Injury (1990) 21, 5-8
Printed in Great Britain
Disaster epidemiology: or why most international disaster relief is ineffective J. Seaman Senior Medical Q$Gr, The Save the Children Fund, London SE5 8RD, UK
Introduction A report of a major disaster overseas, particularly in a developing country, generally evokes a powerful desire to help. We in the West are rich and have technology. They are poor and it seems a reasonable assumption that our resources must be of value. Any publicized major disaster is likely to be followed by a gift of government aid, fundraising by voluntary agencies and often by the spontaneous organizations of individuals who wish to travel to the disaster area to assist. The desire to help another people in time of great need is natural, and the gift of aid often received with gratitude by the recipients, who are often touched by the knowledge of outside interest. However, enormous resources can now be devoted to disaster relief operations, and their effects are far beyond that of a simple gift. All evidence is that our power to help is more limited than we might think: worse, there is much evidence that much, if not most, international disaster assistance is not only useless for its intended purpose but often, by its nature and quantity, actively obstructs actions which might be of use. This paper has two themes. The first is an attempt to define the health problems caused by disasters, a subject known as ‘disaster epidemiology’: that is who suffers, why, how this varies between disasters and, crucial for relief, the timing of these effects. The second is concerned with what can be achieved by international disaster relief. The material presented here is based on a book (Seaman et al., 1984) in which the topic is discussed in more depth and where more source material is given.
Definitions There have been many attempts to define ‘disaster’, none of which is very satisfactory, e.g. ‘an overwhelming ecological disruption occuring on a scale sufficient to require outside assistance’. The chief problems, illustrated by this example, are of scale and need -a small flood which kills one family is overwhelming to those affected although it is unlikely to attract international attention. The classification used here is simply by disaster type. Those considered are (i) earthquakes; (ii) floods, to include both catastrophic floods such as the ‘tidal wave’ of cyclonic storm-surge, dam-burst and tsunami (caused by undersea earthquakes) and slower rising 0 1990 Butterworth & Co (Publishers) Ltd 0020-1383/90/010005~4
ones; (iii) high winds, including cyclones and tomados. Mixed forms of course occur. Torrential rain and flooding is often associated with tropical cyclones. The effects of disasters on health are considered under four headings which cover most aspects relevant to relief. These are (I) death and injury, (2) communicable disease, (3) environmental exposure and (4) food supply and nutrition. The psychological effects of disasters are the subject of a large literature but are not discussed here, as they rarely receive much practical attention during relief operations.
The effects of disasters on health Death and injury The degree to which disasters, regardless of their location, cause death and injury varies within and between disaster types. The main distinction is between earthquakes, which often cause deaths and injuries on an enormous scale, and the other types of disaster. Floods may cause deaths, again sometimes on a large scale, but rarely, if ever, cause significant numbers of non-fatal injuries. High winds cause both death and injury, but never alone in very large numbers. The reason for these differences is to be found in the mechanical effects of the disasters concerned. Earthquakes generally cause death and injury through the collapse of dwellings and other structures. It is no surprise that where structures are intrinsically dangerous, e.g. the unframed rock and earth houses of Eastern Turkey or the adobe of Central America, relatively slight shocks may cause large numbers of casualties: or that larger shocks are required to produce casualties in California where building stands are higher. For similar reasons diurnal variation is observed in the relationship between earthquakes and casualties in some regions, as more people are likely to be at home at night. Age- and sex-specific mortality and injury vary among earthquakes, but in a largely explicable way. For instance Hogg (1980) noted that in an area affected by the Friuli, Italy, earthquake of 1976 ‘agile groups suffered more than the elderly or the very young. This is because they ran out into the streets . . . which are especially narrow, and were crushed by falling masonry’. A study in the village of Santa Maria Cauque in Guatemala after the 1976 earthquake showed higher mortality for the young and the old and
6
Injury: the British Journal of Accident Surgery (1990) Vol. Zl/No. 1
