Legal Preparedness for Hurricane Sandy: Authority to Order Hospital Evacuation or Shelter-in-Place in the Mid-Atlantic Region

Abstract

Hospitals were once thought to be places of refuge during catastrophic hurricanes, but recent disasters such as Hurricanes Katrina and Sandy have demonstrated that some hospitals are unable to ensure the safety of patients and staff and the continuity of medical care at key times. The government has a duty to safeguard public health and a responsibility to ensure that appropriate protective action is taken when disasters threaten or impair the ability of hospitals to sustain essential services. The law can enable the government to fulfill this duty by providing necessary authority to order preventive or reactive responses-such as ordering evacuation of or sheltering-in-place in hospitals-when safety is imperiled. We systematically identified and analyzed state emergency preparedness laws that could have affected evacuation of and sheltering-in-place in hospitals in order to characterize the public health legal preparedness of 4 states (Delaware, Maryland, New Jersey, and New York) in the mid-Atlantic region during Hurricane Sandy in 2012. At that time, none of these 4 states had enacted statutes or regulations explicitly granting the government the authority to order hospitals to shelter-in-place. Whereas all 4 states had enacted laws explicitly enabling the government to order evacuation, the nature of this authority and the individuals empowered to execute it varied. We present empirical analyses intended to enhance public health legal preparedness and ensure these states and others are better able to respond to future natural disasters, which are predicted to be more severe and frequent as a result of climate change, as well as other hazards. States can further improve their readiness for catastrophic disasters by ensuring explicit statutory authority to order evacuation and to order sheltering-in-place, particularly of hospitals, where it does not currently exist.

Full text

Legal Preparedness for Hurricane Sandy:
Authority to Order Hospital Evacuation
or Sheltering-in-Place in the Mid-Atlantic Region
Meghan D. McGinty, Thomas A. Burke, Beth A. Resnick, Katherine C. Smith,
Daniel J. Barnett, and Lainie Rutkow
Hospitals were once thought to be places of refuge during catastrophic hurricanes, but recent disasters such as
Hurricanes Katrina and Sandy have demonstrated that some hospitals are unable to ensure the safety of patients and
staff and the continuity of medical care at key times. The government has a duty to safeguard public health and a
responsibility to ensure that appropriate protective action is taken when disasters threaten or impair the ability of
hospitals to sustain essential services. The law can enable the government to fulfill this duty by providing neces-
sary authority to order preventive or reactive responses—such as ordering evacuation of or sheltering-in-place in
hospitals—when safety is imperiled. We systematically identified and analyzed state emergency preparedness laws that
could have affected evacuation of and sheltering-in-place in hospitals in order to characterize the public health legal
preparedness of 4 states (Delaware, Maryland, New Jersey, and New York) in the mid-Atlantic region during Hur-
ricane Sandy in 2012. At that time, none of these 4 states had enacted statutes or regulations explicitly granting the
government the authority to order hospitals to shelter-in-place. Whereas all 4 states had enacted laws explicitly
enabling the government to order evacuation, the nature of this authority and the individuals empowered to execute it
varied. We present empirical analyses intended to enhance public health legal preparedness and ensure these states and
others are better able to respond to future natural disasters, which are predicted to be more severe and frequent as a
result of climate change, as well as other hazards. States can further improve their readiness for catastrophic disasters by
ensuring explicit statutory authority to order evacuation and to order sheltering-in-place, particularly of hospitals,
where it does not currently exist.
Meghan D. McGinty, MPH, MBA, was, at the time this article was written, a Research Assistant at the UPMC Center for Health
Security, Baltimore, Maryland, and a PhD candidate, Department of Health Policy and Management, Bloomberg School of Public
Health, Johns Hopkins University, Baltimore. Thomas A. Burke, PhD, was Professor, Department of Health Policy and Management,
Bloomberg School of Public Health, Johns Hopkins University, Baltimore, and is Deputy Assistant Administrator of EPA’s Office of
Research and Development, Washington, DC. Beth A. Resnick, MPH, is Associate Scientist; Daniel J. Barnett, MD, MPH, is
Associate Professor; and Lainie Rutkow, PhD, JD, is Associate Professor; all in the Department of Health Policy and Management; and
Katherine C. Smith, PhD, is Associate Professor, Department of Health, Behavior, and Society; all in the Bloomberg School of Public
Health, Johns Hopkins University, Baltimore.
Health Security
Volume 14, Number 2, 2016 ªMary Ann Liebert, Inc.
