Disaster preparedness and public health

Chapter 12 Disaster preparedness and public health



Gerry FitzGerald



Learning objectives


After reading this chapter, you should be able to:


image define disasters

image explain the principles of disaster management

image describe trends in disasters and their impact

image describe the particular impact of special disaster types

image explain the role of public health practitioners in disaster management.


Introduction


Effective disaster management can reduce the health consequences of both natural and man-made disasters. The aim of this chapter is to outline the principles and practice of disaster health management with a view to providing public health practitioners with an understanding sufficient to enable them to participate in disaster preparation and response management, and thus to reduce the health consequences of disasters on the community.



Defining disasters


There are many definitions of disasters, but little agreement on what is a disaster. In reality, it depends on a range of factors. Events or health challenges range from a single emergency or single patient through to catastrophes, and while we may be able to define the ends of the continuum, there is no single defining point at which this transition to a disaster occurs, but rather a gradient whereby the challenge and the resources available to deal with that challenge are influenced by multiple factors.


The extent of the challenge to the health and wellbeing of the community is determined by the nature of the event, its location, spread and impact, and by the characteristics and size of the community. The resources available to deal with the event are defined by the location, culture and socioeconomic status of the community and such variables as the time of day or day of the week. Thus, whether any single event or challenge to health and wellbeing is a disaster or not, depends on the influence and interaction of many factors. Figure 12.1 seeks to demonstrate the variable nature of this relationship. The slide on the scale marks a particular event, but its position on the scale is determined by those factors that influence the mismatch of resources and challenges to health.


image

Fig. 12.1 The relative nature of disasters.


Some have distinguished between emergencies and disasters based on the number of patients affected. However, the extent of the impact will depend not only on the numbers affected but also the nature of the effect, and the resources available to deal with the impact.


Emergency Management Australia (EMA) defines a disaster as:




A serious disruption to community life which threatens or causes death or injury in that community, and damage to property which is beyond the day-to-day capacity of the prescribed statutory authorities and which requires special mobilisation and organisation of resources other than those normally available to those authorities (emphasis added). (Australian Emergency Manuals Series Part 1 1998)


This definition seeks to capture the special nature of events at the extreme end of the continuum. We use the term ‘Disaster Health’ as a working term for the focus of this chapter and for the special consideration of policy makers and service planners. The term ‘Disaster Health’ is used on the grounds that the principles and management practice outlined in this chapter are most necessary when the event stretches available resources sufficiently as to require special mobilisation and organisation. In addition, we use the term ‘Disaster Health’ as a means of drawing focus to both the health consequences of disasters and the impost the event may make on health services. Thus, public health authorities must have in place scalable arrangements whereby emergency responses may be escalated on the basis of standard principles and practices to such a level as to meet the particular challenge at that particular time.


Notwithstanding these definitional issues and the need for scalable arrangements, there is a time when the event reaches a stage where the approach of the authorities changes from a focus on the individual patients to the greater good of the community as a whole. This occurs because of the absolute or relative mismatch between the demands made on the system and its resources, or because the resources and health infrastructure have been degraded by the event. There is also a time when the approach changes from treating the sick to preserving the infrastructure, including the people who have a key role to play in the community. There are no rules related to when this occurs. It depends on the relative and absolute resources available and the level of mismatch between those resources and the demands being placed on them.


Some disasters are associated with single events such as a crash, explosion or earthquake. Some may be highly localised, while others are widespread. Some may be relatively silent, such as the HIV/AIDS pandemic, and others develop more slowly and less dramatically, such as influenza pandemics.


Sundnes and Birnbaum (2003) described the context of disaster health as involving three essential domains: public health; emergency and risk management; and clinical and psychological care. Their conceptual map describes the interrelationship between these domains within a broader framework defined by community preparedness, response capability and resilience, political and social structures and the support resources available. The focus of this discussion is mostly on the public health domain.



Context



Epidemiology


The number of recorded natural events and the number of people affected by those events continues to increase (WHO CRED 2009). Figure 12.2 demonstrates the number of events and the number of people killed in disasters over the last century. What this figure demonstrates is that the while the number of events has increased, the recorded number of people killed has declined.


image

Fig. 12.2 Trends in incidents and deaths.


EM-DAT: The OFDA/CRED International Disaster Database – www.emdat.net – Université catholique de Louvain – Brussels – Belgium.


Why are the events increasing? It is unclear whether the apparent increase is merely an increased level of recording. It is difficult to understand why the number of natural events would be increasing except where the effect of human intervention may be contributing to an increase in the frequency or severity of events. In particular, it has been suggested that global warming is contributing to the increased frequency and severity of cyclones (Intergovernmental Panel on Climate Change 2007), and deforestation may be contributing to the frequency of mudslides and forest fires.


