While the treachery of Hurricane Sandy still lingers, the destruction and devastation inflicted by the superstorm serves as a poignant reminder of Mother Nature’s divine powers. Through the harsh lessons of past natural disasters and emergency situations, modern disaster management has evolved. In time, we have learned that preparedness and mitigation yield the best possible outcomes.
THE FOUR PHASES OF DISASTER MANAGEMENT
The four-phased approach of disaster management includes mitigation, preparedness, response, and recovery. These require the collaborative participation of the following individuals/organizations: local first responders, the governments of the affected countries and additional countries, international organizations and financial institutions, regional organizations and associations, non-profit organizations, private organizations, and local and regional donors (Butcher, 2011). With the increased prevalence of disasters occurring all throughout the world, we have witnessed a paradigm shift that aggrandizes the importance of preparedness and evidence-based mitigation prior to response and recovery. The UN, international disaster management organizations, agencies, and interest groups now place an increased emphasis on prevention, especially in developing countries (Butcher, 2011).
The history of complex humanitarian agencies repeatedly teaches us that prudent disaster preparedness and mitigation strategies ensure the best possible outcomes. The management of complex humanitarian emergencies is most efficacious when it has been preceded by a comprehensive physical risk assessment. This contributes to the identification of elevated risks as well as the particular country or geographic area’s vulnerabilities to hazards. This information can also be used to implement a plan for the procurement, organization, management, and coordination of all necessary personnel and relevant stakeholders. This will ultimately ensure that the efforts of emergency management personnel, organizations, and citizens provide opportunities for the adequate preparation and mitigation of all forms of complex humanitarian emergencies and natural and man-made disasters.
Due to a compromised authority, the presence of civil conflict, the fragmentation of the economic system and the decline in food security, emergency preparedness and risk protection is essential for the maintenance of critical economic assets and community resources during a complex humanitarian emergency. Mitigation practices can be achieved through the assistance of national and international response communities to minimize adverse effects of the disaster and limit further loss of human life. Effective mitigation strategies can be as simple as boarding up the windows of vulnerable infrastructures, placing sandbags around critical areas to prevent flooding, and maintaining water storage tanks in anticipation of possible water shortages. By using effective management strategies for the preparedness, mitigation, response, and recovery of complex humanitarian emergencies, risks can be eliminated or reduced over the long term.
Even superior planning, preparedness, and mitigation programs cannot prevent all disasters from occurring. Response actions must therefore be put into place “prior to, during, and immediately after the hazard event occurs” (Butcher, 2011). The treatment of hazards requires immediate action in the form of search and rescue, first aide, and evacuation. Provisions for the procurement of food, water, and reliable infrastructure are necessary in addition to health and medical aide, disease surveillance, sanitation infrastructure, and security of humanitarian personnel and victims. Critical infrastructure resumption, emergency social services, and donations management are essential components for long-term disaster management (Butcher, 2011).
Lasting up to a year, recovery is also a long-term process as it contributes to the rehabilitation and repair of the physical and mental health of victims, necessary infrastructure, and social and economic systems (Butcher, 2011). The complexity and urgency of recovery requires the skills of a variety of emergency management professionals and the application of extensive resources and equipment. This serves as justification for increased global attention and required collaboration among individuals and families, communities, and even countries to recover lost assets and plan for the future.
In the early phases of a disaster, assessment activities provide the authorities the critical information to set disaster response and recovery objectives and policies for emergency assistance. Emergency and humanitarian responders must be cognizant of the magnitude of the disaster, the location(s) impacted, and any disparities between the amount of resources required and those available. Data collection by the authorities must therefore commence as soon as hazard risks are realized to enhance the capabilities for response and recovery, to minimize the disaster’s growth in intensity, and to reduce the overall number of lives lost, injuries sustained, property damage and loss, and environmental degradation (Butcher, 2011). Accurate assessment information assists policy-makers who are tasked with prioritizing population needs and determining the most beneficial uses of existing resources. Assessments monitor the progress of recovery, identifying crucial areas in need of more advanced analysis and further intervention.
