When Superstorm Sandy pushed a wall of seawater through South Brooklyn and up Ocean Parkway toward Coney Island Hospital, staff in the emergency room — less than a mile from the iconic boardwalk — had only a few minutes to evacuate dozens of patients.
The water soon met their knees, and hospital employees used buckets to fight off the storm surge. The gushing ocean drowned the hospital’s boilers and servers, shutting off the electrical supply and emergency power. More than 150,000 square feet of the hospital, which serves more than 850,000 people a year, sat underwater.
In a matter of hours, the flood from Superstorm Sandy — the largest Atlantic hurricane on record — had forced the hospital to shutter. And for three months, it stayed that way. But thousands of people who still lived nearby needed medical care. Staff set up triage services for patients who required immediate attention and diverted everyone else to nearby hospitals, many of which were also damaged by the storm. When they reopened, staff found sand in the hallways. Nearly a decade after that late October storm in 2012, Coney Island Hospital and the people it serves are still recovering.
Experts predict that human-driven climate change will significantly increase the number of communities vulnerable to flooding, how often disasters such as Superstorm Sandy occur and the devastating extent of the damage. Unless dramatic action is taken by world leaders to mitigate these effects, climate change will also undermine the health care systems that support cities and towns already in harm’s way.
“We’re very good about responding to crises,” said Doug Farquhar, director of governmental affairs for the National Environmental Health Association. “We’re terrible about finding money for the day-to-day environmental work that we need to mitigate these problems in the first place.”
Since it was established in 1875, the hospital has been flooded several times by nor’easters and hurricanes, such as Irene in 2011 and, in recent weeks, Ida. But damages from those events “were nowhere near as bad” as Superstorm Sandy, said Svetlana Lipyanskaya, who joined the NYC Health + Hospitals/Coney Island in 2019 as chief executive. In South Brooklyn, the effects of that storm and climate change are ongoing, she said, having traumatized many who still talk about Sandy and its aftermath “as if it just happened.”
Floods can hurt a health care system in different ways. The actual buildings can be rendered unusable by rising waters, the utilities that keep the lights working and water running can be shut off or the roads around the facilities can be cut off by rising water, making it difficult for people to get the help they need when they need it — not only in the moment, but in the weeks and months that follow, said John Macomber, a senior lecturer at Harvard Business School who has studied outcomes when investments are made to boost infrastructure resilience.
In other words, storms “happen, but they don’t go away,” Lipyanskaya said.
Mapping out flood risk
Coney Island Hospital might be particularly vulnerable to flooding, given its proximity to the coastline. But communities outside of the areas usually hit hardest by these storms might also be at risk, and not even know it. And the risk is likely to change and grow in the coming years.
Flooding is the most frequent type of severe weather-related disaster in the U.S. Every five years, the Federal Emergency Management Agency works with local community leaders to maintain and update the nation’s flood maps. The process, however, is often bogged down by bureaucratic back-and-forth. When the federal government alerts local communities that they live in a flood plain, that news can discourage developers and economic growth, so local residents often file appeals. And no matter whether someone’s protest is ultimately successful, the proceedings can be delayed for years, said Dr. Ed Kearns, chief data officer for the First Street Foundation, a nonprofit research group dedicated to quantifying flood risk for American households.
“There are people who are living in harm’s way today that have significant risk of flooding, and they don’t know it,” Kearns said.
Eventually, these findings are stored in the National Flood Hazard Layer, a database intended to illustrate flood risk accurately and to inform the National Flood Insurance Program, which Congress created in 1968 to protect properties in areas prone to rising waters, including hospitals. According to FEMA, when floodwaters rise 3.5 feet, that is high enough to “knock a hospital out of action,” Kearns said. The program’s debt has grown, along with the number of properties that have flooded at least twice in a decade, up from about 150,000 in 2009 to roughly 200,000 in 2018, according to a 2020 study from the Government Accountability Office.
