Public Health Management and Disaster Preparedness
Kathryn Reese (2005), Lisa Bunosky (2003)
Disasters include emergencies of such a severity and magnitude that they result in deaths, injuries, illness and/or property damage which cannot be effectively managed through the application of routine procedures and resources and that result in the call for outside assistance. These events can be caused by nature, technological attach, manmade error, or emerging disease. Disasters present an ubiquitous risk, have increased in occurrence across the United States and are likely to continue increasing, and negatively affect public health. Therefore, the public health community should give priority to planning for these events (Landesman 2001).
Public health disasters present a number of problems which are not routinely encountered in the practice of emergency health care. Examples of these unique problems include the need for warning and evacuation, interorganizational coordination, casualty distribution, and disruption of shelter, utilities, communication systems, and transportation. The management of these challenges in an effective manner requires special expertise. Furthermore, hospitals and other health care agencies must be able to rapidly address these situations to meet the standards of the Joint Commission on Accreditation of Healthcare Organizations and the regulations of the Occupational and Safety Health Administration (Landesman, 2001).
Several different classifications of disasters must be considered. Natural disasters include such events as earthquakes, floods, hurricanes, and volcanic eruptions. Hazardous material spills, industrial explosions, and transportation accidents are examples of technological disasters. Riots, terrorist attacks, and nuclear war are examples of civil hazards. Examples of biological disasters include outbreaks and emerging disease (ICMA, 2003).
History of Public Health Responses to Disasters
February 1976, a landmark event occurred in the history of the study of medical and public health impact of disasters, as an earthquake struck Guatemala leaving 23,000 dead. The epidemiologic inquiries conducted following this Guatemalan earthquake identified significant logistic deficiencies in the international disaster relief system. For example, Lechat and de Ville de Goyet identified many myths and incorrect beliefs that were widely associated with the public health impact of disasters (Noji, 1997).
Myth 1: Foreign medical volunteers with any kind of medical background are needed.
Reality: The local population almost always covers immediate life-saving needs.
Myth 2: Any kind of international assistance is needed and it is needed immediately!
Reality: A rapid response that is not based on an impartial evaluation only contributes to the chaos.
Myth 3: Epidemics and plagues are unavoidable after every disaster.
Reality: Epidemics do not suddenly occur after a disaster. The solution to preventing disease is to improve sanitary conditions and educate the public.
During this time period, Roger Glass and colleagues described the first application of analytic epidemiology to investigate the health effects of a disaster. Furthermore, he was the first to attempt to identify risk factors for specific outcomes of disasters such as death and injury. His goal was developing effective strategies to prevent future disaster-related morbidity and mortality. For example, despite widespread distribution of tornado citizen-safety recommendations in the U.S., the effectiveness of these guidelines in reducing the toll of deaths and injuries had never been tested until Glass and colleagues examined a tornado disaster in Wichita Falls, TX. The circumstances of death and severe injury among the victims and the protective measures taken by a representative sample of community residents who suffered no major injury was found to be a practice that was useful in identifying new prevention strategies. Furthermore, the information provided the scientific basis for increasing effective prevention and targeted intervention strategies to decrease mortality in several different disaster situations (Noji, 1997).
Also occurring throughout this period, the World Health Organization (WHO) and the PanAmerican Health Organization (PAHO) were establishing specialized emergency units. After Lechat and de Ville de Goyet described how in the absence of an adequate field assessment, disaster scenes were often cluttered by unnecessary, useless, outdated, unlabeled drugs, vaccines for cholera and typhoid fever that were not needed or effectively used, medical and surgical teams without proper support and relief programs that did not address immediate local needs, they made a standard list of essential drugs, medical supplies and equipment. The “Emergency Health Kit” was first published in 1984 by the WHO with the assistance of UN High Commissioner for Refugees (UNHCR) and the London School of Hygiene and Tropical Medicine and updated in 1990 with additional contributions by others such as UNICEF, Medicins Sans Frontieres (MSF), International Federation of the Red Cross, and Red Crescent Societies and International Committee of the Red Cross (Noji, 1997). Although the WHO Emergency Health Kit had been adopted by most relief organizations and national authorities as a reliable, standardized, inexpensive, appropriate, and quickly available source of the essential drugs and health equipment urgently needed in a disaster situation, on-the-ground problems persisted with unsorted shipments, unintelligible labeling, perishable goods, out-dated products, late arrivals. The PAHO, however, developed a computer system called SUMA (supply management) which is design to sort, classify and make an inventory of relief supplies at the port (s) of entry in a disaster-affected country in order to assure appropriate distribution.
