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M O D U L E 1

Disasters and their Effectson the Population: Key Concepts

Patrick Mahar | Julia Lynch | Joe Wathen | Eric Tham | Stephen Berman

INTRODUCTIONThe recent advances in technology and the ease with which news and informationtravel around the world has made learning about disasters in distant countries analmost weekly occurrence. From the recent earthquakes in Haiti and China, to thesevere flooding in Pakistan and the deadly Asian tsunami, these disasters have leadto unimaginable levels of destruction and death. Although most of these disastersoccur in underserved areas in the world without adequate resources andtechnology, they can also occur in societies with advanced medical systems such asthe United States, Europe and Japan. It is impossible to predict when and where thenext disaster will take place. However, we can strive to be prepared to handle boththe 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 areseveral consequences of disasters that are predictable and thus we can be preparedto deal with these consequences. As pediatricians, we must ensure that disasterpreparedness includes the unique needs of children. Children are a vulnerablepopulation with physiologic, psychological and developmental needs that are notseen in adult populations. There is a professional obligation to take an active role indisaster preparedness in order to advocate for the needs of infants, children andteenagers. In this module, we will review disaster definitions, classifications, andmeasures of severity; describe the phases of a disaster, review the 10 World HealthOrganization emergency relief measures; discuss the role of relief organizations;and present key issues that medical volunteers may face in the relief role. The keymessage of this module is to understand that, while it is not possible to predictdisasters, planning and preparation can help mitigate some of the morbidity andmortality that occur in the aftermath of a disaster. This message has been clearlystated by Benjamin Franklin: “Failing to plan is planning to fail.”

Disasters and theirEffects on the Population:Key Concepts

Patrick Mahar, MD; Julia Lynch, MD;Joe Wathen, MD; Eric Tham, MD; Stephen Berman, MD

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DefinitionsWhat makes an event a disaster? Why isone hurricane or tornado a disaster andthe next one, even with stronger winds, isjust a bad storm? The answer lies with howthe population is affected: both the directeffects on the people as well as the indi-rect effects or damage to infrastructure.The World Health Organization and the

DEFINITIONS

OBJECTIVES� Recognize events that can lead to disasters and humanitarian emergencies.

� Understand the individual and socialfactors associated to vulnerability andadverse outcomes.

SECTION I / DEFINITIONS

CASE 1.You are informed there has been aflood affecting the entire coastal areain the capital city of one of theprovinces of your country. Accordingto the latest population census, around200,000 people who are mostly poorlive in this area.� What are the characteristics thatindicate that this event can bedefined as a disaster?

� What type of disaster is it?

Continues on page 12.

Pan American Health Organization(WHO/ PAHO) define a disaster as anevent that most often occurs suddenly andunexpectedly, resulting in loss of life, harmto the health of the population, destruc-tion of community property, and damageto the environment. A disaster disrupts thenormal pattern of life, causing both physi-cal and emotional suffering and an over-whelming sense of helplessness and hope-lessness. The impact on the socioeconom-ic structure of a region and environmentoften requires outside assistance andintervention. Although there are many def-initions for disaster, there are three com-mon factors. (Box 1) First, there is anevent or phenomenon that impacts a pop-ulation or an environment. Second, a vul-nerable condition or characteristic allowsthe event to have a more serious impact.For example, a hurricane will cause muchgreater damage to life and structures if itdirectly strikes an area with poorly con-structed dwellings compared to striking acommunity of well-built homes withgreater structural support. Identifyingthese factors has practical implications forcommunities’ preparedness and provides abasis for prevention. Third, local resourcesare often inadequate to cope with theproblems created by the phenomenon orevent. Disasters affect communities in mul-tiple ways. Their impact on the health careinfrastructure is also multi-factorial. Thedisaster event can cause an unexpectednumber of deaths. In addition, the large

Any adverse episodeor phenomenon canexploit a vulnerabilityin the affectedpopulation orcommunity to createdamage, and thisawareness will formthe basis for anadequate intervention.

numbers of wounded and sick oftenexceed the local community’s health caredelivery capacity. The community’s capacityto care for those affected is often reducedbecause professionals, clinics and hospitalshave been affected or destroyed. This willhave long-term consequences leading toincreased morbidity and mortality. Anexample of this can be seen in the 2010Haiti earthquake disaster. Prior to theJanuary 12, 2010 earthquake in Haiti therewere only 11 hospitals in Port-au-Prince.The earthquake damaged or destroyed at

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least eight of these hospitals. The remain-ing health facilities were quickly over-whelmed by large numbers of survivorsrequiring a wide range of care, particularlyfor traumatic injuries. The 2010 earth-quake in Haiti demonstrates how a disas-ter becomes much more devastating whenthe preexisting medical system is alreadyinadequate and poorly functional. Thismakes integrating and organizing outsideassistance more fragmented and chaotic.An epidemic/pandemic can cause a surgein the number of people seeking medicalcare/treatment, and thus overwhelms theabilities of even a well established medicalsystem. The 2009 H1N1 pandemicstressed the emergency medical servicesand hospitals throughout the world. Thedisaster can have adverse effects on theenvironment that will increase the risk forinfectious transmissible diseases and envi-ronmental hazards. The loss of clean drink-ing water and proper sewagedisposal/treatment can have devastatingeffects on a population affected in the dis-aster. This will impact morbidity, prematuredeath, and future quality of life. There canbe shortages of food, with severe nutri-tional consequences. All these conditionslead to a sense of hopelessness, vulnerabil-ity, and inability to think that the future willbe better. This means that people nolonger visualize their future by makingplans such as finishing school, getting mar-ried and working. This “foreshortenedfuture” affects the psychological and socialbehavior of the community. (Figure 1)

Classification of disastersDisasters can be divided into 2 large cat-egories (Box 2): – Those caused by natural forces – Those caused by man.

BOX 1. Definitions of a disaster

“A disaster is a crisis resulting from a failure inhuman interactions with the physical and socialenvironment. Disaster situations outstrip thecapacity of individuals and societies to cope withadversity”.HDI, From Disaster Relief to Development, Studies onDevelopment, No 1 (Geneva: Henry Dunant Institute,1988), p. 170.

“A disaster is the convergence, at a given momentand in a given place, of two factors: risk andvulnerability”.G. Wilches-Chaux, “La vulnerabilidad global,” in Herramientaspara la crisis: Desastres, ecologismo y formación profesional(Popayan, Colombia: Servicio Nacional de Aprendizaje[SENA], Sept. 1989).

“A disaster has occurred when the destructiveeffects of natural or man-made forces overwhelmthe ability of a given area or community to meetthe demand for health care.”Mothershead JL et al. Disaster Planning. Available at:http://www.emedicine.com/emerg/topic718.htm#section~definitions_and_terminology.

“A disaster can be defined as a serious disruptionof the functioning of a society, causing widespreadhuman, material or environmental losses whichexceed the ability of the affected society to copeusing only its own resources.”Bryce, C.P. “Stress management in disasters”, WashingtonD.C, OPS, 2001.

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Disasters can bedivided into 2 largecategories: thosecaused by naturalforces and thosecaused by man.

7SECTION 1 / DEFINITIONS

Natural disasters Natural disasters are caused by naturalforces, such as earthquakes, volcanic erup-tions, hurricanes, fires, tornados, andextreme temperatures.

FIGURE 1. Components of a disaster

Adapted from Handbook of War and Public Health; ICRC; 1996.

