1

M O D U L E 1

Disasters and their Effects

on the Population: Key Concepts
Patrick Mahar | Julia A. Lynch | Joseph Wathen | Eric Tham | Stephen Berman |
Sathyanarayanan Doraiswamy | Allen G.K. Maina
Disasters and their 1
Effects on the Population:
Key Concepts
Patrick Mahar, MD; Col. Julia A. Lynch, MD, FAAP;
Joseph Wathen, MD; Eric Tham, MD, MS, FAAP;
Stephen Berman, MD, FAAP; Sathyanarayanan
Doraiswamy, MD; Allen G.K. Maina, MD
INTRODUCTION
The recent advances in technology and the ease with which news and information
travel around the world has made learning about disasters in distant countries an
almost weekly occurrence. From the recent conflicts in Syria, Iraq, South
Sudan, the Central African Republic to the recent typhoon in Philippines
and recent flooding in Zambezi, these disasters have lead to unimaginable
levels of destruction and death. Although most of these disasters occur in
underserved areas in the world without adequate resources and technology,
they can also occur in societies with advanced medical systems such as
the United States, Europe and Japan. It is impossible to predict when and where the
next disaster will take place. However, we can strive to be prepared to handle both
the acute and longer-term effects of a variety of disasters in different populations.
While the timing and the actual disaster event are difficult to predict, there are
several consequences of disasters that are predictable and thus we can be prepared
to deal with these consequences. As pediatricians, we must ensure that disaster
preparedness includes the unique needs of children. Children are a vulnerable
population with physiologic, psychological and developmental needs that are not
seen in adult populations. There is a professional obligation to take an active role in
disaster preparedness in order to advocate for the needs of infants, children and
teenagers. In this module, we will review disaster definitions, classifications, and
measures of severity; describe the phases of a disaster, review the World Health
Organization recommended emergency response measures; discuss the role of
humanitarian organizations; and present key issues that health care workers and
medical volunteers may face in the relief role. The key message of this module
is to understand that, while it is not possible to predict disasters, planning and
preparation can help mitigate some of the morbidity and mortality that occur
in the aftermath of a disaster. This message has been clearly stated by Benjamin
Franklin: “Failing to plan is planning to fail.”
 S EC TI O N I / D E F I N I T I ON S

DEFINITIONS

Definitions
OBJECTIVES What makes an event a disaster? Why is
one hurricane or tornado a disaster and Any adverse episode
l Recognize events that can lead to
disasters. the next one, even with stronger winds, is or phenomenon can
just a bad storm? The answer lies with how exploit a vulnerability
l Understand the individual and social in the affected
factors associated to with vulnerability,
the population is eventually affected: both population or
coping, and risk. the direct effects on the people as well as the community to create
damage, and this
indirect effects or damage to infrastructure. awareness will form
The United Nations International Strategy the basis for an
for Disaster Reduction defines disaster as adequate intervention.
CASE
1.You are informed there has been a a serious disruption of the functioning
flood affecting one of the provinces of of a community or a society involving
your country. According to the latest widespread human, material, economic
population census, around 200,000 or environmental losses and impacts,
people who are mostly poor live in which exceeds the ability of the affected
this area.
community or society to cope using its
l What are the characteristics that
own resources.
indicate that this event can be
defined as a disaster? Disasters are often described as a result
l What type of disaster is it? of the combination of: the exposure to
a hazard; the conditions of vulnerability
2. Twenty-five percent of the
population affected by the flood are that are present; and insufficient capacity
children aged 0 - 12 years old. This or measures to reduce or cope with the
population is more vulnerable than potential negative consequences. Disaster
others in disaster situations. impacts may include loss of life, injury,
l What characteristics make
disease and other negative effects on
children more vulnerable?
l What specific interventions are
human physical, mental and social well-
necessary to diminish the effects of being, together with damage to property,
disaster upon children? destruction of assets, loss of services, social
3. After arriving at the flooded area, and economic disruption and environmen-
you must decide what to do to deli- tal degradation. A disaster disrupts the
ver health care to the victims normal pattern of life, causing both physical
l What is the first step to be taken? and emotional suffering and an overwhelm-
l How useful are field hospitals in
ing sense of helplessness and hopeless-
these situations? ness. The impact on the socioecono­ mic
l How would you estimate the need

for external help? structure of a region and ­ environment

often requires outside assistance and
 6 S ECTI ON 1 / DEFINITIO NS

intervention. Although there are many def­

initions for disaster, there are three com­ BOX 1. Definitions of a disaster
mon factors. (Box 1) First, there is an
event or phenomenon that impacts a pop­ “A disaster is a crisis resulting from a failure in
ulation or an environment. Second, a vul­ human interactions with the physical and social
nerable condition or characteristic allows environment. Disaster situations outstrip the
capacity of individuals and societies to cope with
the event to have a more serious impact. adversity”.
For example, a hurricane will cause much HDI, From Disaster Relief to Development, Studies on
greater damage to life and structures if it Development, No 1 (Geneva: Henry Dunant Institute,
1988), p. 170.
directly strikes an area with poorly con-
structed dwellings compared to striking a “A disaster is the convergence, at a given moment
Disasters can be and in a given place, of two factors: risk and
divided into 2 large
community of well-built homes with vulnerability”.
categories: those greater structural support. Identifying
­ G. Wilches-Chaux, “La vulnerabilidad global,” in Herramientas
caused by natural these factors has practical implications for para la crisis: Desastres, ecologismo y formación profesional
(Popayan, Colombia: Servicio Nacional de Aprendizaje
forces and those communities’ preparedness and provides a [SENA], Sept. 1989).
caused by man.
basis for prevention. Third, local resources
“A disaster has occurred when the destructive
are often inadequate to cope with the effects of natural or man-made forces overwhelm
problems created by the phenomenon or the ability of a given area or community to meet
event. Disasters affect communities in mul­ the demand for health care.”
Mothershead JL et al. Disaster Planning. Available at:
tiple ways. Their impact on the health care http://www.emedicine.com/emerg/topic718.htm#section~
infrastructure is also multi-factorial. The definitions_and_terminology.
disaster event can cause an u­nexpected “A disaster can be defined as a serious disruption
number of deaths. In addition, the large of the functioning of a society, causing widespread
numbers of wounded and sick often human, material or environmental losses which
exceed the local community’s health care exceed the ability of the affected society to cope
using only its own resources.”
delivery capacity. The community’s ­capacity
Bryce, C.P. “Stress management in disasters”, Washington
to care for those affected is often reduced D.C, OPS, 2001.
because professionals, clinics and hospitals
have been affected or destroyed. This will
have long-term consequences leading to
increased morbidity and mortality. An ter becomes much more devastating when
example of this can be seen in the 2010 the preexisting medical system is already
Haiti earthquake disaster. Prior to the inadequate and poorly functional. This
January 12, 2010 earthquake in Haiti there makes integrating and organizing outside
were only 11 hospitals in Port-au-Prince. assistance more fragmented and chaotic.
The earthquake damaged or destroyed at An epidemic/pandemic can cause a surge
least eight of these hospitals. The remain- in the number of people seeking m ­ edical
ing health facilities were quickly over- care/treatment, and thus overwhelms the
whelmed by large numbers of survivors abilities of even a well established m­ edical
requiring a wide range of care, ­particularly system. The Ebola epidemic in West Africa
for traumatic injuries. The 2010 earth- is an example of how a disaster can affect
quake in Haiti demonstrates how a disas- the rest of the world, as cases of Ebola were
 S ECTION 1 / DEFINITIO NS 7

seen outside the boundaries of Guinea, Classification of disasters

Liberia, and Sierra Leone including in the US Disasters can be divided into 2 large cat-
and Europe. The Ebola epidemic stressed egories (Box 2):
the emergency medical services and hos- – Those caused by natural forces.
pitals throughout the world, particularly – Those caused by man.
in Guinea, Liberia and Sierra Leone. The
disaster can have adverse effects on the Natural disasters
environment that will increase the risk for Natural disasters are caused by ­ natural
infectious transmissible diseases and envi­ forces, such as earthquakes, volcanic erup­
ronmental hazards. The loss of clean drink­ tions, hurricanes, fires, tornados, and
ing water and proper sewage disposal/ extreme temperatures.
treatment can have ­ devastating effects They can be classified as rapid onset dis­
on a population affected in the dis­ aster. asters such as earthquakes or tsunamis,
This will impact morbidity, p­remature and those with progressive onset, such as
death, and future quality of life. There can droughts that lead to famine.
be shortages of food, with severe nutri- These events, usually sudden, can have
tional consequences. All these conditions tremendous effects. For instance, in
lead to a sense of hopelessness, vulnerabil­ November 2013, more than 6000 people
ity, and inability to think that the future will died and displaced over 4 million people in
be better. This means that people no Philippines as a result of Typhoon Haiyan.
longer visualize their future by making
­ Since it is still extremely difficult to pre-
plans such as finishing school, getting mar- cisely predict the climatic and geological
ried and working. This “foreshortened changes capable of causing a disaster, pre-
future” affects the psychological and social paring for these types of disasters remains
behavior of the community. (Figure 1) a major challenge. Great natural disasters
have also occurred recently throughout
the world (Box 3).