However, at the same time, improvements in the relative safety of transportation, occupational health and safety and reductions in the level of major conflict has reduced the exposure of the community to man-made risks, although increased population and levels of human activity may increase the frequency of such adverse events. The vulnerability of the community has been increased by demographic changes. Population growth and urbanisation has resulted in the growth of megacities; often in areas that are particularly vulnerable to natural disasters, because they are built on flood plains or in seismic areas. In addition, the social consequences of rapid urbanisation, including poverty and congestion, may lead to outbreaks of violence. Either way, this social change has increased the vulnerability of the community and the potential health consequences.


Each day over 19 000 people attend hospital emergency departments (EDs) in Australia (Steering Committee for the Review of Government Service Provision 2011). Australia has never had a single event with 19 000 casualties, yet every day we manage those numbers in our EDs. The difference between a quiet day and a busy day would exceed any major event to have confronted Australia. Thus, the cornerstone of our emergency health response arrangements should be the systems and structure, which characterise and respond to the daily burden of emergency health.



Health impacts


The health impacts of disasters may be categorized into two dimensions:


• timeliness of the consequences; immediate, medium term and long term

• relationship of the consequences to the hazard; direct consequences are those related to direct contact of humans with the hazard, and indirect consequences are those in which the human impact is a consequence of damage to something else

For example, the health impact of floods has been categorised into immediate, mid term and long term by Du et al. (2010). Direct effects of floods are those related to exposure to the water or debris contained within the water. Thus, drowning and injury are direct immediate consequences. On the other hand, floods often disrupt transportation or industry, leading to longer-term economic constraints, and the health consequences of poverty. Finally, the loss and grief that may accompany the flood, or the impact that the flood has on society, can have a long-term affect on an individual’s mental health.


The health consequence of any particular event can be so mapped. The strategies designed to reduce health consequences are then matched against those particular risks. Thus, reduction in immediate direct effects would involve prevention and mitigation, along with immediate rescue or evacuation. Strategies aimed at preventing long-term mental health consequences include psychological first aid, follow up and dealing with the economic and social uncertainties that often characterise a poorly managed recovery phase.


Health is involved in such events in two ways:


• Any event is likely to cause adverse impact on the health and wellbeing of people, and health services have a key role to play in the provision of health care or the protection of life.

• Health services are part of the community’s critical infrastructure, which needs protection to maintain services. Health infrastructure may be subject to the same risks as has caused the incident in the first place.


Principles of disaster management


As outlined earlier, effective disaster health management can reduce the health consequences of serious events. Effective disaster health management is complex and multifactorial, so there is potential for complexity to paralyse any action. However, a number of core principles have been identified, which may govern the approach to disaster health management, and these principles should form the core of the management strategies.



An engaged and prepared community


All disaster management is ultimately local disaster management. It is not possible for governments or external agencies to do everything without the direct involvement of the community in its own protection and recovery. This local engagement is critical. In major events, particularly those associated with the destruction of major infrastructure, the community will be on its own until help can be organised. Initial response will be from local agencies, local resources and bystanders; the destruction of roads and other means of access may reduce the capacity for outside assistance.


Critical to an engaged community is the concept of community resilience, which while ill defined, implies the capacity of the community to withstand challenges to its wellbeing and to ‘bounce back’, taking control of its own destiny and restoring functionality. This concept places an important emphasis on the partnership required between the community, and government and non-government agencies. An engaged, resilient community helps governments and other agencies to obtain support for the investments required and the strategies necessary to facilitate preparedness, and efficient response and recovery. Such a community also participates directly in the planning and preparedness required to protect the community from the hazards that place it at risk. A resilient community is able to respond immediately to render initial aid and act quickly to restore community functionality.



Risk-based approach


Defining risk is difficult in this context. The terms risk and hazard are often used with little variation in meaning or understanding. A hazard is something that may cause damage. Thus, a volcano is a hazard. The risk to the community arising from that hazard is a combination of the nature of the hazard and the vulnerability of the community (risk = hazard × vulnerability). The vulnerability of the community is determined by the size, location and socioeconomic characteristics of the community. For example, the risk associated with Vesuvius in southern Italy is a combination of the risk posed by the presence of the volcano and the millions of people who now live within its potential impact zone.


Hazards have been categorised by the World Association for Disaster and Emergency Medicine (WADEM) into natural, man-made and mixed hazards (TFQCDM/WADEM 2002):


Natural hazards are those arising from the natural environment.


• biological: pandemics etc.

• geophysical: volcanos, landslides, earthquakes

• hydrological: floods and mudslides

• meteorological: storms and cyclones

• climatological: heat waves and droughts.

Manmade hazards are those derived from the human environment.


• technological: including transport and industrial technology

• conflict: including armed and unarmed conflict (e.g. sanctions).

Mixed hazards are those derived from the interaction of human development with the natural environment. Examples include desertification from land clearing, and erosion and landslides from deforestation. In addition, the consequences of climate change on meteorological and climatological hazards may be classed as the ultimate mixed hazard.


