of danger, and agencies that would be legally required to assist in event of serious threat, concerned that their own capacity would be compromised by ill-prepared partners in community response. Figure 1 shows the dominant relationship between the EM organization in Beaver County, PA, and the other organizations that are recognized as participants in the county’s PHS.

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Figure 1.

Rankings of public health actors, Beaver County, Pennsylvania.

All three strategies reflect particular risks and particular strengths, but, importantly, they show a growing interaction between the increased demand for public health services in counties with limited resources and the more experienced and often better funded EM agencies. In many respects, these trends point toward increased collaboration among the agencies that provide public health and emergency services. This trend, however, carries the increased risk of the overextension of demands on emergency services in event of a major, region-wide event. The pattern of increased collaboration between EM and public health organizations has likely been strengthened by the Regional Counter Terrorism Task Force of Southwestern Pennsylvania, known as Region 13 for the 13 counties and the City of Pittsburgh that make up its formal membership (Counterterrorism Planning, Preparedness and Response Act of 2002). Funded in large part by federal grants from the DHS, Region 13 has created over the last decade a program of exercises and training that has increased the level of skills and performance of emergency services personnel in the region. These exercises have also included actors that are nominally actors in a distinct PHS, such as PADOH, EMS companies, and major regional hospitals. Although the exercises have highlighted different points of needed collaboration among agencies and built a level of awareness of regional capacity, they have not yet articulated a coherent framework for coordinated action based on a consistent assessment of needs and capacities in the set of communities that make up Region 13.

Although a major driver of collaboration or lack of same among public health and EM organizations has been the tightening vise of increasing demand, but declining resources, there has still been an initial resistance on the part of both sets of agencies to accommodate a broader set of demands. The two sets of agencies—public health and EM—have not only different organizational cultures but also have had largely different funding streams for their preparedness activities. Yet, in any extreme event, they are necessarily engaged in collaborative action to protect their communities. This sense of shared mission is the basis for building a new pattern of collaboration that will enable them to anticipate risk and allocate scarce resources more efficiently in countering extreme events. The focus groups conducted with practicing county managers during the spring and early summer of 2010 documented a beginning recognition of the need to balance tasks and resources in communities to meet interacting public health and emergency threats. For example, Beaver County personnel reported a collaborative response among public health and EM agencies to the H1N1 threat in the spring and early summer of 2009.

Reframing the Issue as Community Resilience to Threat, Not Separate Agencies

This strategy will require adjustment among agencies, responders, and the members of the community. In this case, members of the community include not only residents but also all stakeholders such as businesses, elected officials, and nonprofit agencies. This adjustment relies on the human capacity to learn. One of the benefits of this type of collaboration is cross-training among the agencies that not only increases flexibility but also can extend human cognitive limits (Simon, 1997). This flexibility also enhances the resilience of the evolving response system by loosening what might otherwise be a tightly coupled system (Perrow, 1984). This loosening of the system occurs through increasing the number of assets as well as the diversity in the system. There is no longer reliance on only governmental agencies for response. The revision of “the PHS” not only brings additional assets to the public health emergency preparedness but also provides a means for including spontaneous volunteers in the system prior to a crisis.

Yet, there are limitations. As Vaughn (1999) pointed out, the same characteristics of a system that produce the bright side will regularly provoke the dark side from time to time. These limitations can be reduced with time and experienced personnel working as a group through drills and exercises. It also requires a concerted effort to educate the community on the risks posed and the implications of economic restrictions. This education must reinforce recognition that risk is a far-reaching issue that requires a holistic approach to optimize effectiveness. Such efforts and changes are most easily enacted, if supported by a well-developed information infrastructure to optimize outcomes by sharing information. Situational awareness increases with timely access to information, shared effectively among organizations and individuals within the community. The process builds recognition that the focus of managing risk and response operations is to create community resilience rather than to protect any single organization’s political or fiscal turf.

