Disaster Health Management : A Primer for Students and Practitioners 9781138911161, 9781138911185, 9781315692951

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Disaster Health Management

Disaster health is an emerging field that focuses on dealing with health problems caused by disasters through prevention, preparation, response and recovery. As disasters worldwide differ in their nature, scope and cultural context, it is essential for both students and practitioners to have a thorough understanding of the fundamental tenets of sound disaster health management to allow them to participate confidently and effectively in the field. Disaster Health Management is the first comprehensive textbook to provide a standard guide to terminology and management systems across the entire spectrum of disaster health. Authored by experienced educators, researchers and practitioners in disaster health management, this textbook provides an authoritative overview of: • • • • • • •

The conceptual basis for disaster management. Systems, structures and the legal and ethical challenges of disaster management. Managing disasters through the continuum of planning, preparedness, response and recovery including identifying, managing and communicating risks, community engagement and business continuity. Incident assessment, evaluation and management. External assistance and psycho-social considerations of disasters. The variations associated with both natural and technological disasters. The strategic considerations associated with leadership, evaluation and learning, education and training, and future directions of disaster management.

Disaster Health Management is an essential text for both undergraduate and postgraduate students, as well as for professionals involved in all aspects of disaster management. Gerry FitzGerald is Professor of Public Health in the Faculty of Health at Queensland University of Technology (QUT), Australia, and Director of the Centre for Emergency and Disaster Management. Mike Tarrant holds adjunct appointments including Associate Professor in the Faculty of Health at QUT and in the Department of Tropical Medicine at James Cook University, Townsville, Australia.

Peter Aitken is an Associate Professor in the School of Public Health, Tropical Medicine and Rehabilitation Sciences at James Cook University, Australia. Marie Fredriksen is Lecturer in the Faculty of Health at QUT and a Paramedic with the Queensland Ambulance Service, Australia.

Disaster Health Management

A primer for students and practitioners

Edited by Gerry FitzGerald, Mike Tarrant, Peter Aitken and Marie Fredriksen

First published 2017 by Routledge 2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN and by Routledge 711 Third Avenue, New York, NY 10017 Routledge is an imprint of the Taylor & Francis Group, an informa business © 2017 G. FitzGerald, M. Tarrant, P. Aitken and M. Fredriksen The right of the editors to be identified as the authors of the editorial material, and of the authors for their individual chapters, has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data A catalog record for this book has been requested ISBN: 978-1-138-91116-1 (hbk) ISBN: 978-1-138-91118-5 (pbk) ISBN: 978-1-315-69295-1 (ebk) Typeset in Sabon by Keystroke, Neville Lodge, Tettenhall, Wolverhampton

Contents

List of illustrations ix Notes on contributors xiii List of acronyms xxi Forewordxxv PART 1

The conceptual basis of disaster management

1

  1 Definitions and terminology

3

LIDIA MAYNER AND ERIN SMITH

  2 Disaster trends and impact

21

BENJAMIN RYAN AND RICHARD FRANKLIN

  3 Concepts and principles

37

BRETT AIMERS AND LINDA WINN

PART 2

Key elements of disaster management

47

  4 Disaster management systems

49

PETER CHANNELLS AND GRAEME McCOLL

  5 Legal and ethical aspects of disaster management

58

FIONA McDONALD, MICHAEL EBURN AND ERIN SMITH

  6 Risk and its management

70

MIKE TARRANT AND CARL GIBSON

  7 Business Continuity Management DAVID PARSONS AND PETER BROUGGY

81

vi  Contents

  8 Risk and crisis communication during health disasters

92

AMISHA MEHTA, BOB JENSEN, INGRID LARKIN AND ROBINA XAVIER

  9 Community engagement

104

GHASEM-SAM TOLOO AND MARIE FREDRIKSEN

PART 3

Healthcare considerations

117

10 Health systems and disaster management

119

CHARLES BLANCH, GERARD O’REILLY AND NATASHA MURRAY

11 Healthcare considerations in disasters

129

ANDREW JOHNSON, MICHAEL AITKEN AND PETER A. LEGGAT

PART 4

Getting ready

145

12 Prevention and mitigation

147

GERRY FITZGERALD

13 Planning

156

MARK CANNADINE AND ROSEMARY HEGNER

14 Preparedness

167

JULIAN MEAGHER AND ROSEMARY STEINHARDT

PART 5

Incident management

181

15 Incident assessment and evaluation

183

GERRY FITZGERALD

16 Incident management

193

MARIE FREDRIKSEN, JUSTIN DUNLOP AND ANDREW PEARCE

17 External assistance in disasters CHARLES BLANCH, IAN NORTON, BRONTE MARTIN AND PETER AITKEN

209

Contents  vii

PART 6

Recovering

227

18 Community recovery

229

BOB LONNE, GRAEME McCOLL AND GREG MARSTON

19 Psychosocial aspects of disasters

243

JANE SHAKESPEARE-FINCH AND PAUL SCULLY

PART 7

Unique challenges of particular disasters

253

20 Natural disasters

255

WEIWEI DU, MARK LITTLE AND ANGIE JACKSON

21 Manmade disasters

267

CARISSA OH, STEFAN MAZUR AND PETER LOGAN

22 Complex events

282

PENNY BURNS, BRETT SUTTON AND PETER A. LEGGAT

PART 8

Strategic considerations

297

23 Leadership

299

DUDLEY McARDLE, PETER CHANNELLS AND BOB JENSEN

24 Evaluation and learning

310

GERRY FITZGERALD AND MARIE FREDRIKSEN

25 Education, training and research

320

AMY HUGHES, VIVIENNE TIPPETT, NIEVES AMAT CAMACHO AND PETER HORROCKS

26 Future challenges

332

GERRY FITZGERALD, MIKE TARRANT, PETER AITKEN AND KARA BURNS

Index

341

Illustrations

Figures   1.1 The track and intensity of Severe Tropical Cyclone Ingrid 6   1.2 The mismatch between resources and health needs that 7 determine a disaster   1.3 The Shizugawa Public Hospital one month after the 2011 Japan earthquake and tsunami 10   1.4 The IAEA scale used to qualify a nuclear accident 14   1.5–1.7 Images of the 2011 Japan tsunami 16   1.8 Iron lung ward filled with polio patients, Rancho Los Amigos Hospital, 1953 17   1.9 Pyne Gould building destroyed by earthquake, Christchurch, New Zealand, 2011 18   2.1 Timeline for the Union Carbide chemical plant disaster 26   2.2 The economic impact of a disaster 31   3.1 The elements that contribute to the impact of disasters 39   4.1 The relationship between organisational systems and structures 50   6.1 The effect of VUCA on achieving successful outcomes in 72 disaster management   6.2 The risk spectrum 73   6.3 The health disaster risk management process 74   7.1 The business continuity continuum 82   7.2 Key elements in business continuity management 86   8.1 Identifying key communication stakeholders 94   8.2 Functions of social media in disasters 95   9.1 The dimensions of social cohesion 110   9.2 The process for strengthening community resilience 113 13.1 Vertical and horizontal integration of disaster plans 163 14.1 The disaster management cycle: before, during and after 169 14.2 The critical infrastructure protection cycle 172 16.1 The structure of an incident management system 196 16.2 IMS levels of response: strategic, tactical and operational 198 16.3 Transition of multi-agency response into a major incident 205 16.4 Human elements in multi-agency incident management 206 17.1 Number injured vs. number of deaths in natural disasters, 2003–2015212

x  Illustrations

17.2 FMTs present in Nepal on 1 June 2015 18.1 Effect of disaster on ongoing community development 18.2 The pause in the emergency management cycle between response and recovery 18.3 Sample recovery organisational structure 22.1 World Health Organization pandemic phases 22.2 Clinical severity and transmissibility of influenza pandemics 25.1 Exercise management cycle for a disaster

213 230 231 237 285 287 327

Tables   1.1 Geophysical disaster types 12   1.2 Meteorological disaster types 12   1.3 Hydrological disaster types 12   1.4 Climatological disaster types 12   1.5 Biological disaster types 13   1.6 Extra-terrestrial disaster types 13   1.7 Technological disaster types 13   2.1 The ten worst disasters in history 22   2.2 Natural disasters 1990–2015 23   2.3 Examples of natural disasters that became man-made catastrophes 25   2.4 Mortality and morbidity in the months and years following disasters29   2.5 Direct and indirect costs in a major chemical accident at a factory31   2.6 Direct/indirect and tangible/intangible losses in the event of a flood 32   3.1 Levels of management 40   3.2 Strategies to deal with threats throughout the disaster management cycle 42   6.1 Alignment of the disaster health-related risk process with ISO 31000 74   6.2 Examples of sources of risk: an all-hazards approach 75   6.3 Examples of vulnerability types 76   7.1 Defining context of a healthcare organisation 84   7.2 A BIA template 87 11.1 Levels of activation in a disaster management plan 137 16.1 Examples of incident management systems 195 17.1 EMT classifications 220 19.1 Potential responses to traumatic experiences 244 21.1 Risk analysis considerations for mass gathering planning 271 21.2 Examples of CBR agents in warfare 275 21.3 Biological weapons of concern 278 22.1 National pandemic preparedness planning in Australia 286 23.1 Comparison of two leadership styles 301 23.2 A disaster management strategy for a crisis leader 305 23.3 Example of a leader’s decision-making process after a bushfire 305

Illustrations  xi

24.1 Recurring themes in Australian bushfires and NASA space shuttle accidents 25.1 A framework for disaster health education and awareness

313 322

Case studies   1.1 Severe Tropical Cyclone Ingrid, 2005   2.1 Union Carbide chemical plant disaster, 1984   2.2 Severe Tropical Cyclone Yasi , 2011   4.1 Hurricane Katrina, 2005   5.1 SARS management, Singapore, 2003   7.1 Eruption of volcano Eyjafjallajökull, 2010   8.1 Ebola outbreak, US, 2014   9.1 Cyclone Nargis, 2008   9.2 Cyclone Yasi, 2011 12.1 Tasman Bridge disaster, 1975 14.1 Damage to undersea cables, Europe, Asia and Middle East, 2006 15.1 Control of Toussaint L’Ouverture airport, 2010 16.1 Sarin nerve gas attack, 1995 17.1 Earthquakes – Iran (2003) and Haiti (2010) 18.1 Asian tsunami, 2004 20.1 Typhoon Haiyan, 2013 20.2 Great Eastern Japan earthquake and tsunami, 2011 20.3 Bushfires in Victoria, 2009 21.1 Industrial accident in Seveso, 1976 21.2 Gas use in Dubrovka Theatre, 2002 22.1 Norway strategy for 2009 influenza pandemic 25.1 Exercise NUGENTS, 2012

6 26 33 56 62 87 96 108 109 154 171 186 203 218 240 256 258 263 269 277 292 325

Notes on contributors

Brett Aimers is adjunct Associate Professor at James Cook University, Queensland, Australia, where he provides expert advice on Masters-level education on Emergency Management Systems and Disaster Health. He is the immediate past Deputy Chief Commissioner (Clinical) for St John Ambulance Australia. Michael Aitken is Emergency Physician and Senior Staff Specialist at the Gold Coast University and Robina Hospital Emergency Departments on the Gold Coast, Australia. He has a Masters degree in Biosecurity and Disaster Health Management, and has been involved in AusMAT deployment and disaster education and training in QLD as a MIMMS and HMIMMS Instructor. Peter Aitken is an emergency physician with postgraduate qualifications in Disaster Medicine and Clinical Education. He is currently Senior Director of the Health Disaster Management Unit, Queensland Health; Associate Professor at James Cook University, Queensland, Australia; and adjunct Professor at Queensland University of Technology. He has been involved in all aspects of disaster health PPRR: from leading response teams and emergency operations centres to administrative and academic and research roles. He has also worked in disaster-related roles for a number of NGOs and professional organisations including: St John Australia National Office; the International Federation for Emergency Medicine; the World Association for Disaster and Emergency Medicine; the Emergency Medicine Foundation; and the World Health Organization. Nieves Amat Camacho is Assistant Coordinator for the Erasmus Mundus Master of Public Health in Disasters at Karolinska Institutet, Sweden. Working with the Centre for Research on Health Care in Disasters at Karolinska Institutet and the World Health Organization, she develops training strategies for emergency medical teams. She has worked with Médecins Sans Frontières to implement emergency interventions in the Democratic Republic of Congo. Charles Blanch is responsible for disaster risk management within the New Zealand Ministry of Health and has led national health responses to the Canterbury earthquakes, Ebola readiness, emergency medical team deployments and other national security challenges. He previously worked for the London Resilience Team and London Fire Brigade. Peter Brouggy is Executive Manager in the Group Protective Services team with the Wespac Group, Australia. He is also Co-Chair of the Resilience Expert Advisory

xiv  Notes on contributors

Group, which provides strategic advice on key aspects of critical infrastructure resilience; and an Honorary Fellow of the Business Continuity Institute. Kara Burns is Senior Research Assistant for the Centre for Emergency and Disaster Management at Queensland University of Technology, Australia. Her PhD investigates the effects of digital disruption in healthcare, specifically the effect of patient-generated health data on patient engagement. Penny Burns is Senior Lecturer in General Practice at Western Sydney University, Australia, and a PhD candidate at the Australian National University. She represents general practitioners in disaster management at state and national level and chaired the development of the 2014 Royal Australian College of General Practitioners pandemic flu kit. Mark Cannadine has more than 20 years’ experience in both frontline operations and coordination of numerous natural and technological disasters and mass gathering events in both the Policing and Health sectors in Australia and overseas. He was part of the UK Government response to Thailand following the Indian Ocean tsunami; and the Australian Government team in Fiji following Cyclone Winston. With a broad experience in policy and strategy development, he has provided planning and systems development advice and support to health services across Australia, and designed and delivered training and exercise programs including defensive counter-terrorism marine operations, disaster victim recovery training and Health Executive incident management and coordination. He is currently Director of Emergency Management with South Australia Health. Peter Channells has over 20 years’ public service experience with emphasis on emergency management, national security, risk and public policy. He is now a consultant in private practice running his own company (Risk and Emergency Solutions Pty Ltd) in Australia. Weiwei Du is an Assistant Professor and Program Manager in the Office of International Cooperation at Peking University Health Science Center. He gained his PhD in Disaster Health Management at Queensland University of Technology, Australia. His research interests include disaster health management, policy analysis, science of collaboration and medical education. Justin Dunlop has had a lengthy career in health response, in both volunteer and paid roles with Ambulance Victoria, the Council of Ambulance Authorities and St John Ambulance Australia (Victoria). With roles ranging from first responder to Board member, he has been heavily involved in disaster health planning and management for major public events in Australia, including bushfire, flood and pandemic response, as well as coordinating international aid. Michael Eburn is a barrister and Associate Professor at the Australian National University College of Law. He is Chief Investigator on a research project funded by the Bushfire and Natural Hazards Cooperative Research Centre on policy, institutions and governance of natural hazards. He worked as a legal officer with New South Wales Health prior to joining the university sector. He is the author of Emergency Law (4th edition, 2013, Federation Press) as well as numerous papers on the law and the emergency services.

