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EDITORIALS

Disaster epidemiology1990 began the decade in which the World HealthOrganisation hopes to reduce the frequency andimpact of disasters, especially among underprivilegedcommunities of the developing world. In 1975,at the International Colloquium on Disaster

Epidemiology,2 Michel Lechat, a prominent "disasterepidemiologist" described contemporary disasterrelief as "the crisis dominated convergence ofunsolicited donations of mobile hospitals, time

expired drugs, medical students volunteering fordisaster safaris and vaccines for diseases with zeroincidence". A Lancet editorial the next year,describing relief programmes following theGuatemala earthquake,3 3 confirmed that such

responses did indeed occur, and emphasised the needfor objective data on which to base relief interventions.Has any progress heen made in mitigating the

consequences of disasters and famines?Where disease and mortality surveillance has been

carried out, many preconceptions of disasters andfamines have been shown to be invalid. The way inwhich the health of the victims is affected depends onthe type of disaster.4 In acute disasters, such asearthquakes and cyclones, most deaths occur withinhours of the precipitating event, and post-disastermorbidity is generally low;5,6 in particular, large-scaleepidemics or disease outbreaks are uncommon.’ 7

Droughts, famines, and the exodus of refugees lead toa very different epidemiological picture. These"chronic" disasters are usually associated with a

period of displacement and migration, and

subsequent congregation in relief camps. Few data areusually available during the migration because ofinaccessibility or insecurity, but reports fromsouthern Sudan emphasise both the disease risks andthe excessive mortality. 8.9 Moreover, arrival in reliefcamps may not always lead to rapid improvements inhealth-such camps have been described as "one ofthe most pathogenic environments imaginable". 10

Several studies, lately reviewed by Toole andWaldman of the Centers for Disease Control,Atlanta,9 have examined patterns of morbidity andmortality in refugee camps in Africa and South-EastAsia. Crude mortality rates in such communities maybe 20-30 times higher than the local "normal" rates.In camps in eastern Sudan in 1985 with crude

mortality rates of 27/1000 per month, mortalityamong severely malnourished children rose to

300/1000 per monthy lWhat are the causes of such high mortality and how

accurate are media images of epidemics andstarvation? Where data on cause of death have been

documented, diarrhoeal diseases, measles, acute

respiratory infections, and malaria have been shown tobe mainly responsible." Epidemics of diseases such astyphoid, cholera, meningitis, and typhus have

occasionally been reported, but their overall impact onmortality is low. In the Sudan in 1985, a choleraepidemic affecting two camps caused 60 deaths;12 bycontrast, in a nearby camp 2000 children died ofmeasles.

Is malnutrition per se an important cause of death?Although severely malnourished children in camps ineastern Sudan experienced the highest death rates, thegreatest numbers of deaths were due to infections inchildren who were not severely malnourished." In astudy of famine-affected communities in western

Sudan, de Waal" showed that mortality rates were notaffected by the degree of destitution: increased diseasetransmission in relief centres affected children ofdestitute and non-destitute families equally. Thus,while severe malnutrition (below 70% weight/heightor kwashiorkor) is a major risk factor for mortality,communicable diseases rather than starvation causemost morbidity and death among refugeecommunities.

Disease surveillance has shown that in the

emergency phase of relief camps, increasedtransmission of the diseases common among poorcommunities is more important than "epidemic"

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diseases. Relief interventions should be aimed at thesecommon conditions, especially prevention of measlesand management of diarrhoeal diseases and respira-tory infections.

Epidemiological surveillance can be equally usefulin long-term refugee camps. Elias et al14 havedescribed the system adopted in one such camp on theThai-Cambodian border. Disease surveillance wasachieved by ensuring reporting, within 24 hours, ofany patient with symptoms compatible with a diseaseon the camp notification list, which included the maincommunicable diseases. In addition, discharge dataon all patients who had been admitted to hospital andon all outpatients diagnosed on one day a week wereincluded. Mortality data were collected by monthlyconsultations with the Buddhist monastery thatundertook death formalities. This system led to

improved planning of health interventions, earlydiagnosis of a dengue outbreak, and identification ofvulnerable subpopulations.

Although disease surveillance remains an

uncommon component of disaster relief and the crisis

approach is still dominant, 15 some progress has beenmade since Lechat’s assessment in 1975. His

continuing work at the Centre for Research on theEpidemiology of Disasters, Louvain; the studies byToole and Waldman at the Centers for Disease

Control; and the recent formation of Epicentre byMedecins Sans Frontieres in Paris together provide animportant resource. In the coming decade, wideracceptance of the role of epidemiology in disasters maylessen the crisis management approach and shouldhelp to reduce morbidity and mortality.1. Anon. International disaster decade is launched. Disaster preparedness in

the Americas no 41. New York: Pan American Health Organization,1990.