lower rates in the 15-44 year age group. Infants under one year had lower mortality rates than their older siblings, probably owing to the fact that babies normally slept with, and were protected by the mother. By contrast, serious injury showed a progressive increase in rate with age, with higher rates for older women, an effect which may be analagous to fractures of the neck of femur in affluent countries (Glass et al., 1977). Earthquake injuries are predominately orthopaedic; ‘crush syndrome’ is common after many but not all earthquakes. The variability is probably related to both undereporting and actual differences in incidence relative to building type. There are obvious difficulties in the defining the word ‘injury’, as accurate records are rarely kept, but a rule-ofthumb is that the ratio of deaths to injuries is generally of the order of I : 3 or higher. Floods may cause injuries as a population relocates to higher ground but not many deaths, or where floods are violent, as in the tsunami, cyclonic storm-surge or damburst, there are deaths but few, if any, serious injuries. An individual who is caught by the flood drowns: one who is not survives, generally uninjured. The great cyclonic stormsurges which affect low-lying areas of the Bay of Bengal and which have killed enormous numbers dramatically illustrate this effect. The great storm surge which struck East Pakistan (Bangladesh) in 1970 killed, approximately 240 000 people (Sommer and Mosely, X972), 14.2 per cent of the population. However, injury was largely limited to cuts and bruises and the occasional fracture.’ A ‘cyclone syndrome’ of severe abrasions to the arms, chest and thights where people had clung to trees was noted. Age-specific mortality showed, as might be expected, a greater mortality amongst the young and the old, as these groups would be least able to cling to trees during the hours of the cyclone. There was also a preponderence of female deaths, except in the youngest age groups, probably for the same reason. The wind of cyclones causes some deaths and injuries from flying debris and building collapse, although never in numbers similar to earthquakes or floods. Tomados cause both deaths and injuries, in modest numbers relative to earthquakes, but with a very specific pattern of injuries arising from the sheer violence of the forces involved. There are many head and chest injuries with many and severe soft-tissue injuries. Tornado injuries are also frequently contaminated with debris, often introduced with considerable force, and secondary sepsis is a common problem with management. Communicable disease
A fear of epidemics often exhibited by the authorities and aid agencies and frequently reported by the media after disasters is not well founded in either theory or observation. After many disasters, particularly in rural areas, there are no observed changes in population concentration, water supply, sanitation or other factors which might be expected to affect disease transmission. The diseases which most often cause alarm are typhoid and cholera, the latter sometimes even in regions where it is known not to exist. The fear often voiced, of epidemics arising from the putrefaction of corpses, has no obvious foundation. The only completely unambiguous record of an unusual disease outbreak after a disaster in modem times is of an outbreak of malaria in Haiti after torrential rain associated with a hurricane in 1963 (Mason and Cavalie, 1965). This caused large population movements and interrupted a
chemical control programme. It is estimated that approximately 75 000 excess cases occurred. There are also reports of small outbreaks of leptospirosis associated with floods. However, it must be admitted that information on disease incidence in most developing countries is weak before as well as after disasters, and it is probable that outbreaks have been missed. Specifically, it may be assumed, on the basis of extensive documentation of the health of refugee populations, that where a population is concentrated, epidemics will occur. Most mortality has followed outbreaks of measles and diarrhoeal disease. Although this is not documented after natural disasters, it is probable that such affects regularly occur where populations are concentrated, for example, when retreating to high ground during floods. Environmental
exposure
There are no reliable reports of death from exposure after any disaster on land in recent times. The areas where concern is most often expressed about exposure risk are those where a population loses its housing under very cold conditions, such as Eastern Turkey after an earthquake in winter. This assumption of high exposure risk possibly arises because of the regular exposure deaths amongst climbers, swimmers and others in Western countries, but it is clearly false to assume that an equivalent risk exists for all populations. People who live in cold climates develop appropriate techniques and knowledge about survival. Clothing tends to be heavy and may be worn even at night; and it is often under disaster conditions that basic building materials and firewood are abundant. Populations have proved remarkably effective at rapidly re-establishing the basic ‘microenvironment’ in which they can survive. This is accomplished by movement into undamaged structures or by rapid construction. In Guatemala after the earthquake of 1976, it was estimated that 50 000 improvised dwellings were in use within 24 h of the earthquake (Davis, 1977). From the perspective of theory, however, the risks would seem to be higher than the record would indicate. Environmental exposure is a function not only of a low ambient temperature, but of body insulation, body size, wind and
2
1500
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6 .
5 .
32 'F $ OL f 2 0
/'
500.
-100 .c 1' E t I -80 ; I I -60 3 I 5 /I
:
-40
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: -120 2
-20
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*eOJ..~,,~.,....~.~.,~'O 3 4 5 6 7 8 9 101T121314151617181920 Date in February
1976
Figure 1. The number of cases of trauma attending
hospitals in Guatemala City (solid line), the arrival of medical supplies (broken line) and emergency hospitals (numbered points) from intemational donors after the 1976 earthquake. The origins of emergency hospitals were (I) Nicaragua, (2) Panama, (3) Mexico, (4) Costa Rica, (5) US military and (6) packaged disaster hospitals originally designed as a contingency stock for nuclear war.