Notes on contributors  xv

Gerry FitzGerald is Professor of Public Health at the Queensland University of Technology, Australia. He holds medical specialist qualifications in Emergency Medicine and Medical Administration and a Doctor of Medicine degree in Emergency Department Triage. Prior to taking up his current position, he was the Commissioner of the Queensland Ambulance Service and then the Chief Health Officer for Queensland. His particular research interests are in the organisation and operations of the emergency medical system during both routine and non-routine challenges. Richard Franklin is Associate Professor at James Cook University, Queensland, Australia; and Senior Research Fellow at Royal Life Saving Society Australia. His work involves research, teaching and the effective delivering of programs around injury prevention, disaster, public health, farm safety, workplace health and safety, health promotion, alcohol, leadership, dog bites, and aquatic safety. Marie Fredriksen is Lecturer in the Centre for Emergency and Disaster Management at Queensland University of Technology, Australia, and a paramedic with the Queensland Ambulance Service. She has more than 23 years’ experience in frontline operations during numerous natural and technological disasters, planning and preparedness for mass gathering events, and in a number of education and training roles. While working with Emergency Management Queensland, she wrote and delivered training exercises and helped disaster management groups prepare for, respond to and recover from natural disasters. Her particular research interests are in emergency management systems, pre-hospital patient care and community resilience, including strategies to better prepare individuals and communities for disaster events. Carl Gibson is Director of Executive Impact Pty Ltd in Australia, and undertakes research into the neuroscience of decision-making under crisis situations. He is the author of publications in the areas of disease epidemiology and pathology, and risk, safety and emergency management, including a number of national and international Standards. Rosemary Hegner is Director of the New South Wales Health Emergency Management Unit, Australia, and is responsible for coordinating the PPRR activities. With 32 years’ experience as a paramedic and in emergency management, she has firsthand experience in emergency management coordination of health response through events including the 2011 Queensland Floods, Cyclone Yasi, Christchurch earthquake, Qualkers Hill Nursing Home fire, and more recently the 2014 Martin Place incident. She is a member of the World Association for Disaster and Emergency Medicine and a Fellow at the Institute of Public Administration, Australia. Peter Horrocks is Senior Lecturer in Paramedic Science at Queensland University of Technology, Australia. He is a qualified intensive care paramedic and registered nurse. A Doctor of Health Science candidate, his thesis focuses on preparing paramedics for disaster response. Amy Hughes is Clinical Lecturer in Emergency Response (Humanitarian and Conflict Response Institute) at the University of Manchester, UK, and is extensively involved in the development of the UK Emergency Medical Team. Engaged with the

xvi  Notes on contributors

Emergency (Foreign) Medical Team initiative (World Health Organization), she has a particular focus on standardising approaches to the training of emergency medical teams. An emergency medicine clinician with pre-hospital and retrieval experience, her deployments include the Ebola outbreak, Typhoon Haiyan and post-conflict Northern Sri Lanka. Angie Jackson is an emergency nurse practitioner. She has postgraduate qualifications in Midwifery, Critical Care Nursing, Public Health and Humanitarian Assistance. She has also been admitted as a lawyer. She has experience with AusMAT deployments and also teaches international humanitarian courses at Fordham University in New York, USA. Bob Jensen has over 35 years’ experience across a broad spectrum of assignments, both inside and outside of the US Government. He has provided oversight and input to risk assessments and strategic development for United States national security issues, including cyber-security, natural disasters, pandemics, counterproliferation and counter-terrorism. He is currently Senior Managing Director at Strat3 LLC in the USA. Andrew Johnson is Executive Director of Medical Services at Townsville Hospital and Health Service; and Associate Professor and Head of Medical Leadership and Management at James Cook University, both in Queensland, Australia. He is a medical graduate of the University of New South Wales, Australia, where he also holds a Master of Health Administration; and he is a Fellow of the Royal Australasian College of Medical Administrators. He has been a professional medical leader and manager for over 20 years, with experience in defence, and public and private hospitals. Ingrid Larkin is Lecturer at Queensland University of Technology Business School, Australia. She has been recognised as a Fellow and is a National President’s Award recipient of the Public Relations Institute of Australia, as well as receiving a number of awards for teaching and engagement. Peter A. Leggat is Professor and Director of the World Safety Organization Collaborating Centre for Disaster Health and Emergency Response at James Cook University, Queensland, Australia; and adjunct Professor at Queensland University of Technology. Mark Little is an emergency physician and clinical toxicologist at Cairns Hospital; and an Associate Professor at James Cook University, both in Queensland, Australia. He is involved in training and AusMAT deployments, with missions in Australia and overseas. He also teaches international humanitarian courses at Fordham University in New York, USA. Peter Logan is Fellow in the Centre for Emergency and Disaster Management at Queensland University of Technology, Australia; Clinical Director in the Health Disaster Management Unit at Queensland Health; and Senior Staff Specialist in Emergency Medicine at The Prince Charles Hospital in Brisbane, Australia. Bob Lonne is Professor of Social Work at the University of New England, Australia; and adjunct Professor in the School of Public Health and Social Work at Queensland

Notes on contributors  xvii

University of Technology. He has researched and published regarding child protection, disaster recovery and human services, and workforce planning and development. Greg Marston is Professor of Social Policy in the School of Public Health and Social Work at Queensland University of Technology, Australia. He conducts research on a range of economic and social issues, including poverty, unemployment, development and climate change. Bronte Martin is Director of Nursing (Trauma & Disaster) at the National Critical Care Trauma Response Centre in Australia, providing clinical governance and oversight for in-reach Trauma Services at Royal Darwin Hospital, the NCCTRC Education & Training program, and the Australian Medical Assistance Team deployable field hospital capability. On secondment with the World Health Organization, she developed and established the Emergency Medical Teams Global Classification, Mentorship & Verification program; ensuring validated, quality international emergency medical care is delivered in response to sudden onset disasters. Lidia Mayner is Associate Professor at Flinders University, South Australia, and Director of the Research Program for Disaster Nursing. She is also on the Board of Directors for the World Association for Disaster and Emergency Medicine as the Western Pacific representative. She is part of the United Nations International Strategy for Disaster Reduction Expert Working Group on Terminology for the Sendai Framework for DRR 2015–2030. Stefan Mazur is a pre-hospital and retrieval physician and Medical Retrieval Consultant with the South Australian retrieval service, SAAS MedSTAR; and an emergency physician in the Royal Adelaide Hospital Emergency Department, South Australia. He has previously worked retrievals for NETS in Sydney, New South Wales; for CareFlight Queensland; and for London HEMS in pre-hospital trauma care. He is also an examiner in Retrieval Medicine for the Royal College of Surgeons in Edinburgh, UK, and an Associate Professor at James Cook University, Queensland. Dudley McArdle is proprietor of the DMac DIRECTIONS emergency management consultancy in Australia. He also works as the Monash University Emergency Management Senior Policy Advisor in Melbourne, reviewing and contributing to their emergency management education and research programs, and providing emergency management advice and support to the Monash Emergency Management Forum and to the Monash University Disaster Resilience Initiative. Graeme McColl has over 15 years’ experience in health emergency management, including roles such as Response Manager and Operations Manager in the New Zealand National Health Coordination Centre during the H1N1 pandemic response and offshore health responses. He has also been liaison officer between the Ministry of Health and Christchurch health services during earthquake responses. He is currently Secretary for the World Association for Disaster and Emergency Medicine, Oceania Chapter. Fiona McDonald is Senior Lecturer in the School of Law and the Australian Centre for Health Law Research at Queensland University of Technology, Australia; and adjunct Professor in the Department of Bioethics at Dalhousie University, Canada.

xviii  Notes on contributors

Her research interests are in the governance and regulation of health and health systems, including health professional and health technology regulation, and healthcare ethics, especially rural healthcare ethics. Julian Meagher has a career spanning 16 years in public service. Until 2015 he was Manager for Public Health Emergency at the Department of Health & Human Services in Victoria, Australia. With a nursing background, he has been involved in various disaster responses and their aftermath, both in Australia and internationally. Amisha Mehta specialises in risk, crisis and organisational change at Queensland University of Technology Business School, Australia. She is involved in high-impact industry research with corporate partners and the Bushfire and Natural Hazards Cooperative Research Centre. Her research in risk and crisis communication aims to help businesses and communities to make smarter and safer decisions during risk. Natasha Murray is a Public Health Medicine Specialist with particular interest in international health and emergency management. She has assisted in leading the development of health action plans and frameworks within the Western Pacific region; provided public health clinical leadership regarding New Zealand domestic readiness for emerging infectious diseases during the Ebola outbreak in 2014/15; and has international humanitarian and development experience in West Africa and Central America. Ian Norton is an emergency physician who leads the Disaster Preparedness and Response section of the National Critical Care and Trauma Response Centre of Australia, Darwin. He has field experience of leading multiple disaster response teams in the Asia–Pacific region. He is on long-term secondment with the World Health Organization, Geneva, to establish the WHO global Emergency Medical Team initiative. Carissa Oh is an emergency physician at St George Hospital, New South Wales, and a pre-hospital and retrieval physician with New South Wales Ambulance. She has been involved in major incidents and disaster response through teaching Major Incident Medical Management and Support and Hospital MIMMS, as well as deployments with AusMAT and urban search and rescue. Gerard O’Reilly works as an emergency physician at the Alfred Emergency and Trauma Centre, Melbourne, Australia. He has worked with Médecins Sans Frontières in Afghanistan and Kenya, and with the International Rescue Committee in post-tsunami Aceh, Indonesia. He has led trauma and emergency system capacity development and disaster resilience programs in Sri Lanka, India, Myanmar and Vietnam. David Parsons is Senior Mine Safety Officer – Emergency Management; Honorary Fellow of the Business Continuity Institute; and Fellow of the Australian Institute of Emergency Services. Andrew Pearce is Clinical Director Retrieval Coordination at SAAS MedSTAR Emergency Medical Retrieval Service in South Australia; a Senior Consultant at the Royal Adelaide Hospital Emergency Department and Associate Professor at James

Notes on contributors  xix

Cook University School of Public Health, Queensland. He is also an AusMAT team leader and RAAF Specialist Reservist with multiple overseas deployments. Currently Chair of Major Incident Medical Management and Support, MIMMS Australia, and examiner for the Diploma of Retrieval and Transport Medicine, Royal College of Surgeons, UK. Benjamin Ryan is Disaster Coordinator for the Cairns and Hinterland Hospital and Health and Service, Australia; PhD candidate at James Cook University, Queensland, Australia; and Trainer, Global Education and Training Institute, United Nations Office for Disaster Risk Reduction. Benjamin has worked during responses to natural disasters and disease outbreaks, managed public health projects in Aboriginal and Torres Strait Islander communities and worked in public health at all levels of government in Australia and as a consultant internationally. His professional and research interests are focused on mitigating the impact of disasters and climate change on public health. Paul Scully is Visiting Fellow at the Centre for Emergency and Disaster Management, Queensland University of Technology, Australia. He is Founder and inaugural Manager of Staff Support Services ‘Priority One’ mental health program at Queensland Ambulance Service. He has played a key role in the development of workplace mental health programs within St John Northern Territory Ambulance Service and the Queensland Department of Child Safety in Australia, as well as the Scottish, London and Northumbria Ambulance Services in the UK. Jane Shakespeare-Finch has spent 20 years studying psychological trauma, adaptation and post-traumatic growth in populations as diverse as emergency service workers, survivors of sexual abuse, bereavement and refugees. She is currently President elect of the Australasian Society for Traumatic Stress Studies. Erin Smith has been working in the field of pre-hospital and disaster health for 15 years. She is Course Coordinator for the Master of Disaster and Emergency Response at Edith Cowan University, Western Australia, and is an active member of the World Association for Disaster and Emergency Medicine. Rosemary Steinhardt is Nursing Director of Communicable Diseases in the Prevention Division at Queensland Department of Health, Australia. Her background is in infection, prevention and control, incident investigation and management, response planning, and most recently, influenza pandemic planning. Brett Sutton is Public Health Registrar at the Burnet Institute and Office of the Chief Health Officer in the Department of Health & Human Services, Victoria, Australia. He has extensive experience in international humanitarian and development work, including in Afghanistan, Ethiopia, Kenya and Timor-Leste. Mike Tarrant is adjunct Associate Professor in the Public Health Faculty at Queensland University of Technology, Australia. He was an Assistant Director of Education and Research at the Australian Emergency Management Institute and has worked in disaster management education and research for the past 25 years. Vivienne Tippett is Professor of Clinical Science, Head of the Paramedic Discipline, and Director of Research (Clinical Science) at Queensland University of Technology,

xx  Notes on contributors

Australia. Her research interests are pre-hospital trauma management and emergency health systems development; disaster and mass casualty response; and clinical care and performance indicators for the pre-hospital sector. Ghasem-Sam Toloo is Research Fellow in the School of Public Health and Social Work at Queensland University of Technology, Australia. A sociologist with experience in mixed methods applied research, he specialises in health and medical sociology, health behaviour, socio-cultural and demographic inequalities in health, and emergency health service utilisation. Linda Winn is currently Deputy Director at New South Wales Health Emergency Management Unit, Australia, and has worked in emergency management for 15 years gaining experience in Australia and overseas. She is a registered nurse with the current Australian Health Practitioner Regulation Authority, and has completed a Master of Business Administration (2015), Master of Public Health (2010), and a Master of Nursing (2002) at Newcastle University, New South Wales, with her thesis entitled ‘Chemical, Biological, and Radiological Preparedness in the Emergency Department’. Robina Xavier is Executive Dean of Queensland University of Technology Business School, Australia. Specialising in corporate and financial relations, she has worked as a consultant in both the private and public sectors. She is a former National President of the peak industry body, the Public Relations Institute of Australia and a former chair of the industry’s National Education Committee which oversees accreditation of Australian university programs. A Fellow of the PRIA and a Senior Fellow of the Financial Services Institute of Australasia, she is also co-editor of Public Relations Campaigns (Oxford University Press).