2. Lechat MF. Disaster epidemiology. Ann Soc Belg Med Trop 1976; 56:193-97.

3. Editorial. Disaster management. Lancet 1976; ii: 1394-95.4. Guha-Sapir D, Lechat MF. Reducing the impact of natural disasters.

Health Policy Plann 1986; 1: 118-26.5. Sommer A, Mosley WH. East Bengal cyclone of November 1970:

epidemiological approach to disaster assessment. Lancet 1972; i:

1029-36.6. Spencer HC, Campbell CC, Romero A, et al. Disease surveillance and

decision-making after the 1976 Guatemala earthquake. Lancet 1977; ii:181-84.

7. Woodruff BA, Toole MJ, Rodrigue DC, et al. Disease surveillance andcontrol after a flood: Khartoum, Sudan 1988. Disasters 1990; 14:151-63.

8. Perea WA, Moren A, Ancelle T, Sondorp E. Epidemic visceral

leishmaniasis in southern Sudan. Lancet 1989; ii: 1222—23.

9. Toole MJ, Waldman RJ. Prevention of excess mortality in refugee anddisplaced populations in developing countries. JAMA 1990; 263:3296-302.

10. Dick B. Diseases of refugees: causes, effects and control. Trans R Soc TropMed Hyg 1984; 78: 734-41.

11. Shears P, Berry AM, Murphy R, Nabil MA. Epidemiological assessmentof the health and nutrition of Ethiopian refugees in emergency camps mSudan, 1985. Br Med J 1987; 295: 314-18.

12. Mulholland K. Cholera in Sudan: an account of an epidemic in a refugeecamp in eastern Sudan. Disasters 1985; 9: 247-58.

13. de Waal A. Famine mortality: a case study efDarfar, Sudan 1984-5. PopulStudies 1989; 43: 5-24.

14. Elias CJ, Alexander BH, Sokly T. Infectious disease control in a long termrefugee camp: the role of epidemiologic surveillance and investigation.Am J Publ Health 1990; 80: 824-28.

15. Autier P, Férir M-C, Hairapetien A, et al. Drug supply in the aftermath ofthe 1988 Armenian earthquake. Lancet 1990; 335: 1388-90.

Medical ethics: should medicineturn the other cheek?

Doctors have always tried to learn from the experiencegained when treating patients. The beneficiary is thenext patient. Even today, the daily process of medicineleads to case-reports that are warning signals of

side-effects; to astute observations heralding newdiseases; or to insights into pathogenesis that arise bythe shrewd exploitation of unusual circumstances in aparticular patient. In general the medical professionsees this learning process as both a right and a duty. Itis a privilege to be entrusted with case-notes or toexamine the material remaining from all that dailysuffering, with the aim of improving care in the future.Moreover, society at large expects us to grow everbetter at diagnosing and treating diseases.

In modem medicine, this ancient and natural

learning process often needs to be formalised. Theappropriate choice of a control group in aetiologicalresearch might lead to a case-control design.Appropriate control groups for research to judge theworth of an intervention will often necessitaterandomisation. Over the past two or three decadessuch activities have come under more and more

scrutiny by increasingly professional medical

ethicists, latterly joined by lawyers specialising inhealth matters. Their central dogma seems to be thatwhatever is done for the sake of medical science is aliento the treatment of the individual, and shouldtherefore be labelled an "experiment", necessitatinginformed consent by the patient and adjudication byan ethics committee.

In the conclusion of a 1963 lecture to the RoyalCollege of Physicians, Sir Austin Bradford Hill

prophetically warned that the labelling of all medicalresearch as experimental, even if it was plainlyobservational, meant trouble for the profession.1 Inthe area of randomised controlled trials, T. C.Chalmers (Harvard), I. Chalmers (Oxford), and theircolleagues have repeatedly taken a courageous standby saying, in effect, that the physician who isconvinced that a certain treatment works will almostnever find an ethicist in his path whereas his colleaguewho wonders and doubts and wants to learn willstumble over piles of them.2.3 In non-experimentalresearch the dogma is clearly untenable, as Ingelfingeralready muttered in 1975: "Mr X, I must ask, may Ihave permission to take a piece of that cancer recentlyremoved surgically from your liver, so that I mayexamine it under the electron microscope? You shouldrealize, of course, that this examination will in no wayhelp you to get over your cancer". 4

In 1981 Rothman5 lamented the plight of theepidemiologist who has to defend his non-

experimental research before review committees.Rumour has it that it is not even possible to look atmedical records for the purpose of selecting the casesfor an observational study without informed consentor some higher permission in certain institutions in the