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MOUNT SINAI JOURNAL OF MEDICINE 78:306–318, 2011 306

Principles and Practice of Disaster Relief:Lessons From Haiti

Ernest Benjamin, MD, Adel M. Bassily-Marcus, MD, Elizabeth Babu, MD,Lester Silver, MD, and Michael L. Marin, MD

Mount Sinai School of Medicine, New York, NY

OUTLINE

HISTORICAL PERSPECTIVE

THE DISASTER LIFE CYCLE

Mitigation or PreventionPreparedness and PlanningDisaster ResponseDisaster Recovery

MISTAKES MADE

Deficient Preparedness PlanningInadequately Prepared RescuersInadequate Equipment and SuppliesExcessive Emphasis on SecurityPoor Coordination

among Aid Organizations andwith Local Residents

Inadequate CommunicationRefusing HelpPoor or Uneven Allocation of ResourcesLack of Transparency

and Accountability for DonationsIgnoring the Potential Negative Effects

of Foreign Assistance on Local Activities

LESSONS LEARNED AND GOING FORWARD

ABSTRACT

Disaster relief is an interdisciplinary field dealingwith the organizational processes that help preparefor and carry out all emergency functions necessaryto prevent, prepare for, respond to, and recover fromemergencies and disasters caused by all hazards,

Address Correspondence to:

Ernest BenjaminMount Sinai Medical Center

New York, NYEmail: ernest.benjamin@

mountsinai.org

whether natural, technological, or human-made.Although it is an important function of local andnational governing in the developed countries, it isoften wanting in resource-poor, developing countrieswhere, increasingly, catastrophic disasters tend tooccur and have the greatest adverse consequences.The devastating January 12, 2010, Haiti earthquake isa case study of the impact of an extreme cataclysmin one of the poorest and most unprepared settingsimaginable. As such, it offers useful lessons that areapplicable elsewhere in the developing world.

Emergency preparedness includes 4 phases: mit-igation or prevention, preparedness, response, andrecovery. Periods of normalcy are the best timesto develop disaster preparedness plans. In resource-poor countries, where dealing with the expensesof daily living is already a burden, such planningis often neglected; and, when disasters strike, itis often with great delay that the assistance frominternational community can be deployed. In thisincreasingly interconnected world, the Haiti earth-quake and the important international response toit make a strong case for a more proactive inter-vention of the international community in all phasesof emergency management in developing countries,including in mitigation and preparedness, and notjust in response and recovery.

Predisaster planning can maximize the results ofthe international assistance and decrease the humanand material tolls of inevitable disasters. There shouldbe a minimum standard of preparedness that everycountry has to maintain and the international assis-tance to achieve that. International academic medicalcenters interested in global health could strengthentheir programs by prospectively including in themcontingency planning for international relief opera-tions. Healthcare professionals of these institutionswho travel to disaster zones should rigorously pre-pare themselves and make provisions for collectingand reporting data, which will enrich the knowledgeof this growing activity. Mt Sinai J Med 78:306–318,2011. 2011 Mount Sinai School of Medicine

Published online in Wiley Online Library (wileyonlinelibrary.com).DOI:10.1002/msj.20251

2011 Mount Sinai School of Medicine

MOUNT SINAI JOURNAL OF MEDICINE 307

Key Words: disaster life cycle, disaster prepared-ness, disaster relief, disaster response, earthquake,emergency management.

On January 12, 2010, at 4:53 PM, a powerful 7.0-magnitude earthquake struck 15 miles southwest ofPort-au-Prince, Haiti, destroying not only that capitalcity–home to 3 million people–but also the townsof Leogane, Gressier, Petit-Goave, Grand-Goave,and Jacmel, as well as countless mountain villages.The 35-second tremor devastated the administrativeinfrastructures of the government, several healthcare-delivery facilities, and many nongovernmental reliefagencies. It left more than a million people displaced,more than 300,000 injured, and an estimated 230,000to 316,000 dead, making it one of the deadliestnatural disasters in modern history. The cost of thedestruction was estimated at 120% of the country’sgross domestic product.

This earthquake gave rise to an unprecedentedoutpouring of sympathy and offers of assistance fromaround the world. The Mount Sinai Medical Centerof New York, like many institutions, participated inthat effort. Taking into account Haiti’s fragility andits notorious unpreparedness, as well as the reportedscale of destruction, the administration decided tointervene quickly and strongly. While volunteerswere being assembled, a surgical intensivist wasdispatched along with a team from the Boston-based Partners in Health (PIH) to assess specificneeds. Based on information they provided, MountSinai sent to Haiti’s State University Hospital(HUEH) a 29-person multidisciplinary team, includingpeople who could speak French and Creole.The group included senior surgeons, orthopedists,anesthesiologists, a plastic surgeon, a pediatrician,intensive care unit nurses, operating room nursesand technicians, the director of perioperative servicesand the director of emergency preparedness. Theycarried a substantial complement of medications,battery-operated equipment, orthopedic supplies,communication gear, and other paraphernalia. Themission was clear: to closely partner with PIH,provide the best possible care to as many patientsas possible, help set up a system to managethe operation, and rapidly transition to the localproviders. The Mount Sinai staff in New York wouldremain in constant communication with the remoteteam, sending additional medications and othersupplies and equipment as needed.