Creating an Integrated Knowledge Base and Decision Support System

When risk is assessed, it is possible to compare the risk of a specific type of event to the capacity of the community to respond to that event; then, actions can be taken to address observed gaps. This process is necessarily recurring, as conditions change and actions are taken to recalibrate the system of response and mitigation. Actions involved in building capacity to mitigate disaster consist not merely in purchasing equipment but also in developing effective personnel and organizational procedures, including interorganizational partnerships. Coupled with informed timely action, these steps can mitigate the deaths and damages of a hazardous event through a decisive and coordinated response. The information gleaned from situational awareness data needs to be integrated with a knowledge base to develop knowledge about the potential implications of hazards to the community.

Of the suggested teams of organizations, two teams that are critical to large responses but often are of low profile are EM and public health. EM’s importance for larger incidents is the vital hub, not only of coordination and information but many times of logistics. In the case of public health, these organizations are often a good repository for health information, but public health personnel rarely have much experience at managing large-scale incidents. Consequently, they rely on EM agencies for logistical support and coordination. With the heightened awareness and risk of pandemics and other public health-based emergencies, the integration of these two sets of organizations has become increasingly important.

Obstacles to Resilience

There are many obstacles when considering the types of actions these strategies and environments will create, but none are insurmountable. The first obstacle is getting the organizations to realize that they can no longer operate as independent agencies or that the other segments of the community can rely solely on government’s assistance. It is through this integrated approach, cooperation, and coordination that many public health preparedness and emergency services can be continued. The FEMA all-hazard approach needs to be extended to an all-community approach. Fiscal resources will no longer allow organizations that have emergency responsibilities to remain isolated in their various domains. Instead, a fully functional partnership of organizations, businesses, and residents, in cooperation with agencies that have responsibilities during emergencies such as public health and emergency services, is essential to protect their communities.

A second obstacle is resistance to information sharing. As discussed earlier, the gathering of information through a distributed collection of organizations and individuals will provide additional data, but many of these organizations are accustomed to maintaining their data as a proprietary source. This resistance is not just for business reasons; it has become part of the organizational culture not to disclose information brought in through regulation such as by the Joint Commission and Health Insurance Portability and Accountability Act (HIPAA). Although there is an exception for disasters in HIPAA (Gravely, Whaley, & Sanders, 2007), there is often an ingrained culture of not releasing information without a series of approvals. Some individuals are also hesitant to share information with governmental or research organizations. The information from these individuals can be critical as an expansion of data collection possible on an organizational level. The way to overcome these barriers is to work out the information exchanges before the incidents, so confidentiality and proprietary information can be protected and the restriction of information minimized.

Third, the diversity of the health care sector represents a significant obstacle in practice. When the term health care is used, many people think of hospitals and some include public health organizations, but these organizations are components of a much more diverse network. In many areas, people will seek out their personal physicians, if a condition is not time sensitive. Although many private practice physicians are affiliated with hospitals that extend operating or consultation privileges, physicians are not hospital employees. How this critical group of physicians can be tapped as a resource and coordinated in a widespread health emergency is problematic. Physicians are not difficult to find, but there is a myriad of insurance coverage and payment issues. Similarly, there are an increasing number of urgent care centers or clinics that engage in health care services, the majority of which are private businesses. The same issues of organization and coordination identified with private physicians also apply to urgent care clinics.

One strategy that appears to have overcome some of the obstacles, and developed through governmental action, was the creation of the Citizen Corps, in particular, the MRC. This group is intended to engage volunteers for a variety of purposes, from sharing information to a more active involvement in the CERT or the MRC. These options serve to integrate the whole community. For example, the MRC can strengthen public health, emergency response, and community resiliency by being available to assist in public health incidents. Initially these Medical Reserve units were founded and funded primarily in urban areas. Some have used nonemergency exercises for training and evaluation of the concept. In other cases, medical reservists responded to events inside their local areas. The program is not without challenges. In general, there is a range of training and experience among personnel, so their ability to perform quickly and effectively may vary significantly. In areas where the MRC is well organized and their members are brought into the response system early in planning, organizing, and training for emergencies, Reserve Corps personnel can be beneficial for local areas (Agency for Healthcare Research and Quality, 2007).