The Health Sector in disaster and emergency management



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The Health Sector in Disaster Reduction and Emergency Management

Keynote address delivered at the session

Managing and Preparing for Disasters

of the

International Public Health Congress 'Health 21 in Action'

Istanbul, 8-12 October 2000

Dr Alessandro Loretti

Coordinator, Intelligence and Capacity Building

Department of Emergency and Humanitarian Action

World Health Organization-Geneva

A disaster is an occurrence disrupting the normal conditions of existence and causing a level of suffering that exceeds the capacity of adjustment of the affected community.

Disasters kill. 80,000 people only in 1999, to which Turkey contributed at least 18,000. And these figures refer only to immediate casualties: they don't speak of the victims of secondary effects. Taking a wider view, in 1999, disasters affected 213 Million people worldwide, with total economic losses estimated around 72 Billion US$ (IFRC, 2000)[1]. Directly or indirectly, health-related problems account for more than fifty percent of all humanitarian assistance costs arising from disasters of all types (WHO, 1997)

Disasters kill, but nobody dies "of a disaster". No matter how complex and confused that chain of events that lead to a disaster, epidemiology, e.g. proceeding backwards from the actual cause of each death involved, provides an ideal instrument to understand disasters and ultimately reduce their risk (Western, 1972)[2].

The same as diseases, disasters are not random occurrences but reflect the interaction of human beings with a given environment. General consensus is growing that there are no purely "natural" disasters: there are natural hazards, which impact upon human vulnerabilities that are mostly determined by human causes. Environmental pressures and social inequalities heighten vulnerability to natural disasters. Economic downturns and fast social changes can engender political hazards. Economic development can increase the threat of technological disasters. The interaction of social, natural and technological hazards can trigger off an emergency whenever a country lacks the capacity to cope.

If people are not involved, there is no disaster (WHO, 1987). An earthquake in the desert is no disaster, unless it damages human livelihoods or infrastructures. By definition, all disasters impact upon human systems and all action aimed at mitigating their impact must take these systems into account. The affected communities are always the first forced to cope with and respond to any disaster. Any external intervention aimed at reducing disasters must first of all integrate and support their efforts and coping and recovery systems.

Thinking about disasters and preparing for emergencies is simply good management. Are we fully informed about the environment where we are operating? Are our plans realistic? Are our procedures adequate? Are our structures and systems strong enough to withstand a crisis?

The Role of the Health Sector

Public Health professionals have precise responsibilities and opportunities in disaster prevention and emergency management.

First of all, preserving life and health is both the objective and the measure of success in disaster reduction. In an emergency, Health will always be called upon to collaborate (e.g. in search and rescue operations), or to lead (e.g. in the case of epidemics). The health workers have the most challenging and visible responsibilities in the response during disasters. Failure on their part is especially costly, not only in terms of lives lost, but also technically and politically.

Public Health professionals have comparative advantages in a) conceptualizing strategies, b) influencing national policies, and c) implementing activities for disaster reduction:

□ Health professionals are familiar with the concepts of risk, hazard and vulnerability that are the cornerstones of disaster prevention. We are familiar with the apparent dualities of Health versus Disease, and Prevention versus Cure. The principles ruling Disaster Reduction are the same that underpin the Public Health model and the philosophy of Primary Health Care

□ All disasters affect human life and health: figures of dead, injured, I.e. health information is essential for risks to be assessed and for emergencies to be recognised. Epidemiological surveillance is a type of early warning similar to those used by other disciplines involved in disaster reduction. Health data and advice influence most disaster-relevant policies: population, food security, safe water, habitat, and environment.

□ To a certain extent, being prepared for emergencies is part of any health-related training, at least in clinical terms. In a wider perspective, health professionals and health services have a presence in the field that is matched by few others, in terms of acceptance by the beneficiaries and, therefore, of capacity for implementation.

The Health Sector has also its own concrete interest in disaster reduction.

□ One disaster can offset years of Health development. Health facilities and services are precious assets, for a country - for Ministry of Health as well as for local authorities or private investors.

□ Too often, we see the Health sector penalised, either because emergency needs impose an unexpected overload upon its scarce resources, or because they force their diversion from the Sector.

Public Health contributes to each phase of disaster reduction:

□ In terms of prevention and mitigation, many hazards and vulnerabilities are reduced by preventive care e.g. by immunizations, by vector control, family planning, environmental sanitation, food safety, etc. We have seen above how health data and advice are essential for most inter-sectoral policies. Hospitals must be hazard-resistant, lest they collapse when they are most needed.