DOI: 10.1089/hs.2015.0068
78

From October 22-29, 2012, Hurricane Sandy* ravaged
the mid-Atlantic
{
region of the United States. Hurri-
cane Sandy was the biggest named storm on record in the
Atlantic Ocean and the second—only to Hurricane
Katrina—costliest cyclone in US record-keeping history.
1
At
least 147 deaths were directly attributed to Hurricane Sandy,
with nearly half of those fatalities occurring in the mid-
Atlantic and northeastern United States.
1
Besides resulting in
direct mortality, Hurricane Sandy significantly threatened
the health and safety of all mid-Atlantic residents and, in
particular, vulnerable populations, including hospitalized
patients. Despite lessons learned from Hurricane Katrina in
2005, essential hospital services, including power, steam,
water, and sanitation, were interrupted during Hurricane
Sandy, hindering continuity of patient care and threatening
the safety of both patients and staff.
2,3
In the absence of a
legal order to preemptively evacuate, several mid-Atlantic
hospitals sheltered-in-place, sustained damage, and were
forced to undertake emergency evacuations without lights
and power.
4,5
In New York City alone, to ensure safety and
continuity of medical care, approximately 6,300 patients had
to be evacuated from 37 healthcare facilities.
6
A fundamental duty of government is to protect the health
and safety of its citizens—in particular the most vulnerable
citizens, including hospital patients.
7
As a result of climate
change, coastal storms like Hurricane Sandy are predicted to
be more severe and frequent, and the intensity of rainfall
associated with Atlantic hurricanes is projected to increase.
8
When hurricanes are approaching, hospitals are faced with
the difficult decision of whether to evacuate,
{
shelter-in-
place,
x
or do nothing.When hospitals fail to take appropriate
protective action on their own, it may be necessary for the
government to order compulsory action. To safeguard health
security in light of climate change, there is a critical need to
ensure state governments are prepared to order the im-
plementation of necessary protective actions, including
evacuation and sheltering-in-place in hospitals.
In the United States, states derive much of their public
health legal authority from ‘‘police powers.’’
7
Grounded in
the 10th Amendment to the US Constitution, police powers
give state governments broad authority to protect and pro-
mote the health, safety, and general well-being of the com-
munity. These powers are exercised and enforced through
legislation, regulation, and in some cases litigation. De-
pending on the nature and scope of a disaster or emergency,
state governments may need to declare an emergency or
health emergency; these types of declarations temporarily
change the legal environment and provide state governments
with enhanced legal and operational resources to protect the
public’s health (eg, the ability to order quarantine or isola-
tion, access to emergency funds).
11
Within this broader
context of public health legal authority, public health legal
preparedness plays an essential role in enabling the govern-
ment to fulfill its duty by providing the necessary legal
framework to respond to catastrophic disasters.
12,13
‘‘Public
health legal preparedness’’ is defined as the attainment by a
public health system (eg, a community, state, region, or
nation) of legal benchmarks essential to the readiness of that
system to respond to health threats. Scholars identify 4 core
elements requisite to achieving public health legal pre-
paredness: (1) laws or legal authorities; (2) competencies (ie,
abilities, skills) of those responsible for applying the law; (3)
information to aid these individuals in applying the law; and
(4) coordination across sectors and jurisdictions.
12,14
The aim of this study was to examine the first core
element—laws or legal authorities—to characterize public
health legal preparedness of the mid-Atlantic region, the area
most significantly affected by Sandy, for catastrophic coastal
storms. This empirical research offers insights into how to
improve public health legal preparedness for coastal storms
specifically and, more generally, how to improve our ability
to protect public health and safety against all hazards.
Methods
To assess the public health legal preparedness of the mid-
Atlantic region at the time of Hurricane Sandy in 2012,
Delaware, Maryland, New Jersey, and New York state
emergency preparedness laws pertaining to the authority to
order evacuation and sheltering-in-place were systemati-
cally identified and analyzed. Within these states, organi-
zations or individuals who had legal authority to order
evacuation or sheltering-in-place during Hurricane Sandy
were identified. The nature of these authorities was subse-
quently described and analyzed.
Data Collection
Consistent with established public health law research
methods,
15
emergency preparedness laws in 4 contiguous
mid-Atlantic states were systematically analyzed. These
state-level laws concerned each government’s authority to
*
Although Sandy evolved from a Category 3 hurricane in the Ca-
ribbean to an intense extratropical cyclone before landfall in the
United States, to avoid any confusion it will be referred to as Hurri-
cane Sandy throughout this article. Hurricane Sandy was colloquially
known and often referred to by the media as Superstorm Sandy.
