King and Firefighter Syndrome: Disaster Response Goes Beyond the Front Lines

The western North Carolina experience of Hurricane Helene reminded us that in the wake of disaster, we commonly see different domains of response, including centralized governmental operations, non-governmental organizations, decentralized and ad hoc local networks, and self-deployed responders. Media attention tends to focus on those on the front lines, deep in devastated areas.

What gets left out of response stories, however, are the behind-the-scenes activities that facilitate response efforts. So many people and the resources they provide — while not “in the trenches” or perhaps not even viewed as healthcare — are still essential, albeit less recognized. Such division of labor, along with disproportionate recognition, has long been recognized by anthropologists in other domains, and deserves to be applied to disasters.

King and Firefighter Syndrome

This failure of recognition is what I (Hawkins), drawing on a Sesame Street fable, refer to as the “King and Firefighter Syndrome.” In the fable, after a King’s castle is saved by a firefighter, the King requires everyone to become firefighters. When he subsequently realized that he no longer had a postal worker, a cook, or a doctor to attend to other important needs, he ordered everyone to return to their previous positions.

Similarly, when disasters unfold, many jobs are needed. Emergency responders deploying to the field need colleagues to fill shifts for them in their home environments. Those bringing in water, food, tools, and medications need all those to be sourced. Following Helene, 145 healthcare facilities were evacuated in western North Carolina, including elder care homes. In these contexts, neighboring facilities in less affected areas flex to receive refugees, and are equally part of the solution. It takes a team of professionals, all providing their own particular niche skills (not all field responders or firefighters), to address calamity. Another disaster — the COVID-19 pandemic — taught us the fallacy of the “non-essential worker” concept, which was also the King’s fallacy.

Covering Shifts

A nearly universal response to a disaster is “what can I do?” Many healthcare professional disaster responders are still employed in “day jobs.” In order to respond through the National Disaster Medical System (NDMS), healthcare workers must get time off from their jobs, with their routine work covered by colleagues. While NDMS work is protected through the Uniformed Services Employment and Reemployment Rights Act, it is still quite onerous for the home team to cover absent labor. “Cover shifts for your colleague” may not routinely be seen as a contribution to disaster response, but it is critically important, even “essential,” in order to deploy disaster specialists. We need to recognize and valorize the work done to cover home labor alongside the work of deployed responders.

Adaptability

Tensions can emerge among different tiers of response as well. During Helene, a civilian helicopter pilot was threatened with arrest for engaging in rescue efforts without official authorization. In the early days of response, frustrations also emerged when formal civilian rescue and response teams were not utilized by government emergency managers. Some pivoted to collaborate with ad hoc civilian responses. Many trained responders experienced heartache and even moral injury because they were asked to stand by as they witnessed an unfolding crisis.

Healthcare workers may similarly face decisions about how or if to deploy, and whether it is better to be part of the governmental or civilian solution. King and Firefighter Syndrome teaches that both are critical in different places and times, and we need to do a better job of integrating them. Additionally, healthcare workers need to be aware they may be trained and not deployed, or they may be deployed in ways that are non-glamorous, or in ways that do not utilize their full skill set. This is a normal part of disaster work. As one Asheville resident explained in a widely shared social media post just days after Helene, “If you are coming to offer help or resources, you need to stay flexible and be ready to be turned away or redirected…We do not need Indiana Jones right now, we need adaptable team players.”

Sourcing Relief

The same degree of flexibility in interpreting types of disaster response needs to be applied to goods valued as contributions. This requires sensitivity and humility to the needs of those affected rather than presuppositions.

For example, I (Hawkins) was involved in the disaster response to Helene alongside shifts in emergency departments receiving displaced patients. I found myself responding to emergent needs, sourcing and delivering epinephrine auto-injectors, and delivering Starlink satellite units (to provide internet to affected areas) — items not typically seen as relief resources. While Starlink became politicized and concerns of disaster capitalism prompted the company to extend free internet access, the units became essential for responders and residents in areas cut off from the outside world. As a result of a social media post (which, in retrospect, I never should have made public), some questioned my provision of epinephrine directly to responders rather than through centralized systems. On the one hand, critics did not know that the requests were coming directly from my long-term network of healthcare professionals within the most affected healthcare systems. They were experiencing increased insect stinging aggravated by ecosystem disruptions. On the other hand, local solutions by definition need to be local — within hours I removed posts that were beyond my own networks.

Conversely, the Federal Emergency Management Agency was criticized for allegedly turning away or “stealing” relief materials. These allegations likely centered around the public’s unawareness of traditional disaster management protocols of typing and counting resources, and then distributing them centrally to those with the greatest need — a form of materials triage.

Such allegations illustrate the importance of contextualizing disaster response. There should be different mechanisms to supply resources depending on needs and circumstances rather than a fixed blueprint.

Reconciling All Aspects of the Response

Relief efforts are fertile ground for conflict between centralized and disparate efforts. Disasters are grey areas where sometimes helping neighbors is more appropriate than waiting for formal assistance. At other times, answering the needs of those loudest or within one’s network only perpetuates the marginalization of communities outside that network, a situation for which a centralized approach may be more appropriate.

Each disaster comes with diverse needs and tempos, necessitating a division of labor that society must recognize goes beyond the front line. It includes moral and ethical conundrums of when to act, when to wait, which materials to source, and to whom. King and Firefighter Syndrome teaches that complexity is the norm; we tend towards extremes, but it takes acknowledging and integrating different response domains to address disasters.

Seth C. Hawkins, MD, is an associate professor of emergency medicine at Wake Forest University in Winston-Salem, North Carolina. Erin R. Eldridge, PhD, is an assistant teaching professor of anthropology at the University of North Carolina at Charlotte. Sharon Watson, PhD, is an assistant professor of anthropology at the University of North Carolina at Charlotte.