7
Seaman: Disaster epidemiology
wet. Where an exposure risk would be expected is not in very cold countries but in ‘wet’ disasters, which are more common in the tropics. A thin, lightly clothed population exposed to wet and wind even at quite high ambient temperatures rapidly suffer an exposure risk. The risk is greater for the young. The evidence for the occurrence of such effects in anecdotal but strong after cyclonic storm surges in India, where populations are exposed for many hours to wet conditions, and might also be expected to cause major mortality during extensive and protracted floods, such as those which affected Bangladesh in 1988. Food supply and nutrition Accounts of failures of food supply after disasters are not prominent. It is clear that in many settings problems arise not with food supply as such, but from temporary interuption of the means of distribution. Shops may close and physical supply be interrupted from damage to roads. After earthquakes, household stocks can generally be salvaged, and standing crops are unlikely to be damaged. After slower rising floods, stocks may be removed with the population ahead of the water. The situation is, however, complicated by the fact that in many of the most disaster-prone developing countries governments play a major part in the regulation of staple food supply in normal times and may quickly intervene in time of disaster. For example, after the 1970 Bangladesh storm-surge, following which a large part of the population was either landless or comprised migrant agricultural labourers who might be expected to have had severe problems with employment and supply, cash sufficient to purchase 20000 tonnes of rice was distributed by the government. Similar interventions are recorded from Central America and India.
Relief The experience of the effects of disasters on the health of populations is that it is possible to make generalizations about these which are useful in the planning of emergency relief. To summarize, these generalizations are that there is a potential need for the treatment of large numbers of injured people only after a major earthquake. The need for clothing and shelter, at least for lifesaving purposes, will be confined to specific circumstances which are likely to arise only in direct association with some types of disaster and possibly from a brief period afterwards. There is a potential, indefinable without reference to the specific case, for the spread of communicable disease, although the historical record suggests that the probability of this occurring is not high. Lastly, food shortages of a type likely to cause starvation are only likely to arise under specific conditions. These are likely to be encountered only in specific regions, particularly those prone to major violent flooding. It may be added that the regions of the world in which specific disasters regularly occur are relatively restricted, and it is possible to have an up-to-date knowledge of the local context even from a distance. Against this picture must be set both the actual and theoretical performance of formal relief efforts. These may be divided into two: firstly, those originating within or very close to the disaster area and secondly, those from longer range (in a large country such as India relief may come from all over the subcontinent) including those from abroad.
Local relief The assumption, sometimes implicit in appeals for assistance for disaster-affected populations, that these are passively dependent upon outside relief and, in poorer countries, without material resources, is false. A consistent theme of the disaster literature is the speed and coherence of local response. In many locations active attempts to rescue people from the rubble will be observed minutes after an earthquake; a few hours will see the removal of the injured to any remaining medical facilities; and, as already noted, a day may see the construction of temporary housing. Where medical facilities exist (which includes all urban areas), these will frequently work around the clock to secure treatment for as many people as possible. From hospital records kept after earthquakes, it is clear that most of the injured will be ambulant and only a proportion will require hospital admission. In Managua, Nicaragua an earthquake on December 23, 1972, which was essentially confined to the capital city, caused an estimated 20000 injuries. By December 25 it was reported that the patient load had peaked. A report from an emergency hospital which became operational on December 26 was that ‘The.. . type of patients more closely paralleled those found in any general hospital.. as opposed to an acute disaster situation’ (Coultrip, 1974). After earthquakes, shortages may occur of specific items, e.g. casting materials and anaesthetics, of which consurnption is heavy. But even in countries where drugs are normally in very short supply, such stocks as there are may be rapidly released and supplies may temporarily be adequate. A recent example is that of the 1988 Khartoum floods, where drugs were released from stock (intended as a capital stock for a drug scheme) within hours of the disaster. There are of course many locations, particularly in mountainous regions, where communications are poor and formal services non-existent, e.g. parts of rural Peru and the Himalayas. Under these conditions medical assistance will be slight. External relief To be useful, external relief must meet exacting targets of specificity of type and speed. The problem may be viewed from two aspects: what is possible theoretically and what has been achieved in fact. The theoretical case is not entirely so, as it has often been proposed that standing, usually military, ‘disaster forces’ should be created in western countries for rapid deployment overseas. In theory, a ‘standing disaster force’ in an industrialized country, properly equipped, with free access to transport aeroplanes and material, should be able to reach the site of a disaster in a period of hours, assuming that the main airport of the country concerned is undamaged. All that should be required is adequate notice of the occurrence of the disaster for movement to be initiated. Neglecting real impediments, such as visa requirements, which are not usually waived in time of disaster, or, where a standing force is military, the disinclination of many countries to have foreign armed forces arrive unannounced, there is one currently insurmountable obstacle. In an era of instant communications and live broadcasts from scenes of crisis it may be assumed that we are instantly aware of the existence and nature of all disasters. In fact, nothing could be further from the truth. News of some disasters reaches Western countries very quickly - within an hour or two. However, not all disasters are reported.