Risk is the product of the presence of a hazard and the vulnerability of the community to that hazard and describes the level of threat to the community. A risk-based approach involves the identification of likely hazards and their impact, and the development of a risk profile or register for the community. The identified risks need to be evaluated for their likelihood and impact, and management strategies, which may either prevent, moderate or offset the risk.


Risk identification is informed by history; thus a history of floods or cyclones in a particular area, or earthquake-prone areas, will identify those risks. But it may also be informed by research or by creative and analytical thought. The possibility of a particular risk may be informed by thoughtful analysis of potential problems, even when there is no history of such event to inform planning.



All-hazards approach


Because of the diversity of risks and because of the initial confusion that characterises major incidents, it is not possible, and potentially confusing, to plan or prepare for individual hazards. The all-hazards approach seeks common approaches to the preparation and response, regardless of the hazard. Put simply, communities should respond in a standard way (at least initially) regardless of the challenge. This allows for standardised training and awareness, and for a relatively automated immediate response, even when the full extent or even nature of the event may not be known. For example, the first information available may not identify the source of an explosion (accidental or deliberate). It is necessary to develop and implement safe and consistent initial responses that take into consideration the possible risks.



All-agencies approach


There is a risk that different agencies, or different levels within individual agencies, may react to a major incident in different ways. The consequence could be confusion, gaps in response or overlap and wasted effort.


A more effective approach is for all agencies involved in preparation and response to major incidents to operate on the basis of similar and standard approaches. Approaches such as those outlined in the Major Incident Management System (MIMS) (Hodgetts & Porter 2002) help with definition of roles and responsibilities, and the determination of the standard principles of action. In addition, the efforts of national standard setting bodies such as Emergency Management Australia (EMA), and its interaction with similar international bodies, allows for consistency in approach.



Familiarity


The principle of familiarity describes the understanding that the most effective response to major incidents is achieved when those responding are familiar with their roles and responsibilities. This is best achieved if the response arrangements are based on those that people undertake on a daily basis. This is not the time to learn new tasks but rather to utilise the expertise present within the community. Accordingly, task allocation should, wherever possible, reinforce normal practice. Surgeons should do the surgery and firefighters rescue people and put out fires. Organised responses should reflect normal practice wherever possible. For example, pre-hospital management should be undertaken by those who normally undertake this role, rather than place individuals into new and challenging environments.


This principle not only reflects reality, but also ensures that the definitional issues discussed earlier become irrelevant. Response agencies will initiate the response on the basis of their familiar practice, then enhance that response until such time as resources appear sufficient to the particular challenge. This approach minimises the aspects of disaster response that require unusual responses and, therefore, reduces the training needs of the community. Those additional areas should be the subject of special training that is reinforced by regular exercises, so as to build into the community’s familiarity the special actions required.



Comprehensive approach


The principle of a comprehensive approach is based on the cycle of disaster management, which seeks to ensure consistency throughout the life cycle of prevention, preparation, response and recovery (PPRR).



Prevention and mitigation


Some hazards can be prevented or at least reduced in likelihood. For example, road traffic management strategies are aimed at preventing or reducing the frequency of major transportation incidents, and land use policies may reduce the impact of desertification.


Other hazards are not preventable, but their impact can be mitigated by a combination of infrastructure investment and behavioural modification. Thus while we cannot prevent cyclones, we can reduce their impact by imposing higher standards of building construction in cyclone-prone areas and evacuating people at risk into secure shelters. Equally, we may not prevent floods but we can reduce their impact by investing in dams and high-level bridges over waterways, or by reducing the risk to people by constructing shelters above flood height and by building flood-resistant community infrastructure, such as dams and bridges.



Preparedness and planning


Preparing the community for major incidents is part of building community resilience.


The most significant aspect of preparedness is planning. Planning describes the process of identification, evaluation and management of risks, and the development of strategies to mitigate or respond to those risks, should they cause an adverse impact on the community.


It is often considered that the process of planning is more significant than the plan itself. The process of formulating a plan engages the key agencies and leading individuals of the community, ensures their interaction and helps identify the potential problems associated with the management of response and recovery. The planning process is educational itself and allows for the sharing of expertise. It also ensures the key players know each other and are familiar with the capability of other individuals and agencies.


The planning process is further complicated by the need to ensure plans are consistent with those of other agencies, and with other levels of government or community. For example, an agency’s pandemic plan should be consistent not only with other agencies, but also with national and international pandemic preparedness plans. There is a need to avoid confusion in the planning process by ensuring that any plan is consistent with international principles, national standards and the response arrangements of other agencies.


Sensible construction of plans needs to follow some basic principles:


• Develop a hierarchy of plans which are consistent with each other but allow maximum flexibility.

Related posts:

  1. The impact of globalisation on health
  2. History and development of public health
  3. Evidence-based practice
  4. Environmental health

Stay updated, free articles. Join our Telegram channel
Tags:
Apr 12, 2017 | Posted by in MEDICAL ASSISSTANT | Comments Off on Disaster preparedness and public health

Full access? Get Clinical Tree
Get Clinical Tree app for offline access