Disasters: Introduction and State of the Art


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Epidemiology, as the applied instrument of public health interventions, can provide much needed information on which a rational, effective, and ?exible policy for the management of disasters can be based. In particular, epidemiology provides the tools for rapid and effective problem solving during public health emergencies, such as natural and technologic disasters and emergencies from terrorism.

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Disasters: Introduction and State of the Art

  1. 1. Epidemiologic Reviews Vol. 27, 2005Copyright ª 2005 by the Johns Hopkins Bloomberg School of Public Health Printed in U.S.A.All rights reserved DOI: 10.1093/epirev/mxi007Disasters: Introduction and State of the ArtEric K. NojiFrom the Centers for Disease Control and Prevention, Washington, DC.Received for publication January 23, 2005; accepted for publication March 18, 2005. Fifteen years have passed since the last update on this Epidemiology, as the applied instrument of public healthtopic was published in Epidemiologic Reviews (1) and 24 interventions, can provide much needed information onyears since the first (2). In the intervening years, disaster which a rational, effective, and flexible policy for theprevention, mitigation, and preparedness have evolved in management of disasters can be based. In particular,important ways (3). Clearly, it was time to update the last epidemiology provides the tools for rapid and effectivereview. Fifteen years ago, disaster management was simply problem solving during public health emergencies, such asleft to a few dedicated professionals. Roles were clear: natural and technologic disasters and emergencies fromRescue workers rushed to help victims, and certain agencies terrorism.stepped in to provide temporary shelter and food. Usually After sudden-impact disasters, time constraints and dis-within weeks after the disaster’s impact, most people forgot ruption of an area’s infrastructure have frequently made itabout the disaster—until the next one came to wreak new necessary to conduct rapid assessment surveys using non-destruction. Unfortunately, disasters throughout the world, probability sampling methods. These methods may producesuch as the series of four destructive hurricanes that struck biased results because they are often based on purposive,the southeast coast of the United States from August to convenience, or haphazard selection of subjects for interviewSeptember of 2004 (4) and the tsunami disaster in December (6). In the last 15 years, investigators demonstrated the use of2004, have provided ample opportunities to test the policies a modified cluster-sampling method to perform a rapid needsand recommendations set out in the late 1980s. At least 80 assessment after hurricanes (7, 8). In the first survey con-percent of the population growth in the 1990s has occurred ducted 3 days after Hurricane Andrew struck south Florida inin towns and cities. According to the United Nations, in the August 1992, clusters were systematically selected fromyear 2005, one half of the world’s population will live in a heavily damaged area by using a grid that had been overlaidurban areas, crowded onto just 3 percent of the earth’s land. on aerial photographs. Survey teams interviewed sevenThis is an alarming increase in population density. Problems occupied households in consecutive order in each selectedinherent in such rapid growth are especially unwieldy in cluster. Results were available within 24 hours of beginningdeveloping countries; 17 of the 20 largest cities are now in the survey. Surveys of the same heavily damaged area and ofdeveloping countries compared with seven of 20 in 1950. By a less severely affected area were conducted 7 and 10 days2025, 80 percent of the world’s population will reside in later, respectively.developing countries. One of every two large cities in the Initial survey workers found few households with injureddeveloping world is vulnerable to natural disasters such as residents, but a large proportion of households were withoutfloods, severe storms, and earthquakes (3). telephones or electricity. The workers’ findings convinced Fortunately, over the past decade, the public health disaster relief workers to focus on providing primary careapproach to disasters has changed significantly. Today, the and preventive services to residents rather than to divertmanagement of humanitarian assistance involves many resources in order to establish unnecessary mass-casualtymore and different players, and disaster management is trauma services. The cluster-survey method used in thisrecognized as a significant priority of the public health rapid assessment was modified from methods developed bysystem. Today, prevention, mitigation, and preparedness are the World Health Organization’s Expanded Programme onpart of the vocabulary of public health officials in national Immunization to assess vaccine coverage. Although clusterand international organizations and, more importantly, they surveys have been used in refugee settings to assess nutri-are used to advance the cause of reducing mortality and tional and health status, this activity represented the firstmorbidity from disasters (5). use of the Expanded Programme on Immunization survey Correspondence to Dr. Eric K. Noji, CDC Washington Office, 200 Independence Avenue, SW, Room 719-B, Washington, DC 20201 (e-mail: exn1@cdc.gov). 3 Epidemiol Rev 2005;27:3–8