FIGURE 1. Components of a disaster

PHENOMENON X VULNERABILITY = IMPACT

• Droughts • Human
• Volcanic • Economic
eruptions • Social
• Floods • Ecological
• Earthquakes • Political
• Hurricanes • Legal
Adapted from Handbook of War and Public Health; ICRC; 1996.
 8 S ECTI ON 1 / DEFINITIO NS

BOX 2. Types of disasters

Natural disasters Man-provoked disasters

• Hurricanes or cyclones Technological/industrial disasters
• Tornadoes • Leaks of hazardous materials
• Floods • Accidental explosions
• Avalanches and mud slides • Bridge or road collapses, or vehicle
• Tsunamis collisions
• Hailstorms • Power cuts
• Droughts Terrorism/International violence
• Forest fires • Bombs or explosions
• Earthquakes • Release of chemical materials
• Epidemics • Release of biological agents
• Release of radioactive agents
• Multiple or massive shootings
• Mutinies
• Intentional fires
Complex emergencies
• Conflicts or wars
• Genocide

Modified from Lou Romig, Disaster Management, in APLS, 4TH Edition, J&B Publishers, 2004

BOX 3. Natural disasters in the Americas in 2013

Heat Waves:
Bolivia: August 2013, People affected 17490, 18 died
Earthquakes:
Colombia: September 2013, people affected 3957
Peru: September 2013, people affected 7084
Epidemics:
Costa Rica: Viral outbreak July 2013, People affected 1200, 3 died
Guatemala: Viral outbreak August 2013, People affected 1977, 8 died
Floods:
Argentina: July 2013, people affected 350000, 52 died
Usually, a great Bolivia: February 2013, People affected 145000, 25 died
number of persons Brazil: January 2013, People affected 200000, 4 died
die when a complex Peru: Feb 2013, people affected 180766, 67 died
humanitarian Volcanic Eruptions:
emergency occurs. El Salvador: December 2013, people affected 63079
Tornado:
USA: May 2013, Oklahoma city, people injured 370, killed 26

Modified from: http://emdat.be/disaster_list

 S ECTION 1 / DEFINITIO NS 9

The inability to accurately predict these Complex humanitarian emergencies

types of events underscores the need The term complex emergency is usually
for countries to have disaster response used to describe the humanitarian emer-
plans to mobilize appropriate resourc- gency resulting from an international or A person recognized
es rapidly and efficiently. A well-defined civil war. In such situations, large numbers as a refugee is entitled
organizational structure also must be of people are displaced from their homes to certain protections
created to coordinate both national and under the terms of
due to the lack of personal safety and the international
­internation­al  assistance. disruption of basic infrastructure including humanitarian laws.
Although significant progress in sanita- food distribution, water, electricity, and san­
tion and response to disasters has been itation, or communities are left stranded
achieved in certain regions of the world, and isolated in their own homes unable to
developing countries continue to be access assistance. These settings are often
high­ly vulnerable because of their fragile characterized by a breakdown in social and
­economy and health care and transporta- physical infrastructure, including health care
tion infrastructure. systems. Any emergency response usually
has to be implemented in a problematic
Man-made disasters political and safety environment.
Disasters caused by man are those in There has been a global increase in civil
which major direct causes are ­identifiable
war fueled by ethnic confrontations since
intentional or non-intentional human
the mid-1990s (Figure 2). In modern
actions. They can be subdivided into three
conflicts the greatest loss of life (90%)
main categories:
occurs among civilian nonfighters because
of direct physical injury and the public
Technological disasters
health impact of war (Figure 3).
Unregulated industrialization and inade-
Complex humanitarian emergencies
quate safety standards increase the risk for
often result in a staggering loss of lives.
industrial disasters. Examples include the
Table 1 shows the estimated excessive
radioactive leak in the Chernobyl nuclear
deaths among civilians in several recent
station in Ukraine (1986) and the toxic gas
and ongoing crises.
leak in a Bhopal factory in India (1984). Both
of these disasters were associated not only
with many deaths but also with long-term Displaced populations
health effects in the affected population. Natural disasters and complex emergen-
cies can force many people to leave their
Terrorism/Violence homes. The primary purpose of United
The threat of terrorism has also increased Nations High Commissioner for Refugees
due to the spread of technologies i­nvolving (UNHCR) is to safeguard the rights and
nuclear, biological, and chemical agents used well-being of people who have been
to develop weapons of mass destruction. forced to flee including the right to seek
Too often the professionals who must asylum and find safe refuge in another
respond to such disasters are not appropri- country. Refugees and internally displaced
ately trained, although several national and persons (IDPs) are among the categories
international organizations are developing of persons that UNHCR assists.
training programs for these types of events.
10 S ECTI ON 1 / DEFINITIO NS

FIGURE 2. Number of disasters and victims in the world from 1990 to 2012

800 500

431 438
428 428 450
700 417 417
402
Number of reported victims (in millions) *

372 370 400

671
369 360 364
600 345 349
330 350

Number of reported disasters

303
500
278 273 300
266
253 261
239 234
400 224 250

364 200

342
300
302
293
292

150

270
268

266
253
243
200
233

226
226
214
201

100

179
161
147
100

128
50
100

97
85

81

0 0

Victims (in millions)* No. of reported disasters

*Victims : Sum of deaths and total affected

Source: “Annual Disaster Statistical Review 2013: The numbers and trends.” Debarati Guha-Sapir, Philippe Hoyois and Regina Below http://reliefweb.int/sites/
reliefweb.int/files/resources/ADSR_2013.pdf

FIGURE 3. Global conflict-induced internal displacement, 1993–2013 (end-year)

(in millions)
35

30

25

20

15

10

0
‘93 ‘95 ‘97 ‘99 ‘01 ‘03 ‘05 ‘07 ‘09 ‘11 ‘13
Portion of IDPs protected/assisted by UNHCR

Source: “War’s Human Cost.” UNHCR Global Trends 2013. http://www.unhcr.org/5399a14f9.html

 S ECTION 1 / DEFINITIO NS 11

TABLE 1. Deaths among civilian populations during recent complex

humanitarian emergencies

Country Deaths Period

Sudan Over 1 million 1983 to date

Rwanda 500,000-1 million 1994 to date

Cambodia Over 1 million 1975-1993

Bosnia-Herzegovina 200,000 1992-1996

Refugees flee their countries because of 1. Preparedness phase

war, violence, famine, or well-founded fear 2. Emergency phase
of persecution for political, ethnical, reli- 3. Recovery phase
gious or nationality reasons. According 4. Mitigation and prevention phase
to the 2015 UNHCR estimates there
are 21.3 million refugees and 10 million Preparedness phase
stateless people. (Figure 5). A person Planning comprises all the activities and
recognized as a refugee is entitled to actions taken in advance of a disaster.
certain protections under the terms of Planning should be based on the analysis
international humanitarian laws. of a community’s or organization’s risk for
IDPs leave their homes for similar rea- exposure to specific types of ­ disasters.
sons but do not cross the boundar- Preparedness plans should take into
ies of their countries. These individuals account the frequency of occurrence of
do not receive the same kind of legal each type of dis­ aster, the ­anticipated
­protection, so helping them can be much ­magnitude of effect, the degree of advanced
more ­ diffi­
cult. According to the 2015 warning or suddenness of onset and off-
Internal Displacement Monitoring Centre set, characteris­ tics of the populations
estimates, there are 65.3 million dis- most likely to beaffected, the amount and
placed people. More information is avail­ types of r­esources available within the
able at http://www.unhcr.org/figures-at- community or organizational structure,
­
a-glance.html and/or http://www.unhcr. and the ­ability to function independently
org/internally-displaced-people.html. without a­dditional outside resources for
periods of time. For more information on
Phases of disasters planning, see Module 3.
Since interventions in emergencies evolve
as a continuum, the identification of the Emergency phase
following four phases is useful to better Response comprises all activities and
establish priorities and response activities, actions taken during and immediately
and to systematize previous experiences: after a disaster. This includes notification
12 S ECTI ON 1 / DEFINITIO NS