Furthermore, epidemiologic assessment techniques were another exploratory focal point in public health response to disasters. Guha-Sapir and Lechat have developed useful needs-assessment indicators for use following natural disasters. “Rapid needs assessment refers to a set of tools designated to provide, quickly and at a low cost, accurate and reliable population-based information to emergency managers” (CDC, 2003). The objective is to obtain information about needs of an affected community as these needs change in the aftermath of a disaster event.
1. Strengthening human resources and building institutional capacity
a. Incorporating key principles of emergency preparedness and responses into the curricula of institutions such as schools of medicine and public health.
2. Integrating key emergency preparedness principles and procedures into ongoing public and primary health programs
a. Environmental health and public health surveillance
3. Improving collaboration on preparedness and response
a. Strengthening relations between health programs and other sectors involved in emergency preparation
4. Conducting community-based epidemiologic research immediately following natural disasters on the public health consequences of such events.
a. Developing models that predict the public’s vulnerability to different types of natural disasters or identifying populations at increased risk from disasters.
5. Improving technology and information-transfer strategies
6. Improving communication between communities at risk before, during, and after a disaster
a. Coordination between public health agencies and other key response organizations to streamline communication procedures, exploring technology alternatives for improved data retrieval and developing databases about natural hazards specific to each country
b. Information about regional and international resources available for immediate emergency assistance.
7. Developing early warning systems.
The NCEH is part of the Centers for Disease Control and Prevention (CDC), and although it plays a role in ensuring the health of the people within the United States, one of the organization’s goals is to work with various partners to improve global health, and in 1998 the Office of The Associate Director for Global Health was established to help identify its global priorities and to help coordinate its actions (CDC, 2003). In addition, the Health Studies Branch of the NCEH has the major responsibility for disaster epidemiology. The mission of the disaster epidemiology program is to promote health and quality of life by service, applied research, and distribution of information in preparing for, responding to, and recovering from a disaster event. The goals of the disaster epidemiology program are (CDC, 2003):
a. Conduct surveillance of deaths, injuries and illnesses related to a disaster event
b. Assess the needs of disaster-affected communities
c. Evaluate emergency preparedness programs, response activities and
a. Identify preventable risk factors contributing to disaster-associated
morbidity and mortality
b. Conduct prevention effectiveness studies
c. Refine surveillance and other methodologies
a. Community at large
b. State/local/foreign health departments
c. Other federal agencies
d. Professional interest groups
e. Academic institutions
f. International organizations
Importance of Preparedness
The overriding purpose of disaster preparedness is to anticipate potential problems and propose possible solutions to these problems. Preparedness can limit the disruption that disasters cause to life, property, and the environment and allow for expedient return to predisaster conditions. Also, a successful plan can increase communication and cooperation during disaster as well as reduce a jurisdiction’s legal liability (ICMA, 2003).
Obstacles to Preparedness
Lack of Support
Since disasters occur on a fairly infrequent basis, other department leaders may not recognize the need for preparedness for events that may not occur when issues such as road repair and crime prevention are ever-present. Also, local government employees may not understand their roles in emergencies if they have not previously been involved in disaster response. This may cause them to neglect their duties in preparedness as well as fail to see the relevance of preparedness planning (ICMA, 2003).
The public plays a dynamic role in the practice of disaster prevention and protection. In fact, some emergency procedures are entirely the responsibility of the individual like building up food reserves or taking out personal insurance policies. However, many people are not interested in preparedness, and unwilling to take precautionary measures themselves. “One reason behind lack of willingness to prepare may be that people judge it to be highly unlikely that they will find themselves in an accident or disaster situation” (Larsson, 1997). Another reason is that some people believe they are less vulnerable than others, a belief which is sometimes termed unrealistic optimism. Other reasons for lack of action may be that people do not know what they should do, or preparations are of little or no use if a disaster should occur.
Denis (1995) found “the preparations which the greatest number were willing to make included obtaining a first-aid kit, finding out how to get information if a disaster should occur, planning how to evacuate the home in a fire, and learning how to deal with crisis reactions.” The preparations that people made or are willing to make are generally those that cost little in time or money, do not require major commitment, and may be seen to have high personal consequence. On the other hand, preparations people were least willing to make were joining voluntary organizations, using alternative sources of energy or taking extra insurance. The strongest argument for not making preparations seemed to be uncertainty, not knowing what one should prepare for.
It is important that government leaders should not assume that they are prepared for an emergency if a disaster plan has been created. The plan will not be effective if employees and citizens are not educated about what they should do in a disaster. It is also imperative that the activities outlined in the plan are practiced to ensure that they are carried out correctly and efficiently (ICMA, 2003).