  2. 2. 4 Nojimethod to obtain population-based data after a sudden- ambulances are not immediately available in sufficientimpact natural disaster. numbers, the survivors will use whatever means of transport Although cluster-survey techniques hold promise for that is expedient to accomplish that objective (e.g., privateproviding information rapidly after a disaster, in certain car, bus, taxi, or even on foot). During the September 11,settings these techniques may be less applicable. For ex- 2001, World Trade Center attack, for example, only 6.7ample, epidemiologists who used a cluster-survey technique percent of the casualties were transported by ambulance.after the January 1994 earthquake in Northridge, California, As a result, in most disasters the closest hospitals receivefound that the technique needed modification. Unlike the most of the casualties, while those slightly farther away waitdamage from hurricanes, which is generally uniform over for casualties that never arrive. Furthermore, field triage,a large geographic area and thus can support the use of cluster first aid, and decontamination stations are often bypassedsampling, earthquake-related damage varies considerably, because those transporting victims are unaware of theirwith some areas experiencing little destruction and others existence or location, or because they believe that better careexperiencing heavy destruction. The extent of damage is available at hospitals. This all happens very quickly, withafter earthquakes depends on local soil conditions, the hospitals usually receiving no warning that a disaster hasdistance and rate of ground-shaking attenuation from the even occurred and, most importantly, that they will beepicenter, and the quality of building construction. There- inundated with casualties beginning to arrive within a fewfore, using a cluster-sampling approach to assess damages minutes.after an earthquake may cause health authorities to miss Officials who are unaware of this evidence may in-seriously affected areas and, thus, to underestimate overall advertently create dysfunctional plans. For example, theydamages (9). may designate one hospital to receive casualties contami- Results of epidemiologic studies of disasters have not nated by hazardous substances. They may assume that theonly led to the scientific measurement and description of fire department will decontaminate casualties at the scene,disaster-associated health effects but also been used to or that hospital staff will have advanced notice so they canidentify groups in the population at particular risk for don chemical protective suits and set up decontaminationadverse health events, to help emergency managers match equipment before patients arrive.resources to needs, to monitor the effectiveness of relief Evidence collected by epidemiologists is also useful forefforts, to improve contingency planning, and to formulate planning. For example, the primary focus for disasterrecommendations for decreasing the adverse public health medical planning has traditionally been on hospital treat-consequences of future disasters (3). Unfortunately, it is ment of the critically injured. However, evidence fromassumed by many that all disaster research has been and will epidemiologic studies indicates that most disaster injuriesbe based upon ‘‘scientific evidence.’’ Evidence consists of are relatively minor and could easily be treated in urgentdata upon which a judgment or conclusion may be based. care centers, private physicians’ offices, outpatient surgeryEvidence must be ‘‘valid.’’ Evidence-based disaster medi- centers, and clinics—sparing hospitals for the more seriouscine, therefore, supposedly is based upon facts. For cases. Additional evidence suggests that many postdisasterexample, disaster planning is only as good as the assump- visits to hospital emergency departments are for medicaltions on which it is based. However, these assumptions are conditions other than injuries (10). In some cases, theseoften based on conventional wisdom and stereotypes rather patients are elderly people who have lost access to theirthan on systematically collected evidence. While these routine sources of medical care (e.g., pharmacies, privateassumptions may be logical, what is logical is not always doctors, home health care). Yet, there seems to be littlewhat is true (10). For example, it is often assumed that planning to ensure that these sources of medical care candisasters trigger widespread panic and leave stricken survive, function, or expand capacity in disasters (4).populations helpless and dependent on government author- Evaluation of the medical and public health responses toities and rescue and relief organizations for strong leader- disasters is one of the principal responsibilities of epidemi-ship and assistance. Disaster planning often focuses on what ologists with an eye toward progressive improvement in thethese agencies can do for the public with the view that the ability of the health system to respond more effectively andpublic can do little for itself. efficiently to disasters (2). Such responses must be evaluated Planners may be unaware that there exists a large body of from the perspective of their outcomes and to what extentevidence on disaster responses that has been collected these interventions benefited victims of the disaster, espe-over several decades by rapid-response field teams from cially relative to the goals that were expected by such plannedscientific institutions specializing in disaster research. This responses. Epidemiologists have used a great variety of dataevidence shows that panic is extremely rare in disasters and collection methods and strategies to study the postdisasterthat members of the public in the