The devastating 2023 Maui wildfires claimed 102 lives, destroyed more than 2,200 structures and caused an estimated $5.5 billion in damages. One year later, as communities recover, caregivers and first responders are reflecting on what was learned and how to prepare for future disasters. In this conversation, Hilton Raethel, president and CEO of the Healthcare Association of Hawaii, describes how the tragedy unfolded, the steps health care providers took in the face of an unparalleled crisis and what can be improved when the next disaster strikes.

This podcast episode is presented as part of Cooperative Agreement 5 HITEP210047-03-00, funded by the Department of Health and Human Services’ Administration for Strategic Preparedness and Response (ASPR). The Health Research & Educational Trust, an American Hospital Association 501(c)(3) nonprofit subsidiary, is a proud partner of this Cooperative Agreement. The contents of this publication are solely the responsibility of the Health Research & Educational Trust and its partners and does not necessarily represent the official policies or views of the Department of Health and Human Services or of the Administration for Strategic Preparedness and Response. Further, any mention of trade names, commercial practices, or organizations does not imply endorsement by the U.S. Government.

Tom Haederle

Tom Haederle

Welcome to Advancing Health, the podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. In today's podcast hosted by Ben Wise, senior program manager of operations for AHA Funded Partnerships, we hear from those who were on the scene as the historic fires scorched the beautiful island of Maui last year. Hilton Raethel, president and CEO of the Health Care Association of Hawaii, describes how the tragedy unfolded and what health care providers did right and perhaps would do differently next time.

Tom Haederle

The local health care system and larger community have largely overcome immense adversity in the wake of the wildfire. But, as Raethel notes, "we'll be dealing with the consequences of this disaster for many, many years."

Ben Wise

Hilton R. Raethel

We first heard about the fires on the morning of August 8th, which was a Tuesday of last year. And like in many places, fires occur. And so you just track them. We heard later that morning that the fires, at least the Lahaina fire was contained and the Kula fire was burning. But the Kula fire is more of a what we call upcountry, more rural.

Hilton R. Raethel

And the Lahaina fire was in some brush and some grass. However, later in the afternoon, we heard that the fires had flared up again. We did not know, however, at least on Oahu, which is the main island here, because Lahaina was on Maui, a separate island. We did not know until very early the next morning, just on Oahu, at least the severity of the fires.

Hilton R. Raethel

Hilton R. Raethel

And at that point in time, we knew there'd been some damage but we were not aware of deaths. So we did not become aware, at least on Oahu, we did not become aware of the deaths until early the next morning. What we didn't know is that over 90 people had died that prior evening and overnight. So it was a very, very challenging situation.

Hilton R. Raethel

Part of the problem was that the landlines were down - because of the fires, because it destroyed most of Lahaina -the landlines were down, the cellular towers were down. And so communication and the people on the ground, the emergency services, fire, police, they were focused just on taking care of the community, trying to put out the fires, trying to protect, get people to hospitals, for example.

Hilton R. Raethel

They were focused on what was right in front of them. There was a breakdown in communication between the people on the ground in Lahaina, which is on the west side of Maui, and even the county, Maui County and the state, the governor's office, the emergency management office. So that communication did not start to build until Wednesday the 9th.

Hilton R. Raethel

So over 2,200 structures were damaged or destroyed in Lahaina, 85% of which were residential. And in Kula, the upcountry, there were about 700 acres destroyed and burnt. And there was about 19 homes destroyed. About 8,000 residents were displaced. And this has been described as the deadliest fire in the U.S. in the past 100 years.

Ben Wise

And the logistical and operational and geographical aspects aside, the immediate health impacts must have also been profound. What stood out to you or stands out to you in terms of the challenges faced by those communities, especially in Lahaina and Kula?

Hilton R. Raethel

Fortunately, we have a very good health care system in Hawaii. We have one primary hospital on Maui called Maui Memorial and a couple of critical access hospitals. A lot of tertiary services are provided on Oahu. It's a small state. We only have 1.4 million people in the entire state. So, for example, we only have one level for NICU.

Hilton R. Raethel

We only have one major trauma center. We only have one major burn center in the state. The burn center is a hospital called Straub, which is on Oahu. So there were 82 people admitted to hospital in the first couple of days. Seventy-one of those went to Maui Memorial, the hospital on Maui, and 11 were flown over to Oahu.

Hilton R. Raethel

The majority of those ended up in the burn unit. Now we only have a four-bed burn unit at Straub. This was the largest number of burns that we've ever had in that hospital. So the burn unit expanded into the critical care unit at the hospital so that we could accommodate all these burn patients. Fortunately, we have a great team of doctors and nurses who were able to take care of those 11 patients.