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

BOX 2. Types of disasters

PHENOMENON X VULNERABILITY = IMPACT

• Droughts• Volcanic eruptions• Floods• Earthquakes• Hurricanes

• Human• Economic• Social• Ecological• Political• Legal

Natural disasters• Hurricanes or cyclones• Tornadoes• Floods• Avalanches and mud slides• Tsunamis• Hailstorms• Droughts• Forest fires• Earthquakes• Epidemics

Man-provoked disastersTechnological/industrial disasters• Leaks of hazardous materials• Accidental explosions • Bridge or road collapses, or vehiclecollisions• Power cutsTerrorism/International violence• Bombs or explosions• Release of chemical materials• Release of biological agents• Release of radioactive agents• Multiple or massive shootings• Mutinies• Intentional firesComplex emergencies• Conflicts or wars• Genocide

They can be classified as rapid onset dis-asters such as earthquakes or tsunamis,and those with progressive onset, such asdroughts that lead to famine.

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These events, usually sudden, can havetremendous effects. For instance, inDecember 2004 more than 200,000 peo-ple died in Southern Asia as a result of atsunami. Since it is still extremely difficultto precisely predict the climatic and geo-logical changes capable of causing a disas-ter, preparing for these types of disastersremains a major challenge. Great naturaldisasters have also occurred recentlythroughout the Americas (Box 3).

The inability to accurately predict thesetypes of events underscores the need forcountries to have disaster response plansto mobilize appropriate resources rapidlyand efficiently. A well-defined organiza-tional structure also must be created tocoordinate both national and internation-al assistance.Although significant progress in sanita-tion and response to disasters has beenachieved in certain regions of the world,developing countries continue to be high-ly vulnerable because of their fragileeconomy and health care and transporta-tion infrastructure.

Man-made disastersDisasters caused by man are those inwhich major direct causes are identifiableintentional or non-intentional humanactions. They can be subdivided into threemain categories:

Technological disastersUnregulated industrialization and inade-quate safety standards increase the risk forindustrial disasters. Examples include theradioactive leak in the Chernobyl nuclearstation in Ukraine (1986) and the toxic gasleak in a Bhopal factory in India (1984). Bothof these disasters were associated not onlywith many deaths but also with long-termhealth effects in the affected population.

Terrorism/ViolenceThe threat of terrorism has also increaseddue to the spread of technologies involvingnuclear, biological, and chemical agents usedto develop weapons of mass destruction.Too often the professionals who mustrespond to such disasters are not appropri-ately trained, although several national andinternational organizations are developingtraining programs for these types of events.

SECTION 1 / DEFINITIONS

Usually, a greatnumber of personsdie when a complexhumanitarianemergency occurs.

BOX 3. Natural disasters in theAmericas in 2007

Cold WavesPeru: Jun 2007

EarthquakesPeru: Aug 2007

EpidemicsParaguay: Dengue Outbreak - Feb 2007

FloodsColombia: Floods and Landslides - May 2007Uruguay: Floods - May 2007Argentina: Floods - Mar 2007Haiti: Floods - Mar 2007Argentina: Floods - Feb 2007Bolivia: Floods - Jan 2007Peru: Floods - Jan 2007

HurricanesHurricane Felix - Sep 2007Hurricane Dean - Aug 2007

Mud SlidesBrazil: Jan 2007

TornadoesUSA: Florida Storm and Tornado - Feb 2007

Volcanic EruptionsColombia: Nevado del Huila Volcano - Apr 2007Avalanches - Apr 2007Montserrat: Volcanic Eruption - Jan 2007

Modified from: www.reliefweb.int


Complex humanitarian emergenciesThe term complex emergency is usuallyused to describe the humanitarian emer-gency resulting from an international orcivil war. In such situations, large numbersof people are displaced from their homesdue to the lack of personal safety and thedisruption of basic infrastructure includingfood distribution, water, electricity, and san-itation, or communities are left strandedand isolated in their own homes unable toaccess assistance. These settings are often

A person recognizedas a refugee is entitledto certain protectionsunder the terms ofinternationalhumanitarian laws.

characterized by a breakdown in social andphysical infrastructure, including health caresystems. Any emergency relief responseusually has to be implemented in a prob-lematic political and safety environment.There has been a global increase in civilwar fueled by ethnic confrontations sincethe mid-1990s (Figure 2). In modernconflicts the greatest loss of life (90%)occurs among civilian nonfighters becauseof direct physical injury and the publichealth impact of war (Figure 3).

FIGURE 2. Number of natural and complex disasters in the world between 1985 and 1995

From Humanitarian and Peace Operations. NGOs and Military in the Interagency Process, Workshop Memory, OFDA Briefing sponsored by the Center forAdvanced Concepts and Technology

WWI WWII

FIGURE 3. Proportion of civilian deaths (in millions) during armed conflicts.Comparison between the World Wars and conflicts in the ‘80s and ‘90s

From Bellamy C. The State of the World’s Children. New York: Oxford University Press, 1996. Ahlstram C. Casualties of Conflict: Report for the Protection ofVictims of War. Upsala, Sweden: Peace and Conflict Research Department, Upsala University, 1991.WWI = World War l; WWII = World War II

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Complex humanitarian emergenciesoften result in a staggering loss of lives.Table 1 shows the estimated excessivedeaths among civilians in several recentand ongoing crises.

Displaced populationsNatural disasters and complex emergen-cies can force many people to leave theirhomes. The specific job of the office of theUnited Nations High Commissioner forRefugees (UNHCR) is to register and

TABLE 2. Refugee population by UNHCR regions

UNHCR regionsStart 2006

End2006

Annual change

Central Africa and Great 1,193,700 1,119,400 -74,300 -6.2%Lakes

East and Horn of Africa 772,000 852,300 80,300 10.4%

Southern Africa 228,600 187,800 -40,800 -17.8%

West Africa 377,200 261,800 -115,400 -30.6%

Total Africa* 2,571,500 2,421,300 -150,200 -5.8%

Central Asia, Southwest Asia, 2,716,500 3,811,800 1,095,300 40.3%North Africa and Middle East

Americas 564,300 1,035,900 471,600 83.6%

Asia and Pacific 825,600 875,100 49,500 6.0%

Europe 1,975,300 1,733,700 -241,600 -12.2%

TOTAL 8,653,200 9,877,800 1,224,600 14.2%

*Excluding North AfricaFrom: UNHCR. 2006 UNHCR Statistical Yearbook. Available at: http://www.unhcr.org/

Absolute %

assist displaced populations and individu-als. This office recognizes two categoriesof affected people: refugees and internallydisplaced persons (IDP).Refugees flee their countries because ofwar, violence, famine, or well-founded fearof persecution for political, ethnical, reli-gious or nationality reasons. According tothe 2006 UNHCR estimates, there arealmost 10 million refugees worldwide(Table 2). A person recognized as arefugee is entitled to certain protections

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


TABLE 3. Internally displaced persons: global trends

Total conflict-related IDP population: 24.5 million (as of December 2006)Number of countries affected: At least 52Most affected continent: Africa (11.8 million IDPs in 21 countries)Countries with highest number of IDPs: Sudan (5 million), Colombia (3.8 million),

Iraq (1.7 million), Uganda (1.7 million), DRC (1.1 million)

Number of countries with conflicts 23generating displacement:Countries with most new displacement: Lebanon, DRC, Iraq, Sudan, IsraelCountries with most return: Sudan, Lebanon, DRC, Uganda, IsraelCountries with worst displacement situations Burma (Myanmar), Central African Republic, Chad, (In alphabetical order): Colombia, Côte d’Ivoire, DRC, Iraq, Somalia,

Sri Lanka, Sudan, UgandaEstimated number of IDPs exposed to serious 15.6 millionthreats to their physical safety:Countries with governments or occupation Burma (Myanmar), CAR, Chad, Colombia, Côte forces directly or indirectly involved in deliberately d’Ivoire, DRC, Iraq, Lebanon, Kenya, Pakistan, displacing people: Palestinian Territories, Philippines, Senegal,

Sri Lanka, Sudan (Darfur), Uganda (Karamoja), Zimbabwe

Estimated number of IDPs without any significant 5 million in at least 11 countrieshumanitarian assistance from their governments:Estimated number of IDPs faced with governments 6 million in at least 13 countriesindifferent or hostile to their protection needs:Proportion of women and children among IDPs: 70-80%

IDP (Internally Displaced Persons); DRC (Democratic Republic of the Congo) From: Internal Displacement Monitoring Centre. Internal Displacement- Global Overview of Trends and Developments in 2006. Available at:http://www.internal-displacement.org/

under the terms of international humani-tarian laws.IDPs leave their homes for similar rea-sons but do not cross the boundaries oftheir countries. These individuals do notreceive the same kind of legal protection,so helping them can be much more diffi-cult. According to the 2006 InternalDisplacement Monitoring Centre esti-mates, there are 24.5 million IDPs world-wide (Table 3). More information is avail-able at http://www.internal-displace-ment.org.

