Principles and Practice of Disaster Relief: Lessons From Haiti

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  • MOUNT SINAI JOURNAL OF MEDICINE 78:306318, 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



    THE DISASTER LIFE CYCLEMitigation or PreventionPreparedness and PlanningDisaster ResponseDisaster Recovery

    MISTAKES MADEDeficient Preparedness PlanningInadequately Prepared RescuersInadequate Equipment and SuppliesExcessive Emphasis on SecurityPoor Coordinationamong Aid Organizations andwith Local Residents

    Inadequate CommunicationRefusing HelpPoor or Uneven Allocation of ResourcesLack of Transparencyand Accountability for Donations

    Ignoring the Potential Negative Effectsof Foreign Assistance on Local Activities



    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@

    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 78:306318,2011. 2011 Mount Sinai School of Medicine

    Published online in Wiley Online Library (

    2011 Mount Sinai School of Medicine


    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 capitalcityhome to 3 million peoplebut 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 countrysgross 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 Haitis 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 Haitis 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.


    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



    Fig 1. Number of reported worldwide natural disasters, 19002009. 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.


    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 Organizations EducationBuilding Program to develop earthquake-resistant



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

    Preparedness and Planning

    Emergency planning requires global, national,community, and individual inputbut 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-Hatien 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 Gonaves, leaving2500 people dead or unaccounted for and severelyaffecting 300,000 people. Four years later, 4hurricanesFay, Gustav, Hanna, and IkeslammedHaiti 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 effortneither 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 2448 hours after a

    The first 2448...