8
Injury: the British Journal of Accident Surgery (1990) Vol. Zl/No.
Nether or not a disaster is reported appears to be a complex function of several variables: its likely scale, its location, some countries being of more interest than others, and competing news. An interesting account of these effects, relating to famine rather than natural disaster, but illustrating the same effects, is given by Harrison and Palmer (1986). More important, the scale of a disaster is not usually accurately known until days or weeks after it has occurred. For example, the Guatemala earthquake of 1976 was initially reported to have killed less than 1000 people. By day 4 the estimate had risen to 14 000. The hue total of over 20 000 was not appreciated until day 7. The 1980 Algeria earthquake showed the reverse of this effect, the estimate falling from 20000 on day 1 to a more accurate 4000 on day 4, although the higher estimates persisted until day 9. The experience of major international disaster relief operations, which it should be emphasized are only initiated for some major disasters, is that they proceed primarily on the basis of the assumption that all disasters require large amounts of medical assistance of all types, clothing, blankets and food. Further, they are initiated and carried through very slowly relative to the evolution of events in the disaster area. Typically they reach a peak a week or two after the disaster impact. Lastly, they are pursued by large numbers of agencies and individuals without reference to each other, nor can coordination occur, as the numbers of agencies and the creation of new groups preclude it. The result is frequently chaotic, the recipient country being swamped with unlabelled drugs and other materials which are not required, and people who neither speak the language nor, often, possess useful skills. Here only one case is presented, that of Guatemala in 1976 (&we I). It is of note that the only emergency hospitals deployed during the period when there were untreated casualties were from the neighbouring Spanishspeaking states. British assistance was declined because of the territorial dispute with Belize. The quantity of drugs supplied after the Guatemala earthquake amounted to over 120 tonnes, mostly unlabelled, much unsuitable and some outdated. One item was a 1934 medical sample from North America.
Postscript Two additional points should be made. The first is that the case presented neglects the fact that in many situations a medical need, although much reduced in scale, persists after the first few days of a disaster. One recent example is the earthquake in Soviet Armenia, where there were cases of renal failure secondary to the ‘crush syndrome’ that could have benefitted from dialysis, which was not locally available. Clearly these are potentially accessible to international assistance. The cost of providing such assistance is very high
I
(the deployment of a military emergency hospital may cost hundreds of thousands of pounds) and it is a judgement as to whether this is, particularly for poorer countries, money well spent. A sharper example would be the Khartoum flood of 1988, in which millions of pounds were spent on air freight (chiefly of redundant blankets and tents, many of which accumulated at the airport), and in a country where health expenditure in 1989 was approximately x0.5 per person per year. The second point concerns what assistance can be effectively provided from abroad. For emergency relief there are some requirements in certain countries. Heavy lifting equipment may sometimes be of value after earthquakes, and the control of communicable disease may require epidemiological help to set up a surveillance system. However, help should chiefly come at a later time. Disasters cause not only loss of life but vast damage to economy and infrastructure, which developing countries can ill afford to repair. In general, there is less international interest in this than in emergency relief. An estimate by the US Govemment Office of Foreign Disaster Assistance for the period 1965-1975 showed that the ratio of costs borne locally to those met by international aid was of the order of 42 : I. There is ample time to provide effective international disaster assistance.
References Co&rip R. L. (1974) Medical aspects of US disaster relief operations in Nicaragua. M&t. Med. 139, 879. Davis I. (1977) Housing and shelter provision following the earthquakes of February 4th and 6th 1976. DisustersI, 82. Glass R. I., Urrutia J. J., Sibomys S. and Smith H. (1977) Earthquake injuries related to housing in a Guatemalan village. !%ience(N.Y.1 197,638. Harrison P. and Palmer R. (1986) News art ofAfrica Biafra to iha’ Aid. Hilary Shipman Ltd. Hogg S. J. (1980) Reconstruction following seismic disaster in Venzone Friuli. Disasters 4,173. Mason J. and Cavalie P. (1965) Malaria epidemic in Haiti following a hurricane. Am. J Trap. Med. l-fyg. 14,533. Seaman J., Leivesley S. and Hogg C. (1984) Epidemiology of natural disaskrs. Karger: Basel. Sommer A. and Moseley W. H. (1972) East Bengal cyclone of November 1970: epidemiological approach to disaster assessment. Lancet i: 1029.
Requpsfsfor reprinfs shouti be aallressed to: Dr J. Seaman, Senior Medical Officer, The Save the Children Fund, 17 Grove Lane, London SE5 SRD, UK.