This mission was locally regarded as a success.In addition to the medical and surgical interventionsit performed, the mission quickly helped expandoperating capacity at the HUEH, centralize thelogistics, and manage the surgical workflow of

different surgical teams around a single operatingschedule. It also helped smooth the relationshipbetween the international teams and the local staffintegrated in a common workflow. This experiencehighlights several valuable lessons to be learned andmistakes to avoid when planning for disaster reliefand serves as a basis for the discussion that follows.

HISTORICAL PERSPECTIVE

A disaster implies that the number of sick andinjured overwhelms the local capacity for rescueand treatment, mandating a request for national orinternational assistance.1 Because the local copingcapacity varies among countries depending on theirlevel of socioeconomic development and their levelof preparedness, the threshold at which outsidehelp may be requested is also variable. Resource-poor countries like Haiti are likely to need externalassistance even for relatively moderate naturaloccurrences, whereas a country like Chile, soon afterHaiti, demonstrated that even after a catastrophic8.8-amplitude earthquake that lasted 3 minutes andcaused major destruction, it was able to quicklyrespond with adequate resources and minimize thecasualties.

Since 1988, the World Health Organization(WHO) Collaborating Centre for Research on the Epi-demiology of Disasters has maintained an importantrepository for disaster data: the Emergency EventsDatabase, or EM-DAT, which contains essential coredata on the occurrence and effects of >18,000 disas-ters from 1900 to date. The WHO considers an eventto be a disaster if it kills ≥10 people or leaves ≥100injured, homeless, or displaced. Complex humani-tarian disasters may be defined as relatively acutesituations affecting large populations and causedby a combination of factors, including civil strifeor war, food shortages, and population displace-ment. Mass casualty incidents are events with enoughcasualties to potentially overwhelm the medical andpublic-health services of the affected community. Thenumber of natural disasters and their lethality havebeen rising, with 2010 shaping up to be the deadli-est year in recent memory (Figure 1). Several factorsmay contribute to this worsening pattern. A majorone is the rapid increase in population densities,especially in developing countries. Of the 20 largestcities, 17 are now located in the Third World, upfrom 7 in 1950, and half of them are vulnerable to

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308 E. BENJAMIN ET AL.: PRINCIPLES AND PRACTICE OF DISASTER RELIEF

Fig 1. Number of reported worldwide natural disasters, 1900–2009. Abbreviations: CRED, CollaboratingCentre for Research on the Epidemiology of Disasters; EM-DAT, Emergency Events Database; OFDA, Officeof Foreign Disaster Assistance. Last accessed April 20, 2011.

The number of natural disastersand their lethality have beenrising, with 2010 shaping up to bethe deadliest year in recentmemory.

natural disasters such as floods, severe storms, andearthquakes.2 Between 1992 and 2001, 96% ofdeaths from natural disasters were in countries ofmedium and low development. Other factors includeincreasing settlement in high-risk areas and increaseduse of hazard-prone land for productive purposes.

THE DISASTER LIFE CYCLE

As outlined by WHO and the Federal EmergencyManagement Agency (FEMA), disaster managementinvolves 4 interconnected phases: mitigation, pre-paredness, response, and recovery.3,4 Mitigation,considered the cornerstone of emergency manage-ment, includes any action aimed at minimizing theimpact of a potential disaster, such as construction ofdams or levees, vulnerability assessments, and public

Disaster management involves 4interconnected phases: mitigation,preparedness, response, andrecovery.

education. Preparedness refers to specific measurestaken before a disaster strikes, such as prepared-ness planning, emergency drills and training, orinstallation of warning systems. Response refers to theefforts to minimize the effects of a disaster, includingsearch and rescue, evacuation, emergency medicalcare, food, and shelter. Recovery is defined as thereturn of the community to normalcy and includestemporary housing and restoration of services andmedical care.

Mitigation or Prevention

Normal periods, before disaster strikes, are thebest times for systematic vulnerability assessments,preventive measures, and preparedness activities.Some, but not all, countries have made good useof such opportunities. For example, Armenia andNepal have used the United Nations Education,Scientific and Cultural Organization’s EducationBuilding Program to develop earthquake-resistant

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schools, Costa Rica and Viet Nam built tropicalstorm–resistant schools, and Bangladesh and SriLanka constructed stilt-supported schools to avoidflooding.5

Preparedness and Planning

Emergency planning requires global, national,community, and individual input–but it is not alwaysmet with enthusiasm and is almost always resisted, atleast passively.5 When disaster preparedness is effec-tive, measures to mitigate problems ensure that theinfrastructure can withstand the forces of disastersand that people can respond in their communitiesand at the same time protect themselves. Planningincorporates all activities that could enhance theemergency response in the local community andthroughout the country. Examples of such activi-ties include developing and testing warning systems,educating and training officials and the populationat risk to respond to the disaster, and establishingemergency-response policies, standards, and opera-tional plans to be followed by emergency workers.A great emphasis is placed on the local responsebecause most disaster survivors are saved by theirneighbors or by the local authorities, if they arefunctional. Ideally, therefore, first responders shouldinclude disaster-trained individuals with access tomedications and basic equipment. Community health,humanitarian, and development workers participatein the planning process, together with communityrepresentatives. Focal points for emergency planningare clearly defined, but do not necessarily rest withthe local authorities.3

Planning and coordination procedures are uni-fied under a single emergency preparedness andresponse unit. Emergency preparedness plans are all-inclusive and cover coordination; information toolsand support services; environmental health (includ-ing water, sanitation, and hygiene); management ofchronic diseases (including mental health disorders);maternal, newborn and child health; control of com-municable diseases; nutrition; pharmaceuticals; andbiological and healthcare-delivery services.6

