Interventions: From Response to Prevention
The immediate lifesaving response time is much shorter than humanitarian organizations recognize. In a matter of weeks, if not days, the concerns of both the population and authorities shift from search and rescue and trauma care to the rehabilitation of infrastructure (temporary restoration of basic services and reconstruction). In Banda Aceh, Indonesia, after the December 2004 tsunami, victims were eager to return to normalcy while external medical relief workers were still arriving in large numbers.
Response and Rehabilitation
Immediate emergency response is provided under a highly political and emotional climate. The public demands visible, albeit perhaps unnecessary, measures at the expense of proven low-key approaches. The international community, eager to demonstrate its solidarity or to exercise its"right of humanitarian intervention,"undertakes its own relief effort on the basis of the belief that local health services are unwilling or unable to respond. Donations of useless medical supplies and medicines and the belated arrival of medical or fact-finding teams add to the stress of local staff members who may be personally affected by the disaster. The cultural disregard of the humanitarian community to cost-effective approaches in times of disaster and the tendency to base decisions on perceptions and myths rather than on facts and lessons learned in past disasters contribute to making disaster relief one of the least cost-effective health activities.
The responsibilities of the national or local health authorities are significant.
Assessment of the Health Situation
A country's ministry of health is expected to assess the health situation. To influence the course of humanitarian response, this assessment must be rapid and, therefore, simple; transparent in collaboration with the main actors—nongovernmental organizations (NGOs) and donors; and technically credible. The input of WHO, as the lead agency in health matters, is most valuable. Confusion should be avoided between assessing emergency needs and inventorying or valuating the damage. In the first hours or days, relief actors base their decision making on the ministry of health's assessment of what is required and, more importantly, what is not required for emergency response. Later, the international community will request detailed data, such as the number of persons affected, buildings damaged, and monetary valuation.
Mass Casualties Treatment
Following natural disasters, hospital capacity may be considerably reduced by actual damage to the facility or, in the case of a seismic event, an often unnecessary—but hard to reverse—evacuation. Triage of patients is required in order to first treat those likely to benefit most, rather than the terminally injured or those whose care can be delayed. Lifesaving primary care takes place in the first six hours (the golden rule of emergency medicine), making most of the foreign field hospitals irrelevant for intensive acute care of traumas (WHO and PAHO 2003). Effectiveness of immediate care will depend on local preparedness before the disaster, not on faraway resources.
Strengthened Surveillance, Prevention, and Control of Communicable Diseases
Because the surveillance, prevention, and control of communicable diseases are strengthened, the anticipated massive outbreaks generally do not actually occur.
Traditional surveillance systems that are based on periodic notification of diseases by the health services are inadequate in a crisis situation. Early warning requires flexible and simple syndrome-based monitoring in temporary settlements and health centers, with information collected not only by the official health services but also by the medical humanitarian organizations. Systems that do not include consultation with NGOs are unlikely to succeed.
Disease control programs in place before the disaster are the fruit of local experience and external technical advice. In a disaster situation, there is generally no need to resort to new and expensive control measures. The key is to quickly resume, strengthen, and better monitor the routine control programs. No public health concerns justify the hurried disposal of corpses through mass burial or unceremonious incineration. This practice is socially and culturally damaging. In addition, improvised mass immunization campaigns, especially by external relief groups, should be discouraged in favor of opportunistically strengthening national routine immunization coverage, especially in temporary settlements.
Typical interventions in the aftermath of disasters include strengthening the monitoring and surveillance of water quality, vector control, excreta disposal, solid waste management, health education, and food safety.
A first priority is water supply. It is often preferable to have a large quantity of reasonably potable water than a smaller amount of high-quality water (UNHCR 1998). Massive distribution of water purification disinfectants can be effective if the public is already familiar with their use and not confused by the availability of many different brands and concentrations of donated chemicals.
Health education and hygiene promotion efforts target populations in shelters, temporary camps, collective kitchens, or prepared food distribution centers.
