Emergency management and sustainability: Understanding the link between disaster and citizen participation for sustainability efforts and climate change.

The goal of this study is to examine how disaster experience influences local government views on citizen participation in addressing issues of sustainability, such as climate change. This study considers concepts such as wicked problems, the social order, the environment, economic development, and citizen participation where sustainability can be considered a solution to help manage and solve the challenges of disaster, like climate change. The data are taken from a 2015 International City/County Management Association national survey that examines the link between disaster and sustainability. The results show that more than half of the respondents do not view public participation as having much of an impact on sustainability; however, we can expect public participation to increasingly impact sustainability efforts as communities experience more disaster. This suggests that emergency management needs to understand public pressures regarding wicked problems, such as climate change, to collectively address the global influence of environmental, economic, and social issues that have local effects on their communities.

Identifying and assessing corporate employment variables that influence community resilience: A novel model.

Quantifying the concept of disaster resilience on a local level is becoming more critical as vulnerable communities face more frequent and intense disasters due to climate change. In the United States (US), corporations are often evaluated using social justice or environmental sustainability matrices for financial investment consideration. However, there are few tools available to measure a corporation's contribution to disaster resilience on a local level. This study includes a focused literature review of employment variables that contribute to community resilience and a national survey that asked US emergency managers to rank the variables they believe have the greatest influence on individual resilience. A novel corporate community resilience model that ranks corporate contributions to disaster resilience in the communities where they operate was developed and then tested against data from five employment sectors from the same area. This model can be used by stakeholders to better understand how corporations can most efficiently contribute to county- and subcounty-level disaster resilience. The metrics used in this study are universal and translative, and thus, the development of this resilience model has global disaster resilience implications.

Utilization of the Disaster Medical Assistance Team (DMAT) in an Inner-City Emergency Department During the COVID-19 Pandemic.

OBJECTIVE: To evaluate the effect of the Disaster Medical Assistance Team (DMAT) in an inner-city emergency department during the coronavirus disease (COVID-19) pandemic. METHODS: Data were abstracted from individual emergency department encounters over 6 weeks. The study compared left without being seen (LWBS) percentage, door-to-provider, and door-to-disposition times for 2 weeks before, during, and after the DMAT. RESULTS: The LWBS percentages for the 2 weeks before and after the DMAT were 16.2% and 11.6%, respectively. The LWBS percentage during the DMAT was 8.1%. Door-to-disposition times for the 2 weeks before and after the DMAT were 7.36 hours and 8.53 hours, respectively. The door-to-disposition during the DMAT was 7.33 hours. Door-to-disposition was statistically significant during the 2 weeks of the DMAT compared to the 2 weeks after the DMAT (7.33 vs 8.53, P < 0.05) but not statistically significant when compared to the period before the DMAT (7.36 vs 7.33, P = 1.00). Door-to-provider time was the longest during the DMAT (122.5 minutes [2.04 hours]) when compared to the time frame before the DMAT (114.54 minutes [1.91 hours]) and after the DMAT (102.84 minutes [1.71 hours]). CONCLUSION: The DMAT had the most positive impact on LWBS percentages. The DMAT showed no improvement in door-to-provider times in the study and only in door-to-disposition times when comparing the time the DMAT was present to after the DMAT departed.

Understanding Challenges Women Face in Flood-Affected Areas to Access Sexual and Reproductive Health Services: A Rapid Assessment from a Disaster-Torn Pakistan.