Whereas disaster planning is an importantfunction of national and local governments in thedeveloped countries, where it is given the properpriority and funding, that is not always so in resource-poor countries. In the case of Haiti, for example,being the poorest country in the Western Hemispherealso means being the most unprepared for naturaldisasters, despite a long history of catastrophic naturaland manmade disasters. Cataclysmic earthquakeshave regularly occurred in Haiti throughout its

history. Port-au-Prince was destroyed in 1751 andagain in 1771. Cap-Haıtien was severely damagedby an earthquake in 1842 and, in 1946, a powerful8.1 earthquake struck both the Dominican Republicand Haiti. In addition, the North Atlantic tropicalhurricanes often affect Haiti. In 2004, HurricaneJeanne destroyed the city of Gonaıves, leaving2500 people dead or unaccounted for and severelyaffecting ≥300,000 people. Four years later, 4hurricanes–Fay, Gustav, Hanna, and Ike–slammedHaiti from August 15 to September 8, 2008, killing>1000 people and affecting >1 million others.

On each of these occasions, the massiveoutpouring of assistance from abroad was notaccompanied by a local effort–neither in immediateresponse nor in preparedness for the future. InNovember 2008, after the collapse of College LaPromesse, a 3-story school in the outskirts of Port-au-Prince, killed ≥90 students and teachers and injured>150, rescue workers had to be flown in fromthe United States and from Martinique. In suchdeveloping countries that are prone to disasters buttotally depend on foreign assistance, the need todeploy the international rescue response, as soon andas massively as possible, cannot be overemphasized.In such countries, perhaps it should be incumbentupon the international community to mandatedisaster preparedness and assist knowledgeable localleaders in its planning and implementation.

Disaster Response

The timing of response is critical for a successfulintervention in disaster relief. The longer it takesfor care to arrive, the higher the fatality rate.7

Following the 1995 earthquake in Kobe, Japan,which killed 6434 people, 71% of the victims diedwithin 14 minutes and another 10.7% within 6 hoursof the tremors. About 54% of the deaths resultedfrom crush injuries and other types of trauma fromcollapsed buildings. The first 24–48 hours after a

The first 24–48 hours after adisaster is when appropriateinterventions can have the greatestimpact on survival.

disaster is when appropriate interventions can havethe greatest impact on survival. Those first 2 daysare also the most challenging time, because roads,communication, transportation, and public utilitiesare likely to be severely affected.

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The emergency medical response to any disasterincludes 4 sequential elements: (1) search and res-cue, (2) triage and initial stabilization, (3) definitivemedical care, and (4) evacuation. It is sometimes acyclical process, involving repeated assessment, plan-ning, action, and review, to respond appropriately toneeds and capacities as they evolve.3

RespondersSchultz et al.8 in an excellent review article inThe New England Journal of Medicine, ‘‘A MedicalDisaster Response to Reduce Immediate MortalityAfter an Earthquake,’’ detail a plan for earthquakerescue operations that can be used for other typesof disasters as well. It includes fundamentals ofa disaster-training course and how to triage masscasualties, but it is likely to be much more effectivein developed countries with solid disaster-responsepreparedness than in much of the Third World.

Wherever feasible, a rapid, seamless interactionbetween the rescue workers who respond to thescene and the individuals and healthcare facilitiesthat will provide definitive care is a key to optimiz-ing outcomes.9 First responders should have trainingcomparable to emergency medical service person-nel and carry in the trunks of their cars ‘‘medicalbackpacks’’ containing equipment to secure an air-way, stabilize a spine, decompress an abdomen andevacuate a chest, and administer fluid and medi-cations. It should also contain a kit for obstetricsand amputations. Medications for analgesia, sedation,cardiovascular support, infection, and fluids shouldalso be included. Additionally, batteries, flashlights,lanterns, emergency blankets, nonperishable food,bottled water, and a hard hat, hammer, and goggleswill be needed to support the rescuer. Each back-pack would be outfitted to care for 4–6 criticallyill or injured patients.8 Although, in the developingcountries, it is most unlikely to find first respon-ders carrying such medical backpacks with them,this concept is worth considering when redesign-ing emergency preparedness for disaster-prone ThirdWorld countries. In addition, some of the interna-tional medical relief teams that went to Haiti didcarry their medical backpacks with them.10

Patients should then be moved to a ‘‘disastermedical aid center’’ as soon as possible. Thesecenters should be set up within a short distanceof each other to serve as field hospitals and triagecenters; the volunteer staff should have formaltraining in disaster medicine11 and be able towork in austere conditions with limited access totechnology, sanitation, and resources. They shouldalso have some understanding of the psychological

challenges they will face. Trained volunteers whointegrate themselves into a coordinated disaster-response mission can be most effective. Disastermedical aid centers should be self-sufficient, easyto set up, waterproof, and have satellite and Internetcapabilities to communicate needs that cannot be metat the site. Patients who require a higher level of careshould be transported to casualty collection points,which should be located in vast open areas suchas shopping mall parking lots. These spaces wouldbe ideal to accommodate helicopters that transportsupplies and evacuate patients. The success of suchan operation requires a functioning and well-fundedlocal team and disaster-management infrastructure.8