{
For the purpose of this study, mid-Atlantic states are defined as
states located in the middle of the Eastern seaboard (ie, the east
coast) of the United States off the Atlantic Ocean. The study area
of this research consisted of 4 contiguous states in this region:
Delaware, Maryland, New Jersey, and New York.
{
Evacuation is defined as the ‘‘mass physical movements of
people, of a temporary or permanent nature, that collectively
emerge in coping with community threats, damages, or disrup-
tions.’’
9
x
Shelter-in-place means ‘‘to take immediate shelter where you
are—at home, work, school, or in between.’’
10
In contrast to
‘‘doing nothing,’’ sheltering-in-place entails remaining in place
until the threat has passed (ie, in a hospital, patients would not be
discharged; staff would not leave when their shift was over).
McGINTY ET AL.
Volume 14, Number 2, 2016 79

order evacuation or sheltering-in-place in any circumstance
or emergency. Using an electronic legal database, Lexis-
Nexis

State Capital,
16
Delaware, Maryland, New Jersey,
and New York statutory and administrative codes were
searched to identify emergency preparedness laws in place
on October 22, 2012, the date on which Sandy became a
named storm. Initial keywords, which were based on a
priori knowledge, included: ‘‘emergency,’’ ‘‘disaster,’’ ‘‘public
health emergency,’’ ‘‘health emergency,’’ ‘‘evacuation,’’ ‘‘shel-
ter,’’ and ‘‘sheltering-in-place.’’ These keywords were piloted
and refined through an iterative process, including review of
preliminary search findings by the study team. After piloting
and finalizing the search terms, distinct queries were con-
ducted of the Delaware, Maryland, New Jersey, and New
York statutory and administrative codes. The final search
string was: ‘‘shelter’’ OR ‘‘evacuat!’’
The full text of every state statute and regulation re-
turned by each query was subsequently reviewed and du-
plicates were removed. The following exclusion criteria
were applied to the identified laws (n=2,263):
Executive orders, which are codified in some states,
were excluded, because they themselves do not confer
authority but rather are examples of the exercise of
authority granted by statute or regulation (eg, guber-
natorial declarations of emergency);
Laws in which the keyword had a meaning unrelated
to health emergency preparedness were excluded (eg,
bus shelters);
Laws pertaining to the evacuation of vehicles (eg,
trains) or rides (eg, fun houses) were excluded;
Laws addressing only fire-related evacuation were ex-
cluded; and
Laws addressing only casino emergencies were excluded.
As a quality control measure, the identified laws were
compared to publicly available lists of state emergency
health laws compiled by the Network for Public Health
Law and the Johns Hopkins Center for Law and the Pub-
lic’s Health.
17,18
When a discrepancy arose between search
findings and existing compilations of emergency health
laws, members of the study team consulted the law’s text to
determine whether it should be included in the data set
(excluded laws =2,091).
Data Abstraction
An electronic data extraction form was created in Qualtrics,
an online survey and data collection program.
19
This form
was used to abstract information from the full text of the
statutes and regulations meeting the abovementioned in-
clusion and exclusion criteria (n=172) (see Supplemental
Materials 1 at www.liebertonline.com/hs). The Association
of State and Territorial Health Officers Emergency De-
clarations and Authorities—State Analysis Guide,
20
as well
as the study’s aim, informed the development of the fields
in the data extraction form. Abstracted data allowed for
comparison of the 4 states’ laws with respect to who can
issue orders, what can be ordered, and under what cir-
cumstances an order can be issued, as well as an overarching
understanding of the legal environments that existed in
Delaware, Maryland, New Jersey, and New York at the
time of Hurricane Sandy in October 2012.
Results
At the time of Hurricane Sandy, none of the 4 mid-Atlantic
states had enacted statutes or regulations explicitly granting
the government the authority to order sheltering-in-place. In
contrast, all 4 states had enacted laws enabling the govern-
ment to order evacuation, but the nature of this authority
and the individuals empowered to execute it varied (Ta-
ble 1). In general, laws allow the government either to order
evacuation of the public from an area when safety is im-
periled or to order evacuation of a specific facility, such as a
hospital, when conditions at that facility pose a threat.
Both Delaware and Maryland have established 2 types of
evacuation authority: the authority to direct and compel the
evacuation of a geographical area (ie, evacuation of the general
population from an area such as a neighborhood or town),
and the authority to order evacuation of a specific facility. In
the event of an emergency, the Delaware governor is autho-
rized to ‘‘direct and compel the evacuation of all or part of the
population from any stricken or threatened area within the
State if this action is necessary for the preservation of life.’’