FIGURE 4. Number of Refugees per 1000 Inhabitants

FIGURE 5. UNHCR Refugee Population 1990 –2014

 S ECTION 1 / DEFINITIO NS 13

of the organizations involved in disas- sons are then applied in an effort to pre-
ter response, setting up of initial com- vent the recurrence of the disaster itself
munication networks, initial search and or to lessen the effects of subsequent
rescue, damage assessment, evacuation, events. Mitigation includes preventive and
sheltering and other multiple activities. precautionary measures such as changing
The response phase lasts until the ini- building codes and practices, ­redesigning
tial casualties have either been rescued public utilities and services, reviewing
or acknowledged as lost, and enough mandatory evacuation practices and
­
resources have been made available to ­warning policies, and educating ­members
meet immediate humanitarian needs of of the community. Mitigation and ­planning
affected population, assessing damages are continuous processes, as lessons
and beginning to plan for restoration and learned from a previous disaster are
recovery. In the case of conflict situation, included in planning for the next one.
displacement could be protracted until
safety and security return to the place Effects of disasters
of origin of affected people. For those Disasters affect communities in multiple
affected, response services may have to ways. They represent a public health haz-
provide in camps designed to host them ard for various reasons (Table 2):
for short periods. While in most instances l Can cause an unexpected number of

of natural disasters, normalcy returns in deaths and wounded or sick people

days to weeks, in the case of conflict, this that exceed the local resources capacity
could take several years before people to respond and require external aid.
return to their homesteads. l Can destroy health infrastructure not

only affecting the immediate response,

Recovery phase but also disrupting preventive activities,
The recovery phase is the period in which leading to long-term consequences with
the affected organization or ­ community increased morbidity and mortality.
l Can have adverse effects on the envi-
works toward re-establishing self suffi­
ciency. This is the period of new commu­ ronment that will increase the risk for
nity planning, rebuilding, and re-establish­ infectious transmissible diseases and
environmental hazards. This will impact
ment of government and public service
morbidity, premature death, and future
infrastructure. The health status of affect-
quality of life.
ed population begins to return to pre-dis­ l Can affect the psychological and social
aster conditions and the outside support
behavior of the community.
services are gradually withdrawn. l Can cause shortages of food, with

severe nutritional consequences.

Mitigation and prevention phase l Can cause large movements of the pop­
This phase usually occurs when condi-
ulation, both spontaneous or orga-
tions are returning to their predisaster nized, to areas where health services
state. Mitigation is the phase in which all might not be able to handle the exces-
aspects of emergency management are sive requirement.
scrutinized for “lessons learned”; the les-
14 S ECTI ON 1 / DEFINITIO NS

TABLE 2. Frequent effects of disasters

Disaster Complex Earthquake Strong Floods Gradual Mud Volcanic
type emergency winds floods slides eruptions
Effect
Immediate deaths Numerous Numerous Few Numerous Few Numerous Numerous
Severe lesions Numerous Numerous Moderate Few Few Few Few
Increased risk for This risk applies to ALL significant disasters, and increases with overcrowding and deterioration
transmissible of sanitary conditions
diseases
Damage to health Moderate; can Severe Severe Severe but Severe Severe but Severe
centers be severe if localized (only for localized
health centers equipments)
are military
targets
Damage to water Severe Severe Slight Severe Slight Severe but Severe
supply localized
Food shortage Severe May result from economic Frequent Frequent Not frequent Not frequent
and logistic factors
Significant Frequent Frequent; Not frequent Frequent
population increased
displacements likelihood in
severely
damaged
urban areas
 S EC TI O N II / M OR T AL I T Y

MORTALITY
per day. In developing nations, the refer-
OBJECTIVES ence CMR value varies from 0.4 to 0.7
deaths per 10,000 people/day. A CMR
l Recognize crude mortality and under 5 above 1 death per 10,000 people/day Most diseases
mortality rates as a measure of disaster or under-5 mortality of over 2/10,000 associated with
severity the event can be
l Recognize the environmental factors
children under 5 per day is considered
prevented by adequate
associated with increased morbidity and a humanitarian emergency. To assess interventions, especially
mortality rates the progression of a disaster and the ensuring basic life
l Know the 5 leading causes of death in
effectiveness of relief interventions, mea- saving needs of the
humanitarian emergencies occurring in sure the CMR over several appropriate population are met.
developing countries This includes shelter,
time intervals. For example, during the food, water, sanitation,
month following the massive movement health care services
Severity of a disaster of Rwandan refugees to Eastern Zaire (the and security measures.
As was demonstrated in Haiti, the more
fragile the pre-event health status of the
affected population and inadequate the
pre-disaster infrastructure, the more
severe the disaster. Disaster severity will,
therefore, vary according to its magnitude
and the vulnerability of the population. An
example of this is seen in earthquakes of
similar magnitude in different parts of the
world. Earthquakes in China and Haiti
resulted in a large number of collapsed
buildings, including schools and hospitals,
related to substandard building practices
in both, and thus high number of casual-
ties. The damage from similar magnitude
earthquakes occurring in Tokyo in 2009
and Chile in 2010 resulted in far less loss
of life in large part due to the higher
­quality of construction and stricter ­building
codes. When assessing the outcome of a
disaster, public health officers describe its
severity by the number of human lives
lost using the crude mortality rate
(CMR). CMR is usually defined as the Natural disasters can result in numerous immediate deaths due to
trauma
number of deaths per 10,000 inhabitants
 16 S E CTI ON I I / MO RTALITY

present Democratic Republic of Congo), needs of the population are met. This
the CMR in that region was 40 to 60 times includes shelter, food, water, sanitation,
above the corresponding reference value. health care services and security mea-
While both conflicts The CMR is usually highest during the ini- sures. Immediate mortality in any type of
and natural disasters
can result in
tial phase of a disaster. Figure 6 ­displays disaster is not higher in a specific age range;
immediate deaths due the differences between baseline and instead, it usually reflects the age distribu-
to trauma or peak disaster CMR experienced by dis- tion of the overall population. However,
drowning, there are placed populations in different countries. later on the mortality rate associated
many preventable Additional information regarding these with the disaster is disproportion-
deaths that occur in
later phases of a
epidemiologic measurements may be ately ­ higher among the youngest
disaster over a longer found in Module 2, “Preventive Medicine and ­ oldest people. In a refugee cri-
time period. in Humanitarian Emergencies.” sis in Northern Iraq in 1991, children
aged 0 to 5 accounted for only 18%
Vulnerable victims of the total refugee population, but they
Most diseases associated with the event accounted for 64% of the overall refugee
can be prevented by adequate interven- mortality rate.
tions, especially ensuring basic life saving

FIGURE 6. CMR and under-5 MR during the 2011 Horn of Africa Drought crisis

Source: “Mortality among populations of southern and central Somalia affected by severe food insecurity and famine during 2010–2012.” A Study commissioned
by FAO/FSNAU and FEWS NET from the London School of Hygiene and Tropical Medicine and the Johns Hopkins University Bloomberg School of Public Health
http://reliefweb.int/sites/reliefweb.int/files/resources/Somalia_Mortality_Estimates_Final_Report_1May2013.pdf
 S ECTION I I / MO RTALITY 17

The most vulnerable groups include cal to attempt to reunite children with
­children, especially those displaced from their families as soon as possible and pay
their families, women who are pregnant, special attention to reducing their vulner-
lactating, or live without their spouse; ability in all disaster response planning
individuals living in households headed (Box 4).
only by women; disabled individuals; and
the elderly. In addition to disproportion­ Causes of mortality
ately high mortality rates, children dis- The immediate goal for any intervention
placed from their family are at high risk in humanitarian emergencies is to reduce
for a number of adverse ­consequences, the number of deaths. While both conflict
including rape, torture, robbery and and natural disasters can result in imme-
exploitation in child labor, child t­ rafficking, diate deaths, there are many preventable
and child soldiering. Additionally, because deaths that occur in later phases of a dis­
of certain physical and physiological char- aster over a longer time period.
acteristics, infants and children are more Five leading medical problems have con-
vulnerable to the release of toxic sub- sistently been found to be the major mor-
stances and the overcrowding associated tality causes in post-war or post-natural
with the displacement of large popula- disaster settings among vulnerable popu­
tions (Table 3). Consequently, it is criti- lations (Box 5).

TABLE 3. Vulnerable pediatric characteristics

Pediatric characteristic Special risk during disaster
Respiratory Higher minute volume increases risk from exposure to inhaled
agents. Nuclear fallout and heavier gases settle lower to the
ground and may affect children more severely.
Gastrointestinal Higher risk for dehydration from vomiting and diarrhea after
exposure to contamination.
Skin Higher body surface area increases risk for skin exposure. Skin
is thinner and more susceptible to injury from burns,
chemicals, and absorbable toxins. Evaporation loss is higher
when skin is wet or cold, so hypothermia is more likely.
Endocrine Increased risk for thyroid cancer from radiation exposure.
Thermoregulation Less able to cope with temperature problems, with higher risk
for hypothermia.
Developmental Lower ability to escape environmental dangers or anticipate
hazards.
Psychological Prolonged stress from critical events. Susceptible to
separation anxiety.