Triage and Initial CareTriage is the most important but the most psycho-logically taxing mission of any medical response,regardless of the nature of the disaster. The mod-ern concept of triage was first introduced by BaronDominique Jean Larrey (1766–1842), a surgeon inNapoleon Bonaparte’s army, who recommended thatsoldiers requiring the most urgent care be attendedto first, regardless of their rank, and be given initialtreatment while still on the battlefield. During the1859 Franco-Sardinian-Austrian battle in Solferino,Italy, Henry Dunant from Switzerland called for thecreation of national relief societies, which evolvedinto the Red Cross organization in 1863. Dunant’swork also paved the way for a code for treatingvictims of wars and disasters that eventually evolvedinto the Geneva Conventions. The earliest emergencymanagement system, reportedly, was the Vienna Vol-untary Rescue Society, formed in the aftermath of theVienna Ring Theater fire in 1881. The Incident Com-mand System concept uses a common organizationalstructure and language and allows disparate agen-cies (fire, police, emergency medical services) and/ormultiple branches of the same agencies to worktogether effectively in response to a disaster.12,13

Medical triage officers must know the medicalconsequences of various injuries (e.g. burn, blast,and crush injuries, and exposure to chemical,biologic, or radioactive agents). Under-triage andover-triage will each limit the effectiveness of themedical disaster response.14 The coordinated healthcare system’s central command may still assist intriaging and directing appropriate patient transfers,although the flow at this stage would likely beunidirectional.15

Ethical ConsiderationsThe inevitable time lag in response and theproper allocation of insufficient resources will be a

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recurring challenge. Even under the worst-imaginablescenarios, emergency healthcare responders shouldpractice with the same ethical standards as theynormally do. For example, they should not performprocedures that they are not qualified for and shouldrequest informed consent and respect the right of thepatient to refuse treatment, even when the patient’slife is at stake.16 How we manage extremely injuredpatients with no hope for meaningful rehabilitationor survival and those whose care requires unavailableresources needs to be clearly established beforethe crisis and be constantly reevaluated on theground.17 Important ethical questions linger, such asthe eventual culpability of medical personnel fleeinga disaster area for their own safety while leavingtheir patients in danger, or the appropriatenessof a physician practicing what may be consideredeuthanasia, as in the case of Dr. Anna Pou in theaftermath of Hurricane Katrina.18,19 In 1994, theSociety of Critical Care Medicine Ethics Committeepublished its consensus statement on the triage ofcritically ill patients in the Journal of the AmericanMedical Association.20 The experiences described inLouisiana, Haiti, and Pakistan should serve as acatalyst for debate and discussion on how to providecompetent care to those with no meaningful chance,or a compromised chance, of survival.

The 2010 Haiti earthquake illustrates several eth-ical dilemmas for the early responders. There was aninordinate number of crushed limbs and compoundfractures. The international medical relief did notbecome operational until 3 days after the earthquake.By then, many patients had overwhelmingly infectedwounds, dead limbs, and life-threatening sepsis andseptic shock. The absence of early intervention, cou-pled with the widespread destruction of healthcarefacilities, forced earliest rescuers to amputate necroticlimbs, often without proper anesthesia or analgesiaand under makeshift or unsanitary conditions. It isestimated that between 2000 and 8000 such amputa-tions occurred in a country notoriously unkind to itshandicapped citizens. Most medical-relief personnelmade a serious attempt at obtaining informed con-sent. Some unaccompanied patients, however, whowere in septic shock and obtunded, did get operatedon without informed consent. This raises the difficultquestion of ethical appropriateness of such noncon-sented interventions under utterly chaotic conditions.

Another issue in Haiti was how to dischargepatients who could leave the hospital but hadnowhere to go, and how to provide them withadditional follow-up care. Many settled in makeshiftcamps, their homes destroyed and their familiesunaccounted for. Considering the scarcity of servicesprior to the earthquake, wound care, prosthetic limbs,

ambulatory assistance devices, and rehabilitationwere not viable options.21

As with amputees, spinal cord–injured patientsface vocational and social challenges that may beinsurmountable without sufficient supportive ser-vices. For these patients, the first responders play themost vital role. In many developing countries, surgi-cal expertise and postoperative rehabilitation centersare scarce. Equipment such as special bedding andspinal braces are not always available. Rathore et al.22

note also that discussion regarding poor functionalrecovery, prognosis, and details about neurologicalsequelae like immobilization, sexual dysfunction, andother complications such as pressure ulcers and needfor urinary catheterization is often avoided.

Public-Health MeasuresNatural disasters displace populations and disruptsanitation and public-health services, resulting inincreased risks of disease transmission and epidemicoutbreak.23 With survivors in overcrowded settle-ments and with the breakdown of sanitation services,water and food are at risk of fecal contamination.Cholera, shigellosis, salmonellosis, and hepatitis Aand E are the major causes of most epidemic diar-rheal diseases associated with natural disasters. InHaiti, the cholera epidemic, which was feared in

Cholera, shigellosis, salmonellosis,and hepatitis A and E are themajor causes of most epidemicdiarrheal diseases associated withnatural disasters.

the early aftermath among the displaced pop-ulation living in the overcrowded and unsan-itary tent cities, actually did not occur until9 months later, in October 2010. It occurred inan area that was not affected by the earthquake,and it is believed to have been inadvertentlyimported from abroad.24 In 4 months, the epi-demic had spread over the entire country, sick-ened ≥225,000 and killed ≥4500 persons. Upper-respiratory infections also cause a great deal ofmortality, but there is little data on the specific agentsresponsible.25