□ Health contributes to preparedness by contingency plans and referral systems, to be activated in case of disaster. Health and nutritional information contribute to early warning systems for all sectors and institutions.

□ When it comes to response, whatever the specific needs, three are the strategic objectives, and they are the same in clinical practice, public health and inter-sectoral emergency management:

- to reduce suffering

- to contain the spread of the disaster (e.g. to contain an epidemic, or the displacement of population)

- to facilitate rehabilitation.

By reducing suffering and death, in fact, Health ensures the cost-effectiveness of all other efforts.

The Role of WHO

As a UN Specialised agency, WHO must assist its constituents and counterparts - the Ministries of Health of its member countries. WHO's role in disaster reduction rests in its Constitution. It has been evolving through various resolutions of the Organization's Governing Bodies, international debate, the work of its technical departments and collaborating centres, and the first-hand experience of its regional and country offices, often directly exposed to emergencies, and always involved in their management.

The general lines of WHO's role in disaster prevention and emergency management stem from the Health sector's responsibilities, interest and opportunities as defined above. A starting point is represented by the absolute value of human life: hence, the mandatory involvement of WHO in humanitarian assistance, with the goal to limit excess death and suffering from the preventable causes that originate from the disaster, immediately and at medium term. WHO’s function in emergency is life saving and as such deserves to be acknowledged.

Then there is the mandate: the Organization must bring the Health sector to appreciate its role in disaster reduction and emergency management and to play it in full. At the same time, the public and the other sectors must be made fully aware of, and be responsive to the needs and capabilities of Health in this respect.

Finally there is the fact that all societies and countries are susceptible to disasters, but by the very nature of WHO, those countries with which the Organization has a closer dialogue are also those that are more vulnerable. Therefore, disaster reduction must be a key objective of WHO's technical cooperation with member countries. In Dr Brundtland's words, "WHO’s ultimate goal is to increase the self-reliance of its member countries... WHO wants them to be more resilient during a crisis, capable to absorb humanitarian assistance without being overwhelmed by it and then, once the crisis is over to move towards a recovery that takes full advantage of the lessons learnt."[3]

WHO's view on disasters in that a) they are preventable, that b) they stem from failed development and/or failed emergency management, and that c) the primary responsibility for disaster reduction and emergency management is with the affected communities, or countries. In extra-ordinary circumstances, this responsibility may be temporarily assumed by the international community. To quote again Dr Brundtland: “at an international level, there is a need to improve the collective capacity for humanitarian assistance and response.... when national health systems cannot cope…"[4]

Therefore, WHO has to assist member countries and all international health partners in order for them to integrate disaster reduction in their development plans; and have the capacity to manage effectively emergencies, with a maximum of self-reliance. Capacity, in this context, summarizes four major elements

a) information on the problem to be tackled,

b) authority to act,

c) plans, resources, and procedures for their application,

d) partnerships.

Thus, in order to strengthen national, regional and international capacities, WHO identifies five operational objectives:

• To promote legislation and strategies

• To promote plans and procedures for coordinated action

• To strengthen human and institutional resources

• To promote programmes for public education, awareness and participation

• To promote the collection, analysis and dissemination of information.

Building capacities for disaster reduction requires long processes, institutional stability and capital investment. It is a difficult activity that must be sustained in spite of competing priorities on the basis of simple forethought: "What if?

There is no quick-fix technology for disaster reduction, which is essentially a process of investment in people and institutions. Financial and political investments are essential for a programme to have enough continuity to induce positive changes. The experience of WHO, in the Americas and, although to a lesser extent, in other regions is that disaster reduction needs to be seen as a core function of the Ministry of Health that should establish a programme or department with specific responsibility for the health aspects of disaster reduction. This programme must coordinate with the national institution responsible for overall disaster management - be it the Prime Minister Office, the National Prevention and Relief Agency, the Civil Protection or other and other relevant actors in the public and private sectors[5] in order to gain the necessary credibility vis-à-vis the public, and among the other national institutions.

We opened by saying that the distinction between natural and human-induced disasters is somehow artificial. To fuel the debate, we can quote "Disasters reflect the ways societies structure themselves and allocate their resources " (Kent, 1997). In this sense, all disasters have political causes: either by commission or by omission; this applies to the local level as well as to the national and the international levels and the role of the Health sector in this context is paramount. If Public Health refers to "..the efforts organized by society to protect, promote and restore the people's health" (Last 1983)[6], disaster reduction is public health.