Phases of disastersSince relief interventions in emergenciesevolve as a continuum, the identificationof the following four phases is useful tobetter establish priorities and response

activities, and to systematize previousexperiences:

1. Planning phase2. Response phase3. Recovery phase4. Mitigation and prevention phase

Planning phasePlanning comprises all the activities andactions taken in advance of a disaster.Planning should be based on the analysisof a community’s or organization’s risk forexposure to specific types of disasters.Plans should take into account the fre-quency of occurrence of each type of dis-aster, the anticipated magnitude of effect,the degree of advanced warning or sud-denness of onset and offset, characteris-

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tics of the populations most likely to beaffected, the amount and types ofresources available within the communityor organizational structure, and the abili-ty to function independently withoutadditional outside resources for periodsof time. For more information on plan-ning, see Module 3.

Response phaseResponse comprises all activities andactions taken during and immediatelyafter a disaster. This includes notificationof the organizations involved in disasterresponse, setting up of initial communica-tion networks, initial search and rescue,damage assessment, evacuation, shelteringand other multiple activities. The responsephase lasts until the initial casualties haveeither been rescued or acknowledged aslost, and enough resources have beenmade available to allow the population toassess damages and begin planningrestoration and recovery. This phase canlast hours to weeks.

Recovery phaseThe recovery phase is the period in whichthe affected organization or communityworks toward re-establishing self suffi-ciency. This is the period of new commu-nity planning, rebuilding, and re-establish-ment of government and public serviceinfrastructure. The health status of affect-ed population begins to return to pre-dis-aster conditions and the outside supportservices are gradually withdrawn.

Mitigation and prevention phaseThis phase usually occurs when condi-tions are returning to their predisasterstate. Mitigation is the phase in which allaspects of emergency management are

scrutinized for “lessons learned”; the les-sons are then applied in an effort to pre-vent the recurrence of the disaster itselfor to lessen the effects of subsequentevents. Mitigation includes preventive andprecautionary measures such as changingbuilding codes and practices, redesigningpublic utilities and services, reviewingmandatory evacuation practices andwarning policies, and educating membersof the community. Mitigation and planningare continuous processes, as lessonslearned from a previous disaster areincluded in planning for the next one.

Effects of disasters Disasters affect communities in multipleways. They represent a public health haz-ard for various reasons (Table 4):� Can cause an unexpected number ofdeaths and wounded or sick peoplethat exceed the local resources capaci-ty to respond and require external aid.

� Can destroy health infrastructure notonly affecting the immediate response,but also disrupting preventive activities,leading to long-term consequenceswith increased morbidity and mortality.

CASE. (cont.)2.Twenty-five percent of thepopulation affected by the flood arechildren aged 0 - 12 years old. Thispopulation is more vulnerable thanothers in disaster situations.� What characteristics makechildren more vulnerable?

� What specific interventions arenecessary to diminish the effects ofdisaster upon children?

Continues on page 19.

13SECTION 1 / Children in disaster

� Can have adverse effects on the envi-ronment that will increase the risk forinfectious transmissible diseases andenvironmental hazards. This will impactmorbidity, premature death, and futurequality of life.

� Can affect the psychological and socialbehavior of the community.

� Can cause shortages of food, withsevere nutritional consequences.

� Can cause large movements of the pop-ulation, both spontaneous or organ-ized, to areas where health servicesmight not be able to handle the exces-sive requirement.

TABLE 4. Frequent effects of disasters

Adapted from Humanitarian Assistance in Disaster Situations. A Guide for Effective Aid. Pan-American Health Organization (PAHO). Washington D.C, 1999.

Complexemergency

Earthquake Strongwinds

Floods Gradualfloods

Mud slides

Volcaniceruptions

Immediate deaths Numerous Numerous Few Numerous Few Numerous NumerousSevere lesions Numerous Numerous Moderate Few Few Few Few

Increased risk fortransmissible

diseases

This risk applies to ALL significant disasters, and increases with overcrowding and deterioration of sanitary conditions

Damage to healthcenters

Moderate; canbe severe if

health centersare military

targets

Severe Severe Severe butlocalized

Severe (only for

equipments)

Severe butlocalized

Severe

Damage to watersupply

Severe Severe Slight Severe Slight Severe butlocalized

Severe

Food shortage Severe May result from economicand logistic factors

Frequent Frequent Not frequent Not frequent

Significant population

displacements

Frequent Frequent;increased

likelihood inseverely damaged

urban areas

Not frequent Frequent

Effect

Disastertype

MORTALITY

OBJECTIVES� Recognize crude mortality rate as ameasure of disaster severity

� Recognize the environmental factorsassociated with increased morbidity andmortality rates

� Know the 5 leading causes of death inhumanitarian emergencies occurring indeveloping countries

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Severity of a disasterAs was demonstrated in Haiti, the morefragile the pre-event health status of theaffected population and inadequate thepre-disaster infrastructure, the moresevere the disaster. Disaster severity will,therefore, vary according to its magnitudeand the vulnerability of the population. Anexample of this is seen in earthquakes ofsimilar magnitude in different parts of theworld. Earthquakes in China and Haitiresulted in a large number of collapsedbuildings, including schools and hospitals,related to substandard building practicesin both, and thus high number of casual-ties. The damage from similar magnitudeearthquakes occurring in Tokyo in 2009and Chile in 2010 resulted in far less lossof life in large part due to the higher qual-ity of construction and stricter buildingcodes. When assessing the outcome of adisaster, public health officers describe itsseverity by the number of human liveslost using the crude mortality rate(CMR). CMR is usually defined as thenumber of deaths per 10,000 inhabitants

per day. In developing nations, the refer-ence CMR value varies from 0.4 to 0.7deaths per 10,000 people/day. A CMRabove 1 death per 10,000 people/day isconsidered a humanitarian emergency. Toassess the progression of a disaster andthe effectiveness of relief interventions,measure the CMR over several appropri-ate time intervals. For example, during themonth following the massive movementof Rwandan refugees to Eastern Zaire, theCMR in that region was 40 to 60 timesabove the corresponding reference value.

Most diseasesassociated with theevent can beprevented by adequateinterventions,especially ensuringbasic sanitation.

Natural disasters can result in numerous immediate deaths due totrauma

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While both conflictsand natural disasterscan result inimmediate deaths dueto trauma ordrowning, there aremany preventabledeaths that occur inlater phases of adisaster over a longertime period.

The CMR is usually highest during the ini-tial phase of a disaster. Table 5 displaysthe differences between baseline andpeak disaster CMR experienced by dis-placed populations in different countries.Additional information regarding theseepidemiologic measurements may befound in Module 2, “Preventive Medicinein Humanitarian Emergencies.”