Adapted from AAP, Pediatric Education for Prehospital Professionals, Jones & Bartlett Publishers, London, 2006.
 18 S E CTI ON I I / MO RTALITY

BOX 4. Immediate measures developed to reduce population’ s vulnerability

during a disaster

l List vulnerable people in the community

It is critical to attempt l Provide visible identification tags to all children
to reunite children
with their families as
l Identify the community leaders –women whenever possible– capable of
soon as possible and taking care of a vulnerable individual or group
give special attention l Guarantee the care and safety of refugees
to reducing their l Consider the vulnerable individuals when planning the distribution systems
vulnerability in all
l Assign priority to the search for parents or families of unaccompanied or
disaster response
planning. otherwise vulnerable individuals
l Post in a central place the photographs of children separated from their

families, to enhance their identification

l Make sure that camps or shelters, if needed, are located as near the affected

areas as possible
l Place families and groups of neighbors together

BOX 5. The five leading causes BOX 6. Predisposing

of death in humanitarian environmental conditions
emergencies occurring in
developing nations l Disruption of food
sources/economy
l Diarrheal diseases and l Disruption of sanitary services
dehydration l Income loss
l Measles l Discontinuation of healthcare
services
l Malaria l Overcrowding
l Acute respiratory infections l Lack of adequate water supply
l Loss of shelter
l Malnutrition

Unique features in each disaster (eg, cli­ immediate cause of death, is the most
mate, topography, pre-existing social important factor correlated to the high
structure, physical conditions) affect the mortality rates due to transmissible dis-
proportion of deaths associated with eases. A study including 41 displaced pop­
each of these, as well as other causes. ulations (Figure 8) showed a clear cor-
Figure 7 shows mortality in various dis- relation between the crude mortality rate
placed populations following natural dis­ (i.e., death from all causes) and the preva-
asters and armed conflicts. Malnutrition, lence of malnutrition.
although not identified as a significant
 S ECTION I I / MO RTALITY 19

FIGURE 7. Causes of death in children less than 5 years old in displaced populations
due to natural disasters and war in Mozambique
Malnutrition Malnutrition
Other
23 % 21 %
3%
Malaria
25%
Malaria Measles
16 % 10 %
Other
Acute 22%
Acute
respiratory respiratory
infection infection Cholera
9% 3% 26 %
Diarrhea Measles
Non-cholera
11 % 10 %
diarrhea
19 %
Natural disasters Malawi, Lisungwe Camp

From MMWR, vol. 41/No. RR-13. Major causes of death in children <5 yo. Source: UNHCR, MSF, IRC monthly report.

FIGURE 8. Crude mortality rates (deaths per 1,000 individuals per month) in
relation to malnutrition prevalence*

*Malnutrition Prevalence in Population (%)

(Malnutrition = <80% weight/height WHO reference population)

In the context of a disaster, each of the national relief experts identified 10

leading causes of death relates to one or essential emergency relief measures
more predisposing environmental condi­ to consider when planning a disaster
tions that increase the incidence of dis­­ response. These interventions should
ease and the mortality rate per case not to be implemented in a strict order;
(Box 6). For interventions to be effec- priority for each of them is corre-
tive, resources should be targeted to lated to the particular needs relating to
prevent and correct these predisposing each emergency situation. In addition,
environmental factors, in addition to these interventions should be adjusted
treating the ill individuals. At a World to the particular situation in the affected
Health Organization conference, inter­ region.
 SECTION III / ESSENTIAL
EMERGENCY RELIEF MEASURES

ESSENTIAL EMERGENCY
RELIEF MEASURES
Unpredicted effects may require urgent
OBJECTIVES attention. For example, safe water ­supply
An appropriate is unlikely to be affected by a strong
response should be l Understand the 10 essential emergency storm or a mudslide. However, if the
based on the relief measures (as defined by WHO). regional system for water pumping or
particular needs in
each disaster.
l Know how these measures should be purification is affected, the shortage of
implemented in the community. safe water becomes the key issue that
must be addressed to prevent disease and
excessive mortality in the affected popu-
Each disaster or humanitarian emergency lation. Use resources in a timely manner,
is a unique situation determined by the within the time frame determined by the
event that caused it, climate, geography, disaster. For example, trauma is likely to
culture, social structure, and previous be the major cause of death immediately
conditions of the affected population. after an earthquake. If trauma surgery
Thus, national and international organiza- teams and field hospitals arrive a week
tions should initially implement a rapid after the earthquake, most of the trauma-
assessment and resist the impulse to related deaths will already have occurred
immediately respond before critical infor- and very little benefit will be obtained
mation is available. Interventions that are from this high-cost resource.
based on speculations rather than on WHO and PAHO have developed
accurate information obtained in the guidelines for the appropriate use of field
place of the disaster are likely to waste hospitals in disasters of sudden impact
time and valuable resources, ultimately (www.paho.org/disasters).
increasing the suffering of the a­ffected
population. Although similar types of dis­ Essential emergency relief
asters have predictable patterns of dis­ measures
ruption as shown in Table 2 (page 13),
the degree of severity and type of 1. Do a rapid assessment of the
response is affected by local features. emergency situation and the
An appropriate response should be ­affected population.
based on the particular needs in each dis­ An assessment should accurately define
aster. Continuously reassess the needs at the needs, so that limited resources will
both the local and community levels, be efficiently used to maximize life-savings
where the disaster has occurred, as well and other vital goals.
as at national or regional levels.
 S EC T I ON III / ESSENT IA L EMERGENC Y RELIEF MEAS U RES 21

National level: Assessments are typical­ outside the disaster area.

ly done by expert teams focused on
promptly defining the emergency magni- 3. Provide adequate nutrition.
tude, the environmental conditions and Large-scale bulk food requirements are Large-scale bulk food
requirements are
infrastructure damage, the major health typically calculated based on a minimum typically calculated
and nutrition needs of the affected popu- of 2,100 kcal/person/day. based on a minimum of
lation, and the local response capacity. Community level: Communities must 2,100 kcal/person/day.
Community level: In the immediate plan to distribute food equitably and
aftermath of a disaster, the initial response include vulnerable groups. As global food
will primarily come from local resources. resources improve, establish targeted
Communities must be prepared to do a supplemental and therapeutic feeding
local assessment of disaster impact. Health ­programs for malnourished individuals.
care professionals should be prepared to
assess the health issues in their com- 4. Provide elementary sanitation
munity, and understand the mechanism and clean water.
of shar­ ing that information with higher The estimated minimum requirement for
levels of authority, in order to contrib- drinking water is 3-5 L/person/day of clean
ute to regional or national assessments. water but 15-20 L are recommended for all
Assessments need to be repeated and the needs including washing and cooking.
quality and specificity of data improved Community level: Re-establish supplies
during the rescue and recovery phases or of clean water and effective sanitation and
whenever any major change occurs, such waste disposal services as soon as possi­
as an aftershock earthquake. Information ble. In an emergency, there should be at
gathered through the assessments is used least one latrine per 20 individuals. As the
by the resource managers to determine situation stabilizes, each family of 5 should
the allocation of resources in any large- have one latrine.
scale disaster.
5. Set up diarrhea control
2. Provide adequate shelter and program.
clothing. An increase in diarrheal disease is a pre-
Exposure to the climatic conditions in dis­ dictable outcome of disasters because of
aster situations can increase caloric infrastructure and health care services
requirements and lead to death. disruption.
Community level: Find short-term Community level: Rapidly implement
­shelters for all homeless individuals, par- community-based education on appropri-
ticularly focusing on vulnerable popula­ ate household sanitation measures, diar-
tions. Shelters should be appropriate for rhea prevention, and household case man-
the climate. Keep individuals within their agement, particularly for young children
communities and family networks as with diarrhea. Health care centers should
much as possible. In general, it is recom- anticipate the needs for additional cases of
mended to direct resources to rebuilding dehydration, using appropriate low-cost
within the community, rather than build- strategies (ORS/ORT) and recognize pos-
ing large camps or temporary settlements sible cases of cholera and dysentery.
 22 S ECT ION III / ES S ENTIAL EMERGENC Y RELIEF MEAS U RES