Printed in Great Britain
Disaster epidemiology: or why most international disaster relief is ineffective J. Seaman Senior Medical Q$Gr, The Save the Children Fund, London SE5 8RD, UK
Introduction A report of a major disaster overseas, particularly in a developing country, generally evokes a powerful desire to help. We in the West are rich and have technology. They are poor and it seems a reasonable assumption that our resources must be of value. Any publicized major disaster is likely to be followed by a gift of government aid, fundraising by voluntary agencies and often by the spontaneous organizations of individuals who wish to travel to the disaster area to assist. The desire to help another people in time of great need is natural, and the gift of aid often received with gratitude by the recipients, who are often touched by the knowledge of outside interest. However, enormous resources can now be devoted to disaster relief operations, and their effects are far beyond that of a simple gift. All evidence is that our power to help is more limited than we might think: worse, there is much evidence that much, if not most, international disaster assistance is not only useless for its intended purpose but often, by its nature and quantity, actively obstructs actions which might be of use. This paper has two themes. The first is an attempt to define the health problems caused by disasters, a subject known as ‘disaster epidemiology’: that is who suffers, why, how this varies between disasters and, crucial for relief, the timing of these effects. The second is concerned with what can be achieved by international disaster relief. The material presented here is based on a book (Seaman et al., 1984) in which the topic is discussed in more depth and where more source material is given.
Definitions There have been many attempts to define ‘disaster’, none of which is very satisfactory, e.g. ‘an overwhelming ecological disruption occuring on a scale sufficient to require outside assistance’. The chief problems, illustrated by this example, are of scale and need -a small flood which kills one family is overwhelming to those affected although it is unlikely to attract international attention. The classification used here is simply by disaster type. Those considered are (i) earthquakes; (ii) floods, to include both catastrophic floods such as the ‘tidal wave’ of cyclonic storm-surge, dam-burst and tsunami (caused by undersea earthquakes) and slower rising 0 1990 Butterworth & Co (Publishers) Ltd 0020-1383/90/010005~4
ones; (iii) high winds, including cyclones and tomados. Mixed forms of course occur. Torrential rain and flooding is often associated with tropical cyclones. The effects of disasters on health are considered under four headings which cover most aspects relevant to relief. These are (I) death and injury, (2) communicable disease, (3) environmental exposure and (4) food supply and nutrition. The psychological effects of disasters are the subject of a large literature but are not discussed here, as they rarely receive much practical attention during relief operations.
The effects of disasters on health Death and injury The degree to which disasters, regardless of their location, cause death and injury varies within and between disaster types. The main distinction is between earthquakes, which often cause deaths and injuries on an enormous scale, and the other types of disaster. Floods may cause deaths, again sometimes on a large scale, but rarely, if ever, cause significant numbers of non-fatal injuries. High winds cause both death and injury, but never alone in very large numbers. The reason for these differences is to be found in the mechanical effects of the disasters concerned. Earthquakes generally cause death and injury through the collapse of dwellings and other structures. It is no surprise that where structures are intrinsically dangerous, e.g. the unframed rock and earth houses of Eastern Turkey or the adobe of Central America, relatively slight shocks may cause large numbers of casualties: or that larger shocks are required to produce casualties in California where building stands are higher. For similar reasons diurnal variation is observed in the relationship between earthquakes and casualties in some regions, as more people are likely to be at home at night. Age- and sex-specific mortality and injury vary among earthquakes, but in a largely explicable way. For instance Hogg (1980) noted that in an area affected by the Friuli, Italy, earthquake of 1976 ‘agile groups suffered more than the elderly or the very young. This is because they ran out into the streets . . . which are especially narrow, and were crushed by falling masonry’. A study in the village of Santa Maria Cauque in Guatemala after the 1976 earthquake showed higher mortality for the young and the old and
6
Injury: the British Journal of Accident Surgery (1990) Vol. Zl/No. 1