Vulnerable victimsImmediate mortality in any type of disas-ter is not higher in a specific age range;instead, it usually reflects the age distribu-tion of the overall population. However,later on the mortality rate associatedwith the disaster is disproportionately

higher among the youngest and oldestpeople. Figure 4 shows this phenome-non related to a refugee crisis inNorthern Iraq in 1991. Although childrenaged 0 to 5 years accounted for only 18%of the total refugee population, theyaccounted for 64% of the overall refugeemortality rate.The most vulnerable groups includechildren, especially those displaced fromtheir families, women who are pregnant,lactating, or live without their spouse;individuals living in households headedonly by women; disabled individuals; andthe elderly. In addition to disproportion-ately high mortality rates, children dis-placed from their family are at high risk

Age distribution Deaths distribution

0 to 5 years 6 to 14 years 15 to 44 years 45 years or older

FIGURE 4. Age distribution of a population of Kurdish refugees as compared tothe age distribution of deaths

Adapted from Toole MJ. “Mass Population Displacement – A Global Public Health Challenge”. Infectious Disease Clinics of North America, Volume 9; 1995.

TABLE 5. Differences between baseline and disaster crude mortality rate (CMR)experienced by displaced populations

Adapted from Toole MJ. Mass Population Displacement - A Global Public Health Challenge. Infectious Disease Clinics of North America, Volume 9;1995.

Date Host country Country of origin

Reference CMR

Crisis CMR

June 1991 Ethiopia Somalia 0.6 4.7

April 1991 Turkey / Iran Iraq 0.2 4.2

March 1992 Kenya Somalia 0.6 7.4

July 1994 Zaire Rwanda 0.6 34.0

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for a number of adverse consequences,including rape, torture, robbery andexploitation in child labor, child trafficking,and child soldiering. Additionally, becauseof certain physical and physiological char-acteristics, infants and children are morevulnerable to the release of toxic sub-stances and the overcrowding associatedwith the displacement of large popula-tions (Table 6). Consequently, it is criti-cal to attempt to reunite children withtheir families as soon as possible and payspecial attention to reducing their vulner-ability in all disaster response planning(Box 4).

Causes of mortalityThe immediate goal for any interventionin humanitarian emergencies is to reducethe number of deaths. While both conflictand natural disasters can result in imme-

diate deaths, there are many preventabledeaths that occur in later phases of a dis-aster over a longer time period.Five leading medical problems have con-sistently been found to be the major mor-tality causes in post-war or post-naturaldisaster settings among vulnerable popu-lations (Box 5).Unique features in each disaster (eg, cli-mate, topography, pre-existing socialstructure, physical conditions) affect theproportion of deaths associated witheach of these, as well as other causes.Figure 5 shows mortality in various dis-placed populations following natural dis-asters and armed conflicts. Malnutrition,although not identified as a significantimmediate cause of death, is the mostimportant factor correlated to the highmortality rates due to transmissible dis-eases. A study including 41 displaced pop-

TABLE 6. Vulnerable pediatric characteristics

Adapted from AAP, Pediatric Education for Prehospital Professionals, Jones & Bartlett Publishers, London, 2006.

Pediatric characteristic Special risk during disaster

Respiratory Higher minute volume increases risk from exposure to inhaledagents. 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 afterexposure 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 riskfor hypothermia.

Developmental Lower ability to escape environmental dangers or anticipate hazards.

Psychological Prolonged stress from critical events. Susceptible to separation anxiety.

It is critical to attemptto reunite childrenwith their families assoon as possible andgive special attentionto reducing theirvulnerability in alldisaster responseplanning.

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BOX 6. Predisposing environmental conditions

BOX 5. The five leading causes of death in humanitarian emergencies occurring in developing nations

� Diarrheal diseases and dehydration

� Measles

� Malaria

� Acute respiratory infections

� Malnutrition

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

� List vulnerable people in the community� Provide visible identification tags to all children� Identify the community leaders –women whenever possible– capable oftaking care of a vulnerable individual or group

� Guarantee the care and safety of refugees� Consider the vulnerable individuals when planning the distribution systems� Assign priority to the search for parents or families of unaccompanied orotherwise vulnerable individuals

� Post in a central place the photographs of children separated from theirfamilies, to enhance their identification

� Make sure that camps or shelters, if needed, are located as near the affectedareas as possible

� Place families and groups of neighbors together

� Disruption of food sources/economy

� Disruption of sanitary services� Income loss � Discontinuation of healthcare services

� Overcrowding� Lack of adequate water supply� Loss of shelter

ulations (Figure 6) showed a clear cor-relation between the crude mortality rate(i.e., death from all causes) and the preva-lence of malnutrition.In the context of a disaster, each of theleading causes of death relates to one ormore predisposing environmental condi-

tions that increase the incidence of dis-ease and the mortality rate per case(Box 6). For interventions to be effec-tive, resources should be targeted toprevent and correct these predisposingenvironmental factors, in addition totreating the ill individuals. At a World

18 SECTION II / MORTALITY

Health Organization conference, inter-national relief experts identified 10essential emergency relief measures toconsider when planning a disasterresponse. These interventions shouldnot to be implemented in a strict order;

priority for each of them is correlated tothe particular needs relating to eachemergency situation. In addition, theseinterventions should be adjusted to theparticular situation in the affectedregion.

FIGURE 5. Causes of death in children less than 5 years old in displaced populationsdue to natural disasters and war in Mozambique

Malaria25%

Acute respiratory infection

9 %Diarrhea

11 %Measles

10 %

Other 22%

Malnutrition 23 %

Malaria 16 %

Acute respiratory infection

3 % Non-cholera

diarrhea 19 %

Cholera 26 %

Measles 10 %

Other 3%

Malnutrition 21 %

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

Natural disasters Malawi, Lisungwe Camp

FIGURE 6. Crude mortality rates (deaths per 1,000 individuals per month) inrelation to malnutrition prevalence*

*Malnutrition Prevalence in Population (%)(Malnutrition = <80% weight/height WHO reference population)

Each disaster or humanitarian emergencyis a unique situation determined by theevent that caused it, climate, geography,culture, social structure, and previousconditions of the affected population.Thus, national and international organiza-tions should initially implement a rapidassessment and resist the impulse toimmediately respond before critical infor-mation is available. Interventions that arebased on speculations rather than onaccurate information obtained in theplace of the disaster are likely to wastetime and valuable resources, ultimately

ESSENTIAL EMERGENCY RELIEF MEASURES

OBJECTIVES

� Understand the 10 essential emergencyrelief measures (as defined by WHO).

� Know how these measures should beimplemented in the community.

SECTION III / ESSENTIAL EMERGENCY RELIEF MEASURES

increasing the suffering of the affectedpopulation. Although similar types of dis-asters have predictable patterns of dis-ruption as shown in Table 4 (page 12),the degree of severity and type ofresponse is affected by local features.An appropriate response should bebased on the particular needs in each dis-aster. Continuously reassess the needs atboth the local and community levels,where the disaster has occurred, as wellas at national or regional levels.Unpredicted effects may require urgentattention. For example, safe water supplyis unlikely to be affected by a strongstorm or a mudslide. However, if theregional system for water pumping orpurification is affected, the shortage ofsafe water becomes the key issue thatmust be addressed to prevent disease andexcessive mortality in the affected popu-lation. Use resources in a timely manner,within the time frame determined by thedisaster. For example, trauma is likely tobe the major cause of death immediatelyafter an earthquake. If trauma surgeryteams and field hospitals arrive a weekafter the earthquake, most of the trauma-related deaths will already have occurredand very little benefit will be obtainedfrom this high-cost resource.WHO and PAHO have developedguidelines for the appropriate use of fieldhospitals in disasters of sudden impact(www.paho.org/disasters).

CASE. (cont.)3. After arriving at the flooded area,you must decide what to do to deli-ver health care to the victims

� What is the first step to be taken?� How useful are field hospitals inthese situations?