Introduction: According to the Global Climate Risk Index, Pakistan is ranked as the fifth-most vulnerable country to climate change. Most recently, during June-August 2022, heavy torrential rains coupled with riverine, urban, and flash flooding led to an unprecedented disaster in Pakistan. Around thirty-three million people were affected by the floods. More than 2 million houses were damaged, leaving approximately 8 million displaced and approximately 600,000 people in relief camps. Among those, 8.2 million women and 16 million children are the worst affected, with many requiring urgent medical and reproductive healthcare. To plan an efficient healthcare program and a climate-resilient health system, it is crucial to understand the issues that the affected people face during floods. Methodology. This rapid assessment included the population in the most severely affected districts across the four provinces of Pakistan. A mixed methods approach using qualitative and quantitative techniques was utilized. A total of 52 qualitative, in-depth interviews were conducted with community-level healthcare providers, national and provincial government departments, and development partners involved in relief activities. Using a structured questionnaire, the quantitative cross-sectional survey was conducted with a final sample of 422 women, married and unmarried (15-49 years old), residing in the relief camps in the flood-affected areas. The outcome variable of the survey was the access to sexual and reproductive health services faced by the women in the flood-affected districts. Data collection took place four months postfloods during Nov-Dec 2022, while the data analysis was conducted between Dec 2022 and Jan 2023. The quantitative data was analyzed using SPSS (Statistical Package for the Social Sciences) version 20, and qualitative data was analyzed using NVivo 12. Ethical consent was sought from all the participants. Ethical approval was also sought from the ethics committee of the Health Services Academy, Government of Pakistan. Results: The findings indicated that, overall, all the provinces were unprepared for a calamity of such a large magnitude. Access to services and health data reporting from the flood-affected areas was challenging mainly due to a shortage of trained health workforce because of the displacement of a large volume of the health workforce. Overall, equipment, medicines, supplies, and food were scarce. Women residing in the camps were markedly affected, and 84% (375) were not satisfied with the flood relief services provided to them. The floods impacted their monthly income as 30% (132) of respondents started depending on charity postfloods. Almost 77% (344) reported limited access to sexual and reproductive health services and had yet to receive sanitary, hygiene, and delivery kits, while 69% (107 out of 154) of girls stopped schooling postfloods. Almost 77% (112) of the married women reported having a child less than one year of age. Yet, only 30% (44 out of 144 currently married women) were using any form of family planning method-damage to the health facilities affected access to overall maternal care services. Conclusion: The findings concluded that there was no planning for sexual and reproductive health services in the flood-affected areas. Several barriers were identified. The government and development partners needed to prepare to cater to women's needs during the floods. The findings highlight the need for collaborative efforts between the government, civil society, and development partners to address the challenges faced in disaster management and strengthen disaster management capacity.

Exploring Cascading Disaster Risk During Complex Emergencies: Chemical Industry Disaster Risk Assessment in the Aftermath of the Kakhovka Dam Bombing in Ukraine.

OBJECTIVE: This risk assessment aims to investigate the analysis of cascading disaster risks from the perspective of the chemical industry and public health subsequent to the Kakhovka dam bombing in Ukraine. METHOD: The study utilized a modified observational cross-sectional risk assessment method to assess disaster risk. The method involved identifying the location of chemical factories, determining flooded or at-risk factories, analyzing the type and frequency of chemical hazards, assessing population exposure, and plotting a disaster risk metric. Data on chemical industries and flood extent were collected from open-source secondary data. RESULTS: The destruction of the Kakhovka dam in June 2023 led to severe flooding, placing 42 000 individuals at risk. The analysis identified four chemical factories, with 1 affected by flooding and 3 at risk. The overall risk assessment indicated a high likelihood and severe consequences, including loss of life, environmental contamination, and property damage. CONCLUSION: The combination of complex emergencies and high-risk chemical facilities in Kherson Oblast poses a significant risk of a chemical industry disaster. The interplay between compound and cascading risks during complex emergencies amid the current war further exacerbates the situation, leading to the devastation and destruction of the environment to the detriment of life, and aligns with the characterization of ecocide.

Health Disparities in the Aftermath of Flood Events: A Review of Physical and Mental Health Outcomes with Methodological Considerations in the USA.

PURPOSE OF REVIEW: This review applies an environmental justice perspective to synthesize knowledge of flood-related health disparities across demographic groups in the USA. The primary aim is to examine differential impacts on physical and mental health outcomes while also assessing methodological considerations such as flood exposure metrics, baseline health metrics, and community engagement. RECENT FINDINGS: In our review (n = 27), 65% and 72% of studies identified racial, ethnic, or socio-economic disparities in physical and mental health outcomes post-flooding, respectively. The majority of racial/ethnic disparities were based on Black race, while most socio-economic disparities were based on lower household income. Forty-two percent of studies lacked flood exposure metrics, but often identified disparities. Common flood exposure metrics included self-reported flooding, flood risk models, and satellite-based observations. Seventy percent of studies lacked baseline health measurements or suitable alternatives, and only 19% incorporated community engagement into their research design. The literature consistently finds that both physical and mental health burdens following flooding are unequally shared across racial, ethnic, and socio-economic groups. These findings emphasize the need for disaster risk reduction policies that address underlying vulnerabilities to flooding, unequal exposure to flooding, and progressive funding for recovery efforts. Findings also underscore the importance of methodological enhancements to facilitate precise assessments of flood exposure and health outcomes.