impact area will take the health effects of major disasters involving acute events, suchinitiative to help themselves and others. as earthquakes and tropical cyclones. Primarily using de- Most postearthquake or post-building collapse search and scriptive epidemiology, they have collected large amounts ofrescue, for example, is carried out not by police, firefighters, epidemiologic data through case studies of new and previousand formally trained rescue teams but rather by the survivors disasters.themselves (family members, neighbors, coworkers, However, interventions also may be evaluated with regardfriends, and those who just happen to be in the area) (11). to prevention or mitigation of the effect of an event. SuchTo the lay public, the best emergency care is seen as evaluations often are difficult, as their success is assessed bytransport as quickly as possible to the closest hospital. If the fact that nothing happened that could have happened. Epidemiol Rev 2005;27:3–8
  3. 3. Disasters: Introduction and State of the Art 5Identification of risk factors for death or injury will require significantly worsened, especially during the years since thea more sophisticated, analytical approach. Such analytical end of the Cold War. Third, on a more positive note, therestudies have usually been of a case-control design. For has been a steady increase in technical publications in theexample, why did some people die while their neighbors, form of journal articles, books, and manuals documentingfamily members, or others survived? Isolated case studies of public health outcomes and proposing more effectivethe relation between death or injuries and the type of responses to conflict-associated population emergencies.traditional housing structures have provided clear indica- The term complex humanitarian disaster reflects the multi-tions regarding simple measures to be implemented in order causal nature and complicated response mechanisms ofto reduce human losses. Such analyses following disasters recent emergencies. In terms of their public health impact,have yielded new information that has altered traditional complex humanitarian disasters may be defined as ‘‘rela-thinking about the prevention of disaster-related mortality. tively acute situations affecting large populations, caused byResults of epidemiologic research on disasters have formed a combination of factors, generally including civil strife orthe scientific basis for increasingly effective prevention and war, often exacerbated by food shortages and populationintervention strategies to decrease mortality in several displacement, and resulting in significant excess mortality’’disaster situations. For example, epidemiologic studies of (16, p. 1012).tornadoes have resulted in changes in local housing and The public health impact of complex disasters in theland-use regulations regarding the danger of mobile homes 1990s has been extensively documented. The Lancet andand have formed the basis of National Weather Service JAMA have both published reports on emergencies insafety guidelines issued to citizens in tornado-prone parts of northern Iraq, Somalia, Bosnia and Herzegovina, Nepal,the country (12). Results of epidemiologic investigations of and Zaire. One useful article that appeared following thea wide spectrum of adverse medical and health consequen- Somali emergency documented the different approaches toces of disasters have allowed us to target specific inter- the collection of public health information among variousventions to prevent specific disaster-related health effects agencies (17). Several years later, however, when 1 million(e.g., improved warning and evacuation before flash floods Rwandan refugees fled into the eastern Zaire province ofand tropical cyclones (13), the identification of effective North Kivu, there was a remarkable degree of cooperationsafety actions that building occupants should take during and standardization of information-gathering methodsearthquakes (14), and the development of measures to avoid among the agencies present. This was reflected in a land-clean-up injuries following hurricanes (15)), to measure the mark article jointly authored by 24 epidemiologists from theeffectiveness of disaster prevention and preparedness Zaire Ministry of Health, World Health Organization,programs, and to help local communities develop better United Nations High Commissioner for Refugees, USemergency preparedness and mitigation programs. More ´ Centers for Disease Control and Prevention, Medecins Sansanalytical studies such as these are needed to test conven- ` Frontieres (Doctors without Borders), the French Army, andtional warnings and public safety advisories (5). the Red Cross (18). Despite the existence of useful, systematically collected Major advances have been made during the past decade inevidence from hundreds of disasters, this body of knowledge the way the international community responds to the healthcan quickly become out-of-date (1, 2). This is because of and nutrition consequences of complex emergencies. Thechanges in disaster threats (e.g., pandemic influenza, suicide public health and clinical response to diseases of acuteterrorism, specific targeting of medical personnel in war epidemic potential has improved, especially in camps. Case-zones) and in the health-care system (advances in emer- fatality rates for severely malnourished children havegency medical service systems, emergency department plummeted because of better protocols and products.overcrowding, nursing shortages, closures of trauma cen- Renewed focus is required on the major causes of death inters). In