Acronyms

AADMER ADRRN AEMI AHPPC AIHW AIIMS AMA ANZEMC AS/NZS ASD ASEAN AusMAT BAU BCM BCMS BCP BIA CAS CBRN CDC CHE CHS CI CIAC CIMS COAG COMDISPLAN CRED DMAT DRM ECHO EHS EM-DAT EMA

ASEAN Agreement on Disaster Management and Emergency Response Asian Disaster Reduction and Response Network Australian Emergency Management Institute Australian Health Protection Principal Committee Australian Institute of Health and Welfare Australasian Inter-Service Incident Management System American Medical Association Australia–New Zealand Emergency Management Committee Standards Australia and Standards New Zealand acute stress disorder Association of South East Asian Nations Australian Medical Assistance Team business as usual Business Continuity Management Business Continuity Management System Business Continuity Plan business impact analysis complex adaptive system chemical, biological, radiological and nuclear Centre for Disease Control complex humanitarian emergencies Core Humanitarian Standard critical infrastructure Critical Infrastructure Advisory Council Coordinated Incident Management System Council of Australian Governments Commonwealth Disaster Plan Centre for Research into the Epidemiology of Disasters disaster medical assistance team Disaster Risk Management European Community Humanitarian Office emergency healthcare systems CRED’s international disaster database Emergency Management Australia

xxii  Acronyms

EMS EMT EOC ERC EVD FEMA FFH FMT GFDRR GPID HAP HAZMAT HRW IAAG IAEA IAEM IASC ICCPR ICESCR ICRC IED IEHK IFRC IHR ILI IMS IMT IOM ISDR ISO MAO MCP MoU MSF NDMA NDO NDRRA NGO NIMS OCHA OH&S OPCW OSOCC PAHO PMR PPE PPRR

emergency medical systems emergency medical teams emergency operations centre Emergency Relief Coordinator Ebola Virus Disease Federal Emergency Management Agency foreign field hospital foreign medical team Global Facility for Disaster Reduction and Recovery Guiding Principles on Internal Displacement Humanitarian Accountability Partnership hazardous material response Human Rights Watch Infrastructure Assurance Advisory Group International Atomic Energy Agency International Association of Emergency Managers Inter-Agency Standing Committee International Covenant on Civil and Political Rights International Covenant on Economic, Social and Cultural Rights International Committee of the Red Cross improvised explosive device Interagency Emergency Health Kit International Federation of Red Cross and Red Crescent Societies International Health Regulations influenza-like illness incident management system incident management team International Organisation for Migration International Strategy for Disaster Reduction International Organization for Standardization maximum acceptable outage mass casualty plan memorandum of understanding Médecins Sans Frontières National Disaster Management Agency Natural Disasters Organisation Natural Disaster Relief and Recovery Arrangements non-governmental organisation National Incident Management System Office for the Coordination of Humanitarian Affairs occupational health and safety Organisation for the Prohibition of Chemical Weapons onsite operations coordination centre Pan American Health Organization private, mobile, radio personal protective equipment prevention, preparedness, response, recovery

Acronyms  xxiii

PTG PTSD QAS RAIR RHC RTO SARS SDMG SDS SITREPS SOD START TIEMS UAV UN UNDAC UNHCR UNICEF UNISDR UNOCHA USAid USAR WADEM WFP WHO WMD WRR

post-traumatic growth post-traumatic stress disorder Queensland Ambulance Service rail, air or industrial rescue resilient health care recovery time objective Severe Acute Respiratory Syndrome State Disaster Management Group safety data sheet situation reports sudden onset disaster simple triage and rapid treatment The International Emergency Management Society unmanned aerial vehicle United Nations United Nations Disaster Assessment and Coordination United Nations High Commissioner for Refugees United Nations International Children’s Emergency Fund United Nations International Strategy for Disaster Reduction United Nations Office for the Coordination of Humanitarian Affairs United States Agency for International Development urban search and rescue World Association for Disaster and Emergency Medicine World Food Programme World Health Organization weapons of mass destruction World Risk Report

Foreword

“What quarrel, what harshness, what unbelief in each other can subsist in the presence of a great calamity, when all the artificial vesture of our life is gone, and we are all one with each other in primitive mortal needs?” George Eliot

The context Public awareness of, and interest in, disasters and their impact has increased through the combined effects of intense media and political scrutiny of every event, and public entertainment’s best efforts to dramatise (or fictionalise) the countless personal stories that characterise such events. When an earthquake off the coast of Indonesia in December 2004 caused a tsunami that devastated the coastal communities in the nations that ring the Indian Ocean, millions of such stories eventuated; each speaking to the devastating impact such an event has on real people and real communities. The unchallenged public perception is that disasters are becoming more common. Whether this is due to increased frequency or simply greater awareness and reporting is subject to debate. What is not debated, however, is that disasters are having an increasing impact. Partly, this increased impact derives from the community’s lesser tolerance of adversity and public expectations about the maintenance of standards of living and quality of life even in the context of the most extreme events. It may also be due to the direct and indirect costs of disasters as more sophisticated and expensive infrastructure is destroyed. Increased population and population density, coupled with growth in technology, also contribute. A transport accident involving an overloaded horse and cart pales in comparison to one that involves a fully laden A380. What is clear is that there is an increasing public focus on disasters. Modern disasters are played out in real time, on mass media, with every decision and action scrutinised and disassembled by legions of armchair critics. This imposes on those tasked with managing disasters the challenge of doing their best while under intense scrutiny; both contemporaneously and in retrospect. There is a widespread community expectation that the ‘authorities’ (however so defined) should be prepared and ready to respond in even the most extreme event, and failure to do so has political and economic consequences. (Note the impact of Hurricane Katrina on the Presidency of George Bush or of 9/11 events on Mayor Rudy Giuliani.) This expectation exists despite the reluctance of some members of the

xxvi  Foreword

community to participate in any way in providing for themselves or in mitigating the risks they face. This irony is difficult to rationalise but it does impede governments and public authorities.

Disaster management Over past decades, disasters have had a highly significant impact mostly on the poorest nations of the world; retarding their growth and development. In 2010, for example, a total of 385 natural disasters resulted in the deaths of over 297,000 people and affected 217 million (see: CRED, 2011, Annual Disaster Statistical Review 2010, accessed 04/07/2012 at http://www.cred.be/publications). These disasters have caused great suffering to people and required US$123.9 billion to repair damage and help reconstruct lives. In the past, natural disasters may have been accepted as an ‘act of God’, but increasingly societies around the world demand more organised efforts to reduce the impact that disasters have. This is predicated on the justifiable belief that effective disaster management can limit the impact of disasters on people and their communities. These efforts are not limited to responding to disasters but imply a range of strategies that prevent, mitigate, prepare, respond and recover. Traditionally communities relied solely on their own resources but increasingly wider cooperation has characterised disaster management, with resources and support often being provided by remote nations facilitated by the UN and large international aid agencies such as the Red Cross. The international community recognised the importance of disasters management when the UN General Assembly adopted the International Strategy for Disaster Reduction (ISDR) in December 1999. The General Assembly designated the 1990s as the International Decade for Natural Disaster Reduction (IDNDR) and established the UN Office for Disaster Risk Reduction to coordinate risk reduction strategies. The office was subsequently tasked with implementing the international blueprint for disaster risk reduction – the Hyogo Framework for Action 2005–2015: Building the resilience of nations and communities to disasters and more recently the outcomes of the Sendai meeting (see: https://en.wikipedia.org/wiki/International_Decade_for_ Natural_Disaster_Reduction#cite_note-UN_ARES44236-1). The net impact has been a much greater degree of international cooperation in both the preparation for and response to disasters. To a large extent this burden falls onto those countries that have most resources to share and many of these countries have developed quite sophisticated response arrangements which may readily exceed those of the affected people, thus bringing its own challenges, and may contribute further to people’s sense of injustice. However, the increasing sophistication of centralised systems of response and relief has the potential to disempower or discourage the community’s own efforts. At one extreme this can lead to passive dependence and so the focus of management efforts has shifted towards building community resilience as a partnership between the local community and those who may have the resources to encourage and support. Thus from the international to the very local, there has been an increasing focus on improving disaster management throughout the cycle of prevention, preparedness, response and recovery.

Foreword  xxvii

However, despite this the media often reports that bureaucratic mismanagement contributes to issues experienced in the response and recovery phases of a disaster. Effective decision-making requires identification of the appropriate category of the problem, its definition and the development of an appropriate response (see: Drucker P. ‘The effective decision’. In: Harvard Business Review on Decision Making. Boston: Harvard Business School Publishing Corporation; 2001). The rapid distinguishing of the best suited decision will avoid concerned parties and stakeholders adapting solutions based on their own interests. Following a disaster, decisions such as providing compensation payments, purchasing temporary housing and restoring community centres may be made out of concern for those affected, but implementation of these decisions needs to be carefully evaluated. This allows improvement of future responses and leads to improved and timelier decisions in the future. Disaster management involves the establishment of a temporary organisation for a specific purpose, but one which builds upon the organisations that exist. It is not about supplanting existing organisations and their roles and responsibilities, but about enhancing those roles with improved coordination and management. To better understand how such structures are organised and managed, it is critical to first understand the policy, legal and organisational environment. It is also critical to have a sound understanding of the system and its guiding strategies. Individuals responsible require skills to develop policies and plans, capabilities within the health system, and to strategically manage responses and system recovery. Making improvements to the system of disaster management requires leadership and effective management at all levels, and this in turn is reliant on effective education and training and a common language and conceptual understanding.

The aim and focus of this text In order for the ‘authorities’ to respond in the most effective and coordinated fashion it is critical that there is common understanding and agreement amongst responders of the principles of disaster management and their application to practice. This common language forms the basis of a common understanding which aims to enable greater cooperation within and between communities. The principal aim of this text is to propose such a common language that may underpin coordinated approaches to disaster management. The contents are drawn from experience and practice and from the literature. We seek to define disasters within the context of other community events and to explain the complexity of ‘management’ tasks required. We will distinguish the concepts of disasters management from leadership but seek to explain how these concepts complement each other. The text is aimed at practitioners; both existing and future. It is intended to guide practice and to form the core material for educational programs which seek to develop the skills of new practitioners in this field. The text is not intended to foster debate amongst experts. That is done in published literature. Rather it seeks to lay the ground work of basic principles and practice that should support consistency of practice. Where there is significant debate we will refer to that debate without exploring its detail and certainly without attempting to ‘decide’ the issue.

xxviii  Foreword

The text focuses on the impact that disasters have on people and the communities in which they live and therefore on management from the community and people perspective. As such it has a strong focus on their health and wellbeing and therefore considers how health and wellbeing may be protected and preserved. It does not seek to address risks or hazards and their prediction and management. It does aim to identify the way in which communities seek to manage the impact that those hazards have on their community and in particular on the health and wellbeing of people. The text inevitably relies heavily on disaster management arrangements in Australia as examples. This is purely practical and does not imply in any way that those arrangements are exemplars. The text will cover the scope of disaster management; from the core underpinning principles through to the principles of leadership that are required to ensure that the objects of disaster management are achieved within communities and organisations. This text is divided into eight parts. The first explores the concepts and principles that underpin a comprehensive understanding of disaster management. The second examines the systems and structures that are required to support effective disaster management; the third, fourth, fifth and sixth focus on healthcare, getting ready, responding and recovering respectively. The seventh part addresses the challenges of particular events and finally the last part addresses the leadership and transformational issues required to ensure effective disaster management occurs and is in accordance with evolving and emerging best practice and with community needs and aspirations. This text is not intended to be prescriptive of how disaster management should occur. That would be in breach not only of our mandate but of the principles that have proven effective. In general, we take an all-hazards approach; but also discuss the special considerations of particular events. We recognise that the most effective disaster management for any particular community is a product of that community’s history, culture, politics, economy, resources, geography and demography and therefore not only may arrangements vary but by necessity they should be tailored to the particular need of that community. Each chapter outlines the objectives that we consider the reader should achieve from that chapter. We will offer examples and case studies drawn from the literature and from history to demonstrate or illuminate particular points. We summarise at the end of each chapter key points to allow you to consolidate and test your understanding. We also offer activities in each chapter to help you test your understanding or to help you consolidate your thinking. Finally we seek to provide not only a basic level of understanding but also to encourage and challenge you to go beyond accepted norms. We provide extension readings that may explore particular issues in greater depth. We welcome you to share this journey with us! Gerry FitzGerald, Peter Aitken, Mike Tarrant, Marie Fredriksen

Part 1

The conceptual basis of disaster management

Chapter 1

Definitions and terminology Lidia Mayner and Erin Smith

Introduction and objectives Disasters are a recurring feature of human life and the extent to which they can be identified and managed is contingent upon our collective understanding of the meaning and dimensions of the concept. So what is a disaster and what is disaster health? The aim of this chapter is to summarise the development and evolution of the definition of disaster along with other terms relevant to disaster management. On completion of this chapter, you should be able to: • • •

Demonstrate a detailed understanding of disasters and of related terms. Discuss the elements of these definitions and the relationships between concepts. Identify ways in which disasters may be categorised and the relative benefits of these measures.

Defining disasters Descriptions of disasters are common throughout history, as evidenced by Pliny the Younger’s graphic portrayal of the eruption of Vesuvius. However, Canadian Samuel Henry Prince is considered to be the pioneer of disaster research. In 1917, Prince began the formal study of disasters with his dissertation on Canada’s worst catastrophe, the 1917 ship explosion in the harbour of Halifax, Nova Scotia (Prince 1920). His pioneering study and sociological exploration of the effects of disaster stimulated further empirical and theoretical research throughout the 1930s, 1940s and 1950s, with a resulting shift in the way that disasters were defined. Instead of referring primarily to a physical agent, definitions and descriptions of disasters began to emphasise the social impact of the event. In 1957, Fritz and Mathewson published a study exploring convergence behaviour of victims, responders, volunteers, onlookers and concerned members of the community during disasters (Fritz and Mathewson 1957). The study highlighted how this type of convergence may obstruct and complicate rescue operations. Fritz (1961) proposed a sociologically based definition for disaster, claiming they were events: in which a society or a relatively self-sufficient sub-division of society, undergoes severe danger and incurs such losses to its members and physical appurtenances that the social structure is disrupted and the fulfilment of all or some of the essential functions of the society is prevented.