Hilton R. Raethel

Unfortunately, we did lose one of those after a few days because of the extent of the burns. We also had almost 700 outpatient visits in the week after the fire. There were two phases of outpatient visits. Apart from the inpatient, you know, people who had significant injuries. The outpatient visits, you know, it's a lot of outpatient, you know, minor burns,

Hilton R. Raethel

just smoke inhalation, things like that. Cuts, bruises. So there was this initial wave in the first 24 to 48 hours. What we discovered is that when the shock of this whole trauma of this disaster set in, some people two, three, four days later - once the adrenaline had settled down, once they'd sort of...you know, taken a little bit of stock of what was happening, they realized, oh, I've got a burn or, you know, my feet are burned or I've got a bad cut.

Hilton R. Raethel

And so we had this initial wave of visits to the hospitals and then that second wave a few days later. Fortunately, there were no nursing homes or hospitals in this area, either in Lahaina or Kula. And so we did not have any major structures that were damaged or even burned or damaged. There were three physician clinics that were destroyed.

Hilton R. Raethel

There were pharmacies that were destroyed or damaged or shuttered because of the lack of staff, and there were many houses and businesses that were damaged or destroyed. So our immediate concern was ensuring that all of those inpatients, all of those outpatients, were being taken care of.

Ben Wise

That's a really interesting thing to reflect on in thinking about those immense response efforts and needs that you're describing. I'm curious as to, what you and your team at the Health Care Association of Hawaii were doing to kind of step in to support these health care workers and the patients and even the broader community during these critical early moments.

Hilton R. Raethel

A fire like this, when a town, most of a town burns, it means that houses burn, cars burn. People didn't have transport, for example, because all their cars were literally destroyed. But, you know, burned to the ground. So everything in the house was burned. Licenses, passports, medications, you know, baby formula, diapers, toothbrushes. You know, all of those things were destroyed.

Hilton R. Raethel

Many people only had the clothes that they were wearing. So, and then we had the landlines and the cellular towers were down. We had health care workers who lost homes, lost all their possessions, and they were sleeping in the hospital or the long term care facility taking care of patients. They had lost everything, but they went to work. They took care of patients and then were sleeping in the hospital because they, like that literally did not have a place to sleep.

Hilton R. Raethel

So there were two sets of emergency services. We have an emergency services team funded through the hospital preparedness program, the national federal program. We had our team on the ground within 24 hours of the fire. So the fires happened on the evening of Tuesday afternoon and evening of Tuesday and overnight. We had a team on the ground Wednesday morning.

Hilton R. Raethel

They were embedded with state and county officials. We were working with...one of the challenges we had was medications. Again, people lost medications. Everything was destroyed. So we had about 8,000 people in what we call congregate shelters, which is stadiums, high schools, you know, things like that. And we had teams of people come in from primarily from Kaiser and our Blue Cross Blue Shield plan, talking to these individuals to say, you know, what sort of medications do you need?

Hilton R. Raethel

And the challenge was that we have all these people, thousands of people literally in these different shelters that were trying to survive. We would do the rounds. The nurses or the doctors would do the rounds in the morning and saying, you know, what sort of medication do you need? Those orders would get sent to a pharmacy, which was on a different part of the island, and then the medications would be brought back in the afternoon.

Hilton R. Raethel

The problem is, many of the people who were there in the morning, were maybe not there in the afternoon or moved to another shelter or were with friends. We set up the system very quickly, for example, for vital medications, which are critical for individuals. But we had for the first few days about an 80% return rate because the people in the afternoon were not there in the morning and we couldn't track them down.

Hilton R. Raethel

So we're having to send medications back. We worked to coordinate volunteers. There were so many volunteers. We were getting, again, all of these basic supplies, basically setting up a free store next to these congregate shelters where people could just go and get all of these basic supplies, including, again, things like a toothbrush, toothpaste, clothes, anything that they needed.

Hilton R. Raethel

We had dialysis patients. Again, they'd lost their transport. They didn't have their homes, so were having to shuffle around. Dialysis is obviously a critical service. We were having to arrange transport for patients to get from these congregate shelters, these large shelters where they're sleeping on cots on the floor of these stadiums. They had to still get to dialysis.

Hilton R. Raethel

So there were many, many details that our teams, along with state and county officials, worked with to address the immediate needs of these individuals.

Ben Wise

And it sounds like there's a theme of a lot of collaborative work happening here. I was wondering, you can maybe speak a little bit to, what those collaborations were and how they kind of helped aid across sectors to the recovery response that was going on.