6. Immunize against measles and community health education and access

provide vitamin A supplements. to appropriate primary care. This included
Measles has been a major source of mortal- emergency obstetric and neonatal care,
Many casualties can ity among crowded, displaced populations prevention and management of sexually
largely be prevented
by community health
in which malnutrition is prevalent. transmitted infections, management of the
education and access Therefore, measels immunization is the health effects of sexual violence, ensuring
to appropriate primary only vaccine that is routinely considered for safe blood transfusion and universal pre-
care for treatment. use as a preventive measure ­ immediately cautions in health facilities. Initial efforts
­following a disaster. Since vitamin A deficien­ should be focused on identifying those
cy is common and contributes to measles- who were on treatment before the onset
related mortality, consider mass distribu- of the disaster and to restart treatment
tion of vitamin A for vulnerable populations. for them.
National level: National and international Community level: Health professionals
agencies work together to determine if should know the emergency transport
measles immunization or vitamin A distri- and response systems in their ­community.
bution is necessary following a particular Health care interventions during the res-
event. If necessary for all or part of the cue phase should include minimizing life
deemed population, national authorities losses caused by the direct impact of the
establish the central logistics (e.g., cold event (e.g., trauma, drowning). After the
chain, personnel, materials) to manage a rescue phase, health care resources should
mass immune ization/distribution campaign. be focused on re-establishing and improving
Community level: Health officers must the access and quality of primary care, par-
immediately assess the available cold ticularly for the most vulnerable groups.
chain as part of its health care assess-
ment. Health care professionals must 8. Set up disease surveillance and
monitor for cases of measles and develop health information systems.
a plan for mass immunization and/or mass Effective health information and disease
distribution of vitamin A to the vulnerable surveillance systems are necessary to
groups in their community. monitor effectiveness of health interven-
tions and reassign priorities.
7. Establish minimum reproduc- National level: Health authorities will
tive health and HIV services and use available information to define initial
improve primary medical care. priorities in the use of limited resources.
Immediate casualties (rescue phase) of a They should develop specific surveillance
sudden impact disaster are likely to guidelines for each disaster in order to
include a limited number of trauma vic- track relevant disease/mortality trends.
tims. In most disasters in fragile communi- Community level: Every health care
ties the larger number of disaster-related delivery setting should immediately imple-
deaths (i.e., deaths above the baseline ment a simple but effective health infor-
crude mortality rate) will be due to pre- mation collection system based on estab-
ventable causes of mortality in the weeks lished WHO, PAHO, or ­ governmental
and months following the impact. These guidelines. Health care professionals
casualties can largely be prevented by should know how to share this informa-
 S EC T I ON III / ESSENT IA L EMERGENC Y RELIEF MEAS U RES 23

tion regularly with higher level health 10. Coordinate activities.

authorities. National level: In a large-scale disaster
there will be many national and interna­
9. Organize human resources. tional agencies attempting to assess, devel­
The initial shock of an event can make it op plans, and establish priorities for fund-
difficult for a disaster-affected ­population ing at national and regional levels. Most
to effectively respond in a quick and ­effective relief efforts have resulted from
organized fashion. Having a pre-defined effective collaboration between many
emergency plan with clearly-identified ­agencies, each bringing their own ­expertise
leaders can help the local community and experience. However, all of these
to cope until more external resources agen­cies will ultimately depend on quality
arrive. assessments from the affected communi-
Community level: Have an emergency ties to make appropriate decisions and
plan and pre-defined community leaders determine the ability of the communities
for: to implement the plans and projects that
l Conducting rescue operations will help diminish suffering and restore the
l Conducting assessments (e.g., health baseline situation in the communities.
services, transportation, food, sanita- Community level: Develop local emer-
tion/water systems) gency plans that link into regional and
l Organization of food and water distri- national plans and agencies. Understand the
bution, and the sanitary program mechanisms for communication of infor­
l Health services management mation (e.g., assessments, surveillance data)
l Corpses and gravesite management during disasters. Build relationships with
l Identification of unaccompanied minors key individuals within and outside the com-
or other extremely vulnerable individu- munity before a disaster occurs.
als (e.g., elderly or persons with a dis-
ability) and organization of a caregiver
program.
 SECTION IV / ORGANIZATIONS

ORGANIZATIONS
occurs: governmental and nongovernmen-
tal organizations (NGOs).
OBJECTIVES
l Identify national and international organi- Governmental organizations
zations that may respond to a humanita- Governmental organizations work under
rian emergency in your country. the authority of one or multiple govern-
l Recognize the available resources,
ments. The most common include:
strengths, and limitations of these
organizations. National ministries—These are agen-
cies at the national ministry level that
have authority for disaster planning and
response. A regional conference on disas-
ters took place in 1986 to optimize the
preparedness and response mechanisms
Organizations capable of of Latin American and Caribbean nations.
providing assistance during As a result of this conference, most
humanitarian emergencies nations established a health disaster coor-
When local resources are insufficient, dinator within the Ministry of Health
assistance from multiple national or per- (MoH.) The health disaster coordinator
haps multinational organizations will be not only coordinates health-related relief
needed. Each involved organization has its efforts in the event of a disaster, but also
own institutional structure and culture, in continuously updates emergency plans
addition to other features, such as capac- and conducts preparedness training for
ity for response, technical and ­ logistic health care professionals.
resources, and thematic or regional
approach. Pan American Health Organization
Several international agencies may have (PAHO)—This is an international ­public
activities in the country prior to the health agency serving as the Regional
event. In response to the disaster these Office for the Americas of the World
agencies may retarget their resources in Health Organization. It provides health
the country to emergency relief. Effective policy guidance and technical assistance in
coordination and cooperation among disaster planning and response (Box 7).
involved organizations are essential but More information is available at:
very difficult to achieve in the chaotic sit­ www.paho.org.
uation of a massive emergency. There are
two major types of organizations that can World Health Organization (WHO)—
get involved in assistance when a ­disaster The WHO provides technical advice and
 S ECT ION IV / O RGANIZATIO NS 25

BOX 7. Some technical recommendations for disaster situations issued by

the PAHO

Specific topics related to disasters – For example, frequent effects of

specific types of disasters, such as volcanic eruptions.
Special needs – Special considerations regarding vulnerable groups.
Transmissible diseases – Vector control; specific behaviors for cholera
and tuberculosis in the context of disasters.
Food safety – Guidelines for food preparation and nutrition.
Immunization – For example, the adequate use of measles and equine
encephalitis vaccines in the context of disasters.
Environmental sanitation – Rodent prevention; general health recom-
mendations for camps and shelters; guidelines for temporary shelters.
Source: www.paho.org

develops health policies relating to disas- problems worldwide. Its primary purpose
ters. More information is available at: is to safeguard the rights and well being
www.who.int. of refugees. It strives to ensure everyone
can exercise the right to seek asylum and
SUMA (Humanitarian Supply find safe refuge in another State, with
Administration System, developed the option to return home voluntarily,
by the PAHO)—This organization facili- integrate l­ocally, or to resettle in a third
tates the reception, inventory, and rapid country. More information is available at:
distribution of essential humanitarian sup- www.unhcr.org.
plies and equipment. In the event of a dis­
aster, PAHO can send SUMA-trained staff World Food Program (WFP)—This
to the affected country to assist in manag- organization coordinates the delivery of
ing the inflow of supplies. food to regions in need around the world.
More information available at:
United Nations (UN)—The UN is a www.wfp.org.
multinational organization that functions
mainly through its sub-agencies, which are United Nations International
independently funded. More i­nformation Children’s Emergency Fund (UNICEF)
is available at: www.un.org. This organization was created by the UN
General Assembly to advocate and p­ rotect
The Office of the United Nations children’s rights, to help fulfill their basic
High Commissioner for Refugees needs, and to provide opportunities for
(UNHCR)—The agency is mandated to maximizing the development of their poten-
lead and co-ordinate international action tial. When an emergency occurs, UNICEF
to protect refugees and resolve refugee focuses on ensuring that basic needs of
26 S ECTI ON I V / O RGANIZATIO NS

BOX 8. Foreign agencies for disaster assistance

US Aid for International Development – Office for Foreign Disaster

Assistance (OFDA)
www.gov/our work/humanitarian assistance/disaster assistance

Canadian International Development Agency (CIDA)

www.acdi-cida.gc.ca

European Commission Humanitarian Organization (ECHO)

www.acdi-cida.gc.ca

United Kingdom Department for International Development (DFID)

www.dfid.gov.uk

Japan International Cooperation Agency (JICA)

http://www.jica.go.jp/worldmap/english.html

women and children are fulfilled and on affected by humanitarian emergencies.

protecting their basic rights. More informa- PAHO and WHO have developed guide-
tion is available at: www.unicef.org. lines to assist disaster-affected countries
in managing donor offers from various
Office for the Coordination of agencies. According to the 1999 PAHO
Humanitarian Affairs (OCHA)—In publication Humanitarian Assistance in
1998 the OCHA resulted from the reor- Disaster Situations: A Guide for Effective
ganization of the UN Department of Aid, “In the most advanced developing
Humanitarian Affairs (DHA). Its mission countries, in particular in Latin America,
was expanded to include the coordina- national health services, voluntary organi­
tion of humanitarian response, policy zations and the affected communities
development, and advocacy. OCHA’s mobilize their own resources to meet the
tasks are done through the Inter Agency most compelling medical needs in the
Permanent Committee that includes mul- early phase after a disaster. Requirements
tiple participating organizations, such as for external assistance are generally limit­
UN agencies, funds, and programs, the ed to highly skilled expertise or equip-
Red Cross, and NGOs. More information ment in a few specialized areas.”
is available at: http://www.unocha.org. Military help—Both local and foreign
military can be mobilized to assist in the
Foreign organizations that ­ provide response to natural disasters or ­complex
help in case of disaster—Box 8 emergencies. Certain unique features
identifies some of the governmental agen- make military organizations useful in a
cies of developed countries that provide disaster.
funding and technical help to countries
 S ECT ION IV / O RGANIZATIO NS 27