Rapid land assessments should be completed as soon as possible by qualified experts working in collaboration with the IASC Country Team under the coordination of the UN Humanitarian Coordinator or Resident Coordinator so as to secure humanitarian funding and UN flash appeals, which require formulation “within five to seven days of declaration of an emergency disaster” (UN-HABITAT , 2010). Led by the relevant government agency or department, land needs assessments utilize quantitative and qualitative data collection techniques to determine needs related to safe and secure access to land for shelter and livelihoods, particularly for the displaced populace (UN-HABITAT, 2010). This information is critical to early recovery planning and mobilization of available resources.
A damage and loss assessment is necessary to estimate the total loss of life and the extent of physical damages to land, infrastructure, personal property, and important documents. Data obtained through ministry assessments, relief and recovery agencies on the ground, satellite imagery, aerial photography, and pre-disaster surveys can help formulate a cost projection for the relief and recovery projects required (UN-HABITAT, 2010). Surveys for land availability facilitate the identification of suitable locations for emergency shelter and medical aide along with the amount of corresponding staff, medical supplies, equipment, and security needed to support relief operations. According to the International Federation of Red Cross and Red Crescent Societies (2000), on-site visual inspections combined with interviews can help obtain factual information that can be cross-checked with other sources and minimize potential for bias. Continuous assessments are critical for determining the changing needs of victims and providing guidance to the affected country’s government, UN humanitarian agencies, NGOs, and other humanitarian organizations delivering assistance.
The honest communication of risk is critical to the public’s welfare as the delivery of information is essential for making informed decisions following the initial impact of a natural disaster. A symbiotic relationship must exist between the public, policymakers, and the media that accommodates a timely and accurate risk assessment, the release of pertinent information, ongoing disaster surveillance, and trust. “Citizens have a right to know the worst-case scenario and to participate in their own protection” (Butcher, 2011). A satisfactory level of awareness and comprehension will promote a sense of trust between the public and authorities to minimize violence, injury, and death and promote collaboration and cooperation between victims and governmental and humanitarian agencies.
STRATEGIES TO MEET THE MEDICAL NEEDS OF DISPLACED POPULATIONS
Populations that are displaced following a catastrophic disaster or complex emergency have a broad range of medical and public health needs including, but not limited to, access to the following: medical care for the treatment of acute and chronic conditions, shelter, security, hygiene facilities, safe food and drinking water, and psychological care. The victims of Hurricane Katrina faced “unprecedented death, injury, destruction, and population displacement” following “the deadliest U.S. hurricane since 1928 and likely the costliest natural disaster on record in the United States” (CDC, n.d.). The excessive rainfall, mass flooding, and extreme winds caused by Hurricane Katrina heavily exposed its victims to traumatic injury and infectious disease, the two leading causes of death due to a disaster (Reilly, 2008). Traumas attributed to automobile crashes, drowning, and carbon monoxide poisoning were worsened by the loss of access to healthcare (Lister, 2005). Flooding compromised the quality of the water supply and the integrity of sewage disposal, increasing susceptibility for waterborne illness, while power line damage and power outages increased the risk for foodborne illness and electrocution (Lister, 2005). Conditions for dehydration and heat stress were exacerbated by poor ventilation and lack of access to a potable water supply (Lister, 2005).
An effective prophylactic strategy for controlling the spread of infectious disease following a disaster is the administration of vaccinations to victims and emergency responders. In the aftermath of Hurricane Katrina, the CDC facilitated the immunization of evacuees, emergency responders, and relief workers to reduce risks of tetanus from wounds and contraction of influenza, measles, chickenpox, and hepatitis A due to crowded conditions where some children may not have had current immunizations (Lister, 2005). Due to the severity of illness associated with Vibrio infections, the CDC alerted health officials and other authorities to cases of Vibrioinfection amongst Hurricane Katrina victims (Lister, 2005). The threat of infectious disease necessitated diarrheal illness surveillance to enable epidemiologic assessments for determining incidence rates and identifying potential epidemic levels of disease.
The treatment of acute and chronic conditions for displaced populations can be hampered due to a lack of access to healthcare facilities, the absence of medical records, displaced clinicians, and language barriers. The aftermath of disasters can be characterized by the manifestation or exacerbation of symptoms of chronic illnesses and pre-existing conditions which are more prevalent in lower socioeconomic populations where access to healthcare is less common (Reilly, 2008). Hurricane Katrina victims were in need of dialysis treatments, oxygen, and medication to treat asthma, hypertension, diabetes, COPD and other chronic diseases (Reilly, 2008). The death of loved ones, the destruction and loss of homes and property, forced evacuation, separation from family, migration to unfamiliar places, and incidents of violence also necessitated short and long term psychological care.