Vector-borne diseases such as malaria anddengue fever predominate where vector habitatsare created and vector-control measures are com-promised. When infectious diseases produce a highmortality rate, the cause is usually an existingendemic condition rather than an explosive outbreak.In Indonesia, where malaria and dengue are endemic,

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the rainy season immediately after the 2004 tsunamiled to flooding and the creation of stagnant pools thatserved as breeding grounds for the Aedes mosquitoes.The subsequent epidemics were fueled by thesebreeding grounds in the crowded refuges, the paucityof vector control such as mosquito nets and insecti-cides, as well as inadequate access to healthcare.26

To decrease the risk of outbreaks, one shouldavoid the overcrowding of temporary shelters;provide clean water for drinking, cooking, andhygiene; and collect and dispose of liquid andsolid wastes.27 Health education should emphasizehand-washing before cooking and eating, and afterlatrine use; drinking boiled or chlorinated water; andeating foods that can be peeled, or that have beencooked until steaming hot. Because the nutritionalstatus of a patient plays a key role in his ability toovercome disease, promoting nutritional programsis also helpful.28 An effective surveillance andreporting system for communicable disease needsto be put in place, with the capacity to investigateoutbreaks, confirm pathogens, and identify the modeof transmission and risk factors. In addition, thesystem should incorporate outbreak management andcontrol methods and communicate timely informationto the affected group.29,30

Infectious-Disease ProphylaxisMass immunization has not been an effectiveepidemic-control measure following natural disasters,with the exception of the measles immunization andvitamin A supplementation.31

The highly contagious measles virus is transmit-ted through aerosol droplets. Measles has a highmortality, and the risk of epidemics is high incrowded settlements and where national vaccinationrates are poor. Measles vaccination should be givento children aged 6 months to 14 years, with priorityto those who are malnourished and younger than4 years, regardless of prior vaccination or diseasehistory, because it has an especially high mortalityrate in this population. Tetanus vaccination shouldbe given to those with open wounds. However,because

Measles vaccination should begiven to children aged 6 months to14 years, with priority to those whoare malnourished and youngerthan 4 years, regardless of priorvaccination or disease history.

of the frequent lack of electricity and refrigeration,it may be a challenge to obtain tetanus toxoid.Several cases of tetanus were observed in Haiti. Oralcholera, hepatitis A, and typhoid vaccinations are notroutinely recommended after disasters. That practice,however, is being questioned in the wake of thecurrent cholera epidemics in Haiti.32 Both the USCenters for Disease Control and Prevention and WHOrecommend that, following an earthquake, infectedwounds should be treated with antibiotics primarilyaimed at gram-positive organisms. However, the

Experience during the Haitianearthquake disaster relief efforthas shown most of the woundinfections (77%) to bepolymicrobial, with 89% involvinggram-negative pathogens.

Israeli medical-relief team’s experience in Haitishowed that, in agreement with the data from thelast 4 catastrophic earthquakes, the majority of thesewounds are infected by polymicrobial flora. Mostof the wound infections (77%) were polymicrobial,with 89% involving gram-negative pathogens, withpredominance of Escherichia coli, Proteus speciesand Acinetobacter baumannii.33

Psychological HealthMental disorders are common after disasters. Theymay be secondary to a treatable medical condition,such as head trauma, intoxication, infection, ordehydration, or be a normal psychological responseto disaster. The patients may demonstrate anger,sadness, fear, irritability, sleep disturbances, andincreased alcohol or tobacco intake. Phobia wasespecially ubiquitous in Haiti, where, for monthsafter the earthquake, people refused to enter evensound, undamaged buildings and preferred to sleepin rather unsafe, open spaces such as streets andyards, even when their houses were not affected.Patients with a history of psychiatric disorder, whichmay not be known at the time, may not have hadaccess to their regular prescriptions or care.

The psychological impact differs with age andwith history of previous psychiatric illnesses. Forchildren, the most common disaster responsesare specific fears, separation anxiety, and sleepdisturbances. In acute stress disorder, the symptomsoccur within and persist for <1 month, whereas inpost-traumatic stress disorder symptoms persist for>1 month. The psychological reactions stem fromvarious factors including survival probability, grief

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for personal loss (loved ones and possessions), fearand anxiety about the safety of loved ones, concernabout relocating, and one’s ability to participate inthe recovery effort.34

Mental-health interventions, such as cognitivebehavioral therapy, should give priority to disorien-tation, depression, anxiety, mental illness, inability tocare for self, suicidal or homicidal thoughts or actions,domestic violence or child abuse, and alcohol or drugabuse.35

Management of the DeadCultural beliefs surrounding death, dying, and thehandling of dead bodies differ widely. At a timewhen priority must be given to finding and rescuinginjured survivors, no country has the resources orthe forensic capabilities for rapid identification oreven counting of the dead.36 Mass graves are oftenthe most practical solution for disposing of deadbodies. Yet, the handling of the dead with dignityneeds to be given proper priority in national-disasterrelief operations as a means to provide accountabilityand closure to the living. For families facing utterdevastation and tragedy, the confusion about the fateof loved ones, the sight of dead persons not beingtreated with respect and dignity, and being deniedthe opportunity to perform appropriate burial ritualscan add to the psychological stress. Aside from thepsychological closure, knowing what happened totheir missing loved ones is also critical for purposesdealing with inheritance, compensation, insurance,and remarriage of spouses.37