Besides delays, other hurdles might prevent residents from knowing they are at risk. The maps don’t cover the whole country. About 40 percent of the U.S. is unmapped because assessing each river basin in the U.S. would take more time and money than FEMA can currently allot. Some communities only have paper copies, not digital, which are sometimes stashed away in a municipal building, Kearns said. Typically, these maps focus on floodplains around rivers, creeks and other stable bodies of water — not accounting for flooding caused by heavy rainfall or the effects of climate change, he said. In January, the National Resources Defense Council and the Association of State Floodplain Managers petitioned FEMA to update their maps “to adequately account for increased flood risk due to climate change.” In recent weeks, FEMA issued a call for public comment about how to transform the National Flood Insurance Program’s Community Ratings System so that it might “better align with the current understanding of flood risk and flood risk approaches” and put greater responsibility on local communities to manage and reduce their flood risk.
In 2017, the Department of Homeland Security’s Office of the Inspector General criticized the nation’s flood maps as too often being outdated and incorrect.
“FEMA needs to improve its management and oversight of flood mapping projects to achieve or reassess its program goals and ensure the production of timely and accurate flood maps,” the report’s authors wrote. Four years later, experts still were wringing their hands over how “badly out-of-date” FEMA’s flood maps remained, saying the billions needed to update those maps could prevent far greater costs in flood damage.
Climate change accelerates the need for good, up-to-date data. The conditions that erode beaches and redirect rivers also reshape flood plains, with researchers struggling in an endless game of catch-up. And the price of not doing enough to combat climate change is going up, too. The federal government counted a record number of billion-dollar natural disasters — so called because the damage adds up to at least $1 billion — in 2020. Twenty-two such disasters cost Americans a total of $95 billion. According to First Street Foundation’s Flood Factor data, which builds insurance claims and data of flooding from rainfall, rivers and creeks and coasts into its risk modeling, nearly all properties around Coney Island Hospital — 99 percent — remain at risk for flooding. Federal data estimates 8.7 million properties are at risk of a 100-year flood, but taking into account excess rainfall and worsening climate change, the foundation says the actual number is nearly double that — 14.6 million. These data support years of expert guidance that if more investments are made to improve infrastructure now, post-disaster recovery will be less costly.
Beyond building more resilient physical infrastructure, people need to consider what climate change is doing to destabilize the very land they build (and rebuild) their communities upon, Farquhar said. States and the federal government alike need to be more proactive about funding and preparing against climate disasters. Typically, hospital and health care systems’ finances rely on federal health programs, such as Medicare and Medicaid, as well as insurance reimbursement fees for services, like diagnostic blood work or X-rays. But to cover costs for these kinds of big projects, hospitals often must seek funding from FEMA, or health administrators may ask local residents to pay more in taxes, which can invite peril if voters reject the plan, said Michael Topchik, national leader for the Chartis Center for Rural Health.
When Hurricane Andrew made landfall in Florida in 1992, the widespread destruction laid bare the need for improved building codes that recognized the threat of hurricanes. At that time, “none had complete, mandatory provisions that were consistent with the minimum requirements of the National Flood Insurance Program,” according to a FEMA report. Since then, the agency has worked with Florida to strengthen building codes in anticipation of high water. But more local communities need to boost such regulation and limit zoning in flood-prone areas, Farquhar said.
The future is not going to be like the past, said Melissa Finucane, a social and behavioral scientist who directs the RAND Climate Resilience Center, and already, there are “so many examples of flooding where it hasn’t flooded before.”
Who is at risk
The threat of flood damage to medical buildings — and the challenge of mitigating it — reveals persistent disparities in the U.S. health care system. Some hospitals can reach into deep pockets to bolster their resilience, said Kara Brooks, who manages sustainability programs for the American Society for Health Care Engineering.