� How would you estimate the needfor external help?

An appropriateresponse should bebased on theparticular needs ineach disaster.

Essential emergency reliefmeasures

1. Do a rapid assessment of theemergency situation and the affect-ed population.An assessment should accurately definethe needs, so that limited resources willbe efficiently used to maximize life-savingsand other vital goals.National level: Assessments are typical-ly done by expert teams focused onpromptly defining the emergency magni-tude, the environmental conditions andinfrastructure damage, the major healthand nutrition needs of the affected popu-lation, and the local response capacity.Community level: In the immediateaftermath of a disaster, the initial responsewill primarily come from local resources.Communities must be prepared to do alocal assessment of disaster impact. Healthcare professionals should be prepared toassess the health issues in their communi-ty, and understand the mechanism of shar-ing that information with higher levels ofauthority, in order to contribute to region-al or national assessments.Assessments need to be repeated and thequality and specificity of data improvedduring the rescue and recovery phases orwhenever any major change occurs, suchas an aftershock earthquake. Informationgathered through the assessments is usedby the resource managers to determinethe allocation of resources in any large-scale disaster.

2. Provide adequate shelter andclothing. Exposure to the climatic conditions in dis-aster situations can increase caloricrequirements and lead to death.

Community level: Find short-termshelters for all homeless individuals, par-ticularly focusing on vulnerable popula-tions. Shelters should be appropriate forthe climate. Keep individuals within theircommunities and family networks asmuch as possible. In general, it is recom-mended to direct resources to rebuildingwithin the community, rather than build-ing large camps or temporary settlementsoutside the disaster area.

3. Provide adequate nutrition.Large-scale bulk food requirements aretypically calculated based on a minimumof 2,000 kcal/person/day.Community level: Communities mustplan to distribute food equitably andinclude vulnerable groups. As global foodresources improve, establish targetedsupplemental and therapeutic feedingprograms for malnourished individuals.

4. Provide elementary sanitationand clean water.The estimated minimum requirement forwater is 3 to 5 L/person/day of clean water.Community level: Re-establish suppliesof clean water and effective sanitation andwaste disposal services as soon as possi-ble. Vulnerable groups must be consideredregarding the access, safety, and securityof each plan.

5. Set up diarrhea control program.An increase in diarrheal disease is a pre-dictable outcome of disasters because ofinfrastructure and health care servicesdisruption.Community level: Rapidly implementcommunity-based education on appropri-ate household sanitation measures, diar-

Large-scale bulk foodrequirements aretypically calculatedbased on a minimum of2,000 kcal/person/day.

20 SECTION II I / ESSENTIAL EMERGENCY RELIEF MEASURES

21SECTION II I / ESSENTIAL EMERGENCY RELIEF MEASURES

rhea prevention, and household case man-agement, particularly for young childrenwith diarrhea. Health care centers shouldanticipate the needs for additional cases ofdehydration, using appropriate low-coststrategies (ORS / ORT) and recognizepossible cases of cholera and dysentery.

6. Immunize against measles andprovide vitamin A supplements.Measles has been a major source of mortal-ity among crowded, displaced populationsin which malnutrition is prevalent.Therefore, measels immunization is theonly vaccine that is routinely considered foruse as a preventive measure immediatelyfollowing a disaster. Since vitamin A deficien-cy is common and contributes to measles-related mortality, consider mass distribu-tion of vitamin A for vulnerable populations.National level: National and internationalagencies work together to determine ifmeasles immunization or vitamin A distri-bution is necessary following a particularevent. If necessary for all or part of thedeemed population, national authoritiesestablish the central logistics (e.g., coldchain, personnel, materials) to manage amass immune ization/distribution campaign.Community level: Health officers mustimmediately assess the available coldchain as part of its health care assess-ment. Health care professionals mustmonitor for cases of measles and developa plan for mass immunization and/or massdistribution of vitamin A to the vulnerablegroups in their community.

7. Re-establish and improve primary medical care.Immediate casualties (rescue phase) of asudden impact disaster are likely toinclude a limited number of trauma vic-

tims. In most disasters in fragile communi-ties the larger number of disaster-relateddeaths (i.e., deaths above the baselinecrude mortality rate) will be due to pre-ventable causes of mortality in the weeksand months following the impact. Thesecasualties can largely be prevented bycommunity health education and accessto appropriate primary care.Community level: Health professionalsshould know the emergency transportand response systems in their community.Health care interventions during the res-cue phase should include minimizing lifelosses caused by the direct impact of theevent (e.g., trauma, drowning). After therescue phase, health care resourcesshould be focused on re-establishing andimproving the access and quality of pri-mary care, particularly for the most vul-nerable groups.

8. Set up disease surveillance andhealth information systems.Effective health information and diseasesurveillance systems are necessary tomonitor effectiveness of health interven-tions and reassign priorities.National level: Health authorities willuse available information to define initialpriorities in the use of limited resources.They should develop specific surveillanceguidelines for each disaster in order totrack relevant disease/mortality trends.Community level: Every health caredelivery setting should immediately imple-ment a simple but effective health infor-mation collection system based on estab-lished WHO, PAHO, or governmentalguidelines. Health care professionalsshould know how to share this informa-tion regularly with higher level healthauthorities.

Many casualties canlargely be preventedby community healtheducation and accessto appropriate primarycare for treatment.

22 SECTION II I / ESSENTIAL EMERGENCY RELIEF MEASURES

9. Organize human resources.The initial shock of an event can make itdifficult for a disaster-affected populationto effectively respond in a quick andorganized fashion. Having a pre-definedemergency plan with clearly-identifiedleaders can help the local community to cope until more external resourcesarrive.Community level: Have an emergencyplan and pre-defined community leadersfor:� Conducting rescue operations� Conducting assessments (e.g., healthservices, transportation, food, sanita-tion/water systems)

� Organization of food and water distri-bution, and the sanitary program

� Health services management� Corpses and gravesite management� Identification of unaccompanied minorsor other extremely vulnerable individu-als (e.g., elderly or persons with a dis-ability) and organization of a caregiverprogram.

10. Coordinate activities.National level: In a large-scale disasterthere will be many national and interna-tional agencies attempting to assess, devel-op plans, and establish priorities for fund-ing at national and regional levels. Mosteffective relief efforts have resulted fromeffective collaboration between manyagencies, each bringing their own expertiseand experience. However, all of these agen-cies will ultimately depend on qualityassessments from the affected communi-ties to make appropriate decisions anddetermine the ability of the communitiesto implement the plans and projects thatwill help diminish suffering and restore thebaseline situation in the communities.Community level: Develop local emer-gency plans that link into regional andnational plans and agencies. Understand themechanisms for communication of infor-mation (e.g., assessments, surveillance data)during disasters. Build relationships withkey individuals within and outside the com-munity before a disaster occurs.

SECTION IV / ORGANIZATIONS

ORGANIZATIONS

OBJECTIVES� Identify national and international organi-zations that may respond to a humanita-rian emergency in your country.

� Recognize the available resources,strengths, and limitations of theseorganizations.

Organizations capable of providing assistance duringhumanitarian emergenciesWhen local resources are insufficient,assistance from multiple national or per-haps multinational organizations will beneeded. Each involved organization has itsown institutional structure and culture, inaddition to other features, such as capac-ity for response, technical and logisticresources, and thematic or regionalapproach.Several international agencies may haveactivities in the country prior to theevent. In response to the disaster theseagencies may retarget their resources inthe country to emergency relief. Effectivecoordination and cooperation amonginvolved organizations are essential butvery difficult to achieve in the chaotic sit-uation of a massive emergency. There aretwo major types of organizations that canget involved in assistance when a disaster

occurs: governmental and nongovernmen-tal organizations (NGOs).