addition, there still exist critical data gaps in how conflict-affected societies—particularly, acute respiratorythe health-care system deals with disasters. An example is infections, diarrhea, malaria, measles, neonatal causes, andthe lack of systematically collected data on the medical and malnutrition—outside camps and often across regions andpublic health response to releases of hazardous chemicals. even political boundaries. In emergencies in sub-SaharanFurthermore, we lack an effective, nationally institutional- Africa, particularly, southern Africa, human immunodefi-ized process of knowledge transfer for gathering and ciency virus/acquired immunodeficiency syndrome is alsodisseminating lessons learned from health and medical an important cause of morbidity and mortality. Strongerresponses to disasters from researchers to first responders. coordination, increased accountability, and a more strategic Fifteen years ago, the term ‘‘complex humanitarian positioning of nongovernmental organizations and Uniteddisasters’’ was not commonly used. The focus of attention Nations agencies are crucial to achieving lower maternalwas usually the plight of refugees fleeing conflicts related to and child morbidity and mortality rates in complex emer-the tensions between the two superpowers, the Soviet Union gencies (19, 20).and the United States. Much has changed in the intervening While our understanding of the public health problems ofyears. First, the geopolitical context has altered dramati- refugees and displaced persons steadily improved, thecally, with an initial increase in the intensity and scope of causes of and response mechanisms to man-made emergen-Cold War-related conflicts in the 1980s followed by the cies became significantly more complicated. Whereas thecollapse of the Soviet Union and the subsequent ‘‘epi- focus of assistance programs in the 1970s and early 1980sdemic’’ of ethnic and religious conflicts. Second, the public was on refugees who had crossed borders to escape armedhealth impact of armed conflicts on civilian populations has conflicts, in the 1990s it was often necessary to provideEpidemiol Rev 2005;27:3–8
  4. 4. 6 Nojiassistance to civilians still in the proximity of the conflict or threatening environment of armed conflict in a globaldisplaced within their own countries. Civil wars in the climate of political indecisiveness and moral inconsistency.Darfur region of western Sudan, Somalia, Liberia, Sierra While we await a concrete manifestation of the much-Leone, Angola, Afghanistan, Chechnya, Sri Lanka, East heralded new world order, relief agencies and the individ-Timor, and the former Yugoslavia had profound and tragic uals who make up their field teams will continue to work oneffects on the health of local civilian populations (21). the front lines in an ethical limbo’’ (22, p. 134).Today, complex emergencies are humanitarian crises that On September 11, 2001, the United States experiencedinvolve, if not war, then high levels of violence. Increas- the worst terrorist attack in its history. As the nation soughtingly, civilians have become the intentional target of to deal with this tragedy, it would face a second wave ofviolence. Hundreds of thousands of civilians have been terrorism—this time, in the form of a biologic attack. Theretrapped in urban enclaves and siege-like situations where should be no doubt by now that the challenge of terrorismpublic utilities have been destroyed and basic medical has left an indelible mark on the world as we know it,services have collapsed. Children have been forcibly spanning all inhabited continents, crossing all cultures, andconscripted into opposing armed forces and have proved penetrating the borders of all countries.to be the most violent and pitiless of combatants. The Unfortunately, a disaster caused by the intentional releaseprovision of humanitarian assistance in these settings has of biologic weapons would be very different from otherproved extremely difficult and dangerous. The symbol of the natural or technologic disasters, conventional militaryRed Cross is no longer a guarantee of neutrality or even strikes, or even attacks with other weapons of mass destruc-safety, with dozens of staff from the International Commit- tion (e.g., nuclear, chemical, or explosive). The initialtee of the Red Cross murdered. Similar targeting and responders to a biologic disaster will most likely includeassassination of United Nations and humanitarian relief county and city health officers, hospital staff, members ofworkers have now become an accepted hazard of doing such the outpatient medical community, and a wide range ofwork. We all mourn the death of Sergio Viera de Mello, personnel in the public health system and not traditional firstUnited Nations Special Representative to Iraq, on August responders such as police, fire, rescue, and ambulance19, 2003. services. Expanded public health laboratory capacity, in- Since Somalia in 1992, military involvement has often creased surveillance (disease monitoring), early alert,become essential for the provision of security, intelligence, warning and outbreak response capacity, and health com-and logistic support to international relief organizations. In munication and training are critical for an effective responsefact, without such assistance in Bosnia, Kosovo, Liberia, to bioterrorism—with the focus of such public healthSierra Leone, and the recent tsunami disaster in South Asia, preparedness resources and expertise at the state and localrelief operations would have ground to a halt. As could be levels.predicted, the decade of the 1990s brought much confusion It is likely that recognition of the nature of andand uncertainty to the traditional humanitarian relief appropriate response to future bioterrorist attacks andcommunity (both government and nongovernment) in the natural epidemics, such as West Nile virus, pandemicrole of the military in complex emergencies. Usually, in influenza, and the international outbreak of severe acutethese situations, organizations such as the United Nations respiratory syndrome (SARS), also will unfold over time.