The cost-effectiveness of the external relief effort could often be increased by shifting resources from the overattended medical response to the improvement of environmental health in temporary settlements.
Transparent Management of Donations and Supplies
If donations and supplies are managed transparently during the emergency, the flow of assistance to the intended beneficiaries will be improved. Unsolicited and often inappropriate medical donations compete with valuable relief supplies for scarce logistical resources. Good governance is critical, and effective logistics cannot be improvised following a disaster. A humanitarian supply management system developed by PAHO and WHO successfully helped developing countries improve transparency and accountability in managing humanitarian supplies and donations (de Ville de Goyet, Acosta, and others 1996).
Coordination of the Humanitarian Health Effort
Coordination of the humanitarian health effort is essential to maximize the benefit of the response effort and ensure its compatibility with the public health development priorities of the affected country. Effective coordination in the health sector must do the following:
Be comprehensive and include all external health actors.
Be based on mutual respect rather than regulatory authority alone. Dialogue and consultation are more effective than enforcement.
Benefit all parties, starting with the victims. It should aim to support and facilitate the activities of other partners.
Be evidence-based and transparent. Information is made to be shared and used, not jealously guarded.
Coordination cannot be improvised in the aftermath of a disaster. Preparedness before the occurrence of the hazard is essential.
Emergency Preparedness of the Health Sector
Effective response by national health authorities cannot be impromptu. Ministries of health that neglected to invest in capacity building before emergencies have generally experienced serious difficulties in exercising their technical and political leadership in the immediate aftermath of a disaster. Disaster preparedness is primarily a matter of building institutional capacity and human resources, not one of investing heavily in advanced technology and equipment.
Building local coping capacity is one of the most cost-effective ways to improve the quality of the national response and the external interventions.
Disaster preparedness is not merely having a disaster plan written by experts. It must involve the following:
Identifying vulnerability to natural or other hazards. The health sector should seek information and collaborate with other sectors and institutions (civil protection, meteorology, environment, geology) that have the primary responsibility for collecting and analyzing this information.
Building simple and realistic health scenarios of a possible and probable occurrence. It is challenging enough to prepare for a moderate-size disaster; building and sustaining a culture of fear based on unrealistic worst-case scenarios may serve the corporate interests of the disaster community but not the interests of the public at large.
Initiating a participative process among the main actors to develop a basic plan that outlines the responsibilities of each actor in the health sector (key departments of the ministry of health, medical corps of the armed forces, private sector, NGOs, UN agencies, and donors). What matters is the process of identifying possible overlaps or gaps and building a consensus—not the paper plan itself. Disasters often present problems that are unforeseen in the most detailed plans.
Maintaining a close collaboration with these main actors. A good coordinator is one who appreciates and adapts to the strengths and weaknesses of other institutions. Stability is essential. Changes of key emergency staff members during a disaster situation or when a new administration or minister take over have occasionally complicated the tasks.
Sensitizing and training the first health responders and managers to face the special challenges of responding to disasters. Participation of external actors (UN agencies, donors, or NGOs) in designing and implementing the training is critical. The incorporation of disaster management in the academic curriculum of medical, nursing, and public health schools should complement the on-the-job training programs of the ministry of health, UN agencies, and NGOs. Well-designed disaster management training programs will improve the management of daily medical emergencies and accidents as well.
Prevention and Mitigation
The slogan "prevention is better than cure" was invented by the health sector. However, this sector has been slow to adopt the concept of preventing deaths and injuries from disasters through the mitigation (that is, reduction) of damage to its own facilities. As is unfortunately often the case, political action is often triggered only by a major disaster, such as the collapse of Hospital Juarez in Mexico in the earthquake of 1985; in that disaster 561 patients and employees died, (Poncelet 1997). Evaluating the damage (the past vulnerability) helps establish mitigation criteria for the future.