Although many people think public education is the ultimate answer to disaster preparedness, care must be taken with regard to assuming that the provision of information on hazards or risk will facilitate the adoption of preventive measures. Johnston et al (1999) noted that individuals describe themselves, compared with others in their community, as being better prepared to deal with volcanic hazard effects. “For example, evaluation of a volcanic risk communication program revealed that providing hazard information resulted in some 28 per cent of respondents feeling less concerned about hazards” (Paton, 2000). The people assumed that the source of the information would take responsibility for managing both the risk and their well being, reducing the probability of their both attending to risk messages and implementing recommendations.
Attributing better responsiveness to oneself, relative to the community as a whole, individuals may accept the need for greater preparedness, but perceive this as applying to others, not themselves. Hence, the probability of their attending to information or acting on warnings will be reduced. Furthermore, actions to increase people’s preparedness are more likely to be effective if they are directed towards certain target groups. For example, younger women have made fewer preparations than other groups, but indicate a willingness to undertake such measures (Larsson, 1997).
Necessity of Collaboration
A disaster plan cannot be successful without the cooperation of all levels of government as well as the private sector and nonprofit organizations. Therefore, emergency managers need to work closely with others to develop community disaster preparedness. To ensure that all necessary parties are included in planning, it can be very useful to develop a preparedness council. Just in the manner that disaster response must be multi-organizational, so must be disaster preparedness planning (ICMA, 2003).
Principles of Disaster Planning
Though most disasters are unexpected, effective planning can anticipate common problems encountered and required tasks.
In order for a disaster response plan to be effective, it must be sensitive to the manner in which the public is likely to behave. Empirical knowledge of how people normally behave in emergency situations is essential. Also, plans must be flexible enough to change in reaction to the numbers of laws, organizations, populations, technology, hazards, resources, and personnel involved in response (Landesman, 2001).
Furthermore, to ensure a timely response to those most in need during any major disaster, local authorities will likely execute the main rescue effort during the first 24-hour period. Therefore, it is important that disaster plans are acceptable to elected officials and other departments that will be involved. These plans should be distributed widely to ensure that the necessary individuals are familiar with execution and will have the ability to raise questions well before they might become relevant. As a result of the primary local response, disaster plans should include the provision for authority at the lowest levels of organization without reliance on top-down decision making to optimize resources (Landesman, 2001).
Two different strategies for disaster planning include the agent-specific approach and the all-hazards approach. In the agent-specific approach, communities create plans specific to only the disasters likely to occur in their region (Landesman, 2001). For example, in Ohio, agencies would likely plan for response to tornadoes, but not hurricanes. These strategies, which may seem more relevant to taxpayers and local officials, are more likely to garner support (Landesman, 2001).
The all-hazards approach allows for maximization of the level of preparedness for the expenditures and effort involved. In this method, planning occurs for the common problems and tasks that arise in the majority of disasters, since many disasters pose similar obstacles (Landesman, 2001).
Risk is a result of proximity or exposure to triggering agents, which increases the probability of disaster and the potential for human or material losses (McEntire, 2001). Every state in the United States has communities at risk from one or more natural hazards. People at most risk include (CDC, 2003):
· Those living in housing that are standard or cannot withstand an event
· Those living in geographic areas prone to severe natural events such as coastal areas, flood plains and seismically active
· Those not educated about how to protect themselves before and after an event
Risk management should seek to promote resilience and preparedness through a mix of strategies involving communication, managing vulnerability and facilitating resilience and growth. Hood and Jones (1996) point out that risk management typically involves some combination of anticipation and resilience, so conferring upon risk management models, the potential to summarize perspectives that cover growth and distress (Paton, 2000). In addition to promoting the competence and resilience of community members, the adoption of a growth-oriented strategy may provide a context conducive to sustaining resilience over time, and important issue given the rarity of hazard activity. A deficit or loss paradigm leads to strategies where community members are urged to spend money on strengthening or altering their houses or building to reduce losses from earthquake hazards. From a growth perspective, the focus would be on investing in structural alterations to increase the capital value of property, increase its resale vale, or reduce insurance costs.
Resilience is the amount of coping capacity or the ability to react or effectively recover from a triggering agent (e.g. earthquake, flood, and tornado) that becomes disastrous. “Resilience describes an active process of self-righting, learned resourcefulness and growth-the ability to function psychologically at a level far greater than expected given the individual’s capabilities and previous experiences” (Paton, 2000). It is important to investigate factors that encourage resilience and growth and, as far as possible, seek to intervene in ways that assist resilience and growth rather than dependence and loss.