Comparing the Natural History of Disease * with the Disaster-Development Continuum

Health action in disasters: different scenarios

|Type of Disaster |Epidemic Environmental pollution |Storm, Earthquake, Volcanic eruption, Floods, Landslide, Tsunami,|Drought, Insect infestation/Pest War and Civil strife, |

| | |Fire, Explosion, Collision, Collapse of building |Economic crisis |

|Impact upon Public Health |Immediate increased risk of death, illness and disability |Immediate increased risk of death, illness and disability by |Displacement of population, loss of shelter, decrease/loss of |

| |by a specific agent |physical causes |access to food, water and services |

| | |Possibility of environmental pollution |Immediate increased risk of violent death. |

| |Risk of infection/contamination for Health personnel |Loss of lifeline systems: water, shelter, etc. | |

| | |Displacement/relocation of people may occur; in which case the |Medium-term increased risk of nutritional disorders and |

| |Overload upon Health facilities and routine |same scenario as for war and drought applies. |infectious diseases |

| |services/programmes | | |

| | |Damage to/loss of Health facilities and routine services |Damage to/loss of Health facilities and routine services |

|Health priorities for |Confirm the problem- Identify the cause, Assist the sick, |1. On-the spot assistance to victims: |Immediate and medium-term Health Care |

|Response |Prevent the spread of the problem |Triage of casualties - Search and rescue |1.Make sure that vital needs are satisfied:, food, water, |

| |Protect Health Personnel and facilities |Medical evacuation |security, shelter, sanitation, blankets, clothes, pots, |

|(following rapid need | |Hospital emergency care |buckets, fuel, soap (through inter-sectoral coordination) |

|assessment) |Monitor cases and deaths, documents the problem for future| |2. Immunization, Vitamin-A, Basic curative care (diarrhoeas & |

| |action |2. Activation of back-up systems as needed |respiratory infections) |

| | | |(through Health outreach services) |

| | |3. Health care for homeless/displaced: food, water, security, |Assess and monitor nutritional status, diseases and deaths |

| | |etc, and Health services | |

|Elements of Recovery and |Health education and community awareness; study the |Training of local H. workers, community involvement, support to |Training of local H. workers, community involvement, support |

|Rehabilitation |lessons learnt |local initiatives; lessons learnt; readjusting plans and |to local initiatives |

| | |programmes |Readjusting plans and programmes |

|Elements of Prevention & |Environmental sanitation, Immunization, Diseases & Vector |Health action for population & habitat policies |Health action for food security policies, community |

|Mitigation |control. Awareness & Training |Structural measures for hospitals, etc., |participation and conflict resolution |

| |Laws & Programmes for chemical safety PHC and Global |Inter-sectoral arrangements in place |Inter-sectoral arrangements in place |

| |Health Development |PHC and Global Health Development |PHC and Global Health Development |

|Elements of Preparedness |Epidemiological surveillance |Community awareness, First-aid & chain of medical relief, |Information systems, Decentralized H. management, stockpiles, |

| |Contingency plans, training, stockpiles etc., |Information systems, Ambulances Hospital preparedness plans, |Contingency plans, Training Emergency logistics & procedures |

| |Reference Centres, experts, documentation etc., |Back-up systems Inter-sectoral arrangements tested |Inter-sectoral arrangements tested |

| |Contingency plans tested & updated | | |

EPR-Hre/w.p./8.4.94

Essentials of Contingency Planning and Preparedness Planning for the Health Sector

|Type of Emergency |Primary Hazard |Primary Causes of Death |Main responsibility of the Health |Risk to Health |Capacities needed |

| | |& Illness |Sector |Network | |

| | | | | |Technical |Support |

|Epidemics of |Known Disease |Agent-specific |Alert and Assessment |+ |Epidemiology & DC |Communications, Laboratory, Facilities & |

|Infectious Origin | | |Case Management | |Medical/Nursing care |Supplies |

| | | |Outbreak Control | |Environmental Health |Inter-sectoral collaboration Funds |

| |New Emerging |Agent-specific |Alert & Assessment |+++ |As above, plus field research, crash |As above, plus access to more sophisticated |