21
Similarly, ‘‘after declaring a state of emergency, the [Mary-
land] Governor, if the Governor finds it necessary in order to
protect the public health, welfare, or safety, may .direct and
compel the evacuation of all or part of the population from a
stricken or threatened area’’ of Maryland.
22
The governors of
both Delaware and Maryland can also prescribe routes for
evacuation, modes of transportation, and destinations. Ad-
ditionally, when the Delaware Division of Public Health
‘‘reasonably believes that it is more likely than not that [a]
facility or material may seriously endanger the public health,’’
the division is authorized to close,evacuate, ordecontaminate
said facility or material.
23
Likewise, Maryland law establishes
the authority to close, evacuate, and decontaminate a facility
‘‘if necessary and reasonable to save lives or prevent exposure
to a deadly agent.’’
24
In contrast to Delaware, it is the gov-
ernor of Maryland who is empowered with this authority, and
he or she must first proclaim a catastrophic health emergency.
New Jersey law addresses only facility evacuation; it does
not explicitly authorize ordering evacuation of the general
population or an area. In New Jersey during a health
emergency, the commissioner of health can close, evacuate,
and decontaminate any facility that endangers public
health.
25
The written order, which must be provided to the
facility within 24 hours, must specify the facility to which it
applies, the terms of and justification for the order, when
the order becomes effective, and the potential for a hearing
LEGAL PREPAREDNESS FOR HURRICANE SANDY
80 Health Security

Table 1. Evacuation Authorities in Mid-Atlantic States: What Can Be Evacuated, When, and By Whom?
State
Law Allocating
Authority to
Order Evacuation
Who Can
Order
Evacuation?
What Can
Be Evacuated?
When Can Evacuation
Be Ordered?
Emergency
Declaration
Delaware 16 Del. C.
§ 508
Division of
Public Health
Any facility When the division
reasonably believes
that it is more likely
than not that such
facility may seriously
endanger public health
Authority may be
exercised in the
absence of an
emergency
declaration.
20 Del. C.
§ 3116
Governor All or part of the
population from
a stricken
or threatened
area in the state
If evacuation is
necessary for the
preservation of life
The governor may
exercise this
authority during
an emergency
or disaster.
Maryland Md. PUBLIC
SAFETY Code
Ann. § 14-107
Governor All or part of the
population from
a stricken or
threatened area
in the state
If the governor finds
it necessary in order
to protect public health,
welfare, or safety
The governor can
exercise this
authority only
after he or she
declares a state
of emergency.
Md. PUBLIC
SAFETY Code
Ann.
§ 14-3A-03
Governor Any facility After the governor
proclaims a catastrophic
health emergency
The governor can
exercise this
authority only
after he or she
proclaims a
catastrophic
health emergency.
New
Jersey
N.J. Stat.
§ 26:13-8
Commissioner
of Department
of Health
Any facility When there is reasonable
cause to believe that
a facility may endanger
the public health
The commissioner
can exercise this
authority after
the governor has
declared a
state of public
health emergency.
N.J.A.C.
10:161B-2.21
Commissioner
of Department
of Human
Services
or his/her
designee
Substance abuse
treatment facility
(or a component
or distinct part
of the facility)
Upon a finding that
violations pertaining to
the care of clients, or
because of hazardous or
unsafe conditions of the
physical structure, pose
an immediate threat to
the health, safety, and
welfare of the public or
the clients of the facility
Authority may
be exercised
in the absence
of an emergency
declaration.
N.J.A.C.
8:43E-3.8
Commissioner
of Department
of Health
Healthcare facility
(or a component
or distinct part
of the facility)
Upon a finding that
violations pertaining to
the care of patients, or to
the hazardous or unsafe
conditions of the
physical structure, pose an
immediate threat to the
health, safety, and welfare
of the public or the
residents of the facility
Authority may be
exercised in the
absence of an
emergency
declaration.
(continued)
McGINTY ET AL.
Volume 14, Number 2, 2016 81

to contest the order. New Jersey regulations authorize the
commissioner of health to suspend the license of a health-
care facility
26
or the commissioner of human services to
suspend the license of a substance abuse treatment facility
27
upon finding patient care violations or when unsafe con-
ditions in the facility’s physical structure pose an immediate
threat to the health, safety, and welfare of either patients or the
general public. Upon the suspension of its license, a healthcare
or substance abuse treatment facility must transfer its patients,
a process that is approved and coordinated by the respective
licensing department.
In New York, a county or city can order the evacuation
of any person who either has no home or for whom the use
of their home jeopardizes their safety or the safety of others
in the event of or in anticipation of an attack that threatens
public health or safety.