The community as a whole exhibits resilience, and it can be described at several interdependent levels. For example, the ability of a community to “bounce back” and recover using its own resources requires attention to protecting the physical integrity of the built environment and lifelines, and ensuring economic, business and continuity (Paton, 2001). Moreover, it involves guaranteeing community members have the resources, capacities and capabilities necessary to use these physical and economic sources in a manner that minimizes disorder and facilitates growth. Those individuals who identify themselves as having no investment in their community, however, may develop a level of disengagement which, following a natural disaster, may trigger feelings of isolation, promote learned helplessness, and intensify vulnerability. “The more people who are involved in community activities that engender a sense of community, efficacy and problem solving, the greater will be their resilience to adversity” (Paton, 2001).
Investigating the efficacy of this concept requires the identification of variables capable of predicting community resilience to hazard effects. Variables found in this category are “sense of community”, “coping style”, “self-efficacy”, and “social support” (Paton, 2001). Self-efficacy describes an individual’s judgment of what they are capable of performing, and influences people’s openness to information and the chance of their acting to deal with hazard consequences. Sense of community encourages participation in community reaction following a disaster and increases access and use of social networks. In addition, it offers insight into the degree of community division and therefore, the level of support likely to exist for collective involvement or mitigation strategies. Finally, coping style affects how people react to a hazard effect. For example, problem-focused coping (confronting the problem) characterizes a mechanism for facilitating resilience, while emotion-focused (suppressing or denying emotional reactions without attempting to tackle the problem) coping strategies have a tendency to increase vulnerability.
Vulnerability is the dependent component of a disaster that is determined by the degree of risk, susceptibility, resistance and resilience (McEntire, 2001). Moreover, vulnerability is a combination of characteristics of a person or group in terms of their capacity to anticipate, cope with, resist, and recover from hazard impacts that threaten their life, well being and livelihood. There are several factors that augment vulnerability (Paton, 2000):
Barriers, however, are introduced by differences in perceived vulnerability to hazard effects. For example, Paton and Johnston (2001) found that risk perception and support for collective mitigation programs were driven less by hazard characteristics and more by their current implications for their livelihood. Their study suggested that focusing communication on concrete factors such as actions designed to protect economic integrity or safeguarding livestock rather than uncontrollable threats like seismic activity or ash fall, will facilitate action.
Components of a Plan
A disaster plan will have several components that will identify jurisdictions that might be affected by a disaster and the relevant agencies to disaster response activities. An effective plan will bring together leaders of these agencies, initiate cooperation, identify types of disasters likely to occur, establish communication, and create a protocol for the assessment of the range of damage, injuries, deaths, and secondary threats (Landesman, 2001).
Risk and Vulnerability Assessment
All communities are at risk for different types of disasters. Information gathered about past disasters will allow a disaster preparedness council to make a determination about the hazards that threaten a community and the degree of vulnerability within the community (ICMA, 2003). The status of health and the health risks of a community must also be assessed. The assessment of the health condition of a community must examine prevalent disease and persons with special needs who will need assistance related to evacuation and continuity of care, ability of the affected population to obtain prescription medications, building safety and ability to protect victims from further incidence, ability to maintain air quality, food safety, sanitation, waste disposal, vector control, and clean water (Landesman, 2001). Once all these determinations have been made, risk, defined in terms of probability and consequences, may be estimated. Risk assessment then requires estimating the number of deaths and injuries, number of damaged and destroyed homes and businesses, and probable losses in economic terms including expected post-disaster challenges (ICMA, 2003). The information from this detailed study can then be used to develop an emergency operations plan.
Presently, vulnerability is used in the field of risk, hazard, and disaster management as well as in the areas of global change and environment and development studies. There are three distinct themes in vulnerability studies (Weichchselgartner, 2001). First, vulnerability can be studied as a risk/hazard exposure. The source (or potential exposure or risk) of biophysical or technological hazards is examined, and the studies are distinguished by a focus on the dispersion of some hazardous condition, the human occupancy of this dangerous zone (e.g. floodplains, seismic zones) and the degree of loss associated with the occurrence of a particular event (flood, earthquake). Second, vulnerability can be studied as a social response. The theme examines coping reactions, including societal resistance to hazards. Furthermore, this perspective highlights the social concept of vulnerability, a condition rooted in historical, cultural, social and economic processes that impose on the individuals or society’s ability to cope with disasters and effectively respond to them. The final theme in vulnerability studies is the vulnerability of places. This topic combines elements of the previous two, but it is inherently more geographically centered. Vulnerability is considered both a biophysical risk as well as a social response, but within a specific area or geographic domain.