Study on agricultural drought disaster risk assessment in Heilongjiang reclamation area based on SSAPSO optimization projection pursuit model.

Heilongjiang reclamation area serves as a crucial hub for commodity grain production and strategic reserves in China, playing a vital role in maintaining national food security. Investigating the assessment of agricultural drought risk in this region can yield valuable insights into spatial and temporal variations in drought risk. Such insights can aid in formulating effective strategies for disaster prevention and mitigation, thereby minimizing food losses caused by drought disasters. This study employs a comprehensive indicator system comprising 17 indicators categorized into hazard, exposure, vulnerability, and resistance capacity. The projection pursuit model is applied to evaluate regional drought risk, while the PSO algorithm, optimized by the SSA algorithm, addresses the limitations of low local search ability and search accuracy during the large-scale search process of the PSO optimization algorithm. This study examines and compares the optimization and convergence capabilities of three algorithms: real number encoding-based genetic algorithm (RAGA), particle swarm optimization algorithm (PSO), and sparrow algorithm-based improved particle swarm optimization algorithm (SSAPSO). The analysis demonstrates that SSAPSO exhibits superior optimization performance and convergence properties, establishing it as a highly effective algorithm for optimization tasks. The findings reveal the following trends: over time, agricultural drought risk in Heilongjiang reclamation area has generally declined, with fluctuations observed in hazard and vulnerability, an increase in exposure, and a continuous enhancement of resistance capacity. Spatially, the western region exhibits significantly higher agricultural drought risk compared to the eastern region, primarily due to elevated hazard and vulnerability, coupled with lower resistance capacity. As the agricultural economy grows and agricultural expertise accumulates, the risk of agricultural drought decreases. However, variations in economic growth among different regions lead to diverse spatial distributions of risk.

Social vulnerability assessment under different extreme precipitation scenarios: A case study in Henan Province, China.

Extreme precipitation usually cause grievous losses&casualties, which varies greatly under different scenarios. This paper took Henan province as an example, it innovatively constructed three different extreme precipitation scenarios and built indicators system of social vulnerability from exposure, sensitivity and resilience based on MOVE framework. Social Vulnerability Indexs(SoVI) were then calculated by mathematical models under three different reoccurrence intervals. The results show that SoVI was low in the west and high in the north. High SoVI areas expanded to the middle and south as recurrence intervals increased. SoVI in each area of Henan province increased along with the recurrence intervals at different growth rates. The larger the recurrence interval was, the faster the SoVI increased. The results indicate SoVI is greatly affected by disaster levels, which need to be incorporated into social vulnerability. This study provides not only a new thought for social vulnerability assessment, but also a reference for the policymakers to formulate related risk management policies.

Assessment of Disaster Preparedness at the Household Level in a Pediatric Cardiology Clinic Population.

Natural and human-provoked disasters pose serious health risks to children, particularly children and youth with special healthcare needs, including many cardiology patients. The American Academy of Pediatrics (AAP) provides preparedness recommendations for families, but little is known about recommendation adherence. Caregivers of children seen in a pediatric cardiology clinic network were recruited to complete an electronic survey. Participants self-reported child medical history and their household's implementation of AAP recommended disaster preparedness items. Families received a link to AAP resources and a child ID card. Data were analyzed using descriptive statistics with Fisher's exact and Wilcoxon rank sum tests. 320 caregivers participated in the study, of whom 124 (38.8%) indicated that their child has a diagnosed cardiac condition, and 150 (46.9%) indicated that their child had special healthcare needs. The average preparedness item completion rate was 70.7% for household preparedness, 40.1% for reunification preparedness, and 26.3% for community preparedness. Households of children with medical needs had similar rates of preparedness compared to overall rates. Of all respondents, 27.8% previously received disaster preparedness resources, 67.7% would like resources on discussing disaster preparedness, and 93.0% intend to talk with their household about disaster preparedness after completing the survey. These results demonstrate a gap between AAP recommendations and household-level disaster preparedness, including patients with cardiac conditions and those with special healthcare needs. Families expressed that they were interested in getting resources for disaster preparedness. Pediatric cardiologists may consider asking about disaster preparedness and providing disaster preparedness resources tailored to the needs of their patients.