Disaster Recovery

Recovery activities involve restoring services to thepublic and returning the affected community to pre-disaster conditions. That recovery phase, by far thelongest, starts as soon as the immediate threat tohuman life has subsided. Due consideration must begiven to when, where, and how to rebuild, mindfulof not reproducing the unsafe conditions that mayhave existed before the disaster. Disaster recovery ina resource-poor developing country is likely to rely,to a disproportionately high degree, on external assis-tance. It involves not only a transfer of goods and ser-vices, but also an infusion of know-how, technology,capacity-building, and organizational skills. Localauthorities and international aid organizations shouldfacilitate the timely relocation of displaced peopleto either their previous homes, when feasible, or totransitional shelters, or help them settle in their hostcommunity. Recovery should also include offers ofpartnerships and collaboration between internationalacademic institutions and their local counterparts.3

MISTAKES MADE

A great deal has been published by teams dealingwith disaster-relief response, but the focus has oftenbeen on success stories: how many volunteers weredeployed, what materials were delivered, and howmany operations were performed.38 There has notbeen clear documentation of challenges: amongthem, transporting equipment, securing supplies atcustoms, maintaining or sharing inventories, andkeeping volunteers safe and psychologically healthy.Further, the intricacies of patient care, includingtriage, providing medical care in resource-limitedsettings, and determining futility of care are lessonsthat need be shared.

There are, however, some reports of mistakes;these have focused on how the affected region failedto mitigate the disaster by lack of a warning system,the inability to involve able and willing aid organiza-tions, the poor allocation of resources, how the deadwere handled, and lack of transparency of aid.

Deficient Preparedness Planning

The assumption that local authorities can provideassistance in the first 48–72 hours, while theinternational assistance is being prepared, does nottake into account the fact that preparedness planningtends to be poorly implemented in resource-poorcountries such as Haiti. Consequently, precious timewas wasted before effective assistance could be

The assumption that localauthorities can provide assistancein the first 48–72 hours, whilethe international assistance isbeing prepared, does not take intoaccount the fact that preparednessplanning tends to be poorly imple-mented in resource-poor countries.

deployed, which left to unprepared neighbors thesole responsibility of helping neighbors withoutknowing what to do and without having the tools todo it. Despite the fact that Port-au-Prince is only1 hour and 20 minutes by plane from Miami, ittook 2 days for the first 82nd Airborne contingentto arrive at the Port-au-Prince airport. Because therewas hardly any pre-positioned supply, and becausethe single-runway airport had a limited capacityand the maritime port was badly damaged, it tookseveral days for the population to start receiving

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any organized distribution of food and water. Thisdelay in aid delivery contributed a great deal to thepopulation becoming restive after the first week.

Inadequately Prepared Rescuers

The outpouring of solidarity that sprang from theHaiti earthquake may explain why some people,wanting to do good, went there without a clearunderstanding of what they were getting into, with-out the proper skills needed at the time and place.With healthcare facilities in tatters, the needs werethe greatest for trauma-trained personnel, emergencymedical staff, and other practitioners who couldperform under the most difficult circumstances. Asurgeon who exclusively practices minimally invasiveor robotic surgery would be of little use in these cir-cumstances. Most medical-aid volunteers performedtirelessly and admirably with great humanity, but afew were not prepared to understand or accept thathumility and compassion were the essence of disasterrelief. Fortunately, under most of these circumstances,peer pressure and common sense ultimately pre-vailed. Similarly, there is very little that can beaccomplished in a disaster theater by a lone health-care volunteer who does not embed himself or herselfinto an appropriate relief organization. In addition tothe challenges of finding something useful to do,there are the difficult problems of credentials vettingand logistics such as local transportation, lodging,and safety.

There is very little that can beaccomplished in a disaster theaterby a lone healthcare volunteerwho does not embed himself orherself into an appropriate relieforganization.

Inadequate Equipment and Supplies

Power, running water, and air conditioning areoften not available in disaster areas. Sophisticated ordelicate equipment that requires a steady electricalsupply or air conditioner, or medical supplies thatmust be refrigerated, may not be very useful.Similarly, medications or supplies packaged withlabels that cannot be read by practitioners in theaffected community may also not be very helpful.In the general population, a similar problem occurswhen there is a mismatch between what is offered ordonated and what is needed, such as winter clothesin a tropical country.

Excessive Emphasis on Security

Perry and Lindell emphasize that, contrary tothe common belief, during disasters looting isvery rare in evacuated areas and that crimerates tends to temporarily decrease.39 Nevertheless,precious time and resources are often diverted tosecurity operations early after a disaster, instead offocusing on search-and-rescue operations when theirbeneficial effects would have been the greatest. Afterthe Haiti earthquake, some criticism has been leveledat the excessive priority given early by the US militaryto bringing security personnel and equipment into thecountry at the expense of rescue teams and medicalrelief missions.40,41

Poor Coordinationamong Aid Organizations andwith Local Residents

In the absence of good emergency planning,aid organizations from different origins, speakingdifferent languages, and with different perceptionsof their mission, often fail to coordinate their effortsamong themselves and with the local healthcarefacility management or with the governmentalauthorities. For example, each medical relief missionmay want to manage its ‘‘own’’ medical or surgicalsupplies and its ‘‘own’’ patients, which leads to waste,duplication of services, and general inefficiency.