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This sociological framework focused on disruptions to the vital functioning of a society. Disasters were examined by how they affected health, social, cultural and economic infrastructure. This was followed by the work of Barker and Chapman (1962), and other books examining communities and behaviour during disasters (Barton 1969; Dynes 1970). Each of these works considered the definitions and concepts of disasters, further shifting the focus from the trigger towards emphasising the sociological aspects of disasters. However, despite continued interest in disasters throughout the 1960s, a discipline encompassing disaster research was lacking. This changed in the 1970s, when Henry Quarantelli pushed for the international recognition of disaster research as an academic speciality, and the need for a specialist journal. Quarantelli’s efforts led to the creation of the Research Committee on Disasters, the International Sociological Association and publication of the International Journal of Mass Emergencies and Disasters (Scanlon 2005). These developments in the field of disaster research further highlighted an issue that had dominated the early works of pioneer disaster researchers: how to define and conceptualise the term ‘disaster’. Quarantelli and his colleagues triggered the emergence of new models for approaching disasters based on the analysis of communities (Gilbert 1998). The next 30 years of disaster research continued to engage academics from a wide variety of disciplines to examine nature, definition and concepts. While this greater multidisciplinary interest in disasters led to more reflection and interpretation, a single definition for the phenomena of disaster was still elusive, with most disciplines proposing definitions that reflected their individual interests. Al-Madhari and Keller (1997) examined whether a universal definition for disaster was feasible. After reviewing 27 existing definitions, it was concluded that one overarching definition was not possible. Nevertheless, Al-Madhari and Keller (1997) suggested a definition incorporating both health and economic aspects as follows: An event localised in time and space if one or more of the following consequences occur: 1 10 or more fatalities; 2 damage exceeds $1 million (US); and or 3 50 or more people evacuated. CRED defines disasters for the purposes of standardising data collection (www.emdat. be/explanatory-notes) as events in which: • • • •

Ten (10) or more people reported killed. Hundred (100) or more people reported affected. Declaration of a state of emergency. Call for international assistance.

Definitions for data collection purposes must necessarily be relatively prescriptive, but they are often distinctly different to those described in impact terms. Given that there is no single accepted definition of disasters, the definitions vary at international, national and local levels where organisations develop their own working

Definitions & terminology  5

definitions of disaster to meet their particular requirements. These reflect not only the professional background of the definer, but also the context of work, studies or research. For example, the United Nations International Strategy for Disaster Reduction (UNISDR: www.unisdr.org/we/inform/terminology) defines disaster as: A serious disruption of the functioning of a community or a society causing widespread human, material, economic or environmental losses which exceed the ability of the affected community or society to cope using its own resources . . . It results from the combination of hazards, conditions of vulnerability and insufficient capacity or measures to reduce the potential negative consequences of risk. The International Red Cross (www.ifrc.org/en/what-we-do/disaster-management/ about-disasters/what-is-a-disaster) adopted a similar definition: A sudden, calamitous event that seriously disrupts the functioning of a community or society and causes human, material, and economic or environmental losses that exceed the community’s or society’s ability to cope using its own resources. Using these definitions, events such as earthquakes, floods and hurricanes/cyclones are not disasters in their own right; rather, they become disasters when they adversely and seriously impact on human life, livelihoods and property. The plethora of disaster definitions tends to relate to the circumstances of the community and the needs of the organisation crafting the definition. Disasters are defined within the context of the need for the definition. A government may define disasters for the purposes of declaring a disaster and thus enabling response and recovery arrangements to be enacted. A response agency may define disasters built around their surge requirements. However, notwithstanding this considerable disparity, most definitions convey the essential components that constitute a disaster. It is these components that make a particular event a disaster: • • •

Causes serious disruption. Beyond day-to-day capacity. Requires special mobilisation of resources and organisations.

These are the elements that capture what is different about disasters, and therefore distinguishes them from other events or challenges. It is a situation or an event in which individuals, organisations and systems have to behave or operate in a nonroutine way, sometimes forging new modes of operation or creating new organisational structures (e.g. disaster coordination centres) which complement routine activities. Figure 1.2 attempts to capture the relative nature of disasters. There is no ‘start’ or ‘end’ point, but rather all events lie along a continuum with the daily (routine) events at one end and the extreme (catastrophic) disasters, such as earthquakes, at the other. Where events are placed along this continuum is dependent on the context and the nature of the event. The event becoming a disaster is dependent on the relative mismatch between the demands and the resources available to deal with the event. Thus the extent of the challenge to the health and wellbeing of the community is

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Case study 1.1: Severe Tropical Cyclone Ingrid, 14 – 16 March 2005 The only cyclone ever recorded to impact as a severe tropical cyclone on the coastline of three different states or territories, Severe Tropical Cyclone Ingrid caused significant impact on the Australian coast (see Figure 1.1). First crossing the Queensland East Coast, south of Lockhart River, as a Category 4, Ingrid then moved across the Gulf into the Northern Territory and impacted on the small islands north of the Arnhem Land Coast as a Category 5 cyclone. Ingrid then weakened back to Category 4 as she crossed Croker Island and the Cobourg Peninsula. As a Category 3 cyclone, she traversed the Tiwi Islands north of Darwin and finally reintensified to Category 4 before making final landfall on the West Australian Kimberley coast.

0

600

1200

Kilometres

Figure 1.1 The track and intensity of Severe Tropical Cyclone Ingrid (Commonwealth of Australia, Bureau of Meteorology, 2016).

Was this a disaster? While small in size, TC Ingrid was very intense, but the remote location, sparsely populated areas, preparedness of the impacted communities, and the accuracy and timeliness of the cyclone watches and warnings, meant there was no loss of life and evacuations were not necessary. Property damage was minimal although there was significant environmental damage. Source: Commonwealth of Australia, Bureau of Meteorology, 2016 (www.bom.gov.au/cyclone/history/ingrid.shtml)

Definitions & terminology  7

Factors influencing resource levels: * Socioeconomic status * Culture and attitudes Time of day

Resources

Demand for healthcare

Factors influencing health needs: • Nature of the event ■ Scope ■ Location

Figure 1.2 The mismatch between resources and health needs that determine a disaster.

determined by the nature of the event, its location, spread and impact, along with the characteristics, culture and size of the community. Even the timing of the event can determine the mismatch as it will influence the available resources.

Other disaster-related terms There is an extensive array of other terms that disaster management practitioners need to familiarise themselves with. The following documents identify not only the array of terms but the variability of understandings (all sites accessed on 14 April 2016). • • • • •

World Health Organization, 2003, EHA Tools, Words are Important. www.who. int/hac/techguidance/tools/Definitions%20for%20HAC%20Oct%202003.pdf UNISDR, 2009, 2009 UNISDR Terminology on Disaster Risk Reduction. www. unisdr.org/we/inform/publications/7817 PreventionWeb/UNISDR, 2015, Proposed Updated Terminology on Disaster Risk Reduction: A Technical Review. www.preventionweb.net/files/45462_backgound paperonterminologyaugust20.pdf PreventionWeb/UNISDR, n.d., Prehospital and Disaster Medicine: Disaster Terminology. www.preventionweb.net/files/3913_VL206323.pdf Guidelines for Evaluation and Research: Volume One – Glossary of Terms. https:// wadem.org/publications/guidelines-evaluation-research

It is not easy to make sense of the huge array of terms. Differentiating emergencies from disasters is challenging. It could be argued emergencies are sudden events that

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may or may not be disasters depending on their scale and impact. A particular subclass of disaster is the complex humanitarian emergency. This is a combination of ongoing risk (usually from military action) with population movements (refugees). These events create massive complex challenges to health and wellbeing. Various terms are often used without careful attention to their precise meaning, or, as stated above, the terms may reflect a particular focus or interest. This only adds to the confusion. For example, some people equate risk management with disaster management. The former implies simply the management of ‘potential’ and not the consequences. It is important for clarity in understanding and communication to develop a dictionary of terms which demonstrates the terms’ relationships to each other and to the underlying concepts. The best advice is to rely on standard English interpretations of terms rather than using technical definitions that may differ and thus confuse. While it is not possible to deal with this diversity in a comprehensive fashion, there are important words worthy of emphasis. These concepts will be explored progressively throughout subsequent chapters. •

• • • •

Risk is defined simply as the likelihood of something going wrong or something which will have an impact on organisations or community objectives. Risk is a result of the interplay between the challenge (hazard) and the vulnerability of the community or organisation. Risk management describes the strategies necessary to reduce risk. Risk management is about ensuring the uncertainties associated with achieving objectives are managed within the available resources. Hazard is a potential harm or dangerous phenomenon that may take life or cause damage. Vulnerability is difficult to define but it implies that individuals and communities (or organisations) differ in their risk and the likely impact of a disaster. Resilience describes the inherent ability of an individual, community or organisation to continue to function despite a challenge. This broad definition of the term incorporates four key elements: 1 The strength (the ability to take the hit), which is influenced by the design of both hard (structure) and soft (systems) infrastructure. 2 The flexibility (agility or elasticity), which implies the ability of the individual, organisation or infrastructure to avoid the damage or ‘bounce back’. 3 The responsiveness, which implies the ability to react and manage the impact and to restore functionality. 4 The adaptability, which describes the ability to alter, adjust and build a new reality. The effectiveness of any community response to major incidents will depend on their adaptability to the new reality. Haiti or Christchurch will never be the same; too much of what was there will never be useable again; the people must adapt to a new reality.

• •

Adaptive capacity enriches resilience by describing the ability of the individual, organisation or community to adapt to changing circumstances. Emergency management (a term first used in the US) is effectively considered to be synonymous with disaster management. The phrase is also used to emphasise

Definitions & terminology  9

• • • •

comprehensive approaches that are integrated with risk management and the management of simple emergencies. Protection is often used to imply defence against terrorism but equally defence against infectious diseases. Mass crowd events capture the unique challenges of large populations, often in an environment which may be unsustaining. Mass casualty (or multicasualty) events describe those with ill-defined levels of many casualties. Disaster management is about an organisation (or community) seeking to maintain services in a very different environment while under severe time and resource constraints. In this context, disaster management could be considered an oxymoron, as disaster by definition implies chaos and disorder.

One of the critical challenges of disaster management is the understanding of how these various terms fit together in a rational manner which reflects clarity of understanding.

Disaster health Health and the ability to contribute to societal productivity and sustainability is a fundamental part of an individual’s quality of life. Health is defined by the World Health Organization as ‘a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity’ (WHO 2003). The health system is fundamental to human life and needs to be able to support people by ensuring it can function effectively regardless of the circumstance. A critical focus of disaster management is on the preservation of health and wellbeing. An understanding of the challenges that face the health system is a critical component of disaster management systems. Terms are used to convey strong messages of principle. In this context, the phrase ‘disaster health’ is preferred to ‘disaster medicine’. Disaster health emphasises that disaster responses are multidisciplinary by nature and not the sole domain of any single profession or expert group. Equally, the term ‘health’ reinforces the understanding that disaster management is not restricted to the treatment of those who may be ill or injured. It also focuses on the preservation of health and wellbeing. Perhaps disaster medicine is best considered a subset of disaster health, restricted to the particular aspects of clinical care that characterise management of patients in a disaster. Bradt et al. (2003) and Sundnes and Birnbaum (2003) described the context of disaster health as involving three essential domains. These are public health, emergency and risk management, and clinical and psychological care. This speaks further to the complexity of disasters and the interrelationships between professional areas of responsibilities. Strict wording is less important than understanding the common themes and ideas. For example, a hospital in a disaster may find itself in any one or combination of scenarios. It may have a surge of patients with no damage or loss of facilities and/or staff. The hospital may have sustained significant damage and staff and their families are affected. It may also have sustained little internal damage but is isolated because of external infrastructure damage (power, water, gas, communications, food supplies, drugs and all manner of consumables). In a disaster any combination of the above

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scenarios is possible. Stakeholders will have different expectations of what a hospital should or should not be able to provide. Within the health context, the distinction between a disaster and an everyday event is often difficult to make. For example, the Australian Institute of Health and Welfare (AIHW) reports that since 2009/2010, public hospital emergency department presentations have been increasing on average 2.9% every year. In 2013/2014, public hospitals provided around 7.2 million accident and emergency services. This figure equates to 19,700 people receiving services at Australian public hospital emergency departments every day (AIHW 2014). Currently, the Australian system (however painfully) copes with the demand of treating almost 20,000 people every day. Emergency departments are very skilled at coping with surges in demand on daily, weekly and yearly cycles. A disaster Each day hospital emergency for them would be when they have a departments in Australia treat almost situation where it is impossible to deliver 20,000 people. Australia has never the standard of care that they are used to had a single event with 20,000 providing. casualties – except every day! The challenge for health services is to surge its response while at the same time dealing with threats to its physical and human infrastructure. Consider the Shizugawa hospital in Minamisanriku, northern Japan, affected by the 2011 Japan earthquake and tsunami (see Figure 1.3). The tsunami arrived with little warning and water inundated the fourth floor of a five

Figure 1.3 The Shizugawa Public Hospital one month after the 2011 Japan earthquake and tsunami. (Photo by Christopher Johnson.)

Definitions & terminology  11

story building. Imagine the array of considerations that would come to play in such a circumstance. How does a hospital prepare, respond or recover from such an assault on health infrastructure? We will explore these issues further in Chapter 7 and Chapter 10. The systems and structures required for everyday health responses form the cornerstone of our disaster response. What is required are scalable arrangements, beginning with the everyday response, then scaling-up to the level required for the challenge. Disaster health management is not intended to describe the management of everyday events, but rather to explore the issues that occur when these everyday events are exceeded. Disaster management often does not address the ‘silent and slow moving’ health disasters. Yet it is very important to be aware of these when considering disaster management arrangements. On a global scale, some of the silent disasters have a level of impact which far exceeds any of the most dramatic catastrophic events: •

•

•

WHO have reported that in 2013, 9 million people, including 550,000 children, fell ill with TB. Of these, 1.5 million people died and 80,000 deaths were children. Over 95% of all TB deaths occur in low- and middle-income countries. TB is amongst the top five causes of death for women aged 15 to 44 years. Globally, an estimated 48,000 people develop multidrug-resistant TB (WHO 2015a). In 2014, there were an estimated 1.2 million (range 1.0–1.5 million) deaths from AIDS (WHO 2015b). HIV and TB form a lethal combination and each speeds the progress of the other. In Africa, HIV is the most important contributor to the increase in TB in the last two decades. Obesity in the developed world may be considered a disaster in historical terms as it is proving a challenge to health and wellbeing, and requires special mobilisation and responses.