Governmental organizationsGovernmental organizations work underthe authority of one or multiple govern-ments. The most common include:

National ministries—These are agen-cies at the national ministry level thathave authority for disaster planning andresponse. A regional conference on disas-ters took place in 1986 to optimize thepreparedness and response mechanismsof Latin American and Caribbean nations.As a result of this conference, mostnations established a health disaster coor-dinator within the Ministry of Health(MoH.) The health disaster coordinatornot only coordinates health-related reliefefforts in the event of a disaster, but alsocontinuously updates emergency plansand conducts preparedness training forhealth care professionals.

Pan American Health Organization(PAHO)—This is an international publichealth agency serving as the RegionalOffice for the Americas of the WorldHealth Organization. It provides healthpolicy guidance and technical assistance indisaster planning and response (Box 7).More information is available at:www.paho.org.

World Health Organization (WHO)—The WHO provides technical advice and

develops health policies relating to disas-ters. More information is available at:www.who.int.

SUMA (Humanitarian SupplyAdministration System, developedby the PAHO)—This organization facili-tates the reception, inventory, and rapiddistribution of essential humanitarian sup-plies and equipment. In the event of a dis-aster, PAHO can send SUMA-trained staffto the affected country to assist in manag-ing the inflow of supplies.

United Nations (UN)—The UN is amultinational organization that functionsmainly through its sub-agencies, which areindependently funded. More informationis available at: www.un.org.

The Office of the United NationsHigh Commissioner for Refugees(UNHCR)—This organization is mainlyresponsible for providing needed food, sup-plies, and other material, but it also plays a

central role in protecting and advocatingfor displaced populations. More informa-tion is available at: www.unhcr.org.

World Food Program (WFP)—Thisorganization coordinates the delivery offood to regions in need around the world.More information available at:www.wfp.org.

United Nations InternationalChildren’s Emergency Fund (UNICEF)This organization was created by the UNGeneral Assembly to advocate and protectchildren’s rights, to help fulfill their basicneeds, and to provide opportunities formaximizing the development of theirpotential. When an emergency occurs,UNICEF focuses on ensuring that basicneeds of women and children are fulfilledand on protecting their basic rights. Moreinformation is available at: www.unicef.org.

Office for the Coordination ofHumanitarian Affairs (OCHA)—In

24 SECTION IV / ORGANIZATIONS

BOX 7. Some technical recommendations for disaster situations issued bythe PAHO

Specific topics related to disasters – For example, frequent effects ofspecific types of disasters, such as volcanic eruptions.

Special needs – Special considerations regarding vulnerable groups.

Transmissible diseases – Vector control; specific behaviors for choleraand tuberculosis in the context of disasters.

Food safety – Guidelines for food preparation and nutrition.

Immunization – For example, the adequate use of measles and equineencephalitis 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

25SECTION IV / ORGANIZATIONS

1998 the OCHA resulted from the reor-ganization of the UN Department ofHumanitarian Affairs (DHA). Its missionwas expanded to include the coordina-tion of humanitarian response, policydevelopment, and advocacy. OCHOA’stasks are done through the Inter AgencyPermanent Committee that includes mul-tiple participating organizations, such asUN agencies, funds, and programs, theRed Cross, and NGOs. More informationis available at: http://ochaonline.un.org.

Foreign organizations that providehelp in case of disaster—Box 8identifies some of the governmental agen-cies of developed countries that providefunding and technical help to countriesaffected by humanitarian emergencies.PAHO and WHO have developed guide-lines to assist disaster-affected countriesin managing donor offers from variousagencies. According to the 1999 PAHO

publication Humanitarian Assistance inDisaster Situations: A Guide for EffectiveAid, “In the most advanced developingcountries, in particular in Latin America,national health services, voluntary organi-zations and the affected communitiesmobilize their own resources to meet themost compelling medical needs in theearly phase after a disaster. Requirementsfor external assistance are generally limit-ed to highly skilled expertise or equip-ment in a few specialized areas.”Military help—Both local and foreignmilitary can be mobilized to assist in theresponse to natural disasters or complexemergencies. Certain unique featuresmake military organizations useful in adisaster.

AdvantagesSpeed: Few organizations are capable ofimplementing a large logistic response asrapidly as the military.

BOX 8. Foreign agencies for disaster assistance

US Aid for International Development – Office for Foreign DisasterAssistance (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


Security: The military can secure a speci-fied environment, population, and materi-al.Transportation: Their fleet of planes andhelicopters, as well as land and navalequipments, enable them to transportresources readily.Logistics: They have experience in main-taining supply lines in problematic envi-ronments and situations.Command, control, and communication:Theyhave a well-defined and responsive orga-nizational structure.Self-sufficiency in the field: When militaryarrive to the region where the event hasoccurred, they are capable of fulfilling theneeds of their own personnel.Specialized units: They often have specifi-cally trained and equipped units. Theseinclude engineers who can provide tech-nical assistance and preventive medicineteams capable of rapidly performing epi-demiologic evaluations and surveillance,outbreak investigations, vector control,and water purification and treatment.Field hospitals and capacity for medical evac-uation: Hospitals can be helpful in certaincircumstances. See the WHO-PAHOguidelines for the use of field hospitals insudden-impact disasters.

ShortcomingsDespite all the advantages mentionedabove, the use of the military can have sig-nificant shortcomings and limitations insome situations.Medical care: Field hospitals are designedfor the care of soldiers wounded in com-bat (i.e., for the care of wounds sufferedby healthy adults). During a disaster, pri-mary care and preventive interventionsfor women and children are major needs.Logistics: Supplies available in the military

response system may not be appropriatefor a disaster in terms of prevailing dis-eases or types of food.Political objectives: The military are an assetof governments; in addition, certainhumanitarian objectives can be subordi-nated to other political or strategic goals.The presence of the army in certain sce-narios can cause tension in certain groupsof the population and compromise reliefworkers who, for their own safety andfunction, wish to be considered neutral.Cost: Military activities are expensive.

Nongovernmental organizationsNGOs are nonprofit organizations work-ing on a full-time basis in assistance forappropriate development. Thousands ofNGOs, both international and national,are functioning throughout the world.Most NGOs are small agencies focusingon very specific development projects(e.g., providing education, working tools,or training in sustainable development).Only a few of them have the resourcesrequired for supporting activities targetedto promote development and to respondto disasters in multiple countries orregions. Each NGO is specialized in spe-cific aspects of assistance in emergencies(Box 9). Although NGOs may receivecontributions from individuals, most oftheir funds come from the governmentsof industrialized countries. These govern-ments distribute their money for assistingprojects through contracts with NGOs.Unlike the International Committee ofthe Red Cross (ICRC), some NGOsmaintain a “right to interfere.” This meansthey can operate across borders withoutwritten approval of their hosts. Althoughusually looking for the neutrality of the


ICRC, some NGOs may be more willingto report any perceived injustice. Theyperform well in emergencies within theirarea of specialty (e.g., water provision,food distribution), but most cannotachieve self-sufficiency in an emergency

setting and rely on UN, military, or otheragencies for security, transportation toremote sites, communication, support oflogistics, or medical care for their ownpersonnel. NGOs have enhanced abilityto provide person-to-person assistancebecause they are likely to have a pre-dis-aster relationship with the affected com-munities and understand the local cultureand public health issues. They can alsoshift easily from disaster relief to develop-ment, and are willing to make a long-termcommitment to community developmentand rebuilding.