The Organization of American States (1991) developed a series of multihazard maps that incorporate vulnerability assessment into their pre-impact planning and mitigation efforts (Weichchselgartner, 2001). These evaluations include human populations, critical facilities and lifelines, economic production facilities, and differences in vulnerability among economic sectors. The following factors are considered as relevant with regard to loss reduction (Weichchselgartner, 2001):
· Hazard (physical process itself)
· Exposure (all individuals, infrastructure etc. which are exposed to hazard)
· Preparedness (all precautionary activities and measures which enable rapid and
effective response to hazard event)
· Prevention (all activities and measures in advance of a hazard event designed to reduce
hazards and their effects and provide permanent protection from their impacts)
· Response (all activities and measures taken immediately prior and following a hazard
event to reduce impacts and to recover and reconstruct an area affected by a hazard
The above five factors are each mapped and together form a final vulnerability map.
The first map, consisting of a hazard analysis, contains inventories of natural hazards and demographics. A list and qualitative mapping of all natural hazards occurring in the area as well as the demographic aspects like socioeconomic factors of the community are considered.
The second map, consisting of an exposure analysis, contains the identification, inventory, and assessment of infrastructure, property, individuals etc. in a given area and both direct and indirect consequences in case of hazard occurrence. Social structure and infrastructure variables are analyzed which forms the basis for an exposure map which shows the probable area, extent of a single even, and social structure and infrastructure variables that may be affected. The important factors that concern exposure are susceptibility of building contents to damage, robustness of building fabric, key installations, public supply services, transportation systems, population distribution and density and land-use activity.
The third map, consisting of a preparedness analysis, contains the identification, inventory, and assessment of all precautionary activities and measures in a given area to be prepared best for natural disasters. This concerns the analysis of awareness, warning, evacuation, and disaster relief variables, and should lead to a preparedness map where precautionary preparedness activities and measures are portrayed. Indicators used for this map are: more than 50 percent of population has personal hazard experience; hazard information and education programs exist; and operative warning system is present; warning time is more than one day; warning includes specific advice; evacuation plans and routes established; disaster relief centers are available in the area.
The fourth map, consisting of prevention analysis, contains the identification, inventory, and assessment of all activities and measures in a given area to prevent hazards and their effects and provide permanent protection from their impact. For the creation of a prevention map, structural and non-structural measures are analyzed and portrayed.
The fifth map, a response analysis, contains the identification, inventory, and assessment of all response activities and measures in a given area to reduce social and economic damage and loses. Measures for the criteria of a response map are analysis of search, rescue, humanitarian assistance, recovery, and reconstruction structures. This map is emergency-oriented and shows existing disaster response structures.
The final map, a vulnerability analysis, is assessed through the existing condition of a given area and its ability to cope and withstand to specific natural hazard events and their impact. Measures are analysis of hazard characteristics, socioeconomic, exposure, preparedness, prevention and response variables. Vulnerability map, also called natural hazard map, shows the degree of ability to cope with and respond to specific natural hazard events. Vulnerability is determined through the overlay of the former maps.
Inside each uniform area a synthesis of values from the previous maps is given which gives an impression of the overall vulnerability of the unit. Since each of the five indices corresponds to a specific factor, the vulnerability map shows not only the degree of vulnerability of an area, but also the reasons for tat vulnerability. Consequently, if one desires to reduce the vulnerability of a particular area, the vulnerability map shows where changes could be introduced.
It is imperative that citizens receive a timely warning about impending hazards in order to ensure the best possible outcome. Therefore, the development of a warning system is one of the most important functions of emergency management. Warning systems tell populations when a hazard will occur, how long the hazard will last, what the possible impact will be, and what might be done about it. Information issued in a warning may include predicted wind strength, expected inches of rain, road closures, and specific steps to take to prepare. Warnings also facilitate the evacuation process and ensure that shelter locations are identified. Different types of warning systems include sirens, media, emergency alert systems, reverse 911, intercoms, teletype writers, telephone devices, strobe lights, loudspeakers, door-to-door notification, and weather radio (ICMA, 2003).