28
Additionally, after declaring a
local state of emergency, the chief executive of any county,
city, town, or village in New York is authorized to ‘‘pro-
mulgate local emergency orders to protect life and property
or to bring the emergency situation under control.’’
29
As an
example, the law notes that if safety is imperiled, the chief
executive can designate zones that people are prohibited
from occupying and presumably therefore need to evacuate.
Discussion
When natural disasters such as hurricanes strike, adminis-
trators and public officials are faced with the complex de-
cision of whether to evacuate hospitals or have hospital
patients and their care providers shelter-in-place until the
threat has passed.
30
One challenge to such decisions is that
storm forecasts are inherently uncertain, and it is difficult to
anticipate the best decision. Evacuating in advance of a
storm may prove unnecessary if the storm changes track or
loses strength or, even more dangerous, if patients are re-
located to a receiving hospital that ends up being affected.
Further, healthcare facility evacuation is not without risk
and should be undertaken only if warranted.
31
Conversely,
if hospitals are unable to maintain essential services while
sheltering-in-place, patients and staff may be at risk of in-
jury or clinicians may need to employ altered standards of
care. Also, evacuating after a facility has sustained damage,
which may include loss of power, elevator access, or light-
ing, can be perilous.
4
Hospitals are legally required to ensure their facilities can
allow for patient care and safety.
32
Unfortunately, during
recent disasters, including Hurricanes Katrina and Sandy,
some hospitals, in the absence of government orders to
evacuate, have sheltered-in-place and subsequently proven
unable to sustain essential services and continue patient care
during the storm and in its immediate aftermath.
4,33
In
such circumstances, the government should ensure that
hospitals are evacuated, ideally before essential services and
patient care are disrupted. Public health legal preparedness
plays an essential role in enabling the government to do this
by providing the necessary legal framework to order pro-
tective actions, including evacuation or sheltering-in-place.
Table 1. (Continued)
State
Law Allocating
Authority to
Order Evacuation
Who Can
Order
Evacuation?
What Can
Be Evacuated?
When Can Evacuation
Be Ordered?
Emergency
Declaration
New
York
NY CLS
Exec § 24
Chief executive
of any county,
city, town,
or village
Anything within
any part or all
of the territorial
limits of a local
government
(ie, any county,
city, town,
or village)
In the event of a disaster,
rioting, catastrophe,
or similar public
emergency within
the territorial limits
of any county, city,
town, or village, or in
the event of reasonable
apprehension of
immediate danger
thereof, and upon
a finding by the chief
executive that public
safety is imperiled
Following the
proclamation
of a local state
of emergency
and during the
continuance
of such local
state of
emergency, the
chief executive
can exercise
this authority.
NY CLS
Unconsol
Ch 131, § 25
A county
or city
Any person In the event of or in
anticipation of an attack
within such county
or city that jeopardizes
the safety or health
of the people
Authority may
be exercised
in the absence
of an emergency
declaration.
Abbreviations: Delaware Code (Del. C.); Annotated (Ann.); Statute (Stat.); New Jersey Administrative Code (N.J.A.C.); and Consolidated Laws (CLS).
LEGAL PREPAREDNESS FOR HURRICANE SANDY
82 Health Security

At the time of Hurricane Sandy, the mid-Atlantic states
had achieved varying levels of public health legal pre-
paredness for catastrophic coastal storms. Mid-Atlantic
states were inconsistent in codifying the authority to order
evacuation or sheltering-in-place—protective actions that
can enable the government to ensure public safety and the
continued provision of health services to hospital patients.
Sheltering-in-Place
None of the 4 states examined in this research had explicitly
authorized the government to order people to seek imme-
diate refuge wherever they were (ie, ‘‘shelter-in-place’’) at
the time of Hurricane Sandy. Sheltering-in-place may be
necessary during a variety of emergencies besides natural
disasters to ensure safety, health, and welfare. For example,
after the Boston Marathon bombing in 2013, Massachu-
setts Governor Deval Patrick requested that Bostonians
shelter-in-place while law enforcement officers were in
pursuit of one of the bombing suspects.
34
In 2015, in the
aftermath of the death of Freddie Gray in police custody,
the University of Maryland
35
and attendees at a nearby
Orioles baseball game in Baltimore, Maryland, sheltered-
in-place while civil unrest erupted nearby.
36
While there is
typically advance notice for approaching hurricanes, there
may be little warning for other incidents that necessitate
sheltering-in-place, such as natural disasters that occur
suddenly (eg, tornados), or other emergencies including
active shooters, chemical spills, or radiological releases,
which may occur at hospitals or elsewhere. In such cir-
cumstances, public health officials must be able to expedi-
tiously order sheltering-in-place. The lack of laws explicitly
authorizing officials to mandate sheltering-in-place could
delay the issuing of such orders by hindering the develop-
ment of ‘‘implementation tools’’ (eg, predrafted orders) or
the ability and skills of public officials to understand and
apply the law.