Categorising disasters There have been many attempts to categorise disasters by describing the nature and the extent of events. Disasters are often categorised according to the specific hazard that led to the event. CRED developed a classification standard for both natural and technological disasters. Natural disasters have been divided into six main disaster types, with each having a number of subtypes. The six main disaster types are: meteorological, hydrological, climatological, geophysical, biological and extraterrestrial. Tables 1.1–1.7 detail CRED’s approach to natural and technological disasters. CRED’s classification of technological disasters has been expanded to include complex humanitarian disasters. There is considerable debate about disaster categorisations because events are often highly complex and resist being simplified to a single hazard. For example, a cyclone (hurricane or typhoon) will produce wind damage, flooding, storm surge and, in some incidents, refugees. Complex humanitarian emergencies encompass unique interplays of multiple challenges. It must thus be recognised that disasters are social, economic and political phenomena; the hazard is only a trigger. While segmentation of disasters into groups or categories provides a starting point for disaster managers, it is important

Table 1.1 Geophysical disaster types (originating from solid earth). Main type

Earthquake

Mass movement (dry)

Volcano

Subtype

Ground shaking Tsunami

Rock fall Avalanche Landslide Subsidence Snow Mudslide Sudden Debris Lahar Long-lasting Debris flow

Volcanic activity

Sub-subtype

Ash fall Lahar Pyroclastic flow

Source: Adapted from Guha-Sapir et al. (2009); Below at al. (2009); IRDR (2014).

Table 1.2 Meteorological disaster types (caused by short-lived micro- to meso-scale extreme weather and atmospheric processes with a duration lasting from minutes to days). Main type

Storm

Subtype

Local/convective storm

Sub-subtype

Thunderstorm/lightning Snowstorm/blizzard Sand/dust storm Generic (severe) storm: derecho, hail, rain Tornado Orographic storm (strong winds) Storm surge

Fog Tropical storm Extra-tropical storm

Source: Adapted from Guha-Sapir et al. (2009); Below at al. (2009); IRDR (2014).

Table 1.3 Hydrological disaster types (caused by deviations in the normal water cycle, both fresh and saltwater, and/or overflow of bodies of water caused by wind set-up). Main type

Mass movement (wet)

Flood

Subtype

Rock fall Avalanche Landslide

Sub-subtype

Snow Debris flow Sudden Debris Long-lasting

Subsidence

Flash flood General (river) flood Storm surge/coastal flood

Source: Adapted from Guha-Sapir et al. (2009); Below at al. (2009); IRDR (2014).

Table 1.4 Climatological disaster types (caused by long-lived meso- and macro-scale processes, including intra-seasonal to multidecadal climate variability). Main type

Extreme temperature

Subtype

Heat wave Extreme winter conditions Snow pressure Icing Freezing rain Debris avalanche

Sub-subtype

Wild fire Cold wave Frost

Forest fire Land fire: grass, scrub, bush

Source: Adapted from Guha-Sapir et al. (2009); Below at al. (2009); IRDR (2014).

Drought

Table 1.5 Biological disaster types (caused by exposure of living organisms to germs, toxic substances or vector-borne diseases, e.g. venomous wildlife/insects, poisonous plants and disease-carrying mosquitoes). Main type

Epidemic

Insect infestation

Subtype

Infectious diseases: Viral Bacterial Parasitic Fungal Prion

Grasshopper Locust Worms

Animal stampede

Sub-subtype Source: Adapted from Guha-Sapir et al. (2009); Below at al. (2009); IRDR (2014).

Table 1.6 Extra-terrestrial disaster types (caused by asteroids, meteoroids and comets as they pass near-earth, enter earth’s atmosphere and/or strike earth, and by changing the interplanetary conditions that affect the earth’s magnetosphere, ionosphere and thermosphere). Main type

Space weather

Impact

Subtype

Energetic particles Geomagnetic storm Shockwave

Airburst

Sub-subtype Source: Adapted from Guha-Sapir et al. (2009); Below at al. (2009); IRDR (2014).

Table 1.7 Technological disaster types (caused by a manmade complex humanitarian crisis, e.g. a conflict, or the breakdown of structures, systems, procedures, infrastructure and/or equipment resulting in loss of life, injury, human suffering and/or environmental degradation. The disaster can evolve rapidly, e.g. a train crash, or over an extended period, e.g. a conflict or a groundwater contamination caused by pollution or industry. Technological disasters can last for minutes, to days, or even years.) Main type

Complex

Industrial

Transport

Misc.

Subtype

Terrorism Conflict (unarmed) Conflict (armed)

Chemical spill Explosion Gas leak Radiation Fire Poisoning Collapse Other

Air Road Rail Water

Collapse Explosion Fire Contamination Other

Sub-subtype

Famine (other than natural disaster) Displaced populations

Source: Adapted from Guha-Sapir et al. (2009); Below at al. (2009); IRDR (2014).

14  L. Mayner & E. Smith

to recognise that the interplay between hazard and communities is particularly relevant in understanding and managing the consequences of these disasters. The CRED disaster classifications provide a checklist of points to consider when identifying, evaluating and managing the risks to your community. Furthermore, they help to foster understanding of the complex interplay of causation. Consider, for example, global warming and its impact on a range of hazards and vulnerabilities. There have also been attempts to categorise disasters on the basis of their extent and impact. Scales have been developed on the basis of economic damage or human deaths, but there is little agreement as to the usefulness of such categorisations. Hazard-specific severity scales have proved slightly more useful. The Richter scale for earthquakes is almost universally recognised by the community, but has no direct correlation with the degree of damage. Rather the extent of damage is related to the interplay between the natural forces unleashed and the community’s vulnerability, and the Earthquake Impact Scale is an attempt to capture both these considerations (Wald et al. 2011). The International Atomic Energy Agency (IAEA) uses a scale of 0–7 to qualify a nuclear accident (see Figure 1.4). The classification depends on the consequences of the accident and not on its causes. This can be confusing because some accidents are due to internal error, such as Chernobyl, while some are due to natural disaster, as was the case with central Fukushima. In health terms, distinguishing an emergency from a disaster has often been based on the number of patients affected, and the Bradford Disaster Scale is an example (Horlick-Jones and Peters 1991). However, it is important to note that the extent of the disaster is not only dependent on the number of people affected but also on the severity and range of illnesses and injuries, and the resources available. It is now well recognised that as disasters are defined contextually, any absolute categorisation on the basis of people affected is meaningless.

7

Major accident Serious accident

6 Accident with wider consequences

5

Accident with local consequences

4 Serious incident

3

2 I

0

Figure 1.4 The IAEA scale used to qualify a nuclear accident.

Incident Anomaly

Deviation

Definitions & terminology  15

The Federal Emergency Management Agency (FEMA) seeks to categorise or describe events on the basis of the management implications (Kreps and Drabek 1996). The following are criteria used by FEMA: • • • • •

Length of forewarning. Magnitude of impact. Geographical scope of impact. Duration of impact. Speed of onset.

Such criterion-based approaches may help to convey something of the challenge without implying a hierarchy of disasters.

Applying disaster definitions Having explored the concept of disasters and the factors contributing to their definition, consider the following events and how they challenge your understanding of the definition of disasters. Japan earthquake and tsunami, 2011 These events and the resulting damage (see Figures 1.5–1.7) have had a lingering impact on the community; not only due to the widespread death and devastation, but also due to the damaged nuclear power station and the ongoing concern for longterm health consequences. People in the vicinity of the power station have been evacuated, land is unavailable for agriculture, children’s education has been disrupted, together with the long-term economic impacts and loss of confidence in Japan’s agricultural products. Polluted water supply: Sydney, 1998 In Sydney, Australia, a major city’s water supply was contaminated with Giardia and Cryptosporidium bacteria. From initial reports, it was difficult to determine if the disaster had occurred given there were no deaths associated with the crisis. However, when the previously discussed definitions are considered, this event caused a serious disruption to community life which threatened or caused death or injury. Controlling and dealing with the problem required an investigation and measures which were beyond the normal capacity of the government and water authorities. For more information on this disaster, read the final inquiry report at: www.dpc.nsw.gov.au/ search?q=sydney%20water%20crisis%20final%20report The global financial crisis, 2008 Although the global financial crisis of 2008 may not meet the immediate (media) definition of a disaster (such as a cyclone, tsunami or earthquake), when you consider the extensive impact on community infrastructure and on the health and wellbeing of people, it may well meet the disaster definition. What impact would it have had on the

Figures 1.5–1.7 Images of the 2011 Japan tsunami. Top: an enormous wave sweeps onshore (Photo by Ophelia Jane Julia). Middle: damage to the port (Photo by Chief Hira). Bottom: Shinchi train station lies in ruin (Photo by Kuha455405).

Definitions & terminology  17

Figure 1.8 Iron lung ward filled with polio patients, Rancho Los Amigos Hospital, California, 1953.

health and wellbeing of the poorest in society? The ongoing consequences for this vulnerable group may last a generation. Other disasters Consider the infrastructural, health and other consequences of each of the following disasters. The Foot and Mouth disease outbreaks not only impact on the economy but also on food supplies. Epidemics such as polio (1938 and 1953) (see Figure 1.8) and influenza (1844, 1919, 1957 and 1968) had a massive impact on the health and wellbeing of people and have required responses well beyond that traditionally associated with the provision of health services. Damage caused by earthquakes can be severe (see Figure 1.9), ruining critical infrastructure such as hospitals.

Community response to disasters Disasters typically impact all aspects of the community and require support from all response agencies. For government, it involves almost every aspect of activity way beyond the capacity of a single department or agency. Whilst planning and preparedness is the key to successful disaster management, anticipation can be limited because the waves of change triggered by a disaster can cascade through organisations and systems in very unpredictable ways. This uncertainty is a fundamental aspect of dealing with disasters. The very complexity that is integral to the systems that give us a remarkable standard of living also produces significant problems when a disaster strikes. Critical infrastructure such as electricity and transport networks are often damaged. This has a significant impact on a country’s economy, and the ability of response agencies to access the whole community. If these are the challenges that disasters create, what then can be done about reducing the effects and increasing the adaptation across society and the economy? This all

18  L. Mayner & E. Smith

Figure 1.9 Pyne Gould building destroyed by earthquake, Christchurch, New Zealand, 2011. (Photo by Gabriel Goh.)

takes place within the context of ever increasing complexity and interdependency in our society and economy. At an individual level and, to an extent, organisational level, the safety paradox is relevant. The safer and more stable the environment, the greater the surprise when there is a major failure. There are also differences in the community reaction according to the type of event. There is often outrage over non-natural events with extensive media coverage and government intervention. These are the events where responsibility, whether real or implied, can easily be apportioned. People also have a strong reaction to events that suggest a horrific experience for those involved. For example, a large number of deaths from one plane crash will be given more attention than one death from a road traffic crash. Yet the reality is that more people die in car accidents than plane crashes. As Boin et al. (2006) asserted: The democratic context has changed over the past decades. Analysts agree, for instance, that citizens and politicians alike have become at once more fearful and less tolerant of major hazards to public health, safety and prosperity. The modern Western citizen has little patience for imperfections; he has come to fear glitches and has learned to see more of what he fears. In this culture of fear – sometimes referred to as the ‘risk society’ – the role of the modern mass media is crucial.

Definitions & terminology  19

Key readings Laakso K, Palomäki J. ‘The importance of a common understanding in emergency management’ Technological Forecasting & Social Change. 2013: 80(9): 1703–1713. Mayner L, Arbon P. ‘Defining disaster: The need for harmonisation of terminology’ Australiasian Journal of Disaster and Trauma Studies. 2015: 19(special issue): 21–25. TFQCDM/WADEM. ‘Health disaster management: Guidelines for evaluation and research in the “Utstein Style”’ Prehospital Disaster Medicine. 2002: 17(3): 31–55.

Activities • •

With the information outlined above, develop a working definition of a disaster. Once done, consider all of the above examples and identify how they meet that definition. Briefly explain the rationale behind your definition. Identify two different disasters and explain how they meet your definition.

References AIHW (Australian Institute of Health and Welfare). Australian Hospital Statistics 2013–14: Emergency department care. Canberra: AIHW: 2014. Al-Madhari AF, Keller AZ. ‘Review of disaster definitions’ Prehospital and Disaster Medicine. 1997: 12(1): 17–21. Barker G, Chapman D. Man and Society in Disaster. New York: Basic Books: 1962. Barton A. Communities in Disaster: A sociological analysis of collective stress situations. New York: Doubleday: 1969. Below R, Wirtz A, Guha-Sapir D. Disaster Category Classification and Peril Terminology for Operational Purposes [Working Paper]. Brussels: CRED: 2009. Boin A, ’t Hart P, Stern E et al. The Politics of Crisis Management: Public leadership under pressure. Cambridge: Cambridge University Press: 2006. Bradt DA, Abraham K, Franks R. ‘A strategic plan for disaster medicine in Australasia’ Emergency Medicine. 2003: 15: 271–282. Dynes RR. Organized Behavior in Disaster. Lexington: Heath Lexington Books: 1970. Fritz C. ‘Disasters’. In: Merton R, Nisbet R, editors. Social Problems. New York: Harcourt Brace: 1961. Fritz C, Mathewson JH. Convergence Behaviour in Disaster: Disaster study no. 9. Washington DC: National Academy Sciences: 1957. Gilbert C. ‘Studying disaster: Changes in the main conceptual tools’. In: Quarantelli EL, editor. What is a Disaster? Perspectives on the question. New York: Routledge: 1998. Guha-Sapir D, Below R, Hoyois PH. EM-DAT: The CRED/OFDA International Disaster Database – www.emdat.be. Brussels, Belgium: Université Catholique de Louvain: 2009. Horlick-Jones T, Peters G. ‘Measuring disaster trends, Part 1. Some observations on the Bradford Fatality Scale’ Disaster Management. 1991: 3(3): 144–148. IRDR (Integrated Research on Disaster Risk). Peril Classification and Hazard Glossary. Data project report no. 1. Beijing: IRDR: 2014. Kreps G, Drabek T. ‘Disasters are non-routine social problems’ International Journal of Mass Emergencies and Disasters. 1996: 4(2): 129–153. Prince S. Catastrophe and Social Change. New York: Columbia University Press: 1920. Scanlon TJ. ‘Forward’. In: Perry RW, Qurantelli EL, editors. What is a Disaster? New answers to old questions. Philadelphia: Xlibris: 2005.