lower rates in the 15-44 year age group. Infants under one year had lower mortality rates than their older siblings, probably owing to the fact that babies normally slept with, and were protected by the mother. By contrast, serious injury showed a progressive increase in rate with age, with higher rates for older women, an effect which may be analagous to fractures of the neck of femur in affluent countries (Glass et al., 1977). Earthquake injuries are predominately orthopaedic; ‘crush syndrome’ is common after many but not all earthquakes. The variability is probably related to both undereporting and actual differences in incidence relative to building type. There are obvious difficulties in the defining the word ‘injury’, as accurate records are rarely kept, but a rule-ofthumb is that the ratio of deaths to injuries is generally of the order of I : 3 or higher. Floods may cause injuries as a population relocates to higher ground but not many deaths, or where floods are violent, as in the tsunami, cyclonic storm-surge or damburst, there are deaths but few, if any, serious injuries. An individual who is caught by the flood drowns: one who is not survives, generally uninjured. The great cyclonic stormsurges which affect low-lying areas of the Bay of Bengal and which have killed enormous numbers dramatically illustrate this effect. The great storm surge which struck East Pakistan (Bangladesh) in 1970 killed, approximately 240 000 people (Sommer and Mosely, X972), 14.2 per cent of the population. However, injury was largely limited to cuts and bruises and the occasional fracture.’ A ‘cyclone syndrome’ of severe abrasions to the arms, chest and thights where people had clung to trees was noted. Age-specific mortality showed, as might be expected, a greater mortality amongst the young and the old, as these groups would be least able to cling to trees during the hours of the cyclone. There was also a preponderence of female deaths, except in the youngest age groups, probably for the same reason. The wind of cyclones causes some deaths and injuries from flying debris and building collapse, although never in numbers similar to earthquakes or floods. Tomados cause both deaths and injuries, in modest numbers relative to earthquakes, but with a very specific pattern of injuries arising from the sheer violence of the forces involved. There are many head and chest injuries with many and severe soft-tissue injuries. Tornado injuries are also frequently contaminated with debris, often introduced with considerable force, and secondary sepsis is a common problem with management. Communicable disease
A fear of epidemics often exhibited by the authorities and aid agencies and frequently reported by the media after disasters is not well founded in either theory or observation. After many disasters, particularly in rural areas, there are no observed changes in population concentration, water supply, sanitation or other factors which might be expected to affect disease transmission. The diseases which most often cause alarm are typhoid and cholera, the latter sometimes even in regions where it is known not to exist. The fear often voiced, of epidemics arising from the putrefaction of corpses, has no obvious foundation. The only completely unambiguous record of an unusual disease outbreak after a disaster in modem times is of an outbreak of malaria in Haiti after torrential rain associated with a hurricane in 1963 (Mason and Cavalie, 1965). This caused large population movements and interrupted a
chemical control programme. It is estimated that approximately 75 000 excess cases occurred. There are also reports of small outbreaks of leptospirosis associated with floods. However, it must be admitted that information on disease incidence in most developing countries is weak before as well as after disasters, and it is probable that outbreaks have been missed. Specifically, it may be assumed, on the basis of extensive documentation of the health of refugee populations, that where a population is concentrated, epidemics will occur. Most mortality has followed outbreaks of measles and diarrhoeal disease. Although this is not documented after natural disasters, it is probable that such affects regularly occur where populations are concentrated, for example, when retreating to high ground during floods. Environmental
exposure
There are no reliable reports of death from exposure after any disaster on land in recent times. The areas where concern is most often expressed about exposure risk are those where a population loses its housing under very cold conditions, such as Eastern Turkey after an earthquake in winter. This assumption of high exposure risk possibly arises because of the regular exposure deaths amongst climbers, swimmers and others in Western countries, but it is clearly false to assume that an equivalent risk exists for all populations. People who live in cold climates develop appropriate techniques and knowledge about survival. Clothing tends to be heavy and may be worn even at night; and it is often under disaster conditions that basic building materials and firewood are abundant. Populations have proved remarkably effective at rapidly re-establishing the basic ‘microenvironment’ in which they can survive. This is accomplished by movement into undamaged structures or by rapid construction. In Guatemala after the earthquake of 1976, it was estimated that 50 000 improvised dwellings were in use within 24 h of the earthquake (Davis, 1977). From the perspective of theory, however, the risks would seem to be higher than the record would indicate. Environmental exposure is a function not only of a low ambient temperature, but of body insulation, body size, wind and
2
1500
5 : 0 2 m ~lOOO-
1234 ,,..
6 .
5 .
32 'F $ OL f 2 0
/'
500.
-100 .c 1' E t I -80 ; I I -60 3 I 5 /I
:
-40
E 2
k 2
: -120 2
-20
i
*eOJ..~,,~.,....~.~.,~'O 3 4 5 6 7 8 9 101T121314151617181920 Date in February
1976
Figure 1. The number of cases of trauma attending
hospitals in Guatemala City (solid line), the arrival of medical supplies (broken line) and emergency hospitals (numbered points) from intemational donors after the 1976 earthquake. The origins of emergency hospitals were (I) Nicaragua, (2) Panama, (3) Mexico, (4) Costa Rica, (5) US military and (6) packaged disaster hospitals originally designed as a contingency stock for nuclear war.