In 2001, Tropical Storm Allison drenched Houston in a 1,000-year flood, including Texas Medical Center, costing the facility $1.5 billion and years of lost medical research. On the city of Houston’s tourism website, the center is billed as “the largest life sciences destination in the world” and home to the largest cancer facility in the U.S., globally renowned for innovative treatment. After the storm, the hospital invested $80 million in flood control measures, Brooks said, including a moat made of granite and glass and a series of flood doors.
“Nothing happened for years, and it looked like a bad investment,” Macomber said. “Then, [in 2017], Hurricane Harvey happened.”
The center closed its floodgates and was able to bounce back from Harvey better than before, Brooks said, but “smaller health care systems don’t have those kinds of resources.”
After Sandy shut down Coney Island Hospital, Lipyanskaya said staff advocated for help from local state and federal politicians to help restore the facility and make the facilities more resilient than before the storm. For generations, the hospital’s patients have tended to be immigrants — many of them from Eastern Europe, like Lipyanskaya herself — who don’t have reserves of money that could easily cover unexpected medical problems or accidents, she said. These residents also need a health care system close to home that can withstand the effects of climate change for years to come.
In her research, Finucane explores how social infrastructure relates to physical infrastructure and how climate change disproportionately affects communities of color, households with low incomes, people who live with disabilities and those with limited English proficiency — the very people who often have fewer resources to respond to disasters when they happen.
In rural parts of the U.S., where shortages of medical professionals and fewer facilities already produce disparities, experts say climate change will worsen these effects if leaders and systems do not respond. And the cost for rural health care systems, about half of which were in financial distress long before the COVID-19 pandemic, can threaten to put meaningful action and improved outcomes out of reach for some communities. Even before the pandemic, about half of these systems were operating in the red, Topchik said. Elevating generators above predicted flood levels or buying new pumps to keep things dry gets complicated when hospitals are scrambling to pay staff or keep the lights on, Topchik said.
“It’s really hard to spend money you really don’t have on something that might happen in the future,” he said.
But research from the Resilience in Survivors of Katrina Project, published in December in Health Affairs, suggests long-term effects in public and mental health and the trauma that often follows flooding and major disruptions could be reduced through “investments in climate resilience and the elimination of impediments to evacuation when major disasters strike.”
“People are not in harm’s way by coincidence,” Finucane said. “The inequities that exist today are the result of many decisions over the years that have led to this situation.”
The health care industry contributes an estimated 10 percent of total U.S. greenhouse gas emissions annually, according to the 2018 National Climate Assessment. The congressionally mandated report studies climate change’s effects on the U.S. and suggests a few ways that the industry could rethink its operations. Combining systems that produce heat and power, for instance, can reduce a health care system’s carbon footprint and also “enhance hospitals’ resilience in the face of interruptions to the power grid,” the report said. Last month, the Biden administration created a new Office of Climate Change and Health Equity to coax hospitals into cutting their emissions. But these changes can be costly.
In 2014, Coney Island Hospital was awarded a $923 million federal grant from FEMA to build a new facility that is built to function more sustainably and be more resilient to climate change. No services will be offered on the first story, Lipyanskaya said, and the emergency department will be relocated to the second floor. The boilers, servers and other machines that make the hospital function will go on the fifth floor, above the 500-year-flood level and presumably beyond the ocean’s reach. Lipyanskaya said the 10-story tower is scheduled to open next summer.
If her hospital hadn’t received that nearly $1 billion grant, Lipyanskaya said they would not have been able to build the more resilient tower (“no public health system has access to that kind of money”), “but that doesn’t mean we wouldn’t be able to do anything.”
At her hospital, they continue to consider what they can do to remain a reliable destination for health care. Until something as catastrophic as Sandy happens to you, many people simply won’t think “about flood preparedness in quite the same way,” Lipyanskaya said.
“Anybody in a leadership role of health care facility, even if you are on higher ground, needs to be thinking, ‘Is my facility safe?’” she said.