How can the Sendai framework be implemented for disaster risk reduction and sustainable development? A qualitative study in Iran.

BACKGROUND: The Sendai Framework is the United Nations' most significant approach to reducing the risk of disasters from 2015 to 2030. This framework designed for all communities. However, communities should create operational and remedial strategies based on their unique circumstances. Considering the gaps in the implementation of Sendai framework strategies in Iran, as a developing country, the present study was designed. METHOD: This study was conducted by using a qualitative direct content analysis method to find out the expert's opinions on the implementation of the Sendai framework in Iran from 2021 to 2023. 35 experts in the focus group discussion and 9 experts in the interview were the participants of the study. RESULTS: Study findings were merged and reported as one main theme entitled Executive actions for implementing the Sendai Framework, four categories, and 37 codes. Eleven codes for the strategy of understanding disaster risk, 11 codes for the strategy of strengthening disaster risk governance to manage disaster risk, eight codes for the strategy of Investing in disaster risk reduction for resilience, and finally, seven codes for the strategy of enhancing disaster preparedness for effective response and to "Build Back Better" in recovery, rehabilitation, and reconstruction were identified as implementation solutions. CONCLUSION: The Sendai Framework has not provided any detailed implementation solutions because the countries' economic, social, level of development, etc., are different. The study's findings can be used as a guide for other developing countries.

Mapping study for health emergency and disaster risk management competencies and curricula: literature review and cross-sectional survey.

BACKGROUND: With the increasing threat of hazardous events at local, national, and global levels, an effective workforce for health emergency and disaster risk management (Health EDRM) in local, national, and international communities is urgently needed. However, there are no universally accepted competencies and curricula for Health EDRM. This study aimed to identify Health EDRM competencies and curricula worldwide using literature reviews and a cross-sectional survey. METHODS: Literature reviews in English and Japanese languages were performed. We searched MEDLINE, EMBASE, CINAHL (English), and the ICHUSHI (Japanese) databases for journal articles published between 1990 and 2020. Subsequently, a cross-sectional survey was sent to WHO Health EDRM Research Network members and other recommended experts in October 2021 to identify competency models and curricula not specified in the literature search. RESULTS: Nineteen studies from the searches were found to be relevant to Health EDRM competencies and curricula. Most of the competency models and curricula were from the US. The domains included knowledge and skills, emergency response systems (including incident management principles), communications, critical thinking, ethical and legal aspects, and managerial and leadership skills. The cross-sectional survey received 65 responses with an estimated response rate of 25%. Twenty-one competency models and 20 curricula for managers and frontline personnel were analyzed; managers' decision-making and leadership skills were considered essential. CONCLUSION: An increased focus on decision-making and leadership skills should be included in Health EDRM competencies and curricula to strengthen the health workforce.

A Pediatric-Focused Self-Assessment Tool on Vulnerabilities to Aid Regional Disaster Planning.

OBJECTIVE: A significant number of disaster and emergency victims are children. Yet, many hospitals are ill-prepared to care for these patients during disasters, as identified by the National Pediatric Readiness Project's survey of hospital pediatric disaster plans. The Region V for Kids Center of Excellence created a self-assessment tool to help regions identify vulnerabilities and ways to enhance care for vulnerable children and families. METHODS: Region V for Kids identified 9 key domains (eg, infrastructures and support mechanisms) that are important to safeguard children's and families' care during disasters. A self-assessment tool to assess these domains was distributed to 24 regional health care coalitions along with a 9-question usefulness survey. The self-assessment tool addressed 3 of the original domains, which have regional or national open-source databases and datapoints that health care coalitions can access for their responses. RESULTS: The survey received a 50% response rate. Approximately 40% of respondents indicated they were "somewhat likely" to make changes based on data gathered by the tool. The original self-assessment tool was revised to create an expanded web-based version. CONCLUSIONS: Health care coalitions and localities can use this tool to evaluate pediatric preparedness, identify needed improvements, and improve outcomes for children, families, and communities.

Species distribution models to predict the impacts of environmental disasters on shrimp species of economic interest.