12
Without explicit legal authorities, public
officials may be unaware of their inherent powers and re-
sponsibilities relative to sheltering-in-place or may be
confused about how to exercise it. Therefore, to ensure
preparedness for all hazards, state governments should
codify the explicit statutory authority to order sheltering-
in-place in a specific facility or an area, either of which
might include a hospital, in response to all hazards where
public health and safety are threatened.
Evacuation
Government protection of the people will sometimes re-
quire an order for people or entire facilities to shelter-
in-place, whereas other emergencies will necessitate evacuation.
When Hurricane Sandy was approaching, all 4 mid-Atlantic
states had laws enabling the government to order evacuation,
but the scope and nature of these authorities differed. New
Jersey explicitly granted its government the authority only
to close, evacuate, and decontaminate a facility that en-
dangers public health, or to suspend the license of a
healthcare or substance abuse facility and subsequently
evacuate its patients (ie, New Jersey does not codify area
evacuation authority). The ability to order facility evacua-
tion is an important public health tool that may be neces-
sary in contained emergencies (eg, biological, chemical, or
radiological contamination of an individual hospital) or in
response to emergencies that result in confined damage (eg,
earthquake or tornado resulting in infrastructure damage
necessitating evacuation of individual hospitals). However,
this authority alone may be inadequate to protect public
health and safety, as it does not enable preventive or area-
wide action, which may be necessary with an approaching
coastal storm. For example, these authorities would not
permit ordering the evacuation of the general public from a
threatened area (eg, an entire neighborhood or town) prior to
a storm’s landfall or ordering the evacuation of a hospital that
has not yet sustained physical damage but for which there is a
reasonable threat of damage that would hinder continuity of
patient care. Moreover, the nature of this authority, which
in New Jersey requires the opportunity for a hearing to
contest the order, is incongruent with the urgency necessary
to achieve evacuation before the arrival of a hurricane—
particularly evacuation of a hospital, which requires even
more time than evacuation of the general public.
It is worth noting that the government’s authority to order
evacuation does not infringe on a hospital’s right to evacuate.
For example, in New York City, 2 hospitals—New York
Downtown and the New York Veterans Administration—
opted to voluntarily evacuate in advance of Sandy’s landfall
in the absence of any government mandate. In Sandy’s
aftermath, 3 additional NYC hospitals—NYU Langone
Medical Center, a private facility, and Bellevue Hospital
Center and Coney Island Hospital, both public hospitals
operated by the NYC Health and Hospital Corporation,
decided to evacuate after sustaining infrastructure damage.
6
While no evacuations were ordered during Hurricane
Sandy, the authority to order evacuation enables the gov-
ernment to mandate evacuation should it be determined
necessary and if a hospital fails to do so on its own.
Therefore, where it does not already exist, state govern-
ments should codify the explicit statutory authority to order
evacuation of either a specific facility or an area in the event
that public health and safety are threatened.
Limitations
Although a thorough and systematic search methodology
was employed, relevant laws may have been inadvertently
excluded from the results. The scope of this research is
limited to state-level statutes and regulations in 4 mid-
Atlantic states in place prior to October 22, 2012, when
Sandy became a named storm. Selection of this date al-
lowed for a characterization of the legal environment that
McGINTY ET AL.
Volume 14, Number 2, 2016 83

existed at the time public officials and hospital executives
were faced with evacuation and shelter-in-place decisions
for hospitals, but laws may have since been updated. Our
findings do not include local ordinances, regulations, or
orders. Practitioners and researchers have noted that di-
sasters, and thus the most effective response to them, are
local.
37
Police powers give state governments broad au-
thority to protect public health. While state-level laws are
essential to public health legal preparedness, future studies
should examine local laws, which may reveal explicit local
authority to order evacuation of or sheltering-in-place in
hospitals. This research examines only the first element of
public health legal preparedness, legal authorities. The
perceptions of key stakeholders involved in evacuation and
shelter-in-place decision making for hospitals throughout
the mid-Atlantic region of the United States during Hur-
ricane Sandy are the subject of a separate, complementary
research study.
38
As laws by themselves are not sufficient to
achieve public health legal preparedness, additional re-
search is needed to understand the impact of the other 3
elements—competencies, information, and coordination—
on evacuation and shelter-in-place decision making during
Hurricane Sandy.