A strategy for the reinforcement of medical response teams to conduct triage can facilitate the prioritization of medical care delivery. The shelter at the George R. Brown Convention Center in Houston, TX was staffed with doctors, nurses, ER Physicians, critical care specialists, and paramedics from the nearby University of Texas Health Sciences Center who delivered care to Hurricane Katrina victims based on their acuity (Reilly, 2008). To supplement staff needs, the Texas State Department of health issued temporary licenses by reciprocity to out of state clinicians (Reilly, 2008). This helped minimize the shortage of medical providers at the San Antonio shelter and other temporary facilities areas that provided medical care.
RESPONDING TO INTERNATIONAL DISASTERS
Launched in 1997, the SPHERE Project was developed to establish global minimum standards for serving the rights of disaster-affected people and to improve the effectiveness and accountability of humanitarian response. A revolutionary initiative, the SPHERE Project is a collaborative effort by which humanitarian NGOs, the Red Cross, and the Crescent movement framed the Humanitarian Charter which defines the rights that individuals have in disaster situations. Based on “the principles and provisions of international humanitarian law, international human rights law, refugee law and the Code of Conduct for the International Red Cross and Red Crescent Movement and Non-Governmental Organizations in Disaster Relief,”the Charter reaffirms the primary responsibility for states and governments to safeguard and assist their constituents in accordance with international legal obligations (SPHERE, 2004). It also reasserts the right of disaster-affected populations to life with dignity, identifies the distinction between combatants and noncombatants, and honors the principles of non-refoulment (SPHERE, 1999). Authorities are also strongly encouraged to allow for the protection and assistance of humanitarian organizations in the event that they are unwilling and/or unable to fulfill their responsibilities (SPHERE, 2004).
The SPHERE project established Minimum Standards and key indicators in six areas including water supply and sanitation, nutrition, food aid, food security, shelter, and health services. The Minimum Standards serve as benchmarks for intervention planning while key indicators determine whether the standard has been met. Most of the standards and the key indicators are ever-evolving as they are the work of over 400 organizations in 80 countries all around the world (SPHERE, 2004). Their continuous refinement is a constant focus that requires the commitment and contributions of governments, NGOs, humanitarian agencies and the disaster response community worldwide.
The World Health Organization (WHO) is a specialized public health agency and a core member of the UN Disaster Management Team (UNDMT). In the occurrence of an international emergency, the WHO, along with other agencies within the UN system, are called upon to provide urgent technical assistance, advice, support, and materials to assist disaster-affected countries and respond to the medical health needs of victims (Ockwell, 2003). The WHO is a member of the Inter-Agency Standing Committee (IASC) and works in cooperation with the UN Resident Coordinator (UNRC), the Office for the Coordination of Humanitarian Affairs (OCHA), governments, local authorities, and other humanitarian organizations to plan, implement, and monitor emergency, rehabilitation, and recovery programs (Ockwell, 2003). The WHO also provides financial support to facilitate the delivery of aide to victims of man-made and natural disasters.
The WHO is a proponent for the safety, protection, and respect of health personnel, infrastructure, and noncombatants (Ockwell, 2003). The organization is responsible for the implementation of effective treatment and rehabilitation programs for victims of violence along with the systematic management of delayed health effects of mental and physical injuries (Ockwell, 2003). The WHO may also provide essential supplies, equipment, training, services, and logistic-related support to address serious and immediate threats to public health in the absence of adequate assistance (Ockwell, 2003). The WHO may also conduct joint inter-agency needs-assessment missions, organized in consultation with the government, and issue consolidated appeals in the name of the UN Secretary-General (Ockwell, 2003).
PUBLIC HEALTH CHALLENGES POSED BY TERRORISM
The broad spectrum of terrorist activities necessitates the application of a variety of public health disciplines. The utilization of explosives, incendiaries, small arms and forms of chemical, biological, and radiological weapons on a population requires trenchant preparedness and response strategies at the local, state and federal levels. Accordingly, the global impacts of terrorism have catalyzed training efforts by the military and civilian sectors as well as the establishment of effective medical countermeasures for the potential use of bacteria, viruses, and toxins as biological weapons. In consideration of the multitude of offensive biological weapons programs by at least twenty-five nations around the world, the threat for global biological warfare is serious and the possibility for devastating casualties remains high (Calhoun, 1996).