7
Seaman: Disaster epidemiology
wet. Where an exposure risk would be expected is not in very cold countries but in ‘wet’ disasters, which are more common in the tropics. A thin, lightly clothed population exposed to wet and wind even at quite high ambient temperatures rapidly suffer an exposure risk. The risk is greater for the young. The evidence for the occurrence of such effects in anecdotal but strong after cyclonic storm surges in India, where populations are exposed for many hours to wet conditions, and might also be expected to cause major mortality during extensive and protracted floods, such as those which affected Bangladesh in 1988. Food supply and nutrition Accounts of failures of food supply after disasters are not prominent. It is clear that in many settings problems arise not with food supply as such, but from temporary interuption of the means of distribution. Shops may close and physical supply be interrupted from damage to roads. After earthquakes, household stocks can generally be salvaged, and standing crops are unlikely to be damaged. After slower rising floods, stocks may be removed with the population ahead of the water. The situation is, however, complicated by the fact that in many of the most disaster-prone developing countries governments play a major part in the regulation of staple food supply in normal times and may quickly intervene in time of disaster. For example, after the 1970 Bangladesh storm-surge, following which a large part of the population was either landless or comprised migrant agricultural labourers who might be expected to have had severe problems with employment and supply, cash sufficient to purchase 20000 tonnes of rice was distributed by the government. Similar interventions are recorded from Central America and India.
Relief The experience of the effects of disasters on the health of populations is that it is possible to make generalizations about these which are useful in the planning of emergency relief. To summarize, these generalizations are that there is a potential need for the treatment of large numbers of injured people only after a major earthquake. The need for clothing and shelter, at least for lifesaving purposes, will be confined to specific circumstances which are likely to arise only in direct association with some types of disaster and possibly from a brief period afterwards. There is a potential, indefinable without reference to the specific case, for the spread of communicable disease, although the historical record suggests that the probability of this occurring is not high. Lastly, food shortages of a type likely to cause starvation are only likely to arise under specific conditions. These are likely to be encountered only in specific regions, particularly those prone to major violent flooding. It may be added that the regions of the world in which specific disasters regularly occur are relatively restricted, and it is possible to have an up-to-date knowledge of the local context even from a distance. Against this picture must be set both the actual and theoretical performance of formal relief efforts. These may be divided into two: firstly, those originating within or very close to the disaster area and secondly, those from longer range (in a large country such as India relief may come from all over the subcontinent) including those from abroad.
Local relief The assumption, sometimes implicit in appeals for assistance for disaster-affected populations, that these are passively dependent upon outside relief and, in poorer countries, without material resources, is false. A consistent theme of the disaster literature is the speed and coherence of local response. In many locations active attempts to rescue people from the rubble will be observed minutes after an earthquake; a few hours will see the removal of the injured to any remaining medical facilities; and, as already noted, a day may see the construction of temporary housing. Where medical facilities exist (which includes all urban areas), these will frequently work around the clock to secure treatment for as many people as possible. From hospital records kept after earthquakes, it is clear that most of the injured will be ambulant and only a proportion will require hospital admission. In Managua, Nicaragua an earthquake on December 23, 1972, which was essentially confined to the capital city, caused an estimated 20000 injuries. By December 25 it was reported that the patient load had peaked. A report from an emergency hospital which became operational on December 26 was that ‘The.. . type of patients more closely paralleled those found in any general hospital.. as opposed to an acute disaster situation’ (Coultrip, 1974). After earthquakes, shortages may occur of specific items, e.g. casting materials and anaesthetics, of which consurnption is heavy. But even in countries where drugs are normally in very short supply, such stocks as there are may be rapidly released and supplies may temporarily be adequate. A recent example is that of the 1988 Khartoum floods, where drugs were released from stock (intended as a capital stock for a drug scheme) within hours of the disaster. There are of course many locations, particularly in mountainous regions, where communications are poor and formal services non-existent, e.g. parts of rural Peru and the Himalayas. Under these conditions medical assistance will be slight. External relief To be useful, external relief must meet exacting targets of specificity of type and speed. The problem may be viewed from two aspects: what is possible theoretically and what has been achieved in fact. The theoretical case is not entirely so, as it has often been proposed that standing, usually military, ‘disaster forces’ should be created in western countries for rapid deployment overseas. In theory, a ‘standing disaster force’ in an industrialized country, properly equipped, with free access to transport aeroplanes and material, should be able to reach the site of a disaster in a period of hours, assuming that the main airport of the country concerned is undamaged. All that should be required is adequate notice of the occurrence of the disaster for movement to be initiated. Neglecting real impediments, such as visa requirements, which are not usually waived in time of disaster, or, where a standing force is military, the disinclination of many countries to have foreign armed forces arrive unannounced, there is one currently insurmountable obstacle. In an era of instant communications and live broadcasts from scenes of crisis it may be assumed that we are instantly aware of the existence and nature of all disasters. In fact, nothing could be further from the truth. News of some disasters reaches Western countries very quickly - within an hour or two. However, not all disasters are reported.