Here, we used distribution models to predict the size of the environmentally suitable area for shrimps of fishing interest that were impacted by the tailing plume from the collapse of the Fundão Dam, one of the largest ecological disasters ever to occur in Brazil. Species distribution models (SDMs) were generated for nine species of penaeid shrimp that occurred in the impacted region. Average temperature showed the highest percentage of contribution for SDMs. The environmental suitability of penaeids varied significantly in relation to the distance to the coast and mouth river. The area of environmental suitability of shrimps impacted by tailings plumes ranged from 27 to 47 %. Notably, three protected areas displayed suitable conditions, before the disaster, for until eight species. The results obtained by the SDMs approach provide crucial information for conservation and restoration efforts of coastal biodiversity in an impacted region with limited prior knowledge about biodiversity distribution.

'Financial fallout' in the US biopharmaceutical industry: Maximizing shareholder value, regulatory capture, and the consequences for patients.

Patients are suffering the consequences of financialization - as shareholders demand high returns from pharmaceutical companies, pharmaceuticals squeeze profits out of top-selling products, and insurers charge higher premiums for limited coverage, the impact of financialization cascades across the value chain to compound the burden of cost for patients. This article offers a novel theoretical perspective and methods for understanding how "financial fallout" has impacted the pharmaceutical value chain, health systems, and patients. Financial fallout describes the cascade of consequences characteristic of and essential to industries reshaped by financialization. It characterizes how the effects of financialization have become so thoroughly engrained in industries and societies as to seem inevitable and how the consequences are also devastating, like the fallout that follows nuclear disasters. The research represented here examines how processes of financial fallout: 1) cascade across the pharmaceutical value chain from innovation to commercialization; 2) are enacted through 'regulatory capture' as regulations meant to safeguard the public from the exigencies of the market ultimately serve the interests of industry; and 3) have devastating consequences for patients who need access to life-saving therapies. The analysis is developed through the example of the market for monoclonal antibodies in the US, and the specific case of Keytruda - one of the top-selling monoclonal antibodies marketed for cancer therapy, which generated over 14 USD billion in revenue in 2020 and 17 billion in 2021. It traces how processes of financial fallout cascade down the value chain to impact health systems and compound the cost of care for patients. Financial fallout signals dire trends in providing health services and access to medicines. It diagnoses how our options for saving lives and improving health are overdetermined by and infused with the interests of financial capital.

The impact of tropical cyclones and water conservancy projects on island's flash floods.

The analysis of the influencing factors of flash floods, one of the most destructive natural disasters, is the basis of scientific disaster prevention and mitigation. There is little research considering the influence of tropical cyclones (TCs) and water conservancy projects on flash floods, which cannot be ignored in the island areas where flash floods often occur due to the complex influence of various factors. In this study, under the pressure-state-response framework (PSR framework), the factors affecting the distribution of flash floods on Hainan Island, China, from 1970 to 2010 were quantitatively analyzed by using the geographical detector method. By dividing the time period, give full play to the advantages of the PSR framework and show the evolution process of various factors. Different from inland areas, extreme precipitation and tropical cyclones play a major role in the spatial distribution of flash floods on Hainan Island, China, and the driving force of tropical cyclones is 1.1 times that of extreme precipitation on average. Medium-sized reservoirs play the greatest role in the prevention of flash floods on Hainan Island, and their driving forces reach 0.38 times of extreme precipitation on average, followed by large-sized reservoirs and small-sized reservoirs. Large-sized reservoirs are limited in quantity and have limited effectiveness in preventing flash floods on Hainan Island. Therefore, in the forecasting and risk management of flash flood in the island area, more attention should be paid to the impact of extreme precipitation and TCs, and the role of medium-sized reservoir should be fully exerted.

Earthquakes, Hurricanes, Pandemics: Pharmacy Students Impacting Pharmacy Practice in Puerto Rico Through Medication Therapy Management Services During Disasters.

BACKGROUND: Community-based medication therapy management advanced pharmacy practice experiences (MTM APPE) can engage pharmacy students in public health initiatives, including emergency response preparedness, to successfully impact patient care. This study aimed to evaluate pharmacy students' perceptions of their experience on an MTM APPE during disasters in Puerto Rico. METHODS: After completing the MTM APPE during times of hurricanes, earthquake or pandemic, pharmacy students were asked to voluntarily participate in a questionnaire about their perception of assisting during a disaster. The survey consisted of 5 questions. Four questions were based on a Likert scale with answers choices ranging from Agree, Not Sure, Disagree, or Not Applicable. One question requested free text comments from participants. RESULTS: Sixteen students completed the survey. Pharmacy students agreed that the MTM APPE taught them the clinical skills needed to assist and educate individual patients and the community that suffered from a disaster, and that the role of the pharmacist is vital when a disaster disrupts a community's health-care system. CONCLUSIONS: Training in emergency response to disasters should be a considered component of MTM APPE.

