Synopsis
The impact of disasters on public health has received broader attention with increases in their occurrence and the number of people affected. The management of humanitarian assistance involves many more and different players, and disaster management is recognized as a significant priority of the public health system. Prevention, mitigation, and preparedness are part of the vocabulary of public health officials in national and international organizations. More importantly, these techniques are used to advance the cause of reducing mortality and morbidity from disasters. Although all disasters are unique, similarities exist among their health effects. Recognizing these common elements can ensure better management of limited resources.
Addressing these challenges, a second edition of the book, Public Health Consequences of Disasters, will be published later this year. Edited by Dr. Eric Noji, this book discusses aspects of public health and disaster response. A primer for humanitarian practitioners and policy makers, the book provides state-of-the art knowledge, best practices, and recommendations. A panel will highlight those chapters of particular relevance to USAID with an overall summary of the state-of-the-art advances in technologies on disasters.
Notes
Anne Ralte, PPC/P and the Global Health Bureau sponsored this year’s fourth USAID Summer Seminar, The Public Health Consequences of Disasters, presented by Eric Noji, M.D., M.P.H. Dr. Noji is a Senior Policy Advisor (Emergency Preparedness and Response) at the Centers for Disease Control and Prevention (CDC), Washington, D.C. He is an expert in disaster epidemiology and the author of the book, The Public Health Consequences of Disasters (Oxford University Press). The presentation summarized the development of disaster management and humanitarian assistance, focusing on epidemiological methods, accident prevention, and disaster mitigation. Dr. Noji provided case studies on natural disasters and technological accidents, and emerging public health challenges to show the evolution of disaster epidemiology.
Disaster epidemiologists have traditionally placed emphasis on assistance following natural disasters like famines and earthquakes. A significant moment in the development of disaster epidemiology was the 1960s Biafra famine, which was the first example of the CDC applying epidemiological methods to a humanitarian emergency. A fifty-person CDC team had been operating in Nigeria as part of a small-pox eradication program and following severe food shortages in the Biafra region, the team was mobilized for famine relief work. The CDC officers had to rapidly adapt many of their small-pox assessment techniques like sampling methods to the emergency famine assistance effort.
The 1976 Guatemalan Earthquake that killed 22,000 people and displaced one million persons was another significant moment in the evolution of disaster management. Epidemiological professors returned to the affected site months and years later to investigate the long term health effects of the earthquake. Information collected from the earthquake and other natural disasters produced greater interdisciplinary cooperation between health and other sectors to help prevent and mitigate the effects of future disasters. Dr. Noji noted that “disturbingly” many of the lessons learned from disaster response efforts from the 1970s and 1980s were not applied this year immediately following the South East Asian tsunami, and many past mistakes were repeated.
Two technological accidents involving nuclear power plants significantly impacted the evolution of disaster planning and administration. The 1979 Three Mile Island accident in the U.S. and the 1986 Chernobyl disaster in the former U.S.S.R. were significant for their long-term health effects decades after the events. Three Mile Island was also a “sentinel event” that contributed to President Carter’s establishment of the Federal Emergency Management Agency (FEMA), which Dr. Noji compared to the creation of the Department of Homeland Security.
Since this early period the realities and challenges of disaster epidemiology have evolved and expanded significantly. The events of September 11, 2001 drastically increased awareness among disaster epidemiologists of the potential public health consequences of terrorism. Dr. Noji noted that the first edition of his book did not include any information on terrorism prevention or management, but one-fourth of the content for the second edition relates to “biological, chemical, radiological, nuclear, blast, or suicide terrorism.” Bioterrorism gained the attention of epidemiologists during the 1996 saran gas attack on the Tokyo subway system, causing twelve deaths and injuring thousands. Today 25 percent of the CDC’s budget is spent on bioterrorism preparedness.
The public health menace of global pandemics has also reemerged with the spread of Severe Acute Respiratory Syndrome (SARS), avian influenza (Bird Flu) and most significantly, HIV/AIDS. With more than 40 million people infected worldwide, HIV/AIDS prevention and treatment have been top concerns for USAID, which has spent $3.2 billion since 1986 on international HIV/AIDS programs. The transmission of all communicable diseases is facilitated by the effects of globalization, including increased human mobility.
The context of providing public health services to effected populations has also changed. Since the early 1990s, the number of humanitarian assistance operations in failed states has risen. Conditions for relief workers in many failed states are unsafe so coordination with military or peacekeeping forces has grown in importance. Dr. Noji described his own experience of needing to be escorted by Israeli soldiers to conduct relief work in the Gaza Strip and West Bank. This can be problematic since in many emergencies, “uniformed personnel are deemed the enemy by the same people that you are trying help,” said Dr. Noji.