International Committee of the RedCross (ICRC)—This is a hybrid agency:neither private nor controlled by a gov-ernment. A number of its characteristicsare unique; its mission is defined by theinternational humanitarian law passed bythe 1949 Geneva Convention and thetwo 1977 protocols. The ICRC getsinvolved mainly when civil disturbancesare present; it has the right and duty tointervene across borders when nationalor international conflicts break out,regardless of whether a “state of war” hasbeen declared. The ICRC brokers reliefassistance during war, assures legal pro-tection for victims, and monitors the wayPrisoners of War are managed. Also, theICRC plays a critical role in reuniting fam-ilies. The ICRC strives to preserve its neu-trality, which is essential for its missionand enables its members to workunarmed in war regions under the con-trol of any of the involved parties. TheICRC provides a complete account of itsactivities to all the parties involved in theconflict. It will refuse to participate in anyactivity that can be seen as showingfavoritism. This may include transporta-

BOX 9. Most important NGOs andtheir specialization fields

Cooperative for the American ReliefEverywhere (CARE)Assistance in logistics and feeding; campmanagementwww.care.org

Catholic Relief ServicesFood distributionwww.crs.org

Médecins sans FrontièresMedical carewww.paris.msf.org

Irish ConcernFeeding supplementation

Oxford Committee for FamineRelief (OXFAM)Water and sanitary serviceswww.oxfam.org.uk

Save the Children Fund Assistance in feeding and development www.savethechildren.org.uk

World VisionAssistance in feeding and developmentwww.worldvision.org

International Rescue CommitteMedical care www.theirc.org

tion in vehicles belonging to one of theparties or joining efforts with groups thathave their own interests. The ICRC is usu-ally self-sufficient and can use its ownresources for air lifts, communication, andlogistics. It will participate only if all par-ties involved in the conflict sign an agree-ment recognizing and showing respect forits neutrality and mission. The ICRC isrelated to but independent from the RedCross and the Red Crescent Societiesnational agencies. These organizationsprovide assistance primarily to victims ofdisasters or wars within their ownnations. They have a similar commitmentwith neutrality, provision of assistancebased only on the need, and independ-ence from national governments.

Coordination of organizationsCoordinating the activities of all theseorganizations poses a tremendous chal-lenge. Following a natural disaster thehost nation’s government/agencies andmilitary are likely to have operationalcommand. Most nations now have definedgovernmental authorities responsible forglobal disaster planning and response, aswell as coordinators for individual sectorssuch as health. External agencies or gov-ernments play a supportive role in provid-ing technical assistance and resources.PAHO has developed a number of techni-cal manuals and training activities to assistnations in the planning of coordinated dis-aster responses at the regional andnational level. In complex emergenciesrelated to a conflict, the armed forces orgovernment authorities will have thecommand of operations, including thecoordination of humanitarian help. Thecoordination in this scenario can be par-

ticularly difficult if the hostile groups arestationed nearby and try to block assis-tance of civilians. In this context, humani-tarian help can be used as a political andstrategic instrument.

Medical VolunteeringFollowing a disaster many pediatriciansand other health professionals volunteerfor a limited time. During the initialresponse phase, the greatest pediatricneeds include air transport teams, surgicalteams (a surgeon, OR nurse, anesthesiol-ogist, and critical care pediatrician), as wellas pediatricians with training and experi-ence in emergency medicine and criticalcare. Volunteers may have to be self suffi-cient for a period of time in terms offood, water, and shelter. Volunteers shouldwork through an established NGO orgovernmental agency rather than simply“show up” to help. Volunteers should beprepared to respond quickly, as the quick-er the response teams can provide appro-priate care, the more effective they can beat saving lives and limiting morbidity. Partof preparation is anticipating the types ofinjuries that will be seen with differenttypes of disasters. When sending aresponse team into a disaster during theacute response phase, it is important tohave the personnel with the ability totreat the most likely injuries seen with thespecific type of disaster. In a major earth-quake like the one in Haiti in January2010, one would expect the majority ofthe casualties to be secondary to trau-matic injuries related to collapsed build-ings. Therefore, a team should be pre-pared to have personnel and supplies thatcan be used to treat crush injuries, a largenumber of open wounds, along with avariety of orthopedic injuries. In a disaster



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

involving an explosion (large industrialaccident or terrorist attack), the patternof injuries would include many of thesame traumatic injuries as seen in anearthquake, but would also include a largenumber of burns and blast injuries such asblast lung. Personnel required in this typeof disaster should include those withtraining in caring for burns as well asexperience with other traumatic injuries.In the first days following the Haiti earth-quake, there were a large number of com-plex orthopedic injuries that requiredemergent treatment. These included openfractures, traumatic amputations, andcrush injuries. The treatment of these

injuries included fracture reductions,wound debridement, and amputations.Thus it was essential to have personnelwith the training to perform the neededprocedures. Personnel with training inemergency medicine, general surgery, andorthopedics are best suited to be part ofthe initial response team when a largenumber of traumatic injuries are expect-ed. Supplies that are essential in caring forthese patients include plastersplinting/casting supplies, wound dressingsupplies, and medications for pain controland sedation. When caring for openwounds, the ability to appropriately irri-gate and clean wounds can greatly reduce


subsequent secondary infections of thesewounds. Response teams should comeprepared with supplies that would be ableto provide pressure irrigation of woundswith either clean water or saline, antibiot-ic ointments, and large supplies of wounddressings. A large number of the orthope-dic injuries can be treated with casting orsplinting. Plaster casting material is farsuperior in this setting since casts madeof fiberglass cannot be easily removedwithout a cast saw, whereas patients/fam-ilies can be instructed to remove a plastercast by soaking it in water. Table 7 provides a list of pediatricequipment that, if possible, should bebrought in if not available on site. Communication in a disaster situation isessential between disaster relief teammembers as well as with coordinatinggroups and logistical support personnel inhome countries. Modern technology hasprovided many different types of communi-cation devices, which have different advan-tages and disadvantages. Communicationnetworks and contingency plans are anessential part of the disaster preparednessphase. Radios are useful for short rangecommunications when a disaster reliefteam is separated. However, they are limit-ed by range and will not allow communica-tion with the other teams or organizationsthat are a long distance away. Satellitephones are ideal for communication withthe team as well as with the home country.They provide a reliable method of commu-nication when telephone services are notworking or there is no infrastructure,because they rely on orbiting satellites totransmit data. However, they are a scarceresource as well as an expensive resource.The main drawback for many portablesatellite phones is that the phone’s antenna

needs an unobstructed view of the sky.Cellular phones are an ideal method forcommunication. Voice calls can be made toteam members as well as to coordinate inthe home country. E-mail and SMS textingare other methods of communicatingthrough the cellular network. However, cel-lular technology is dependent on a cellularinfrastructure and network that has sur-vived a disaster. The cellular networks mayalso become overwhelmed by the numberof people attempting to use it in the timeafter the disaster, thus emergency/disasterrelief providers and organizations need tohave a communication system that is reli-able and free of interference.The availability of the internet throughvarious means including satellite links anddata over cellular networks has allowed formany novel methods of communicationover the internet. There are traditionalmethods such as electronic mail. Web blogsalso allow relief workers as well as thoseaffected by the disaster to reach out to theworld. Other social media tools such asFacebook and the microblogging serviceTwitter allow almost instantaneousupdates from the field.

Mental health considerationsDisaster response providers are oftenthrust in to a high stress situation withexposure to situations they may havenever experienced before. The degree ofdestruction and death will likely be muchgreater than what the health careproviders are accustomed to dealing within their daily lives. Local first respondersand medical providers thrust in to therole of the initial emergency responsephase may be faced with the additionalstress of personally knowing many of thevictims (or their family members) that


TABLE 7. Recommended equipment to bring for pediatric emergencies in disastersituations.