20  L. Mayner & E. Smith Sundnes KO, Birnbaum ML. ‘Health disaster management: Guidelines for evaluation and research in the Utstein Style’ Prehospital and Disaster Medicine. 2003: 7(3): s1–s14. Wald DJ, Jaiswal KS, Marano KD et al. ‘Earthquake impact scale’ Natural Hazards Review. 2011: 2(3): 125–139. World Health Organization. WHO Definition of Health [Internet]. 2003. www.who.int/about/ definition/en/print.html (accessed 16 April 2016). World Health Organization. Fact Sheet No 104: Tuberculosis [Internet]. 2015a. www.who.int/ mediacentre/factsheets/fs104/en/ (accessed 16 April 2016). World Health Organization. Fact Sheet No 360: HIV/AIDS [Internet]. 2015b. www.who.int/ mediacentre/factsheets/fs360/en/ (accessed 16 April 2016).

Chapter 2

Disaster trends and impact Benjamin Ryan and Richard Franklin

Introduction and objectives Chapter 1 discussed the definition of disasters and, in particular, explored how disasters may be considered in a social construct. In other words, is it a disaster if it does not affect people? Therefore, our understanding of the history of disasters is largely constrained to the period of recorded human habitation. Was the event that eliminated the dinosaurs a disaster in that context? Our discussion is necessarily limited to what is known and recorded in detail; not to be disrespectful towards people’s beliefs, but rather simply to say that there is sufficient evidence within recorded history to enable us to understand the nature and trends of disasters and their impacts on humans. There is a broad belief that disasters are increasing, but is this perception real or is it a product of increased awareness and reporting? Are disasters increasing in frequency or severity, or are they having more impact? What does the future hold in terms of disaster trends? The aim of this chapter is to examine the trends in disasters in an historical context, and to identify the factors that influence their occurrence and impact. By understanding the causation and impacts of disasters we may be better placed to identify ways in which disasters may be averted or moderated and their impacts reduced. On completion of this chapter you should be able to: • • •

Demonstrate an understanding of the factors influencing the trends in disasters and their severity. Identify and evaluate future risks. Explain the impacts disasters have on human health and wellbeing, the community, the economy and the environment in the short, mid- and long term.

Historical perspectives Globally, the frequency of natural disasters has been reported as increasing since the 1980s, with the majority resulting from weather, climate extremes and water-related hazards (Hogan and Burstein 2007). Between 1994 and 2013, CRED’s database EM-DAT recorded 6,873 natural disasters worldwide, which claimed 1.35 million lives; or almost 68,000 lives on average each year (CRED 2015c). This affected 4.36 billion people and involved a direct cost of US$2,660 billion (CRED 2015c).

22  B. Ryan & R. Franklin

Floods accounted for 43% of all natural disasters during this 20-year period (1994–2013). Overall, high-income nations experienced 56% of all natural disasters and suffered 32% of lives lost. In contrast, low-income nations experienced 44% of all natural disasters, but the death toll in these countries was 68% (CRED 2015c). No continent in the world was spared; however, Asia suffered the greatest loss in terms of people affected, loss of life, and frequency of disaster events (CRED 2015c). Since 2000, EM-DAT recorded an average of 341 climate-related disasters per annum, up 44% from the 1994–2000 average and well over twice the level in 1980– 1989 (CRED 2015c). The frequency of geophysical disasters (earthquakes, tsunamis, volcanic eruptions and mass movements) remained broadly constant throughout this period, but a sustained rise in climate-related events (mainly floods and storms) pushed total occurrences significantly higher (Hogan and Burstein 2007; CRED 2015c). Disasters have become the focus of considerable public discussion and debate and there is a strong public perception that disasters are becoming more frequent and more severe. However, despite the increase in the number of people affected, death rates are decreasing (Burkle 2010). For example, the death rate per one million people between 1900 and 1989 was 94 per annum compared to five per annum between 1990 and 2006, which is a decrease of 95% (Goklany 2007). Between 2002 and 2011 the annual average number of deaths from disasters was 107,000, while the number affected was 68 million, which is one death per 635 people affected (Guha-Sapir et al. 2012). This ratio highlights the need for disaster management systems to focus resources on assisting those affected, both directly and indirectly, by a disaster (Ryan et al. 2015a). Naming the ten worst disasters of all time depends on the criteria used, meaning that the results are subjective and open to debate. What defines the worst disaster? Is it death toll, extent of damage, economic cost both direct and indirect, and what time frame is used? Table 2.1 lists the ten worst natural disasters in history, according to The Disasterium website (2015). In total, these disasters have resulted in more than 100 million deaths. It can be noted that China figures prominently because of the exposure of large human populations to a range of natural hazards and the relative lack of protective infrastructure. Table 2.1 The ten worst disasters (including disease outbreaks) in history. Rank

Year

Disaster

Death toll

 1  2  3  4  5  6  7

1201 1347–1350 1769–1773 1845–1848 1876–1879 1918–1919 1928–1931 1931

 8  9 10

1959–1961 1981–1984 1995–1998

Earthquake: Egypt and Syria Bubonic Plague (Black Death) Indian Famine Irish Potato Famine Drought: China Spanish Flu Severe Drought: China Yangtze, Yellow and Huai River floods: China Secondary disaster – famine and disease Famine: China Drought: Africa Famine and floods: North Korea

1.1 million 75–200 million > 10 million > 1 million > 9 million 35–75 million Unknown 4 million Unknown 20 million > 1 million > 3 million

Source: From www.disasterium.com/10-worst-natural-disasters-of-all-time/ (2015).

Disaster trends & impact  23

Compared to the number of people dying every year from TB, malaria, HIV/AIDS or injury worldwide, what makes the events in Table 2.1 significant is not just the total body count, but also the localised nature of their impact and the death rates considering the size of the population affected.

Disaster trends and factors influencing those trends CRED was established in 1973 to monitor worldwide trends in disasters and their impact (CRED 2015b). Becoming a World Health Organization (WHO) collaborating centre in 1980, CRED promotes evidence-based research, training and technical expertise on humanitarian emergencies, with a focus on public health aspects and epidemiology (CRED 2015a). CRED maintains EM-DAT, which provides an objective base for vulnerability assessment and priority setting. EM-DAT contains essential consistent core data on the occurrence and effects of disasters since 1900. Examine the CRED website (www. cred.be/). The data indicates that the recorded frequency of all natural disasters has increased dramatically since the 1950s, peaking in 2000, followed by a small decline. CRED was recording over 100 times as many natural and man-made disasters in the 1990s compared to the 1950s. However, it must be noted that there was no standardisation of inclusion criteria until 1990, and thus there was no consistency in data collection prior to that time. The measured data changes how the impact of a disaster is considered. For example the number of deaths due to disasters has decreased; however, the number of people impacted has increased from the 1960s onwards (CRED 2015b). It would appear disasters are being managed better, and so the death toll is reducing due to improved awareness and preparation, including risk reduction strategies and response management. Table 2.2 shows CRED data for natural disasters between 1990 and 2015. The most frequent events are climatic; storms, droughts, temperature extremes and floods, which account for more than two thirds of all disasters (Guha-Sapir et al. 2012). Table 2.2 Natural disasters 1990–2015. Type of disaster (% of all disasters)

Occurrence

Deaths

Injured

Total affected

Flood (36.03) Storm (26.14) Epidemic (11.89) Earthquake/tsunami (7.43) Extreme temperature (4.67) Landslide (4.62) Drought (4.15) Wildfire (2.99) Volcanic activity (1.48) Insect infestation (0.32) Mass movement: dry (0.27) Impact (0.01)

3415 2477 1127 704 443 438 393 283 140 30 26 1

182,702 401,701 180,452 816,294 166,415 22,009 24,272 1,770 1,639 – 1,210 –

1,086,122 607,843 499,176 1,720,306 1,964,945 4,424 – 5,928 1,517 – 312 1,491

2,855,214,859 766,030,113 21,194,391 134,884,514 99,098,929 6,103,932 1,245,945,379 5,598,133 4,034,275 2,802,200 15,130 301,491

Source: EM-DAT, www.emdat.be/ (2015).

24  B. Ryan & R. Franklin

Returning to the fundamental question: are disasters increasing; and if so, why? Chapter 1 provided a range of perspectives on the definition of a disaster. There are a number of factors that may impact on the rate of reported disasters, or the perception that disasters are having an increased impact: •

•

•

•

•

Improved reporting (United Nations 2011) and active identification and recording of disasters may reflect perceived increases. The information age ensures instant and extensive reporting on a global scale through formal and informal news mediums, e.g. social media. This type of reporting was not possible 50 years ago. Many of the events captured by CRED would have gone unreported outside the affected community. Monitoring systems have also improved. Tsunami detection buoys, weather satellites, river flow indicators, and sophisticated computer software to predict earthquakes, cyclones, extreme fire danger days, floods and disease outbreaks are now widely used. Adopting a uniform approach to defining disasters has undoubtedly led to improved identification and recording of events. Increased population and density has resulted in large populations being exposed to the impact of natural hazards. For example, an estimated three million people now live in the vicinity of Mt Vesuvius. When Mt Vesuvius last erupted 2,000 years ago burying the towns of Pompeii and Herculaneum, around 20,000 people were killed. Many of the largest cities in the world are in seismic areas or on flood plains. Additionally, population growth increases the possible impact of disasters due to increased strain on natural and man-made infrastructure. Poorly designed infrastructure may enhance risk of collapse, reduce natural drainage, and remove natural protections increasing the risk of floods and landslides. Water and air pollution impact on population health with man-made disasters from industry adding to the risk. Finally, high-density living and urban congestion increases the risk of transportation incidents and the threat of public disorder. Some examples of natural disasters that became man-made events are described in Table 2.3. The speed and widespread nature of mass transportation increases the risk of catastrophic system failure. In developed countries, technology, enhancements to community infrastructure, improved standards, road safety programs, and occupational and environmental health and safety measures ensure all forms of transportation are relatively safer than in the past. However, this is not the case in many developing countries where large populations live with fewer safety standards, and infrastructure and transport systems struggle to cope with the vast numbers of people. Risk of transportation incidents in these nations is increasing. While dependence on technologies and interdependencies between technologies improve the timeliness and effectiveness of overall communication and societal functioning, they also create a dependency on common power sources, and on each other. Thus a distant minor event causing disruption to power supplies may have a disproportionate impact on societal functioning and health. The greatest challenge to a teenager’s comfort may well be the loss of their smart phone (Ryan et al. 2015b). There may be no evidence for increases in seismic activities, nor any logical reason for any perceived increases. However, improvement in overall economic status translates into improved building standards. This can reduce the impact of earthquakes, and the potential failure of community infrastructure.

Disaster trends & impact  25 Table 2.3  Examples of natural disasters that became man-made catastrophes. Natural disaster

Built infrastructure

Consequence

2013 Floods Uttarakhand, north India 2011 Earthquake/tsunami Japan 2005 Hurricane Katrina New Orleans, USA 2001 Typhoon Usagi Thailand

Hydroelectricity dams

Change to natural watercourse leading to tens of thousands of tons of silt, boulders and debris from the dam construction washed onto the villages below. 70,000 people homeless, death toll > 1,000. Level 7 nuclear meltdown, 100,000 people displaced, 600 die during evacuation.

Fukushima Daiichi nuclear power plant Levee walls

Breach of levee walls, 80% of New Orleans flooded, death toll 1,836.

Deforestation, Phetchabun mountain range

Torrential rain in the mountain range caused loose soil to give way. Villages not directly impacted by the destruction from the typhoon were inundated by mudslides. Death toll 176, thousands of homes damaged or destroyed. 116,720 buildings collapse, sewerage pipes and systems destroyed, chemical spills from industry contaminate waterways causing environmental damage. Death toll 32,968. Failure of a dam intensifies flooding, death toll > 2,200.

1939 Earthquake Erzincan, Turkey

Buildings, industry, critical infrastructure

1889 Flood Johnstown, Pennsylvania, USA

Dam

Sources: Based on http://reliefweb.int/report/india/uttarakhand-flash-floods-%E2%80%93-report (2013); Salerno and Gaudioso (2015); www.emdat.be/ (2015); Divjak and Conachy (2001); www.jaha.org/FloodMuseum/history. html (2016).

•

•

•

It is now widely accepted that global warming is having a significant impact on the frequency and severity of climatic events, particularly storms, floods, droughts and heatwaves. As these are the most common events, there is considerable concern that global warming will cause more significant challenges in the future. Military (or terrorist) conflict remains a significant risk. However, without seeking to engage in any political debate, it is worth noting that in comparison with the global conflicts of the 20th century, we are probably living in one of the safest times in history. It is also worth noting that military conflicts are not considered disasters for the purposes of disaster management. The global financial crisis of 2008 demonstrated the vulnerability of the world’s economic systems. Additionally, growing division between rich and poor creates vulnerabilities and the potential to create economic stress at the individual and community levels. This has flow-on effects and may reduce access to essential infrastructure such as health services.

Public expectations It is difficult to predict the impact of the various factors listed above on future trends in disasters. What is clear is that many societies are less tolerant of the impact that

26  B. Ryan & R. Franklin

Case study 2.1: Union Carbide chemical plant disaster, December 1984 A poisonous methylisocyanate (MCI) gas leak from the Union Carbide chemical plant in Bhopal, India, remains the worst industrial disaster in history. Figure 2.1 shows the timeline during the five hours before workers were evacuated from the plant. This man-made tragedy killed an estimated 20,000 people and exposed a further 200,000 to the toxic MCI gas (Varma and Varma 2005). There were reports of cutting costs and supervision, as well as work and maintenance practices that were, at best, unethical, and at worst, unlawful (Chouhan 2005; Ipe 2005; Peterson 2009). Tens of thousands of people still suffer serious health conditions (Cullinan et al. 1997; Dhara and Dhara 2002). Further information can be found at www.bhopal.com/.

