Planning for Calamity: Deep Uncertainty, Resilience, and the Next Catastrophe

Healthcare disaster preparedness has advanced substantially during the past quarter century, yet catastrophes continue to expose vulnerabilities when events and system behavior differ from expectations. Experience from September 11, Hurricane Katrina, Superstorm Sandy, the Las Vegas mass shooting, and COVID-19 demonstrates that dissimilar catastrophes repeatedly stress many of the same interconnected components of healthcare delivery. Because the next catastrophe cannot be predicted reliably, preparedness must extend beyond anticipated events and prescribed responses to preserving essential function when assumptions fail. We distinguish capabilities—the resources, personnel, structures, processes, and services available to perform a function—from capacities that allow capabilities to remain usable or be reconfigured under changing conditions. We introduce ADSTARS (Absorptive, Distributive, Surge, Transformative, Adaptive, Reserve, and Sustainment capacities) as a synthesis of capacities supporting resilience. Planning for catastrophe should preserve not only what healthcare systems possess, but what they remain able to do when conventional arrangements fail.