Conclusion
In an era of changing climate and other emerging threats,
where natural disasters and other emergencies are likely to
occur with more force and more frequency, governments
urgently need to prepare to fulfill their fundamental duty to
protect public health and safety. Such protection necessarily
involves a consideration of the continued provision of
health services at hospitals during and immediately fol-
lowing such events. The law enables the government to
fulfill this duty by providing necessary authority to order
preventive or reactive response when safety is imperiled and
clear authorities and responsibilities are essential. By pro-
viding a systematic inventory of existing emergency pre-
paredness laws relevant to ensuring continuity of hospital
care during coastal storms in 4 mid-Atlantic states recently
affected by such storms, this empirical research contributes
to enhancing public health legal preparedness. States can
further improve their readiness for catastrophic disasters by
ensuring the explicit statutory authority to order evacuation
and order sheltering-in-place, particularly in hospitals,
where it does not already exist.
Acknowledgments
MDM was supported in part by funding from the NIOSH
Education and Research Center for Occupational Safety
and Health at the Johns Hopkins Bloomberg School of
Public Health (#T42-OH 008428), the Johns Hopkins
Environment, Energy, Sustainability & Health Institute
(E2SHI) Fellowship, and the 2013-2014Lipitz Public Health
Policy Award. The funders had no role in the design and
conduct of the study, or collection, management, analysis,
and interpretation of the data. The contents of this article
are solely the responsibility of the authors and do not
necessarily represent the official views of any of the funders.
References
1. Blake ES, Kimberlain TB, Berg RJ, Cangialosi JP, Beven JL
II. Tropical Cyclone Report Hurricane Sandy. Publication
AL182012. Miami, FL: National Hurricane Center, Na-
tional Oceanic and Atmospheric Administration; 2013.
2. A Stronger, More Resilient New York. New York, NY: City of
New York; 2013. http://www.nyc.gov/html/sirr/html/report
/report.shtml. Accessed December 12, 2015.
3. Kline DG. Inside and somewhat outside Charity. J Neuro-
surg 2007;106(1):180-188.
4. Uppal A, Evans L, Chitkara N, et al. In search of the silver
lining: the impact of Superstorm Sandy on Bellevue Hos-
pital. Ann Am Thorac Soc 2013;10(2):135-142.
5. Davies E. Emergency hospital evacuation as Hurricane
Sandy hits New York. BMJ 2012;345:e7357.
6. Emergency Preparedness and the Response at the City’s Healthcare
Facilities: Hearing before the New York City Council Committee
on Health, the Committee on Mental Health, Developmental
Disabilities, Alcoholism, Drug Abuse, and Disability Services and
the Committee on Aging. (testimony of Thomas A. Farley, MD,
MPH, Commissioner, Department of Health and Mental
Hygiene). New York, NY: New York City Department of
Health and Mental Hygiene; 2013:1-9. http://www.nyc.gov/
html/doh/downloads/pdf/public/testi/testi20130124.pdf. Ac-
cessed November 1, 2015.
7. Gostin LO. Public Health Law: Power, Duty, Restraint.2d
ed. Berkeley, CA: University of California Press; 2008.
8. US Global Change Research Program. Global Climate
Change Impacts in the United States. In: Karl TR, Melillo JM,
Peterson TC, eds. New York, NY: Cambridge University
Press; 2009.
9. Dobalian A, Claver M, Fickel JJ. Hurricanes Katrina and
Rita and the Department of Veterans Affairs: a conceptual
model for understanding the evacuation of nursing homes.
Gerontology 2010;56(6):581-588.
10. US Centers for Disease Control and Prevention. Learn how
to shelter in place. http://emergency.cdc.gov/preparedness/
shelter/. Accessed January 14, 2015.
11. Association of State and Territorial Health Officers. Emer-
gency Authority and Immunity Toolkit. http://www.astho.
org/Programs/Preparedness/Public-Health-Emergency-Law/
Emergency-Authority-and-Immunity-Toolkit/Emergency-
Authority-and-Immunity-Toolkit/. December 2011. Accessed
December 30, 2014.
12. Moulton AD, Gottfried RN, Goodman RA, Murphy AM,
Rawson RD. What is public health legal preparedness? J Law
Med Ethics 2003;31(4):672-683.
13. Jacobson PD, Wasserman J, Botoseneanu A, Silverstein A,
Wu HW. The role of law in public health preparedness:
opportunities and challenges. J Health Polit Policy Law 2012;
37(2):297-328.
LEGAL PREPAREDNESS FOR HURRICANE SANDY
84 Health Security

14. Benjamin GC, Moulton AD. Public health legal prepared-
ness: a framework for action. J Law Med Ethics 2008;36(1
Suppl):13-17.