In any disaster, it is necessary that personnel, equipment, and supplies must be easily reached. Therefore, resource lists should be developed. Essential phone numbers, pager numbers, fax numbers, e-mail addresses, and physical addresses for key city officials, managers of city departments, utility companies, and the National Weather Service should be on hand. The location of physicians, hazardous materials response teams, protective gear, search dogs, generators, sand bags, wrecking services, laboratories, debris removal companies, and other essential companies should also be included. An equipment inventory list should also be developed, containing such things as fork lifts and trucks and should describe the operational status of this equipment (ICMA, 2003). The availability of these lists and their upkeep will help reduce morbidity and mortality during a disaster.
Although these lists are necessary, they will not always guarantee that the community has everything it needs to respond to disaster. It is possible that a planning committee might want to apply for grants in order to acquire funding in order to fund preparedness and build emergency management potentialities. It may also be necessary to develop mutual aid agreements such that access to specialized personnel and unique equipment might be available. These legally binding documents are entered into by two or more jurisdictions to provide aid to each other in event of disaster (ICMA, 2003).
Drills and training
First responders, emergency managers, and all others involved should hold regular training sessions or seek out training from state emergency management offices. Also, the disaster plan that has been developed should ideally be exercised once a year. This can be done one of three ways. First, tabletop exercises are the most basic exercises in which public officials discuss disasters using paper or computer-based scenarios to practice problem solving and identify problems that might occur. The second method uses field exercises to test a limited number of disaster functions to improve specific capabilities. The third type of exercise is a full-scale drill which is the most comprehensive of these methods ((ICMA, 2003 and Landesman, 2001). With each of these exercises, special attention should be payed to what might be changed to improve response.
Effectively educating the public is a key component to any disaster preparedness plan and has the ability to increase support for disaster policy and funding, prevent future events, and help citizens to respond to disaster in a safe manner. Topics covered may include causes and consequences of disaster, how to protect homes, evacuation and shelter, whom to contact for assistance, other self-preservation information, basic first aid, and importance of hazard insurance. This information can be communicated in a variety of ways including developing brochures, talking to children in schools, and enlisting the help of the mass media (ICMA, 2003). The use of the mass media to deliver warnings to the public and to educate about avoidance of health problems after disaster can be a very effective public health tool.
Issues in Planning for Response
The sharing of information is essential, but can be complicated due to the number of people involved and the amount of equipment required. During the impact and post-impact phases of a disaster, two-way radios may be the only reliable form of communication. Even if ground and cellular telephone systems are still in working order, they are likely to be overloaded. Using these radios for communication is difficult since no common frequency has been designated for these purposes. Several different bands have been assigned public safely frequencies by the Federal Communications Commission, making it difficult for agencies to communicate on a common frequency. Newer radios may be programmed to operate on different frequencies, but not on different bands. While radios that operate on different bands have been produced, they are the exception (Landesman, 2001).
The distribution of supplemental personnel, equipment, and supplies among multiple organizations, resource management, requires the determination of needs as well as the location of these resources. A staging area must be set up once a security perimeter has been established where a manager will oversee personnel. Responders and volunteers will be logged in, briefed on the situation, given an assignment, and provided with a means of communication and hardware to link them to the broader response effort (Landesman, 2001).
Warning and Evacuation
Evacuation from areas of danger can be the most effective strategy for saving lives in a disaster situation when advance warnings are possible. This task demands definitive communication among many agencies such as the US Weather Bureau, the sheriff’s office, and radio stations. Threats must be detected and analyzed to determine the specific areas at risk and the nature of the risk. Warnings must be given in such a way that those at risk will heed the notice and take appropriate measures. Factors that improve the effectiveness of a warning include the credibility of the source of the warning, the number of warnings, the uniformity of message content across varying informants, the context of the warning, the inclusion of information that allows recipients to assess whether or not they are directly in danger, and specific information on actions that can be taken for self-protection (Landesman, 2001).
Search and Rescue
In many disasters, casualties are initially treated in the field which influences their entry into the health care system. Most immediate search and rescue is initiated by untrained bystanders in the area and disaster response may occur across jurisdictional boundaries or involve emergency responders from many agencies. These characteristics can create organizational problems (Landesman, 2001).
Triage is the method of assigning priorities for treatment and transport for injured citizens. It is important to consider the possibility of untrained personnel and bystanders who are often the first to respond and are unaware of established field triage and first aid stations. As a result, these constructs may be bypassed by those concerned with transporting victims to the nearest hospital (Landesman 2001). This must be considered in a successful plan.
The establishment of protocols for distribution of casualties between emergency medical services and area hospitals will allow for the even distribution of casualties. This element of the plan will help prevent the closest hospitals from being inundated with patients while the resources of other hospitals are never utilized. It will also help control transport decisions made by untrained volunteers (Landesman 2001).