Due to the ever-evolving mechanisms for biological, chemical, and radiologic acts of terrorism, the continuous development and appropriate application of medical countermeasures are required to minimize casualties and the overall public health impact. Preparedness strategies are essential to protect the integrity and efficiency of local and perhaps national public health infrastructure and the food and water supplies. Large-scale attacks involving the variola virus (smallpox), aerosolized anthrax spores, a nerve gas, or food borne biological or chemical agent could task local emergency medical services and hospitals with an unprecedented deluge of patients, both infected and “worried well,” seeking immediate medical attention. The critical need for emergency transportation vehicles, medical supplies, diagnostic tests, hospital beds, health care providers, and public health personnel could overwhelm the public health system and corresponding infrastructure.
The covert, mass release of biological pathogens requires the knowledge and expertise of highly trained interdisciplinary scientists, medical providers, and laboratory personnel for the timely identification of the contagion(s), correct patient diagnoses, and prevention of the endemic proliferation of communicable disease. Acts of chemical terrorism have similar implications necessitating rapid classification of the hazardous substance(s) and coordinated efforts for rapid response. Since acts of terrorism have a propensity to illicit widespread panic far beyond the affected population, the expertise of a myriad of health care professionals is needed to conduct appropriate risk communication to the media and the public. The dissemination of reliable, accurate information can help distinguish a fallacious activity from an actual threat.
The use of explosives by terrorists also poses a litany of public health concerns. While conventional weapons like rocket-propelled grenades and assault rifles are frequently employed, the threat of suicide bombings, vehicle devices, improvised explosive devices (IEDs), TNT, and plastic explosives is considerably greater for the increased susceptibility for mass fatality and injuries. The destruction of critical transportation and public health infrastructure is also a major burden as it can prevent or delay the delivery of urgent care. Body fragmentation and DNA degradation also complicates the identification of deceased victims. The expertise of medical examiners, fingerprint specialists, radiologists, and forensic odontologists, anthropologists, and pathologists is accordingly required for timely identification and issuance of death certificates to enable the dissemination of benefits to surviving family members and provide the closure they need. Since the implications of a terrorist attack transcend far beyond the initial impact, acute and long term physical, psychological, and occupational rehabilitation is essential for restoring the health of surviving victims and ensuring a timely return to work and restoration of livelihood.
Butcher, Barbara. (2011). Powerpoint presentation slides chapters 1-7 available via Moodle from New York Medical College, Valhalla, New York. Retrieved from http://nymc.mrooms.org/course/view.php?id=272
Calhoun, Martin. (1996, December 1). Chemical and biological weapons. Foreign Policy in Focus. Retrieved from http://www.fpif.org/reports/chemical_and_biological_weapons
The Centers for Disease Control and Prevention. (n.d.) Hurricanes. Morbidity and Morality Weekly Report. Retrieved from http://www.cdc.gov/mmwr/mguide_nd.html
International Federation of Red Cross and Red Crescent Societies (IFRCRDS).Disaster emergency needs assessment. (2000). Retrieved from http://www.ifrc.org/Globa /Disemnas.pdf
Lister, S.A. (2005). Hurricane Katrina: The public health and medical response. U.S. Library of Congress: Congressional Research Service. Retrieved from http://fpc.state.gov/documents/organization/54255.pdf
Ockwell, Ron. (2003). WHO-WPR Emergency Response Manual: Guidelines for WHORepresentatives and Country Offices in the Western Pacific Region. Retrieved from http://www.wpro.who.int/internet/resources.ashx/EHA/docs/ERM.pdf
Reilly, Michael J. (2008) Migration and displacement of populations following a disaster or complex humanitarian emergency. (2008). Retrieved from http://nymc.mrooms.org/file.php/272/IDPs/player.html
United Nations Human Settlements Programme (UN-HABITAT). (2010). Land and natural disasters: Guidance for practitioners. Retrieved from http://www.disasterassessment.org/documents/Land_and_Natural_Disasters_Guidance4Practitioners.pdf