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Injury: the British Journal of Accident Surgery (1990) Vol. Zl/No.
Nether or not a disaster is reported appears to be a complex function of several variables: its likely scale, its location, some countries being of more interest than others, and competing news. An interesting account of these effects, relating to famine rather than natural disaster, but illustrating the same effects, is given by Harrison and Palmer (1986). More important, the scale of a disaster is not usually accurately known until days or weeks after it has occurred. For example, the Guatemala earthquake of 1976 was initially reported to have killed less than 1000 people. By day 4 the estimate had risen to 14 000. The hue total of over 20 000 was not appreciated until day 7. The 1980 Algeria earthquake showed the reverse of this effect, the estimate falling from 20000 on day 1 to a more accurate 4000 on day 4, although the higher estimates persisted until day 9. The experience of major international disaster relief operations, which it should be emphasized are only initiated for some major disasters, is that they proceed primarily on the basis of the assumption that all disasters require large amounts of medical assistance of all types, clothing, blankets and food. Further, they are initiated and carried through very slowly relative to the evolution of events in the disaster area. Typically they reach a peak a week or two after the disaster impact. Lastly, they are pursued by large numbers of agencies and individuals without reference to each other, nor can coordination occur, as the numbers of agencies and the creation of new groups preclude it. The result is frequently chaotic, the recipient country being swamped with unlabelled drugs and other materials which are not required, and people who neither speak the language nor, often, possess useful skills. Here only one case is presented, that of Guatemala in 1976 (&we I). It is of note that the only emergency hospitals deployed during the period when there were untreated casualties were from the neighbouring Spanishspeaking states. British assistance was declined because of the territorial dispute with Belize. The quantity of drugs supplied after the Guatemala earthquake amounted to over 120 tonnes, mostly unlabelled, much unsuitable and some outdated. One item was a 1934 medical sample from North America.
Postscript Two additional points should be made. The first is that the case presented neglects the fact that in many situations a medical need, although much reduced in scale, persists after the first few days of a disaster. One recent example is the earthquake in Soviet Armenia, where there were cases of renal failure secondary to the ‘crush syndrome’ that could have benefitted from dialysis, which was not locally available. Clearly these are potentially accessible to international assistance. The cost of providing such assistance is very high
I
(the deployment of a military emergency hospital may cost hundreds of thousands of pounds) and it is a judgement as to whether this is, particularly for poorer countries, money well spent. A sharper example would be the Khartoum flood of 1988, in which millions of pounds were spent on air freight (chiefly of redundant blankets and tents, many of which accumulated at the airport), and in a country where health expenditure in 1989 was approximately x0.5 per person per year. The second point concerns what assistance can be effectively provided from abroad. For emergency relief there are some requirements in certain countries. Heavy lifting equipment may sometimes be of value after earthquakes, and the control of communicable disease may require epidemiological help to set up a surveillance system. However, help should chiefly come at a later time. Disasters cause not only loss of life but vast damage to economy and infrastructure, which developing countries can ill afford to repair. In general, there is less international interest in this than in emergency relief. An estimate by the US Govemment Office of Foreign Disaster Assistance for the period 1965-1975 showed that the ratio of costs borne locally to those met by international aid was of the order of 42 : I. There is ample time to provide effective international disaster assistance.
References Co&rip R. L. (1974) Medical aspects of US disaster relief operations in Nicaragua. M&t. Med. 139, 879. Davis I. (1977) Housing and shelter provision following the earthquakes of February 4th and 6th 1976. DisustersI, 82. Glass R. I., Urrutia J. J., Sibomys S. and Smith H. (1977) Earthquake injuries related to housing in a Guatemalan village. !%ience(N.Y.1 197,638. Harrison P. and Palmer R. (1986) News art ofAfrica Biafra to iha’ Aid. Hilary Shipman Ltd. Hogg S. J. (1980) Reconstruction following seismic disaster in Venzone Friuli. Disasters 4,173. Mason J. and Cavalie P. (1965) Malaria epidemic in Haiti following a hurricane. Am. J Trap. Med. l-fyg. 14,533. Seaman J., Leivesley S. and Hogg C. (1984) Epidemiology of natural disaskrs. Karger: Basel. Sommer A. and Moseley W. H. (1972) East Bengal cyclone of November 1970: epidemiological approach to disaster assessment. Lancet i: 1029.
Requpsfsfor reprinfs shouti be aallressed to: Dr J. Seaman, Senior Medical Officer, The Save the Children Fund, 17 Grove Lane, London SE5 SRD, UK.