Patient tracking can be very complicated during times of disaster. Most people evacuated from their homes are never registered by the American Red Cross, since they do not go to public shelters. Since no single agency receives information about the location of victims from hospitals, morgues, shelters, jails, or other locations, tracking is further perplexed. Hospital records are often incomplete since most victims arrive without the use of an ambulance. Finally, it is possible that hospitals themselves might be damaged and evacuation might further complicate the issue of tracking where patients are located.
Patient Care with Damaged Health Care Infrastructure
Hospitals, urgent care centers, home health care agencies, pharmacies, and dialysis centers must take appropriate measures to make sure that their facilities will not be damaged or disabled during a disaster and that backup arrangements are in place for patient care. This includes backup supplies of power and water, secure building structures, maintaining essential equipment, surge protection and data backup, and plans for alternative sites (Landesman, 2001).
Management of Volunteers and Donations
Often, more resources than are expected, or even needed, arrive at the site of a disaster. Large numbers of donations and unsolicited volunteers should be expected. Also, a plan for channeling public requests for aid to a locality outside the disaster area where resources can be collected, organized, and distributed without disrupting emergency operations (Landesman, 2001).
Regardless of the level of preparedness planning that takes place, disasters will likely require some unanticipated tasks such as the organized improvisation in response to disruption of shelter, utilities, communication systems, and transportation. Public health officials must therefore develop the capacity, procedures and training to deal with unexpected problems that might arise (Landesman 2001).
The Threat of Bioterrorism
In recent years there has been a growing concern in the public health community over the possibility of biological acts of terrorism. This type of disaster creates a unique challenge in detection, preparation, and response (Garrett, 2001). Absent of an explosion, there will be no immediate evidence of an attack. Therefore, first responders will not be firefighters or police, but healthcare providers. First indication will likely be an outbreak of uncommon illness or incidence of symptoms. The effectiveness of medical and public health response and therefore the extent and severity of the impact on the community will be determined by the rate at which the outbreak is detected, analyzed, and understood. Therefore, enhanced disease surveillance systems are critical (Hamburg, 2001).
Epidemiological capacity to detect and investigate outbreaks and unusual trends in infectious disease will be necessary as well as laboratory capacity to quickly collect and analyze samples. Measures will also need to be taken to allow expedient communication of findings. The release of biological agents may also require rapid access to substantial quantities of pharmaceutical antidotes, antibiotics, and vaccinations (Hamburg, 2001). These considerations vary from the issues taken into account form most other potential public health disasters and increasingly require special consideration.
After a Disaster
The environment after a natural disaster can be unhealthy and unsafe. Hazards that can result in injury, illness or death include (CDC, 2003):
· Physical hazards (e.g. fire, displaced objects, unstable building structures, downed power lines, overexertion during cleanup and animals that may attack humans out of fear or because they are injured and in pain).
· Chemical hazards (e.g. gas leaks, carbon monoxide from generators, and chemicals released from industries and other sources into food, water or the environment).
· Disease hazards (e.g. food or water contaminated with sewage, an increase in mosquitoes that can spread disease and crowded living conditions).
· Psychological hazards (e.g. post-traumatic stress syndrome, anxiety, depression, fear, rage).
Several factors keep people from effectively protecting themselves after a disaster including lack of knowledge about what to do or not to do, or where to acquire health and safety information; ignoring health and safety information; psychological effects of the disaster that weaken clear judgment; disaster-related disturbance of communication channels that could be used to communicate health and safety information; and interruption of social, medical, and community services.
Future of Public Health and Disaster Preparedness
New information technologies are being used in public education and are increasingly being applied to emergency development and tutorial activities to improve emergency preparedness. These technologies will be applied to reveal how emergency planners can more efficiently accomplish their task to educate the larger community on an assortment of issues such as the need to adopt future mitigation strategies, to respond to disaster warnings and evacuation suggestions. Furthermore, they will be applied to establish how response and recovery information can be promptly circulated to an impacted area. Applications will also be made available which demonstrate the advantage of technology in enhancing training activities for emergency personnel as well as offering the prospect for such instruction beyond the time and place of the original trainer.
Selected Web sites at academic institutions (Fischer, 1998)
Disaster Research Center, University of Delaware
Institute of Emergency Administration and Planning, University of North Texas
Natural Hazards Center, University of Colorado, Boulder
Social Research Group, Millersville University of Penn.