Centering Health Equity in the Implementation of the Hospital Incident Command System: A Qualitative Case Comparison Study.

OBJECTIVE: Disasters exacerbate inequities in health care. Health systems use the Hospital Incident Command System (HICS) to plan and coordinate their disaster response. This study examines how 2 health systems prioritized equity in implementing the Hospital Incident Command System (HICS) during the coronavirus disease 2019 (COVID-19) pandemic and identifies factors that influenced implementation. METHODS: This is a qualitative case comparison study, involving semi-structured interviews with 29 individuals from 2 US academic health systems. Strategies for promoting health equity were categorized by social determinants of health. The Consolidated Framework for Implementation Research (CFIR) guided analysis using a hybrid inductive-deductive approach. RESULTS: The health systems used various strategies to incorporate health equity throughout implementation, addressing all 5 social determinants of health domains. Facilitators included HICS principles, external partnerships, community relationships, senior leadership, health equity experts and networks, champions, equity-stratified data, teaming, and a culture of health equity. Barriers encompassed clarity of the equity representative role, role ambiguity for equity representatives, tokenism, competing priorities, insufficient resource allocation, and lack of preparedness. CONCLUSIONS: These findings elucidate how health systems centered equity during HICS implementation. Health systems and regulatory bodies can use these findings as a foundation to revise the HICS and move toward a more equitable disaster response.

A novel integrated Urban flood risk assessment approach coupling GeoDetector-Dematel and clustering method.

Urban flood risk assessment plays a crucial role in disaster prevention and mitigation. A scientifically accurate assessment and risk stratification method are of paramount importance for effective flood risk management. This study aims to propose a comprehensive urban flood risk assessment approach by coupling GeoDetector-Dematel and Clustering Method to enhance the accuracy of urban flood risk evaluation. Based on simulation results from hydraulic models and existing literature, the research established a set of urban flood risk assessment indicators comprising 10 metrics across two dimensions: hazard factors and vulnerability factors, among which vulnerability factors include exposure factors, sensitivity factors, and adaptability factors. Subsequently, the research introduced the GeoDetector-Dematel method to determine indicator weights, significantly enhancing the scientific rigor and precision of weight calculation. Finally, the research employed the K-means clustering method to risk zonation, providing a more scientifically rational depiction of the spatial distribution of urban flood risks. This novel comprehensive urban flood risk assessment method was applied in the Fangzhuang area of Beijing. The results demonstrated that this integrated approach effectively enhances the accuracy of urban flood risk assessment. In conclusion, this research offers a new methodology for urban flood risk assessment and contributes to decision-making in disaster prevention and control measures.

Impact of extreme weather events on healthcare utilization and mortality in the United States.

Climate change is intensifying extreme weather events. Yet a systematic analysis of post-disaster healthcare utilization and outcomes for severe weather and climate disasters, as tracked by the US government, is lacking. Following exposure to 42 US billion-dollar weather disasters (severe storm, flood, flood/severe storm, tropical cyclone and winter storm) between 2011 and 2016, we used a difference-in-differences (DID) approach to quantify changes in the rates of emergency department (ED) visits, nonelective hospitalizations and mortality between fee-for-service Medicare beneficiaries in affected compared to matched control counties in post-disaster weeks 1, 1-2 and 3-6. Overall, disasters were associated with higher rates of ED utilization in affected counties in post-disaster week 1 (DID of 1.22% (95% CI, 0.20% to 2.25%; P < 0.020)) through week 2. Nonelective hospitalizations were unchanged. Mortality was higher in affected counties in week 1 (DID of 1.40% (95% CI, 0.08% to 2.74%; P = 0.037)) and persisted for 6 weeks. Counties with the greatest loss and damage experienced greater increases in ED and mortality rates compared to all affected counties. Thus, billion-dollar weather disasters are associated with excess ED visits and mortality in Medicare beneficiaries. Tracking these outcomes is important for adaptation that protects patients and communities, health system resilience and policy.