Local feelings may be easily bruised if one is notcognizant of the hurt and aggrieved sensibilities of thelocal emergency managers and medical personnel,who may be less knowledgeable than the foreignrescuers, but, nevertheless, may want to be in charge.The resulting frictions can prevent the full utilizationof the unique skill sets of the foreign rescuers indisaster assistance, some of whom have participatedin countless rescue operations before. In addition,because the majority of disaster-assistance personnelwill be leaving sooner rather than later, transitioningto the local providers and managers is an imperativethat is facilitated by fostering mutual respect.

Because the majority ofdisaster-assistance personnel willbe leaving sooner rather thanlater, transitioning to the localproviders and managers is animperative that is facilitated byfostering mutual respect.

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Inadequate Communication

Overestimation of a potential calamity can leadto panic and overutilization of resources, therebyparalyzing daily operations for days. Underestimationcan affect the lives of many and have disastrousimpact on a country, economically, politically, andenvironmentally. Therefore, the pace at which leaderscan notify and advise their constituents becomesparamount from a local, national, and internationalstandpoint. For weeks on end, there was in Haiti adearth of information to the population, who waskept unaware of what was going on and that helpwas being ramped up. This also contributed to thepopulation becoming restive with time.

Refusing Help

Accepting aid in the early stages of a disastermay prove to be valuable, even for rich coun-tries. The international response the United Statesreceived after Hurricane Katrina was immense.According to the Washington Post, cash and oilin excess of $854 million was offered by Amer-ica’s allies. Of the 77 aid offers, 54 were declined,from countries including Canada, Britain, Israel,Venezuela, and Cuba.42 Additionally, some orga-nizations such as the Red Cross and the Salva-tion Army were not given permission to enterthe disaster zone.43 Presumably the presence ofthese organizations would reassure and encouragepeople to stay in the city rather than evacuate.Similarly, when Cyclone Nargis hit Burma in May2008, eventually killing 138,366 people, the militaryjunta steadfastly refused international relief assis-tance. It took 3 weeks of international pressureand a personal visit by United Nations Secretary-General Ban Ki-moon for the Burmese governmentto allow international aid agencies access to thecountry.44

Poor or Uneven Allocation of Resources

Disasters affect various populations differently. Theability to survive and regain one’s livelihooddepends on adequate access to relief aid. Theelderly, the disabled, orphans, and women withsmall children tend to disproportionately sufferthe consequences of disasters. Additionally, whenrelief supplies and materials are being distributed,these groups tend to be pushed aside or robbedbecause of their weakness. For the elderly, thetypical relief packets are not designed with dietrestrictions in mind.45 The disabled are often

unable to get to where aid is distributed, whichleaves them dependent upon their family andneighbors. For women, nutritional and medicalsupport when they are pregnant, hygienic supplies,continued contraception, and safety from sexual andgender-based violence remain constant challenges.Young children who are separated from theirdead or missing parents are perhaps the mostvulnerable population. Unaccompanied children areprey to exploitation by unscrupulous people involvedin for-profit adoption, sex trade, or domesticservitude.46

Lack of Transparencyand Accountability for Donations

The timing of a disaster and the amount of mediacoverage can make a dramatic impact in how fasta disaster-affected community receives aid funds.According to Doctors Without Borders, the fundscollected in 2 weeks for the 2004 Indian Oceantsunami were 6× those collected in the same periodafter the 2003 Bam, Iran, earthquake or in 2 monthsfor Darfur.47

The 2010 Haiti earthquake gave rise to anunprecedented worldwide outpouring of generosity.The Red Cross alone collected almost half a bil-lion dollars. Both private and public donations andpledges reached numbers that, unfortunately, did noteasily align with the persistent squalor on the groundin Haiti and the very slow pace of recovery. Althoughthe resulting controversy was instrumental in forcingaid organizations to become more accountable, itcould have been avoided with more spontaneoustransparency on the part of these organizations. Asnoted by the Red Cross, there needs to be a sustainedeffort after the initial rescue phase, and this can lastseveral years, during which time the donations areno longer forthcoming but expenses, such as for san-itation and potable water, continue.48 Transparencyregarding how all monies are spent is probably thebest indicator of how aid agencies and governmentare accountable to their beneficiaries.49

Ignoring the Potential Negative Effectsof Foreign Assistance on Local Activities

Aid may come in various forms, often with stipu-lations that can adversely affect the local economyand professional activities, such as the requirementthat a certain percentage of aid received be spenton goods from the donor country. This can be dev-astating to local farmers who cannot compete with‘‘free’’ food. Similarly, readily available ‘‘free’’ medical

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care in a country where most people normally don’thave access to quality healthcare is likely to affect thefinancial well-being of existing institutions, or eventheir ability to survive. These experiences have ledto backlashes from certain sectors of local economiesagainst foreign assistance.

LESSONS LEARNED AND GOINGFORWARD

The rapid concentration of immense populationsin disaster-prone areas, especially in developingcountries, coincides with an irreversible advance ofglobalization and an overall sense of interconnectiv-ity. Some academic centers have strengthened theirglobal health programs. Project Medishare of theUniversity of Miami’s Miller School of Medicine, andHarvard Medical School’s partnership with Partnersin Health are 2 examples.