(e.g., World Health Organization, United Nations Children’s This is a difficult lesson in an age of 24-hour media coverageFund, United Nations High Commissioner for Refugees), and expectations of instant answers. It is critical that publicnongovernmental organizations, the International Commit- health authorities familiarize the communities they servetee of the Red Cross, and the International Federation of Red and the media with the likelihood that reliable answers toCross have retained overall coordination, if not leadership questions arising in future attacks will take time to assembleand control. Until recently, this alone was felt to be essential and validate (23). Furthermore, the public must understandfor maintaining the neutrality (and thus safety) of relief that messages (including medical advice, recommendationsworkers. However, since the Balkan wars, Western militar- about who is at risk, and treatment) conveyed at one givenies (particularly those of the United States) have sub- point in time, although based on the best available in-stantially increased their activities in humanitarian formation, are subject to change when new facts becomeprojects, such as providing field clinical hospitals, water, known.sanitation, communicable disease control, food programs, The myth that things go back to normal within a fewand community health. Despite the humanitarian motives weeks is especially pernicious. The truth is that the effectsfor such military operations, many relief organizations of a disaster last a long time (24). Disaster-affectedbelieve that this engagement contributes to the danger to countries deplete many of their financial and materialtheir field staff by blurring the lines between civilian and resources in the immediate postimpact phase. The bulk ofmilitary function and falsely associates them with the the need for external assistance is in the restoration ofmilitary forces. This became a major issue in the planning, normal primary health-care services, water systems, hous-execution, and recovery of the health infrastructure in Iraq ing, and income-producing work. The longer-term recoveryfollowing the end of major hostilities in Operation Iraqi and rehabilitation needs in the affected areas are moreFreedom. One author of World in Crisis concluded his poorly understood than the short-term needs, but they maychapter on the role of medical relief agencies as follows: be even more important. Many of the large relief agencies‘‘many issues remain unresolved and hotly debated . . . have substantial capacity for both relief and development,foremost is the challenge of working in the hostile and but effecting a transition from relief activities to sustainable Epidemiol Rev 2005;27:3–8
  5. 5. Disasters: Introduction and State of the Art 7and meaningful reconstruction activities is neither a simple opportunities in the public health consequences of disastersnor a straightforward task. Relief organizations still have (up from just 10 percent 8 years ago).much to learn about shifting from short-term medical-aid This issue of Epidemiologic Reviews consists of severalefforts to productive, sustainable interventions that promote updates and reviews that will provide readers with sub-the development of a local health-care system (25). stantial technical descriptions of recent disasters and In particular, social and mental health problems will humanitarian crises (3–5, 10, 11, 21, 23, 24, 26). Theappear when the acute crisis has subsided and the victims articles published in this issue of Epidemiologic Reviewsfeel (and often are) abandoned to their own means (10). were selected on the basis of their demonstration ofUnfortunately, mental health and the psychological conse- advances in the conduct of disaster relief and humanitarianquences of disasters have not yet received the attention they assistance and the methodology of disaster research sincedeserve in the epidemiologic literature (especially compared the last major review of this topic.with the extensive research and body of knowledge in the A common theme that runs through every single one ofsocial and behavioral sciences). Research of populations these articles is that, although all disasters are unique, someaffected by disasters (whether due to civil conflict or volcanic similarities exist among the health effects of differenteruptions) has revealed that these populations may have disasters, which, if recognized, can ensure that health andto cope with widespread depression, anxiety, and post- emergency medical relief and limited resources are welltraumatic stress for years after the disaster (24). Successful managed.relief programs incorporate long-term mental health-careservices in their overall planning for disaster relief, recovery,and reconstruction. The physical health of survivors may also be adversely REFERENCESaffected for years, particularly in technologic disasters, suchas those involving chemicals and radiation. For example, the 1. Lechat MF. Updates: the epidemiology of health effects ofmost pressing health concerns associated with nuclear- disasters. 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