The U.S.-led military invasion of Iraq presented unique challenges and opportunities for cooperation between medical experts and the military. In 2003, Dr. Noji served as Deputy Chief of the Medical and Public Health Unit for the U.S. Humanitarian Mission for Operation Iraqi Freedom. He contributed to the rapid determination of the medical and health needs of the Iraqi people. Some of the epidemiological lessons learned from Iraq include:
1. The Department of Defense (DOD) must utilize experienced professionals and allow dedicated international relief agencies to be responsible for their own humanitarian operations.
2. The capacity of DOD’s civil affairs units to provide an occupying power with the ability to restore essential basic services must be appreciated more and there should be a career track that reflects this.
3. DOD must achieve buy-ins from non-governmental organizations (NGOs) and international organizations (IOs) for crucial communication, transition, and exit strategies.
Public health professionals have also been forced to adapt to new domestic situations including the need to communicate better with the public. Dr. Noji noted that when he started his CDC career as an epidemic intelligence officer (EIS), he and the other employees did not receive any training on briefing the press or giving interviews. The need for this type of experience was exposed during the 2001 anthrax attacks in the U.S., and now all CDC EIS officers receive a minimum of three days of media relations training.
Dr. Noji also highlighted the need for standardization among government agencies, relief workers, and public health professionals in data collection and analysis. USAID; the Department of State’s Bureau of Population, Refugees and Migration; and the Canadian International Development Agency (CIDA), founded the Standardized Monitoring and Assessment of Relief and Transitions (SMART) Initiative to address the need to:
1. standardize methodologies for assessing needs based on nutritional status, mortality rate, and food security.
2. establish comprehensive, collaborative systems to ensure reliable data is used for decision making and reporting.
Improved strategic epidemic control planning will require the development of different country models. Epidemiological models of complex emergencies need to be specifically adapted to the needs of developing countries, developed countries, and chronic smoldering countries. Without specific models tailored to the situation of each country type, health care access and availability suffer.
Dr. Noji then examined the potential future of disaster epidemiology. He identified seven trends that will increase the risk of disasters in the near future:
1. Increasing population density
2. Increased settlement in high-risks areas
3. Increased technological hazards and dependency
4. Increased terrorism: biological, chemical, nuclear
5. Aging population in industrialized countries
6. Emerging infectious diseases (example: AMR variant of hantavirus)
7. International travel (global village)
The higher risk of disasters requires that disaster prevention and management experts have increasingly sophisticated tools at their disposal. Dr. Noji noted how the use of handheld computing by relief workers and health professionals has increased the data collection rates from patients in the field, allowing for a more accurate and faster decision making process. Geographic information systems (GIS) are also powerful spatial analysis tools that can aid disaster assessment and assistance to an effected population. GIS during humanitarian disasters can be applied in “hazard, vulnerability, and risk assessments; rapid assessment and survey methods; disease distribution and outbreak investigations; planning and implementation of health information systems; data and program information; and program monitoring and evaluation.”
Dr. Noji concluded by noting that a significant amount of disaster epidemiological experience exists and has been compiled, but it must be studied and applied if disaster relief planners hope to avoid repeating past mistakes. An updated summary of state-of-the-art disaster prevention and response techniques can be expected in the second edition of Dr. Noji’s The Public Health Consequences of Disasters that will be published later this year.
Question and Answer Session
Recently, a local newspaper wrote that disaster preparedness plans seldom include the “average citizen.” What more can be done to help prepare the average citizen for a disaster?
Unfortunately, there is no designated federal agency that is responsible for public education [of disaster preparedness]. We [the Centers for Disease Control and Prevention] have a lot on our web site to prepare citizens for a heat wave, hurricane, cyclone, or pandemic flu, so in public health a lot available. The National Weather Service has a lot on what to do after a hurricane, tidal wave, or tornado, and the FEMA [Federal Emergency Management Agency] web site also has a lot on citizen safety guidelines. Good information is out there and available, but there is no “one-stop shopping” source.
Based on your research, what is the safest response during an earthquake?
The research that I did was during primarily the 1980s and 1990s. I grew up in Los Angeles, and we had a big earthquake in 1971 called the San Fernando Valley Earthquake. The citizen safety guidelines have not changed that much since then. The bottom line is that the proper response depends on building construction. In California, residential construction is basically wood frame and single-story. When those types of structures collapse most of the injuries are from what we call “non-structural elements” falling down, like bookcases, refrigerators, and chandeliers. So getting underneath a table might not be such a bad idea, and getting under a door frame also might not be such a bad idea. But, when you are in a collapsing multi-story concrete or brick building like they have in Armenia or Mexico City, I don’t care how strong your table is. In Turkey we found criminal violations by contractors and workers using cheap materials. Turkey has more stringent and better earthquake building codes than California, but they are frequently criminally violated. In those cases, it is clearly better to run outside. In California, the people who did run outside tended to suffer more injuries than those who did not because of falling architectural ornamentation. So the best response really depends on construction.