Selected Web sites of government agencies and disaster organizations (Fischer, 1998)
American Red Cross
Centers for Disease Control
Federal Emergency Management Agency
International Federation of Red Cross and Red Crescent Societies
Japan’s national Research Institute for Earth Science and Disaster Prevention
National Institutes of Health
Pan American Health Organization
US Federal Emergency Management Agency
US Geological Survey
US National Weather Service
Volunteers in Technical Assistance
World Health Organization
The above organizations not only provide online assistance, but also preparedness and mitigation, response and recovery information. Furthermore, academic research centers, government agencies and disaster organizations provide a variety of information which is used to educate in several respects including:
· What academic institutions are engaged in disaster research
· What research topics are currently under consideration
· Who is engaged in such research
· What government agencies are involved in planning for and responding to disasters
· What information is currently available from such agencies
· What preparedness information is currently available
· What mitigation procedures and suggestions are recommended
· What constitutes an effective response check list
· Disaster agent specific information (e.g. hurricane damage and flood mitigation fact
· How to apply for FEMA assistance
· What disaster organizations exist and the services and information they provide
Our rethinking of disasters leads us towards a policy of long-term loss reduction, only if we accept that complete prevention is ultimately unachievable. This mitigation policy should have a risk task force that identifies problems, coordinates action with other task forces, and delivers data for the data center. They should use standard documents to develop statistical reports to enable consistent evaluation, assessments, and reactions should be developed and used. Periodic reviews of actions and accomplishments in vulnerability assessment should be undertaken; the task force should exchange information and knowledge between different governmental levels and social divisions. Furthermore, evaluation of all measures and feedback to the task forces is strongly suggested. Finally, concerning system and facilities, possible resources with respect to specified objectives, such as increasing preparedness or reducing exposure in a unit area, should be acknowledged and assessed.
Application and service in disaster settings: surveillance and rapid needs assessment http://www.cdc.gov/nceh/emergency/disasterepidemiology/description/surveillance.htm
Denis, H. Scientists and disaster management. Disaster Prevention and Management 1995;4:14-19.
Disaster Epidemiology. http://www.cdc.gov/nceh/emergency/disasterepidemiology/description/mission.htm
Fischer, H.W. The role of the new information technologies in emergency mitigation, planning,
response and recovery. Disaster Prevention and Management 1998;7:28-37.
Garrett, L.C., C. Magruder, and C.A. Molgard. 2001. Taking the terror out of bioterrorism:
planning for a bioterrorist event form a local perspective. Public Health Issues in Disaster Preparedness. Aspen Publishers, Inc. 57-63.
Global Health Activities Report Exec. Summary. http://www.cdc.gov/nceh/globalhealth/GHAR/exec_summ.htm
Hamburg, M.A. 2001. Bioterrorism: a challenge to public health and medicine. Public Health Issues in Disaster Preparedness. Aspen Publishers, Inc. 93-98.
Landesman, L.Y. 2001. Public health management of disasters. American Public Health
Landesman, L.Y., J. Malilay, R.A. Bissell, S.M. Becker, L. Roberts, and M.S. Ascher. 2001. Roles and responsibilities of public health in disaster preparedness and response. Public Health Issues in Disaster Preparedness. Aspen Publishers, Inc. 1-56.
Langan, J.C. and D.C. James. 2005. Preparing nurses for disaster management. Pearson Prentice Hall.
Larsson, G. and Enander, A. Preparing for disaster: public attitudes and actions. Disaster Prevention and Management 1997;6:11-21.
McEntire, D.A. Triggering agents, vulnerabilities and disaster reduction: towards a holistic paradigm. Disaster Prevention and Management 2001;10:189-196.
McEntire, D.A. and A. Meyers. 2003. Disaster preparedness. International City/County
Management Association. 35(11): 1-19.
Natural Disasters http://www.cdc.gov/communication/tips/disasters.htm
Noji, E.K. and Toole, M.J. The historical development of public health responses to disasters. Disasters 1997;21;366-376.
Notice to readers international decade for natural disaster reduction. http://www.cdc.gov/mmwr/preview/mmwrhtml/00030685.htm
Paton, D. and Johnston, D. Disasters and communities: vulnerability, resilience and preparedness. Disaster Prevention and Management 2001;10:270-277.
Paton, D., Smith, L. and Violanti, J. Disaster response: risk, vulnerability and resistance.
Disaster Prevention and Management 2000;9:173-179.
Schneid, T.D. and L. Collins. 2001. Disaster management and preparedness. Lewis Publishers.
Weichchselgartner, J. Disaster mitigation: the concept of vulnerability revisited. Disaster
Prevention and Management 2001;10:85-94.
World disasters report. 2002. International Federation of Red Cross and Red Crescent Societies.