The response to a disaster is complicated bythe tremendous variability of the local conditions.Places with well-organized disaster planning andexperience, such as Chile and China, tend to haveadequate resources in place. They fare very wellwith limited international assistance, even after suchmajor natural catastrophes as the 8.8-magnitude Chileearthquake or the 8.0-magnitude 2008 Sichuan earth-quake. Coincidentally, in these 2 occurrences, thelocal military played a significant role in provid-ing assistance. Places such as Haiti and Costa Ricathat do not have a military should have a well-organized and well-equipped national emergencymanagement agency that can be rapidly and force-fully deployed. Indeed, the 2010 Haiti earthquakewas a case study of the disastrous consequences ofthe poorly functioning and ineffectual Haitian CivilProtection Agency, which was an absolute no-showbefore, during, and after the earthquake. Under thesecircumstances, the international assistance must beimmediate, massive, and comprehensive. This inter-national assistance must include the rebuilding of amuch different, better-prepared, and more effectualnational emergency management agency. An interest-ing suggestion, worthy of serious consideration, wasmade by Kerry et al.50 The authors proposed that anInternational Service Corps for Health be created asan important component of US diplomacy and thatit should work in concert with the academic institu-tions to provide capacity-building in the developingcountries. Clearly such an entity could also help indisaster planning.

In an interconnected world, where providingassistance in every major disaster becomes everyone’s

In an interconnected world, whereproviding assistance in everymajor disaster becomes everyone’sresponsibility, there should be aminimum standard ofpreparedness that every countryshould be expected to maintain.

responsibility, there should be a minimum standardof preparedness that every country should beexpected to maintain, lest it be sanctioned bythe United Nations. The international community,led for example by WHO, should mandate thatevery country develop disaster-preparedness plansand offer technological assistance to implementthe process and to keep the plans up-to-date.Community preparedness should be integral becauseit could provide the greatest benefits in a varietyof emergencies, even when local transportation isseverely compromised. Warehoused stockpiles ofpre-positioned disaster-relief supplies sufficient forthe first 48–72 hours should also be internationallymandated and monitored by the local WHOrepresentatives.

Large organizations such as the InternationalFederation of Red Cross and Red Crescent Societies,Catholic Relief Services, Oxfam, WHO, or UN WorldFood Program can mobilize a substantial number oftrained personnel and a large quantity of suppliesover a sustained duration. Professional organizations,including but not limited to the American Collegeof Surgeons, the American College of EmergencyPhysicians, the American College of Chest Physicians,the Society of Critical Care Medicine, the AmericanSociety of Anesthesiologists, the American NursesAssociation, the Emergency Nurses Association,the Association of Perioperative Nurses, and theirinternational equivalents should collaborate withWHO to maintain a registry of disaster-trainedvolunteer professionals. All such mobilizations,however, typically take time, which in places likeHaiti can make the difference between life anddeath. Organizations such as PIH or Doctors WithoutBorders, with substantial pre-earthquake operationsin Haiti, are very effective in that they can quicklygear up their operations to face the new emergencies.

Institutions that are interested in global healthand want to participate in disaster-assistance oper-ations should be encouraged to form partnershipswith organizations that are already operating inthe disaster-prone zones. Their global-health depart-ments should incorporate well-thought-through

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emergency and disaster-relief planning with a data-bank of trained volunteers, an organizational struc-ture for the eventual deployment of relief teams withrole preassignment, and predesignated readily avail-able supplies. Well-organized, self-sufficient multidis-ciplinary teams should bring everything necessary totheir operation, including personnel, supplies, andequipment.

Such institutions should establish a workingrelationship with their country’s military, which oftenis the most efficient and fastest means of rapidlydeploying emergency assistance.10 At the HUEHin Port-au-Prince, when, after 3 days of workingunder the most chaotic conditions, the absence oflogistical support such as crowd control, drinkingwater supply, food delivery, and assistance withpatient transportation threatened to bring operationsto a screeching halt, the US military respondedby dispatching there a contingent of 80 soldiers,soon relieved by another contingent of 130. Theyprovided valuable assistance with facility accesscontrol, drinking water, meals-ready-to-eat, andpatient transportation, both inside the compound andfrom there to the USNS Comfort off the coast.10

Healthcare providers who are interested in par-ticipating in disaster-relief programs should registerwith the relief organization of their choice or par-ticipate in their institution’s program. They shouldseek and obtain the proper training, maintain theirproficiency by participating in well-planned and well-conducted drills, practice their preassigned roles,and obtain the appropriate immunizations and otherprophylactic measures before actually going on adisaster-relief mission.

Because it is not possible to be equally effec-tive after a flight halfway around the world as aftera short trip, there should be a regional distributionof relief interventions. For example, institutions inthe United States and Canada could develop disaster-relief participation plans that would prioritize NorthAmerica and the Caribbean, where they could berapidly implemented. Interventions elsewhere wouldtake much more time and should only be supportiveto other regionally based interventions on other con-tinents.

Academic institutions that participate in disaster-relief missions should consider their operationsas any academic endeavor and should strive topractice evidence-based interventions. They shouldprepare themselves for these missions with the samerigorousness they apply to other academic medicalendeavors, collecting and reporting data to enrich theknowledge of this growing activity. Disaster-reliefoperations are challenging and possibly risky, butthey are utterly rewarding as well. Every healthcare

professional who participated in the Haiti reliefoperation has reported feeling tremendous personaland professional satisfaction.

DISCLOSURES

Potential conflict of interest: Nothing to report.

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