2 D ecem b er 1984 9.30pm routine maintenance: pipes flushed, overflow device downstream was blocked

water accumulates in the pipes, then enters relief valve pipe 20 feet above ground

10.30pm water enters an open blow-down valve, part of the nitrogen pressurisation system then flows into tank E610 via an open isolation valve

10.45pm shift change

11 pm pressure in tank E6I0 rising, no reliable way to monitor tank temperature

11.30pm workers report MIC smell & observe dirty water coming from relief valve pipe

3 D ecem ber 1984 12.30am pressure indicator for tank E610 at max 55 psi

gas vent scrubber fails & gas cloud escapes from scrubber stack

12.40am operations suspended, alarm raised, firewater sprays cannot reach the gas cloud

cooling efforts fail due to lack of Freon, gas escapes for approximately 2 hours

la m gas smell outside plant obvious

2.30am workers evacuated

Figure 2.1 Timeline for the Union Carbide chemical plant disaster (adapted from Peterson 2009).

Disaster trends & impact  27

disasters may have on their wellbeing and lifestyle (Dodds 2015). In Australia, for example, many die from floodwaters because they underestimate the risks and enter the watercourse (Franklin et al. 2014). The general consensus of opinion is that societies do not believe disasters are an ‘act of God’ to be withstood and tolerated (Dodds 2015). Communities have a role in preventing and mitigating disasters and to ensure systems and structures are in place to respond and to adapt to their consequences. At its extreme, communities may seek to blame someone, and issues of compensation and formal enquiries and investigations reinforce this attitude. Disaster influences are beyond any individual’s control and speak to greater societal changes. It is easy to retrospectively find fault with the conduct of individuals without first understanding the myriad of factors that influence those actions. This is discussed in detail in Chapter 5. People who love natural forest settings often choose to live there because of its pleasing aspects, but they remain vulnerable to bushfires. People in cyclone-prone areas must pay for the increased cost of building in these zones, and no one wants a new dam built in their backyard. In terms of disaster management, some of those demanding retribution after the event would be the same people who fought any mitigation strategies. This dynamic makes it increasingly difficult for governments and other authoritative individuals and bodies to implement mitigation strategies. There is a need for a more balanced public perspective and discourse, and one that understands the restraints that people place on authorities, particularly in a democracy. There is a need for the community to take greater responsibility for their own actions, and for the risks they take. Rivers that have flooded previously are likely to flood again and due diligence would ensure that purchasers familiarise themselves with those risks. It is also necessary for people to accept responsibilities for the risks they choose to take. People who enjoy the aspect of a water frontage must accept that it will occasionally flood and build that fact into the cost–benefit analysis. Finally it is ignorance at best, and racism at worst, to apply developed world standards to poor nations. While it would be better for people whose mud houses are regularly washed away to build concrete structures, the fact remains that they can barely afford to eat and house themselves, so it becomes an irrelevant observation unless the wealthier pay the cost. Yet even in developed countries the economic cost of mitigation is a factor that must be taken into consideration. Bushfires would be reduced if power lines were all moved underground, but the cost of doing so would be immense. Additional costs from increased power bills or taxes remain unpopular. Many factors come into play when mitigating disaster: politics, society and economics. For further study, read the Annual Disaster Statistical Review 2014: The numbers and trends (Guha-Sapir et al. 2012) and consider the array of incidents that occurred in one single year, as well as how each community may have prevented or mitigated the effects.

The impacts of disasters The impact of disasters is dependent on the type, size and scale of the incident, as well as the size, composition and economic standing of the population affected. There is no scientific and predictable relationship between the hazard and its impact. Often the impact is highly variable. Inexplicably, a bushfire will engulf well-protected

28  B. Ryan & R. Franklin

houses while sparing others. The impact of any particular building collapse (or the collective impact of many occurring in an earthquake) will often depend on the particular use of the building at the particular time. For example, a collapsing school building may cause massive loss of life during school hours but have little effect outside of those hours. The impact of disasters can be considered in terms of their effects on health, the community, the economy and the environment. The health impacts of disasters Health impacts and consequences may be overt or covert, direct or indirect, and immediate, mid-term or long term. Deaths resulting from a building collapse in an earthquake are clear. Less clear are the impacts resulting from the economic consequences of a disaster and its impact on life-sustaining public health measures. This limits clarity of understanding of the disaster’s affects. While the number of people drowning in floodwaters can be counted, will we ever know the number of people who die of chronic diseases because they cannot afford life-sustaining medications after losing their employment as a result of a flood? The health consequences of disasters are not necessarily direct or predictable. Health consequences can span from minor distress to death. Often the focus Before the 2010 earthquake, Haiti is on those killed without understanding had not had a cholera epidemic for the range of injuries survivors can suffer. more than 100 years. From October On average, for every death there will 2010 up until August 2015, Haiti be a similar number who are critically reported 744,698 cases of cholera, injured. Many times that number will with 426,884 hospitalisations & 8,826 suffer sufficient injuries that warrant deaths. hospitalisation. Many more will be injured to some extent but not warrant Source: PAHO/WHO, 2015 hospitalisation. The ratio between these is dependent on the nature of the event. For example, an aircraft crash may have many deaths and few injured, while a pandemic may have few deaths and many ill. The public focus is often on the deaths, whilst the focus of health systems will be on those requiring treatment. Permanent injuries arising from disasters can leave a lifelong legacy. Table 2.4 shows mortality and morbidity rates in the months and years following disasters, and understanding the complexity of these relationships is necessary to ensure strategies are tailored to the consequence. This issue has been recognised globally by the UN in the Sendai Framework for Disaster Risk Reduction 2015–2030 (2015). For example item 30(k) relates to chronic diseases that, due to their particular needs, should be included in the design of policies and plans to manage risks before, during and after disasters. The relationship between the health consequences of disasters and the disaster itself is demonstrated in Table 2.4. Consider the relationships that exist between the event and the consequence and the strategies that are necessary to break the connection between cause and effect. An understanding of the interplay between these relationships is critical to the development of effective and resilient disaster management processes.

Disaster trends & impact  29 Table 2.4 Mortality and morbidity in the months and years following disasters. Disaster

Mortality and morbidity

Hurricane Sandy, Caribbean and east coast USA, 2012 Earthquake and tsunami, Japan, 2011 Hurricane Katrina, east coast USA, 2005

•  Cardiac incidents increased by 22%, mortality by 31% (Swerdel et al. 2014). •  Rate of cerebral infarction more than doubled in men over the age of 75 years (Omama et al. 2013). •  One year post hurricane: 47% increase in mortality and morbidity from cardiovascular disease (heart attacks and stroke), cancers, respiratory diseases and diabetes (Ryan et al. 2015b) and a 33% reduction in cancer treatment services (Brown et al. 2008). •  Five years post hurricane: Moscona et al. (2012) observed a notable increase in coronary artery disease, hyperlipidemia, psychiatric disorders, smoking and substance abuse, non-compliance with medication and increased unemployment. •  Six years post hurricane: cardiac-related incidents in New Orleans had increased threefold (Gautam et al. 2009). •  19% increase in cancer-related deaths (McKinney et al. 2011). •  Diabetes-related deaths accounted for 5% of excess deaths while cardiac-related deaths accounted for 34% of excess deaths (Brown et al. 2008). •  Three years post earthquake: 14% increase in heart attacks (Nakagawa et al. 2009). •  One year post hurricane: 19% increase in cancer-related deaths (Hendrickson and Vogt 1996).

Following hurricane season with four major hurricanes, Florida, USA, 2004 Niigata-Chuetsu earthquake, Japan, 2004 Hurricane Iniki, Hawaii, 1992

For example, the strategies to manage drowning (search and rescue) are completely different to those required to manage the long-term consequences of malnutrition resulting from economic deprivation and destruction of livelihoods following a disaster. Disasters can be detrimental to both physical and mental health. The physical impacts are generally obvious and directly related to the nature of the event (e.g. trauma, burns or respiratory problems). However, the mental health impacts are often subtler, and range from understandable and normal reactions to horrendous events or loss, through to severe post-traumatic stress disorder (PTSD). These mental health consequences can be exacerbated by poor management of the event and aftermath, or by subsequent enquiries that defer resolution for the victims or cause ongoing distress for those who rendered assistance. The nature of the emotional response of individuals and the community involved in a disaster is likely to be similar, regardless of the scale and number of others affected. The psychosocial impact of disasters is discussed in detail in Chapter 19. There is also a relationship between the physical injuries and the mental health consequences. Consider the position of someone who has lost their livelihood due to a long-term injury. They are likely to suffer depression and anxiety, which can in turn have physical health consequences. In addition to the effects on the health of individuals and the community, there may be significant damage to the infrastructure required for health service provision, or to

30  B. Ryan & R. Franklin

the infrastructure that supports the health system (for example gas, electricity, and communication and transport networks). Ryan et al. (2015b) found that any disruption to public health infrastructure such as treatment, care, water and food can result in an exacerbation of chronic disease or even death. This may include the people who work within the system as well as the system itself. Probably the most common health impacts of disasters are the impact they have on people with chronic health conditions. Those at greatest risk are patients suffering with cancer, cardiovascular diseases, diabetes, respiratory conditions and renal diseases (Ryan et al. 2015b). Consequences of disasters for patients with chronic illnesses may be grouped into the following: • • •

Exacerbation of chronic health condition due to stress caused by a disaster. Consider the person with heart disease who must rapidly evacuate from a flash flood. Loss of life-sustaining medications or infrastructure, e.g. a loss of power which deprives people with sleep apnoea of access to breathing support. Loss of access to health systems for patients with chronic and acute health needs, such as those undergoing chemotherapy or dialysis.

The economic costs of disasters The economic costs of disasters include both actual costs (with a value) and intangible costs. An event does not constitute a disaster unless it impacts upon a community, causing either disruption or physical damage to buildings and infrastructure. All natural and some technological disasters can cause physical damage with short- or long-term effects (AEMI 2011). The extent of damage may not be immediately apparent: for example, damage to building foundations through subsidence may be discovered months after a flood. A number of the major physical effects include: • • • • • • •

Loss of essential services including gas, electricity, water, hospitals, and communication, transport and sanitation systems. Damage to residential areas, possibly requiring evacuation or long-term relocation. Loss of or reduced services from commercial facilities including banks, service stations, supermarkets, etc. Loss of food security through damage to crops and disruption of primary production, which will have impact in the short and mid-term. Loss of educational and training facilities. Loss of entertainment and recreation facilities: sporting clubs, cultural and entertainment venues, restaurants and hotels may be damaged. Environmental detriments will include pollution, loss of flora and fauna and the degradation of national parks.

The Scandinavian Journal of Public Health (Sundnes 2014) identifies 13 basic societal functions which form the cornerstone of social functioning: Public Health, Medical Care, Water and Sanitation, Shelter and Clothing, Food and Nutrition, Energy Supplies, Public Works and Engineering, Social Structure, Logistics and Transportation, Security, Communications, Economy, and Education. Figure 2.2 illustrates the economic impact of a disaster.

Disaster trends & impact  31

D ire ctly Im pacts

D IS A S T E R

C o m m e rcia l buildings

Agriculture Business disruption

Structure

Clean-up

Contents including equipment & stock Intangible Im pacts Residential housing Structure

Environment

Contents

Death & injury

A griculture

Indirectly Im pacts

Health impacts

Alternative accommodation Emergency & relief agencies Disruption to public services

Dislocation

Fences

Memorabilia

Equipment

Cultural & heritage

Crops & pastures Livestock W ater storage systems

Figure 2.2 The economic impact of a disaster (adapted from Bureau of Transport Economics 2001).

The economic cost of disasters is extremely complex. Every dollar invested in disaster preparedness has been estimated to prevent seven dollars’ worth of disasterrelated economic losses (World Meteorological Organization 2014). For example, Hurricane Katrina caused the largest damages in real dollar terms of any hurricane in America’s history, with estimates of property losses ranging from US$70 to $125 billion (Baade et al. 2007; Tarrant 2008). Subsequent to Katrina, proposals at estimated costs of US$3.5 to $9.5 billion have been made for enhanced flood control infrastructure, presumably sufficient to limit similar future losses (Naghavi et al. 2015). Table 2.5 provides an example of indirect/direct costs in a major chemical accident at a factory. Indirect and direct costs are measured and allocated through routine Table 2.5 Direct and indirect costs in a major chemical accident at a factory. Direct costs

Indirect costs

•  Medical costs •  Private insurance and transfer programs (medical) •  Overhead costs for workers’ compensation, private insurance and transfer programs •  Infrastructure and property damage •  Fatigue and potential chemical exposure to police and fire services •  Direct costs to innocent third parties

•  Lost earnings (including fringe benefits) •  Reduced growth in new home construction •  Workplace training, restaffing and disruption •  Time delays •  Health problems may present many years after the event •  Indirect costs to innocent third parties •  Resources to manage and clean up the incident

32  B. Ryan & R. Franklin Table 2.6 Direct/indirect and tangible/intangible losses in the event of a flood. Can item be bought/ sold for $?