Advantages mary care and preventive interventions

Speed: Few organizations are capable of for women and children are major needs.
implementing a large logistic response as Logistics: Supplies available in the military
rapidly as the military. response system may not be appropriate
Security: The military can secure a speci­ for a disaster in terms of prevailing dis-
fied environment, population, and ­material. eases or types of food.
Transportation: Their fleet of planes and Political objectives: The military are an
helicopters, as well as land and naval asset of governments; in addition, certain
equipments, enable them to transport humanitarian objectives can be subordi-
resources readily. nated to other political or strategic goals.
Logistics: They have experience in main- The presence of the army in certain sce-
taining supply lines in problematic envi- narios can cause tension in certain groups
ronments and situations. of the population and compromise relief
Command, control, and communication: They workers who, for their own safety and
have a well-defined and responsive organi- function, wish to be considered neutral.
zational structure. Cost: Military activities are expensive.
Self-sufficiency in the field: When military
arrive to the region where the event has Nongovernmental
occurred, they are capable of fulfilling the organizations
needs of their own personnel. NGOs are nonprofit organizations work-
Specialized units: They often have specifi­ ing on a full-time basis in assistance for
cally trained and equipped units. These appropriate development. Thousands of
include engineers who can provide tech- NGOs, both international and national,
nical assistance and preventive medicine are functioning throughout the world.
teams capable of rapidly performing epi- Most NGOs are small agencies focusing
demiologic evaluations and surveillance, on very specific development projects
outbreak investigations, vector control, (e.g., providing education, working tools,
and water purification and treatment. or training in sustainable development).
Field hospitals and capacity for medical evac­ Only a few of them have the resources
uation: Hospitals can be helpful in ­certain required for supporting activities targeted
circumstances. See the WHO-PAHO to promote development and to respond
guidelines for the use of field hospitals in to disasters in multiple countries or
sudden-impact disasters. regions. Each NGO is specialized in spe-
cific aspects of assistance in emergencies
Shortcomings (Box 9). Although NGOs may receive
Despite all the advantages mentioned contributions from individuals, most of
above, the use of the military can have sig­ their funds come from the governments
nificant shortcomings and limitations in of industrialized countries. These govern-
some situations. ments distribute their money for assisting
Medical care: Field hospitals are designed projects through contracts with NGOs.
for the care of soldiers wounded in com- Unlike the International Committee of
bat (i.e., for the care of wounds suffered the Red Cross (ICRC), some NGOs
by healthy adults). During a disaster, pri- maintain a “right to interfere.” This means
28 S ECTI ON I V / O RGANIZATIO NS

they can operate across borders without

BOX 9. Most important NGOs and
written approval of their hosts. Although
their specialization fields
usually looking for the neutrality of the
ICRC, some NGOs may be more ­willing
• Action Contre La Faim to report any perceived injustice. They
Prevention, detection and treatment of
malnutrition perform well in emergencies within their
http://www.actioncontrelafaim.org/en area of specialty (e.g., water provision,
• Catholic Relief Services food distribution), but most cannot
Food distribution achieve self-sufficiency in an emergency
www.crs.org setting and rely on UN, military, or other
• Cooperative for the American Relief agencies for security, transportation to
Everywhere (CARE) remote sites, communication, support of
Assistance in logistics and feeding; camp logistics, or medical care for their own
management personnel. NGOs have enhanced ability
www.care.org
to provide person-to-person assistance
• International Medical Corps because they are likely to have a pre-dis­
Health care training, relief and development
aster relationship with the affected com-
programs
munities and understand the local culture
www.internationalmedicalcorps.org
and public health issues. They can also
• International Rescue Committe shift easily from disaster relief to develop-
Medical care
www.theirc.org
ment, and are willing to make a long-term
commitment to community development
• Irish Concern and rebuilding.
Feeding supplementation
• Médecins sans Frontières International Committee of the Red
Medical care
www.paris.msf.org Cross (ICRC)—This is a hybrid agency:
neither private nor controlled by a gov-
• Medicins Du Monde ernment. A number of its ­characteristics
Emergency relief and advocacy
www.medicinsdumonde.org are unique; its mission is defined by the
• Oxford Committee for Famine Relief international humanitarian law passed by
(OXFAM) the 1949 Geneva Convention and the
Water and sanitary services two 1977 protocols. The ICRC gets
www.oxfam.org.uk involved mainly when civil ­ disturbances
• Plan International are present; it has the right and duty to
Child health and development intervene across borders when ­ national
www.plan-international.org or international conflicts break out,
• Save the Children Fund regardless of whether a “state of war” has
Assistance in feeding and development been declared. The ICRC brokers relief
www.savethechildren.org.uk assistance during war, assures legal pro-
• World Vision tection for victims, and monitors the way
Assistance in feeding and development Prisoners of War are managed. Also, the
www.worldvision.org
ICRC plays a critical role in reuniting fam­
ilies. The ICRC strives to preserve its neu­
 S ECT ION IV / O RGANIZATIO NS 29

trality, which is essential for its ­mission cal manuals and training activities to assist
and enables its members to work nations in the planning of coordinated
unarmed in war regions under the con- dis­­
aster responses at the regional and
trol of any of the involved parties. The national level. In complex emergencies
­
ICRC provides a complete account of its related to a conflict, the armed forces
activities to all the parties involved in the or government authorities will have the
conflict. It will refuse to participate in any command of operations, including the
activity that can be seen as showing coordination of humanitarian help. The
favoritism. This may include transporta-
­ coordination in this scenario can be par-
tion in vehicles belonging to one of the ticularly difficult if the hostile groups are
parties or joining efforts with groups that stationed nearby and try to block assis-
have their own interests. The ICRC is usu­ tance of civilians. In this context, humani-
ally self-sufficient and can use its own tarian help can be used as a political and
resources for air lifts, communication, and strategic instrument.
logistics. It will participate only if all par-
ties involved in the conflict sign an agree- Medical Volunteering
ment recognizing and showing respect for Following a disaster many pediatricians
its neutrality and mission. The ICRC is and other health professionals ­volunteer
related to but independent from the Red for a limited time. During the initial
Cross and the Red Crescent Societies response phase, the greatest pediatric
national agencies. These organizations needs include air transport teams, ­surgical
provide assistance primarily to victims teams (a surgeon, OR nurse, anesthesiol­
of disasters or wars within their own ogist, and critical care pediatrician), as well
nations. They have a similar commitment as pediatricians with training and experi-
with neutrality, provision of assistance ence in emergency medicine and ­critical
based only on the need, and independ­ care. Volunteers may have to be self suffi­
ence from national governments. cient for a period of time in terms of
food, water, and shelter. Volunteers should
Coordination work through an established NGO or
of organizations governmental agency rather than simply
Coordinating the activities of all these “show up” to help. Volunteers should be
organizations poses a tremendous chal- prepared to respond quickly, as the quick-
lenge. Following a natural disaster the er the response teams can provide appro-
host nation’s government/agencies and priate care, the more effective they can be
military are likely to have ­ operational at saving lives and limiting morbidity. Part
command. Most nations now have defined of preparation is anticipating the types of
governmental authorities responsible for injuries that will be seen with ­ different
global disaster planning and response, as types of disasters. When sending a
well as coordinators for individual ­sectors response team into a disaster during the
such as health. External agencies or gov- acute response phase, it is important to
ernments play a supportive role in provid­ have the personnel with the ability to
ing technical assistance and resources. treat the most likely injuries seen with the
PAHO has developed a number of techni- specific type of disaster. In a major earth-
30 S ECTI ON I V / O RGANIZATIO NS