| |Diseases | |IDENTIFICATION OF AGENT | |training of personnel, new, specific |Reference Centres, greater capacity for |

| | | |Case Management | |health education possibly Cordon |Isolation, special drugs or vaccines |

| | | |Outbreak Control | |Sanitaire | |

|Emergencies by Other |Mass Food |Agent-specific |Assessment |- |Epidemiology |Communications, Laboratory |

|Natural causes |Poisoning by | |Identification of Cause | |Medical/Nursing care |Facilities & Supplies |

| |Natural Causes | |Case Management | |Education |Inter-sectoral collaboration |

| | | |Information and education | | | |

| |Drought |Diarrhoea, Malnutrition,|Need assessment |+ |Epidemiology |Communications. Logistics & Funds for |

| | |Any other cause, by |Disease Control | |Disease control |Outreach. Supplies Inter-sectoral |

| | |decreased access to |Nutritional Surveillance | |Nutrition |collaboration and coordination of relief |

| | |Health services and |Therap./Supplem.feeding | | | |

| | |higher vulnerability | | | | |

| |Floods |Drowning, Trauma, |Search & Rescue/triage |+ |Mass casualty Management |Special Training for staff and volunteers |

| | |Diarrhoea, ARI, |Need assessment | |Env. Health/Vector Control |Inter-sectoral collaboration and coordination |

| | |vector-borne diseases |Disease control | |Health care in temporary shelters |of relief |

| | | |Assistance in temporary shelters | | | |

| |Cyclone |Trauma, Drowning, |Same as above |++ |Same as above |Same as above |

| | |Diarrhoea, ARI, | | | | |

| | |Vector-borne diseases | | | | |

|Emergencies by Other |Tidal surge & |Drowning, Trauma, |Same as above |+ |Same as above |Same as above |

|Natural causes |Tsunami |Diarrhoea, ARI, | | | | |

| | |vector-borne diseases | | | | |

| |Earthquake |Trauma, suffocation, |Search & Rescue/triage |+++ |Mass Casualty Management |Intensive care facilities |

| | |Burns |Need assessment | | |Hospital vulnerability |

| | | |Casualty Management | |Health Care in Temporary shelters |Assessment and reduction |

| | | |Assistance in temporary shelters | | | |

| |Landslide |Trauma, Suffocation |Same as above |+ |Same as above |Same as above |

| |Volcanic eruption |Trauma, suffocation, |Need assessment |+ |Mass Casualty Management |Intensive Respiratory Care Unit |

| | |burns, Acute Respiratory|Casualty management | | | |

| | |distress |Assistance in temporary shelters | |Health Care in Temporary shelters | |

| |Bush Fire |Burns, Trauma, |Same as above |- |Same as above |Burn care facilities |

| | |suffocation | | | | |

|Emergencies from |Transport Incident|Trauma, Drowning, Burns,|Search & Rescue/Triage |+ |Mass Casualty Management |Intensive care facilities |

|Technological Causes |(road, railways, |suffocation |Casualty Management | | | |

| |air, sea etc.) | | | | | |

| |Fire in Human |Burns, Trauma, |Search & Rescue/Triage |+++ |Mass Casualty Management |Burn care facilities |

| |Settlement |suffocation |Casualty Management | |Intensive care unit |Hospital vulnerability assessment and |

| | | | | | |reduction |

| |Industrial |Blast, Trauma, Burns, |Search & Rescue/Triage |+ |Mass Casualty Management |Intensive care facilities |

| |explosion, fire, |Acute respiratory |Casualty Management | |Specific Medical/Nursing care |Hospital vulnerability assessment and |

| |spill, radiation |distress, suffocation, | | | |reduction |

| | |Agent-specific | | | | |

|Emergencies from |Collapse of |Trauma, suffocation, |Search & Rescue/Triage |+++ |Mass Casualty Management |Intensive care facilities |

|Technological causes |man-made structure|drowning, other |Casualty Management | | |Hospital vulnerability assessment and |

| | |according to type of |Assistance in temporary shelters | | |reduction |

| | |structure | | | | |

| |Failure of |Any cause, by lack of |Prompt back-up |+++ |Mass Casualty Management |Hospital vulnerability assessment and |

| |lifeline systems |critical support care |Casualty Management | | |reduction |

| | |Trauma by crowd panic | | | |Back-up systems |

| |Mass Food |Agent-specific |Alert and assessment |+ |Epidemiology |Toxicology |