The level of protection required for each health installation must be negotiated—from life protection, which prevents an immediate structural collapse to permit the evacuation of people; to investment protection, which minimized the economic losses; to operational protection, which guarantees the sustainability of services under any extreme circumstances. Though a commercial or office building may be structurally designed only to prevent loss of lives, key hospitals must remain operational during the times they are most needed.
Local engineering and architectural experts play a key role in developing the knowledge, technical abilities, and cost-effectiveness analysis to establish mitigation priorities. Technical mitigation guidelines prepared at a global level (PAHO, WHO, World Bank, and ProVention Consortium 2004) need to be adapted to local culture, conditions, and resources.
Reducing the physical vulnerability of infrastructure can take place on three different occasions (UN/ISDR 2004, 324):
When reconstructing the infrastructure destroyed by a disaster. At that time, risk awareness is high, political will is present, and resources are available.
When planning new infrastructure. Reducing vulnerability is most cost-effective and politically acceptable when it is included at the earliest planning and negotiation stage, whether it involves a 1 to 2 percent additional cost for wind resistance or a 4 to 6 percent additional cost for earthquake resilience. Full resistance to any damage is prohibitively expensive.
Strengthening of existing facilities (retrofitting). This most expensive measure has been adopted by several developing countries (Chile, Colombia, Costa Rica, Mexico, Peru, and others) to protect their most critical health facilities. In the earthquake in Colombia in 1999, partial retrofitting of the main hospital is credited for saving the installation. Costs vary greatly (see table 61.3).
Mitigation of Damage to Hospitals
Mitigation does not pretend to eliminate all possible damage from hazards but aims to ensure the continuing operation of the health facility at a level previously defined by the health authority. Hospitals should be subject to stricter norms than other less critical facilities that are designed to prevent only total collapse and loss of life.
Hospital mitigation interventions fall into three categories:
Functional mitigation to ensure that the necessary supporting infrastructure services permit continuing operation: water, electricity, road access, communications, and so forth. Improving routine maintenance will facilitate operations under normal circumstances and in the event of extreme hazards.
Nonstructural mitigation to reduce losses and health injuries from falling or moving objects. Measures include, for instance, proper anchoring of equipment for earthquakes or strong winds or the location of only noncritical services on flood-prone floors.
Structural mitigation to ensure the safety of the structure itself (columns, beams, load-bearing walls).
Given the high economic, health, and political costs represented by the avoidable loss of critical health facilities, health authorities and funding agencies should require that, in all new health infrastructure projects, natural hazards be a decisive factor for selecting the facility's location and for formulating the specifications at the earliest stage of the process.
Mitigation of Damage to Water Systems
Unlike hospitals, water supply systems are geographically extensive and thus are exposed to different types of hazards. The search for technical solutions is more complex, given the diversity of the water system's components. Finally, in many countries, the health authorities have no jurisdiction over the construction or operation of those services owned or administered by many local or municipal agencies.
Even a short disruption of water services may have serious and direct implications for the health of individuals, the operation of health services, and the community at large through its impact on business. A probabilistic model studied the disruptive potential of a water outage in the event of an earthquake in Los Angeles county in the United States. As noted by the authors, "water outage is more likely to be disruptive for businesses in some industries, such as health services, than for others" (Chang and Chamberlin 2004, 89).
The health sector should, therefore, coordinate with the institutions in charge of constructing, operating, and maintaining water and sanitation services, both urban and rural, to promote reduction of the vulnerability of existing systems. The health sector should also ensure that health aspects and mitigation of damage be included in the regulatory framework and operating procedures of water and sanitation services.
Protecting the water supply is feasible in developing countries. The Costa Rican Institute of Aqueducts and Sewage Systems reduced the vulnerability of one of the main aqueducts of the country, the Orosi Aqueduct. Over 10 years, Costa Rica invested almost US$1.5 million in studies and reinforcements, an amount equivalent to 2.3 percent of the total cost of the aqueduct. This investment would prevent a loss of nearly US$7.3 million in direct damages alone (FEMICA 2003).