Hilton R. Raethel

Well, collaboration is incredibly critical. Disasters, by definition, are chaotic. You know, every disaster is different, and it takes days and even weeks to build systems. You know, it depends on what's destroyed, where people are, how people are being moved around. We're incredibly fortunate in Hawaii that because we live on these islands out in the middle of the Pacific, five hours from the West Coast, people have to rely on each other.

Hilton R. Raethel

They're used to working with each other. So we're very fortunate that we as a health care association, have very close working relationships with the governor, who happens to be a physician. We work very closely with the lieutenant governor, with the Hawaii Emergency Management Agency, and we work very closely with the counties as well. And so, because we know who these people are, we have these relationships, we have email addresses, we have phone numbers.

Hilton R. Raethel

We were able to put teams of people together very, very quickly to help coordinate this in all of this chaos. And if you don't have those relationships set up, if you don't have that level of trust, then it's much harder. If you're calling someone up and say, look, you know, we need to deal with dialysis. We need to deal with medications.

Hilton R. Raethel

We need to deal with whatever it is. If you don't have that level of trust built up, it's going to take a while for people to say, well, what do I want to work with you? We even had payers, for example, Kaiser and Blue Cross, Blue Shield of Hawaii. They stepped up tremendously and they had their pharmacists, for example.

Hilton R. Raethel

They had their behavioral health specialists working with us, coordinating with us. So the whole community came together. And I'm not saying it was all perfect. You know, it was a very, very chaotic situation. But we were able to build these systems, bring in mobile clinics, make sure people got dialysis, make sure people got medications and build those systems in a very short period of time.

Ben Wise

That's so interesting and also encouraging to hear that collaborative work happening. And I suppose now thinking not necessarily in those immediate moments, but here we are a year later, I was thinking maybe just tell me about some of the long term challenges that of that have come from this. And, in recovering from the wildfires and any lessons learned.

Hilton R. Raethel

So one of the things that was really critical was emergency proclamations. And again, we have, a very close working relationship with the governor and the attorney general. And it was really critical that we get these emergency proclamations in place, and we're still operating under emergency proclamations to this day. We are currently on our 16th emergency proclamation in the state of Hawaii.

Hilton R. Raethel

An emergency proclamation can only be in effect for a maximum of 60 days. So we've had a whole series of emergency proclamations. And some of those things, for example, is being able to bring in staff from the mainland. And if you are, if you're a doctor or a nurse or behavioral health therapist, for example, and if they are from the mainland and they have a valid state license on the mainland, but they're not licensed in Hawaii, the emergency proclamation allows them to work in Hawaii without getting a state license, because it takes a while to apply for a state license.

Hilton R. Raethel

So we're very fortunate to have that. We don't have enough behavioral health therapists. There's a huge amount of trauma that goes on when a community gets destroyed. We were short of behavioral health therapists, but you have your health professionals even before this disaster and the need just went up dramatically. So again, one of the emergency proclamations, we have a waiver so that people could do telehealth, for example, consults.

Hilton R. Raethel

Now, normally you need to do an in-person visit before you can establish a relationship and do a telehealth visit. So that was waived, for example. The ability of being in-state to prescribe narcotics, that was waived as well. So again, we had this series of waivers that helped us and are helping us to this day to help take care of the community.

Ben Wise

Tell me about the community a little bit. What's special about it and what makes it, resilient in the face of something is as big and disastrous as these fires.

Hilton R. Raethel

We have this concept in Hawaii called Ohana, which is family. And there is a very, very strong sense of family, of community. And this has been incredibly challenging, again, to have literally thousands of people displaced. Just over 12 months later, the rebuilding has started. We've had incredible support from FEMA, and we've had incredible support from the Corps of Engineers as well.

Hilton R. Raethel

President Biden has been here. We've had members of our congressional delegation been out to visit...all the way from the president, through congressional delegation, through FEMA, for the local community has been incredible. There are a lot of long term effects from a disaster like this. A survey was done recently by the University of Hawaii, and 46% of the Maui residents had reported that their health a decline in the past year.

Hilton R. Raethel

We're going to be dealing with the consequences of this disaster for many, many years. It's a multi-year recovery and we are working very hard to rebuild. It's just some houses have started to be rebuilt. Some of the businesses have reopened. There are people who have left either Maui or left the state because of these fires, because I don't know how long it was going to take to rebuild their community.

Hilton R. Raethel

However, many people, the majority of people in the community do want to rebuild their community. They do want to stay living in that area. And those rebuilding efforts are starting right now.

Ben Wise

And out of such difficult circumstances, I just really want to express gratitude for everything that you and HAH and all the health care professionals in the area have done. And thank you for taking this time to speak with us today and really appreciate all that you do.

Hilton R. Raethel

You're very welcome.

Tom Haederle

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