15. Wagenaar AC, Burris SC. Public Health Law Research:
Theory and Methods. San Francisco, CA: Wiley; 2013.
16. LexisNexis. Lexis Nexis State Capital. http://www.lexisnexis.
com/en-us/products/lexisnexis-state-capital.page. Accessed
December 26, 2015.
17. The Network for Public Health Law. The Model State
Emergency Health Powers Act Summary Matrix. https://www.
networkforphl.org/_asset/80p3y7/MSEHPA-States-Table-
022812.pdf. Accessed December 30, 2014.
18. Center for Law and the Public’s Health. Effect of Variations
in State Emergency Preparedness Laws on the Public Health
Workforce’s Willingness to Respond in Emergencies. http://
www.jhsph.edu/research/centers-and-institutes/center-for-law-
and-the-publics-health/research/Protocol.pdf. October 24, 2013.
Accessed December 16, 2013.
19. Qualtrics. http://www.qualtrics.com. Accessed December 26,
2015.
20. Association of State and Territorial Health Officers. Emer-
gency Declarations and Authorities. http://www.astho.
org/Programs/Preparedness/Public-Health-Emergency-Law/
Emergency-Authority-and-Immunity-Toolkit/Emergency-
Declarations-and-Authorities-Fact-Sheet/. Accessed December
30, 2014.
21. Del. Code Ann. Tit. 20, x3116.
22. Md. Code Ann., Public Safety x14-107.
23. Del. Code Ann. Tit. 16, x508.
24. Md. Code Ann., Public Safety x14-3A-03.
25. NJ. Code Ann., 26:13-8.
26. N.J.a.C. 8:43e-3.8.
27. N.J.a.C. 10:161b-2.21.
28. NY. Code Ann., Unconsol Ch 131 x25.
29. NY. Code Ann., Exec x24.
30. Fairchild AL, Colgrove J, Jones MM. The challenge of
mandatory evacuation: providing for and deciding for.
Health Aff (Millwood) 2006;25(4):958-967.
31. Dosa D, Feng Z, Hyer K, Brown LM, Thomas K, Mor V.
Effects of Hurricane Katrina on nursing facility resident
mortality, hospitalization, and functional decline. Disaster
Med Public Health Prep 2010;4(S1):S28-S32.
32. Centers for Medicare and Medicaid Services. CMS State
Operations Manual. Baltimore, MD: US Department of
Health and Human Services; 2008. Provider Certification. Pub.
100-07 State Operations. https://www.cms.gov/Regulations-
and-Guidance/Guidance/Transmittals/downloads/R37SOMA.
pdf Published October 17, 2008. Accessed December 26, 2015.
33. Fink S. The deadly choices at Memorial. New York Times
August 27, 2009. http://www.nytimes.com/2009/08/30/
magazine/30doctors.html?action=click&contentCollection=
Magazine&module=RelatedCoverage&region=Marginalia
&pgtype=article. Accessed December 26, 2015.
34. Salsberg B. Governor: closing Boston amid bomber hunt
‘tough.’ Salon April 19, 2014. http://www.salon.com/2014/
04/19/governor_closing_boston_amid_bomber_hunt_tough/.
Accessed December 26, 2015.
35. Vesely M. Bringing shelter-in-place into practice during
an emergency. mdchhs.com. May 5, 2015. http://www.
mdchhs.com/bringing-shelter-in-place-into-practice-during-
an-emergency/. Accessed December 26, 2015.
36. Shearer MP. By order of the mayor.. bifurcatedneedle.com
April 30, 2015. http://www.bifurcatedneedle.com/new-blog/
2015/4/30/by-order-of-the-mayor. Accessed December 26, 2015.
37. Anderson ED, Hodge JG. Emergency legal preparedness
among select US local governments. Disaster Med Public
Health Prep 2013;3(S2):S176-S184.
38. McGinty MD, Burke TA, Resnick B, Barnett DJ, Smith
KC, Rutkow L. Decision processes and determinants of
hospital evacuation and shelter-in-place during Hurricane
Sandy. J Public Health Manag Pract 2016 Feb 23. DOI:
10.1097/PHH.0000000000000404.
Manuscript received July 14, 2015;
accepted for publication January 6, 2016.
Address correspondence to:
Meghan McGinty, PhD
Research Assistant
UPMC Center for Health Security
621 East Pratt St., Ste. 210
Baltimore, MD 21202
E-mail: mcgintymd@upmc.edu
McGINTY ET AL.
Volume 14, Number 2, 2016 85