| |poisoning by Human| |Identification of Agent | |Specific Medical/Nursing care |Special Decontamination facilities |

| |causes | |Case Management | |Environmental health |Access to special Reference Centres |

|Complex Emergencies |Armed Conflict |Trauma, malnutrition, |Need assessment and Advocacy |+++ |Epidemiology & Disease Control |Special Agreements & Procedures |

| | |ARI, Diarrhoea, Measles,|Disease Control | |Nutrition |War Surgery facilities/capacities |

| | |Meningitis, Vector-borne|Nut. Surveillance & Select. Feeding | |War Surgery |Safe Transfusion facilities |

| | |diseases |Injury Management | |Health Care in temporary shelters |Coordination of International Aid |

| |Mass Labour Unrest|Trauma, any cause by |Mass Casualty Management |+ |Mass Casualty Management |Special Agreements & procedures |

| | |lack of critical support| | | | |

| | |care | | | | |

| |Terrorist Attack |Blast, trauma, Fire, |Mass Casualty Management |- |Mass Casualty Management |Intensive care facilities |

| | |suffocation, Ac. | | | | |

| | |Resp.Distress, other | | | | |

| | |specific (eg. Toxic gas)| | | | |

| |Refugee/ Displaced|Diarrhoea, ARI, |Disease Control |- |Epidemiology & Disease Control |Recruitment of volunteers |

| |Influx |Malnutrition, Measles, |Nut. Surveillance & Select. Feeding | |Nutrition |Outreach and supervision |

| | |Meningitis, vector borne|Assistance in Camps/Transit points | |Health Care in temporary shelters |Coordination |

| | |diseases | | | | |

|Major Public Functions|State Visit |Any: illness of state |Back-up for possible special, |- |Medical/Nursing care |Intensive care facilities |

| | |guests |high-profile medical emergency | | | |

| | |Illness among spectators|Readiness for crowd incidents | | | |

| | |Crowd incidents | | | | |

| | |(stampede etc.) | | | | |

| |Pilgrimage |Epidemic diseases |Disease Control |- |Epidemiology & Disease control |Intensive Care facilities |

| | |Illness among spectators|Readiness for crowd incidents | |Environmental Health |Temporary outreach facilities |

| | |Crowd incidents |Back-up for increased demand | |Mass Casualty Management | |

| | |(stampede etc.) | | | | |

| |Mass Entertainment|Illness among spectators|Back-up for increased demand |- |Mass Casualty Management |Intensive Care facilities |

| | |Crowd incidents |Readiness for crowd incidents | | | |

| | |(stampede etc.) | | | | |

EHA-Add.05.98

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[1] International Federation of Red Cross and Red Crescent Societies. World Disasters Report, 2000

[2] Western. K.A- The Epidemiology of Natural and Man-made Disasters-The Present State of the Art

dissertation thesis, LSHTM/DTPH, 1972

[3] Key note address: Consultation on Planning Ahead for the Health Impact of Complex Emergencies, WHO-Geneva, 13-14 December 1999

[4] "Looking Ahead for WHO - After a Year of Change", WHA 52, Geneva May 1999

[5] Emergency and Humanitarian Action Disasters, Emergencies and WHO, Paper presented at the second meeting of WHO GMPG, March 2000-Geneva

[6] A Dictionary of Epidemiology-Edited by J.M.-Last, IEA, 1983

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The length of the latency will be a function of preparedness and readiness

Recovery and resumption of development

deaths extinction disintegration disappearance of the community

Political awareness

Level of suffering

IMPACT

Environment

Hazards

Population

IMMEDIATE DISTANT

EMERGENCY

LATENCY

DISTANT IMMEDIATE

POST-DISASTER

DISASTER

PRE-DISASTER

PATHOGENIC PERIOD

PRE-PATHOGENIC PERIOD

RECONSTRUC

TION

H E A L T H C A R E

TERTIARY

PREVENTION

SECONDARY

PREVENTION

(Health promotion and)

PRIMARY PREVENTION

D I S A S T E R REDUCTION

RESPONSE & RECOVERY

PREVENTION & MITIGATION

EMERGENCY MANAGEMENT

RECOVERY

RESPONSE

PREPAREDNESS

PREVENTION

REHABILITA

TION

RELIEF

READINESS

ALERT

VULNERABILITY REDUCTION

EHA-Add/12.94

From Leavell & Clark, 1962

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