It is critical to attempt to reunite children with their families as soon as possible and pay special attention to reducing their vulnerability in all
disaster response planning

quake like the one in Haiti in January of disaster should include those with
2010, one would expect the majority of training in caring for burns as well as
the casualties to be secondary to trau­ experience with other traumatic ­injuries.
matic injuries related to collapsed build- In the first days following the Haiti earth-
ings. Therefore, a team should be pre- quake, there were a large number of com­
pared to have personnel and supplies that plex orthopedic injuries that required
can be used to treat crush injuries, a large emergent treatment. These included open
number of open wounds, along with a fractures, traumatic amputations, and
variety of orthopedic injuries. In a ­disaster crush injuries. The treatment of these
involving an explosion (large industrial injuries included fracture reductions,
accident or terrorist attack), the ­pattern wound debridement, and amputations.
of injuries would include many of the Thus it was essential to have personnel
same traumatic injuries as seen in an with the training to perform the needed
earthquake, but would also include a large procedures. Personnel with training in
number of burns and blast injuries such as emergency medicine, general surgery, and
blast lung. Personnel required in this type orthopedics are best suited to be part of
 S ECT ION IV / O RGANIZATIO NS 31

the initial response team when a large the team as well as with the home country.
number of traumatic injuries are expect- They provide a reliable method of commu­
ed. Supplies that are essential in car- nication when telephone services are not
ing for these patients include plaster working or there is no infrastructure,
splinting/casting supplies, wound dressing because they rely on orbiting satellites to
supplies, and medications for pain c­ ontrol transmit data. However, they are a scarce
and sedation. When caring for open resource as well as an expensive resource.
wounds, the ability to appropriately irri- The main drawback for many portable
gate and clean wounds can greatly reduce ­satellite phones is that the phone’s antenna
subsequent secondary infections of these needs an unobstructed view of the sky.
wounds. Response teams should come Cellular phones are an ideal method for
prepared with supplies that would be able communication. Voice calls can be made to
to provide pressure irrigation of wounds team members as well as to coordinate in
with either clean water or saline, antibiot- the home country. E-mail and SMS t­exting
ic ointments, and large supplies of wound are other methods of communicating
dressings. A large number of the orthop­ through the cellular network. However, cel­
edic injuries can be treated with casting or lular technology is dependent on a c­ ellular
splinting. Plaster casting material is far infrastructure and network that has sur-
superior in this setting since casts made vived a disaster. The cellular networks may
of fiberglass cannot be easily removed also become overwhelmed by the number
without a cast saw, whereas patients/fami- of people attempting to use it in the time
lies can be instructed to remove a plaster after the disaster, thus emergency/disaster
cast by soaking it in water. relief providers and organizations need to
Table 4 provides a list of pediatric have a communication system that is reli-
equipment that, if possible, should be able and free of interference.
brought in if not available on site. The availability of the internet through
Communication in a disaster situation is various means including satellite links and
essential between disaster relief team data over cellular networks has allowed for
members as well as with coordinating
­ many novel methods of communication
groups and logistical support personnel in over the internet. There are traditional
home countries. Modern technology has methods such as electronic mail. Web blogs
provided many different types of communi- also allow relief workers as well as those
cation devices, which have different advan- affected by the disaster to reach out to the
tages and disadvantages. Communication world. Other social media tools such as
networks and contingency plans are an Facebook and the microblogging ­ service
essential part of the disaster preparedness Twitter allow almost instantaneous
phase. Radios are useful for short range updates from the field.
communications when a disaster relief
team is separated. However, they are limit- Mental health considerations
ed by range and will not allow communica­ Disaster response providers are often
tion with the other teams or organizations thrust in to a high stress situation with
that are a long distance away. Satellite exposure to situations they may have
phones are ideal for communication with never experienced before. The degree of
32 S ECTI ON I V / O RGANIZATIO NS

TABLE 4. Recommended equipment to bring for pediatric emergencies in disaster

situations.
Airway Management/Breathing
– Tongue Blades
– Suctioning machine (portable, battery-powered)
– Suction catheters -Yankauer, 8, 10, 14F
– Simple face masks - infant, child, adult
– Pediatric and adult masks for assisted ventilation
– Self-inflating bag with 250 cc, 500 cc, and 1000 cc reservoir
Optional for intubation
    – Laryngoscope handle with batteries (extra batteries AA, laryngoscope bulbs)
    – Miller blades - 0, 1,2,3 Macintosh blades 2,3
    – Endotracheal tubes, uncuffed - 3.0, 3.5, 4.0,4.5, 5.0, 6.0, cuffed - 7.0,8.0
    – Laryngeal mask airways
    – Stylets - small, large
    – Easycap (ETCO2 analyzer), 2 sizes
    – Adhesive tape to secure ETT

Circulation/Intravascular Access or Fluid Management

– IV catheters - 18-, 20-, 22-, 24-gauge
– Butterfly needles - 23-gauge
– Intraosseous needles- 15- or 18-gauge, or Eazy IO device
– Boards, tape, tourniquet IV
– Pediatric drip chambers and tubing
– 5% dextrose in normal saline and half normal saline
– Isotonic fluids (normal saline or lactated Ringer’s solution)
– Medications: epinephrine, atropine, sodium bicarbonate, calcium chloride, lidocaine, D25, D10

Miscellaneous
– Broselow tape
– Nasogastric tubes - 8, 10, 14F
– Splints and gauze padding
– Rolling carts with supplies such as abundant blankets
– Warm water source and portable showers for decontamination
– Thermal control (radiant cradle, lamps)
– Geiger counter (if suspicion of radioactive contamination)
– Personal protective equipment (PPE)
– Pain\ Sedation medications: ketamine, morphine, ketoralac
– Other potential medications: albuterol, keflex, ancef, ceftriaxone, diazepam
– Surgical equipment for amputations, incision and drainage of wounds, laceration repairs
– Headlamps with replacement batteries
– Scissors
– Plaster for casting, not fiberglass (hard to remove)

Monitoring Equipment
– Sphygmomanometer/ Blood pressure cuffs - premature, infant, child, adult
– Portable monitor/defibrillator (with settings < 10)
– Pediatric defibrillation paddles
– Pediatric electrocardiogram (ECG) skin electrode contacts (peel and stick)
– Pulse oxymeter with reusable (older children) and nonreusable (small children) sensors
– Device to check serum glucose and strips to check urine for glucose, blood, etc.

Among the recommended equipment, elements for proper airway management in children are crucial. A major
challenge of any disaster response is gathering, organizing, and moving supplies to the affected area. Resource
management within the hospital and other facilities or agencies may prove to be a decisive factor in whether a
mass casualty event can be handled.
 S ECT ION IV / O RGANIZATIO NS 33

TABLE 5. Common Stress Reactions

Behavioral Physical Psychological/Emotional Thinking Social

- Increase or - Gastrointestinal - Feeling heroic, - Memory - Isolation

decrease in problems euphoric, or problems - Blaming
activity level - Headaches, invulnerable - Disorientation - Difficulty in
- Substance use or other aches - Denial and confusion giving or
abuse (alcohol or and pains - Anxiety or fear - Slow thought accepting
drugs) - Visual processes; support or help
- Depression
- Difficulty disturbances lack of - Inability to
communicating - Guilt concentration
- Weight loss or experience
or listening gain - Apathy - Difficulty pleasure or have
- Irritability, - Sweating or - Grief setting fun
outbursts of chills priorities or
anger, frequent making
arguments - Tremors or decisions
muscle
- Inability to rest twitching - Loss of
or relax objectivity
- Being easily
- Decline in job startled
performance;
absenteeism - Chronic fatigue
or sleep
- Frequent crying disturbances
- Hyper-vigilance - Immune system
or excessive disorders
worry
- Avoidance of
activities or
places that
trigger memories
- Becoming
accident prone

Adapted from CMHS, 2004.

destruction and death will likely be much and physically. The emotional stress
greater than what the health care experienced by disaster response
­
­providers are accustomed to dealing with providers has been well documented
in their daily lives. Local first responders after events such as 9/11 and Hurricane
and medical providers thrust in to the Katrina. The affect of stress is a­ mplified by
role of the initial emergency response the long hours of intense work experi­
phase may be faced with the additional enced during the response to a d ­ isaster.
stress of personally knowing many of the Environmental conditions (such as
victims (or their family members) that extreme heat/cold/rain/flooding), lack of
they are caring for. The emotional impact sleep, and inadequate nutrition impair a
of large scale destruction, suffering, and provider’s ability to deal with the ­stressful
death will elicit different ­responses in dif­ situation. Crisis response workers and
ferent people, but all volunteer p­ roviders managers, including first responders, pub-
should recognize how their e­xperiences lic health workers, construction workers,
can affect their wellbeing both ­emotionally transportation workers, utilities ­workers,
34 S ECTI ON I V / O RGANIZATIO NS

and other volunteers, are repeated- Health Services Administration

ly exposed to extraordinarily stressful (SAMHSA), and Center for Mental Health
events. This places them at higher than Services (CMHS) have published a guide
normal risk for developing stress reac- focusing on general principles of stress
tions (Pan American Health Organization management and offers simple, practical
[PAHO], 2001). It is important for all strategies that can be incorporated into
disaster response providers to recognize the daily routine of managers and ­workers.
the potential emotional stress they will be It also provides a concise o­ rientation to
entering before arriving on scene. Stress the signs and symptoms of stress. This
prevention and management needs to be can be found online athttp://mentalhealth.
considered and addressed from the start samhsa.gov/publications/allpubs/SMA-
of the deployment in order to prevent 4113/default.asp. While most people are
problems. By anticipating stressors and resilient, the stress response becomes
individuals’responses to these stressors, problematic when it does not or cannot
the response team and individuals can turn off, that is, when symptoms last too
potentially prevent a crisis within the long or interfere with daily life. Table
team of care providers. The US 5 provides a list of the common stress
Department of Health and Human ­reactions.
Service, Substance Abuse and Mental
 CONCLUSION / SUGGESTED READING 35

CONCLUSION
Disasters are, to a great extent, beyond our control and inevitable. However, we
can be better prepared for the consequences and thus reduce the degree of human
suffering. As Vernon Law has said, “Experience is a hard teacher. She gives the test
first and the lessons afterwards.” Knowledge and understanding are needed for more
effective preparation and planning. Pediatricians have a special role in the planning and
preparation process to ensure that the needs of children are adequately ­considered
in this process. Pediatric volunteers should be prepared for their experiences from
the standpoint of training, available materials and resources, and mental health
considerations.