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 majorchallenge of any disaster response is gathering, organizing, and moving supplies to the affected area. Resourcemanagement within the hospital and other facilities or agencies may prove to be a decisive factor in whether amass casualty event can be handled.


they are caring for. The emotional impactof large scale destruction, suffering, anddeath will elicit different responses in dif-ferent people, but all volunteer providersshould recognize how their experiencescan affect their wellbeing both emotional-ly and physically. The emotional stressexperienced by disaster responseproviders has been well documentedafter events such as 9/11 and HurricaneKatrina. The affect of stress is amplified bythe long hours of intense work experi-enced during the response to a disaster.Environmental conditions (such asextreme heat/cold/rain/flooding), lack of

sleep, and inadequate nutrition impair aprovider’s ability to deal with the stressfulsituation. Crisis response workers andmanagers, including first responders, pub-lic health workers, construction workers,transportation workers, utilities workers,and other volunteers, are repeatedlyexposed to extraordinarily stressfulevents. This places them at higher thannormal risk for developing stress reac-tions (Pan American Health Organization[PAHO], 2001). It is important for all dis-aster response providers to recognize thepotential emotional stress they will beentering before arriving on scene. Stress

TABLE 8. Common Stress Reactions

Behavioral Physical Psychological/Emotional Thinking Social

- Increase ordecrease inactivity level- Substance useor abuse(alcohol ordrugs)- Difficultycommunicatingor listening- Irritability,outbursts ofanger, frequentarguments- Inability to restor relax- Decline in jobperformance;absenteeism- Frequent crying- Hyper-vigilanceor excessiveworry- Avoidance ofactivities orplaces thattriggermemories- Becomingaccident prone

- Gastrointestinalproblems- Headaches,other achesand pains- Visualdisturbances- Weight loss orgain- Sweating orchills- Tremors ormuscletwitching- Being easilystartled- Chronic fatigueor sleepdisturbances- Immune systemdisorders

- Feeling heroic,euphoric, orinvulnerable- Denial- Anxiety or fear- Depression- Guilt- Apathy- Grief

- Memoryproblems- Disorientationand confusion- Slow thoughtprocesses; lackofconcentration- Difficultysettingpriorities ormakingdecisions- Loss ofobjectivity

- Isolation- Blaming- Difficulty ingiving oracceptingsupport or help- Inability toexperiencepleasure or havefun

Adapted from CMHS, 2004.

33SUMMARY / READING

prevention and management needs to beconsidered and addressed from the startof the deployment in order to preventproblems. By anticipating stressors andindividuals’responses to these stressors,the response team and individuals canpotentially prevent a crisis within theteam of care providers. The USDepartment of Health and HumanService, Substance Abuse and MentalHealth Services Administration (SAMH-SA), and Center for Mental HealthServices (CMHS) have published a guidefocusing on general principles of stress

management and offers simple, practicalstrategies that can be incorporated intothe daily routine of managers and work-ers. It also provides a concise orientationto the signs and symptoms of stress. Thiscan be found online athttp://mental-health.samhsa.gov/publications/allpubs/SMA-4113/default.asp. While most peopleare resilient, the stress response becomesproblematic when it does not or cannotturn off, that is, when symptoms last toolong or interfere with daily life. Table 8provides a list of the common stress reac-tions.

34 CONCLUSION / SUGGESTED READING

CONCLUSIONDisasters are, to a great extent, beyond our control and inevitable. However, we canbe 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 firstand the lessons afterwards.” Knowledge and understanding are needed for moreeffective preparation and planning. Pediatricians have a special role in the planning andpreparation process to ensure that the needs of children are adequately consideredin this process. Pediatric volunteers should be prepared for their experiences fromthe standpoint of training, available materials and resources, and mental health considerations.

Bhave S, Mathur Y, Agarwal V, eds. Guidelines on the Management ofChildren in Disaster Affected Situations. Indian Academy of Pediatrics,2005.

Burkholder B, Toole M. Evolution of Complex Disasters. Lancet1995;346:1012.

Burkle FM. Complex Humanitarian Emergencies: I.Concept andParticipants. Prehospital and Disaster Medicine 1995;10: 48-56

Davidson LW, Hayes MD, Landon J. Humanitarian and PeaceOperations: NGOs and the Military in the Interagency Process.Workshop Report, 1996. National Defense University Press, WashingtonDC.

CDC Famine-Affected, Refugee and Displaced Populations:Recommendations for Public Health Issues. CDC, MMWR 1992;41:RR-13.

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SUGGESTED READING

35CASE RESOLUTION

Case resolution

1. A disaster can be defined as a usually sudden event causing damages, affecting manypeople, and because of its magnitude, exceeding the capacity for response of local ornational organizations. High morbidity and mortality rates are frequently found in theaffected population, which is often exposed to critical sanitary situations, both immediatelyafter the disaster and during subsequent phases. There is an additional risk for diseasesassociated with crowding and lack of adequate public services.Disasters can be due to natural causes, such as hurricanes and earthquakes, to alterationsor to technological causes; i.e., related to events triggered by man's intervention (e.g., therelease of toxic or radioactive agents). In addition, civil or international wars cause complexemergencies 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 populationswhen a disaster occurs. For children, the risk of being separated from their familiesdetermines their vulnerability. In addition, their physical, physiological and mental featuresrender them more susceptible to environmental, sanitary and social changes resulting fromdisasters.All affected children should be identified and their identity should be properlydocumented. They should also receive preferential attention during the distribution ofsanitary and feeding resources, as well as effective preventive interventions.

3. The initial and highly critical step is the immediate assessment of the situation and theaffected population. This will define the actual needs and the interventions that are mostappropriate in the current circumstances. It is important to establish clearly definedpriorities and the effective coordination of rescue activities, in both the early and thesubsequent phases.In this case, field hospitals are unlikely to be needed, since traumatized victims requiringimmediate interventions will be less numerous than in other circumstances, when disastershave a more sudden and unexpected start.The capacity for response of local and regional services will determine whether or notexternal assistance is needed. Immediate external help is unlikely to be necessary in thiscase, but there will probably be a need for resources to provide the affected populationwith shelter and clothing.

36 APPENDIX

Myths and realities of disastersThe Pan American Health Organization has identified many myths and erroneous beliefs that arewidely associated with the public health impact of disasters; all disaster planners and managers

should be familiar with them.

MYTH

Foreign medical volunteers with extensivemedical training are needed.

Any kind of international assistance is needed,and it is needed now!

Epidemics and plagues are inevitable afterevery disaster.

Disasters bring out the worst in humanbehavior (e.g., looting, rioting).

The affected population is too shocked andhelpless to take responsibility for its ownsurvival.

Disasters are random killers.

Locating disaster victims in temporarysettlements is the best alternative.

Food aid is always required for naturaldisasters.

Clothing is always needed by the victims of adisaster.

Things are back to normal within a fewweeks.

REALITY

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

A hasty response not based on an impartial assessment only contributes to chaos. It isbetter to wait until real needs have been assessed. As a matter of fact, most needs aremet by victims themselves and their local government and agencies, not by foreignparties.

Epidemics do not spontaneously occur after a disaster, and dead bodies will not leadto catastrophic outbreaks of exotic diseases. The key to preventing disease is toimprove sanitary conditions and educate the affected population.

Although isolated cases of antisocial behavior exist, most people respondspontaneously and generously.

On the contrary, many people find new strength during an emergency, as evidenced bythe thousands of volunteers who spontaneously united to sift through the rubble insearch of victims after the 1985 Mexico City earthquake.

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

It should be the last alternative. Many agencies use funds normally spent for tents topurchase building materials, tools, and other construction-related support in theaffected country.

Natural disasters only rarely cause loss of crops. Therefore, victims do not alwaysrequire massive food aid.

Used clothing is almost never needed; it is often culturally inappropriate, and thoughaccepted by disaster victims, it is almost never worn.

The effects of a disaster last a long time. Disaster-affected countries loose much oftheir financial and material resources in the immediate postimpact phase. Successfulrelief programs gear their opportunities to the fact that international interest wanesas needs and shortages become more pressing.

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