SUGGESTED READING
Bhave S, Mathur Y, Agarwal V, eds. Guidelines on the Management of Romig LE. Disaster Management. In: APLS Course Manual. Jones &
Children in Disaster Affected Situations. Indian Academy of Pediatrics, Bartlett Publishers, 2006.
2005. Sharp TW. Conflict-Related Complex Emergencies, in Chap. 34, Military
Burkholder B, Toole M. Evolution of Complex Disasters. Lancet Preventive Medicine, 1997.
1995;346:1012. Sharp TW. The Challenge of Humanitarian Assistance in the Aftermath
Burkle FM. Complex Humanitarian Emergencies: I.Concept and of Disasters Chap. 32, Military Preventive Medicine, 1997.
Participants. Prehospital and Disaster Medicine 1995;10: 48-56 Sharp T, Yip R, Malone JD. US Military Forces and Emergency
Davidson LW, Hayes MD, Landon J. Humanitarian and Peace International Humanitarian Assistance-Observations and
Operations: NGOs and the Military in the Interagency Process. Recommendations from Three Recent Missions. JAMA 1994;272:386.
Workshop Report, 1996. National Defense University Press, Toole MJ. Mass Population Displacement-A Global Public Health
Washington DC. Challenge. Infectious Disease Clinics of North America 1995;9:353.
CDC Famine-Affected, Refugee and Displaced Populations: Walker P. Foreign Military Resources for Disaster Relief: an NGO
Recommendations for Public Health Issues. CDC, MMWR 1992;41:RR- Perspective. Disasters 2005;16:152.
13.
http://www.reliefweb.int/rw/rwb.nsf/db900sid/EGUA-836R39?Open
Gaydos J, Luz G. Military Participation in Emergency Humanitarian Document&RSS20&RSS20=FS http://www.google.com/hostednews/afp/
Assistance. Disasters 1994;18:48. article/ALeqM5hOiPk5G7TMLjYsBbZ1ajaBMS_lWg or
Handbook of War and Public Health, ICRC, Geneve, 1996 http://www.reliefweb.int/rw/rwb.nsf/db9 00sid/SNAA-
Leaning J, Briggs S, Chen L, eds. Humanitarian Crises: The Medical 82587M?OpenDocument&rc=2&emid=EQ-2010-000009-HTI
and Public Health Response. Harvard University Press, Cambridge, MA, http://www.nytimes.com/2010/02/13/world/americas/13doctors.html?hp.
1999. Merin O, Ash N, Levy G, et al. The Israeli Field Hospital in Haiti
Levy B, Sidel V, ed. War and Public Health. Oxford University Press, - EthicalDilemmas in Early Disaster Response. N Engl J Med 2010
New York 1997. 0:NEJMp1001693 Observations from Ground Zero at the World Trade
Center in New YorkCity, Part I.
Lillibridge SR, Burkle F, Noji E. Disaster Mitigation and Humanitarian
Assistance Training for Uniformed Services Medical Personnel. Military Levenson RL Jr, Acosta JK. Int J Emerg Ment Health. 2001Fall;3(4):
Medicine 1994;159:397. 241-4. Mental health status of World Trade Center rescue and recovery
workers and volunteers - New York City, July 2002-August 2004.
Marks E. Complex Emergencies: Bureaucratic Arrangements in the UN
Secretariat. National Defense University Press, Washington DC, 1996 Centers for Disease Control and Prevention (CDC). MMWR Morb Mortal
Wkly Rep. 2004 Sep 10;53(35):812-5. Mental health of workers and
Mothershead JL, et al. Disaster Planning. Available at: http://www. volunteers responding to events of 9/11: review of the literature.
emedicine.com/emerg/topic718.htm.
Bills CB, Levy NA, Sharma V, Charney DS, Herbert R, Moline J,
Noji E. K. The Public Health Consequences of Disasters, Oxford Katz CL. Mental health of workers and volunteers responding to
University Press, 1997 events of 9/11: review of the literature. Mt Sinai J Med. 2008 ­Mar-
Sandler R, Jones T, eds. Medical Care of Refugees. Oxford University Apr;75(2):115-27.
Press, New York, 1987. Palm KM, Polusny MA, Follette VM. Vicarious traumatization: potential
Mandalakas A, Torjesen K, Olness K, eds. Helping the Children: A hazards and interventions for disaster and trauma workers. Prehosp
Practical Handbook for Complex Humanitarian Emergencies. Johnson and Disaster Med. 2004 Jan-Mar;19(1):73-8.
Johnson Pediatric Institute and Health Frontiers, Kenyon, MN, 1999. Pan American Health Organization. (2001). Stress management in
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36 CONCLUSION
CASE/ RESOLUTION
SUGGESTED READING

Case resolution
1. A disaster can be defined as a usually sudden event causing damages, affecting many
people, and because of its magnitude, exceeding the capacity for response of local or
national organizations. High morbidity and mortality rates are frequently found in the
affected population, which is often exposed to critical sanitary situations, both immediately
after the disaster and during subsequent phases. There is an additional risk for diseases
associated with crowding and lack of adequate public services.
Disasters can be due to natural causes, such as hurricanes and earthquakes, to alterations
or to technological causes; i.e., related to events triggered by man’s intervention (e.g., the
release of toxic or radioactive agents). In addition, civil or international wars cause complex
emergencies that affect civilians and result in their displacement.
In this case, flooding has brought about a natural disaster.

2. Children, as well as old people and pregnant women are the most vulnerable populations
when a disaster occurs. For children, the risk of being separated from their families
determines their vulnerability. In addition, their physical, physiological and mental features
render them more susceptible to environmental, sanitary and social changes resulting from
disasters.
All affected children should be identified and their identity should be properly
documented. They should also receive preferential attention during the distribution of
sanitary and feeding resources, as well as effective preventive interventions.

3. The initial and highly critical step is the immediate assessment of the situation and the
affected population. This will define the actual needs and the interventions that are most
appropriate in the current circumstances. It is important to establish clearly defined
priorities and the effective coordination of rescue activities, in both the early and the
subsequent phases.
In this case, field hospitals are unlikely to be needed, since traumatized victims requiring
immediate interventions will be less numerous than in other circumstances, when disasters
have a more sudden and unexpected start.
The capacity for response of local and regional services will determine whether or not
external assistance is needed. Immediate external help is unlikely to be necessary in this
case, but there will probably be a need for resources to provide the affected population
with shelter and clothing.
 APPENDIX 37

Myths and realities of disasters

The Pan American Health Organization has identified many myths and erroneous beliefs that are
widely associated with the public health impact of disasters; all disaster planners and managers
should be familiar with them.
MYTH REALITY

Foreign medical volunteers with extensive The local population almost always covers immediate lifesaving needs. Only
medical training are needed. medical personnel with skills that are not available in the affected country may
be needed.

Any kind of international assistance is needed, A hasty response not based on an impartial assessment only contributes to chaos. It
and it is needed now! is better to wait until real needs have been assessed. As a matter of fact, most needs
are met by victims themselves and their local government and agencies, not by foreign
parties.

Epidemics and plagues are inevitable after Epidemics do not spontaneously occur after a disaster, and dead bodies will not
every disaster. lead to catastrophic outbreaks of exotic diseases. The key to preventing disease is to
improve sanitary conditions and educate the affected population.

Disasters bring out the worst in human Although isolated cases of antisocial behavior exist, most people respond
behavior (e.g., looting, rioting). spontaneously and generously.

The affected population is too shocked and On the contrary, many people find new strength during an emergency, as evidenced
helpless to take responsibility for its own by the thousands of volunteers who spontaneously united to sift through the rubble in
survival. search of victims after the 1985 Mexico City earthquake.

Disasters are random killers. Disasters strike hardest on more vulnerable groups: the poor, and especially women,
children and the elderly.

Locating disaster victims in temporary It should be the last alternative. Many agencies use funds normally spent for tents
settlements is the best alternative. to purchase building materials, tools, and other construction-related support in the
affected country.

Food aid is always required for natural Natural disasters only rarely cause loss of crops. Therefore, victims do not always
disasters. require massive food aid.

Clothing is always needed by the victims of Used clothing is almost never needed; it is often culturally inappropriate, and though
a disaster. accepted by disaster victims, it is almost never worn.

Things are back to normal within a few The effects of a disaster last a long time. Disaster-affected countries loose much of
weeks. their financial and material resources in the immediate postimpact phase. Successful
relief programs gear their opportunities to the fact that international interest wanes
as needs and shortages become more pressing.