Direct loss (from contact with floodwater)

Indirect loss (no contact: loss is a consequence of flood)

Yes (tangible)

•  Buildings and contents •  Cars •  Livestock •  Crops •  Infrastructure •  Lives and injuries •  Loss of memorabilia •  Damage to cultural or heritage sites •  Ecological damage

•  Disruption to transport, etc. •  Loss of value from commerce and business interruption •  Legal costs associated with lawsuits

No (intangible)

•  Stress and anxiety •  Disruption to living •  Loss of sense of community •  Loss of image/reputation

Source: Adapted from Tarrant (2008).

accounting methods, but note that intangible costs are also an issue. Table 2.6 demonstrates the division of direct and indirect losses into tangible and intangible costs in the case of a flood. There is a direct association between economic standing of a community and the impact and consequences of disasters. Disasters tend to impact disproportionately on the poorest countries with the frequency of disasters potentially reducing economic growth of the community. The impact of disasters on community The different impacts of disaster can be quite disruptive to society and its functioning. ‘Survivor guilt’ may be reinforced by the sometimes subtle, and sometimes overt, resentment of those most impacted and this can disrupt communities and their cohesion (North and Pfefferbaum 2013). Chapter 19 details many of the psychosocial impacts of disasters. Disasters can result in severe civil disruption and conflict. Mostly people do not panic: they generally respond in rational ways. People will act rapidly to protect their own life and safety, and at times this survival instinct is misinterpreted as panic. When lives are placed at risk either through ongoing exposure to a threat, or through the loss of life-sustaining essential items, then people will do everything in their power to secure their own safety and that of their family. When this is complicated by perceptions of injustice, conflict can ensue (Nardulli et al. 2015). Disasters may disrupt the normal social support arrangements (Lawlor et al. 2014). Families may become stressed as competing demands of work and family are further complicated by the need to respond and recover. Children may not be able to access their friends and education, or they may be required to help with the recovery. This loss of childhood can have lifelong consequences for children. Access to the workplace may be disrupted due to loss of the business or inability to reach the workplace due to disruptions in the transport network (Ryan et al. 2016). Disasters can be the final straw for marginal businesses, particularly if business

Disaster trends & impact  33

decisions have left them vulnerable. Loss of work and income adds to the stresses that result from disasters, and this can have life-altering consequences. The impact of disasters is determined by the nature and extent of the hazard and the vulnerability of those affected. The concept of resilience may be considered to be the obverse of vulnerability. Vulnerability is a broad spectrum but encompasses the elderly, children, women, people suffering from a disability or chronic disease, the poor, the homeless and those incarcerated and unable to escape. The social dimensions of disasters are discussed in detail in Chapter 18. The environmental impacts of disasters Disasters can have significant and adverse impacts on the environment, resulting in land degradation and contamination of water supplies – for example, storm surges or tsunamis (Ryan et al. 2015a). Disasters can lead to the loss of valuable artefacts, including historical buildings. Floods can result in fresh water contamination of reefs, damaging fragile ecosystems and the coral reef. Destruction of habitat or specific diseases can result in the extinction of animal species. The environmental consequences of disaster can be extensive and the link between causation and consequence is sometimes ill defined. For example, climate change is a consequence of deforestation but a cause of climate-related hazards.

Case study 2.2: Severe Tropical Cyclone Yasi, February 2011 Tidal surge from Severe Tropical Cyclone Yasi inundated the communities of Tully Heads and Hull Heads in Queensland, Australia. Due to the age of some buildings (pre-1990s), the tidal inundation resulted in asbestos-containing material (ACM) and other debris saturating the soil, sand and vegetation. Given that ACM is not biodegradable, this had the potential to become a major immediate and future public health risk if not managed properly. An expansion of ‘declared disaster officers’ under Queensland’s Disaster Management Act 2003 was required to allow licensed asbestos contractors to enter and clean up public and private land contaminated by the ACM. This declaration was the first time a group of people other than enforcement officers had been given such powers in Queensland. The response included the establishment of the Asbestos Working Group who set about developing and implementing a strategy for remediating these communities. An agreed framework for handling ACM between response organisations opened communication lines, enhanced preparedness and, more broadly, improved responses to public health risks associated with future disasters. Source: Ryan et al. (2014).

34  B. Ryan & R. Franklin

Key readings (All sites accessed on 15 April 2016.) Guha-Sapir D, Hoyois P, Below R. Annual Disaster Statistical Review 2014: The numbers and trends. 2015. http://cred.be/sites/default/files/ADSR_2014.pdf The Sphere Project. The Sphere Handbook: Humanitarian charter and minimum standards in humanitarian response. 2011. www.sphereproject.org/ UNISDR. Sendai Framework For Disaster Risk Reduction 2015–2030. 2015. www.unisdr.org/ WHO. Emergency Risk Management for Health: Overview. 2013. www.who.int/hac/ techguidance/preparedness/risk_management_overview_17may2013.pdf?ua=1 WHO. Humanitarian Health Action: Emergency disaster and risk management for health. 2015. www.who.int/hac/techguidance/preparedness/en/

Activities • • • •

Make a list of the factors that you consider may influence the frequency of disasters. Write a brief paragraph on whether (and why) you consider disasters are becoming more common. Consider a small rural town. What are the factors that influence the impact a disaster (e.g. a flood) would have on the town and its people? Write notes on how poverty contributes to the vulnerability of people in disasters.

References AEMI (Australian Emergency Management Institute). Community Recovery: Handbook 2. Canberra: Commonwealth of Australia; 2011. Baade R, Baumann R, Matheson V. ‘Estimating the economic impact of natural and social disasters, with an application to Hurricane Katrina’. Urban Studies, 2007; 44(11): 2061–2076. Brown D, Young S, Engelgau M et al. ‘Evidence-based approach for disaster preparedness authorities to inform the contents of repositories for prescription medications for chronic disease management and control’. Prehospital and Disaster Medicine, 2008; 23(5): 447–457. Bureau of Transport Economics. Economic Costs of Natural Disasters in Australia: Report 103. Canberra: Commonwealth of Australia; 2001. Burkle F. ‘Complex public health emergencies’. In: Koenig KL, Schultz CH, editors. Disaster Medicine: Comprehensive principles and practices. Cambridge: Cambridge University Press; 2010. Chouhan TR. ‘The unfolding of Bhopal disaster’. Journal of Loss Prevention in the Process Industries, 2005; 18(2005): 205–208. CRED (Centre for Research into the Epidemiology of Disasters). A WHO Collaborating Centre. 2015a. www.cred.be/ (accessed on 17 April 2016). CRED (Centre for Research into the Epidemiology of Disasters). Over 30 Years on the Front Lines. 2015b. www.cred.be/about (accessed on 17 April 2016). CRED (Centre for Research into the Epidemiology of Disasters). The Human Cost of Natural Disasters: A global perspective. Brussels: CRED; 2015c. Cullinan P, Acquilla S, Dhara VR. ‘Respiratory morbidity 10 years after the union carbide gas leak at Bhopal: A cross sectional survey’. BMJ, 1997; 314(7077): 338.

Disaster trends & impact  35 Dhara VR, Dhara R. ‘The union carbide disaster in Bhopal: A review of health effects’. Archives of Environmental Health, 2002; 57(5): 391–404. Divjak C, Conachy J. Flood Tragedy in Thailand Linked to Deforestation. 2001. www.wsws. org/en/articles/2001/09/thai-s04.html (accessed 12 May 2016). Dodds GG. ‘“This Was No Act of God:” Disaster, causality, and politics’. Risk, Hazards & Crisis in Public Policy, 2015; 6(1): 44–68. Franklin RC, King, JC, Aitken PJ et al. ‘“Washed away” – Assessing community perceptions of flooding and prevention strategies: a North Queensland example’. Natural Hazards, 2014; 73(3): 1977–1998. Gautam S, Menachem J, Srivastav S et al. ‘Effect of Hurricane Katrina on the incidence of acute coronary syndrome at a primary angioplasty center in New Orleans’. Disaster Medicine and Public Health Preparedness, 2009; 3(3): 144–150. Goklany IM. ‘Death and death rates due to extreme weather events’ in Civil Society Report on Climate Change. London: International Policy Network; 2007. Guha-Sapir D, Vos F, Below R et al. Annual Disaster Statistical Review 2011: The numbers and trends. Brussels: CRED; 2012. Hendrickson L, Vogt R. ‘Mortality of Kauai residents in the 12-month period following Hurricane Iniki’. American Journal of Epidemiology, 1996; 144(2): 188–191. Hogan DE, Burstein JL. ‘Basic perspectives on disaster’. In: Hogan DE, Burstein JL, editors. Disaster Medicine. Philadelphia: Lippincott Williams & Wilkins; 2007. Ipe M. ‘Bhopal gas tragedy: Lessons for corporate social responsibility’. Social Responsibility Journal, 2005; 1(3/4): 122–141. Lawlor J, Franklin RC, Aitken P et al. ‘Perceptions of the utility and acceptability of an emergency child minding service for health staff’. Disaster Medicine and Public Health Preparedness, 2014; 8(6): 485–488. McKinney N, Houser C, Meyer-Arendt K. ‘Direct and indirect mortality in Florida during the 2004 hurricane season’. International Journal of Biometeorology, 2011; 55(4): 533–546. Moscona J, Tiwari S, Munshi K et al. ‘The effects of Hurricane Katrina on acute myocardial infarction five years after the storm’. Journal of American College of Cardiology, 2012; 59(13): 502–505. Naghavi M, Wang H, Lozano R et al. ‘Global, regional, and national age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013’. Lancet, 2015; 385(9963): 117–171. Nakagawa I, Nakamura K, Oyama M et al. ‘Long-term effects of the Niigata-Chuetsu earthquake in Japan on acute myocardial infarction mortality: An analysis of death certificate data’. Heart, 2009; 95(24): 2009–2013. Nardulli PF, Peyton B, Bajjalieh J. ‘Climate change and civil unrest: The impact of rapid-onset disasters’. Journal of Conflict Resolution, 2015; 59(2): 310–335. North CS, Pfefferbaum B. ‘Mental health response to community disasters: A systematic review’. Jama, 2013; 310(5): 507–518. Omama S, Yoshida Y, Ogasawara K et al. ‘Influence of the Great East Japan earthquake and tsunami 2011 on occurrence of cerebrovascular diseases in Iwate, Japan’. Stroke, 2013; 44(6): 1518–1524. PAHO (Pan American Health Organization), WHO (World Health Organization). Epidemiological Update: Cholera. 2015. www.paho.org/hq/index.php?option=com_docman &task=doc_view&Itemid=270&gid=29233&lang=en (accessed 10 Dec 2015). Peterson MJ. ‘Appendix A: Chronology’ in Bhopal Plant Disaster. International Dimensions of Ethics Education in Science and Engineering – Case Study Series 2009. www.umass.edu/sts/ ethics. Ryan B, Kuhl I, Ware R. ‘Framework for handling asbestos after a tidal surge’. Journal of Environmental Health, 2014; 76(6): 170–176.

36  B. Ryan & R. Franklin Ryan BJ, Franklin RC, Burkle FM et al. ‘Analyzing the impact of Severe Tropical Cyclone Yasi on public health infrastructure and the management of noncommunicable diseases’. Prehospital and Disaster Medicine, 2015a; 30(1): 28–37. Ryan BJ, Franklin RC, Burkle FM et al. ‘Identifying and describing the impact of cyclone, storm and flood related disasters on treatment management, care and exacerbations of noncommunicable diseases and the implications for public health’. PLOS Currents Disasters, 2015b; 1(Sep 28): 1–21. Ryan BJ, Franklin RC, Burkle FM et al. ‘Defining, describing and categorizing public health infrastructure priorities for tropical cyclone, flood, storm, tornado, and tsunami-related disasters’. Disaster Medicine and Public Health Preparedness, 2016: 1–13. Salerno RM, Gaudioso J. Laboratory Biorisk Management: Biosafety and biosecurity. Boca Raton: CRC Press; 2015. Sundnes KO. ‘The transectional structure of society: The basic societal functions’. Scandinavian Journal of Public Health, 2014; 42(Suppl 14): 36–47. Swerdel JN, Janevic TM, Cosgrove NM et al. ‘The effect of Hurricane Sandy on cardiovascular events in New Jersey’. Journal of the American Heart Association, 2014; 3(6). Tarrant M. Presentation for Emergency Management Australia. 2008. UN (United Nations). Global Assessment Report on Disaster Risk Reduction: Revealing risk, redefining development. UK: International Strategy for Disaster Reduction; 2011. UN (United Nations). Sendai Framework for Disaster Risk Reduction 2015–2030. Geneva: UN; 2015. Varma R, Varma DV. ‘The Bhopal disaster of 1984’. Bulletin of Science, Technology & Society, 2005; 25(1): 37–45. World Meterological Organization. WMO Disaster Risk Reduction Programme. 2014. www.wmo.int/pages/prog/drr/ (accessed on 17 April 2016).

Chapter 3

Concepts and principles Brett Aimers and Linda Winn

Introduction and objectives There are significant differences in the way individuals, communities and nations interpret and think about disasters, and their management and consequences. This has the potential to cause confusion, particularly in the event of a multi-agency, multijurisdictional or multi-national response. Disaster management training is tactical based, often without an in-depth understanding of the underpinning philosophy, doctrine or principles that guide management strategies. This has the potential to weaken confidence in those strategies. Whilst the core principles are debatable, having a sound doctrinal and philosophical basis for disaster management is more likely to ensure consistency of practice and to augment cohesion within and between response agencies. The aim of this chapter is to identify the basic concepts, principles and practical application underpinning best practice in all aspects of disaster management. The chapter explores the historical context of thinking about disasters and the current principles that underpin management practice. On completion you should be able to: • • •

Demonstrate an understanding of the evolution of thinking in the way disasters have been regarded, and the impact of this on disaster management systems and practice. Critically analyse the conceptual basis of disaster management practice and the way those concepts relate to one another. Identify, describe and critically evaluate the principles that guide disaster management and their application to practice.

Historical perspectives and evolution of theory Traditional approaches to disasters were strongly influenced by the religious beliefs of the community. Disasters were seen as punishment (e.g. floods, pestilence) for deviation from God’s will. Until recently, insurance companies exempted natural disasters from insurance cover on the basis of their being an ‘act of God’. However, major international conflicts of the 20th century altered perceptions. Wars provide an environment where large numbers of casualties challenge health and other services. Baron Larrey’s introduction of the Ambulance Volante (flying ambulance) into the Napoleonic armies of the early 19th century was one of the first known attempts to create a disaster management system.

38  B. Aimers & L. Winn

Development of military thinking over subsequent centuries resulted in highly organised, structured responses built around tiered medical management: beginning with bystander care, followed by first-aid, forward surgical care, then on to definitive care. This structured and tiered approach became the cornerstone of military medical response until helicopters began providing rapid transport directly to advanced surgical care. However, it was the involvement of large civilian populations during the world conflicts of the 20th century that led to the principles of an organised major response to disasters. Civil defence organisations were established as a result of experience, particularly in World War II. A series of significant natural disasters in the USA and Australia throughout the 1960s and 1970s triggered reflection on the conceptual and organisational underpinnings of disaster management. This resulted in the formation of the NDO (Natural Disasters Organisation, now EMA: Emergency Management Australia) in 1974 in Australia, and the FEMA (Federal Emergency Management Agency) in 1979 in the USA. The all-hazards comprehensive emergency management approach (Neal 1997) was a progressive step forward from the civil defence paradigm of response and relief. The new framework, which included concepts of prevention, mitigation and recovery, generated the need to allocate resources across a range of activities to manage community exposure to hazard impacts. This broadened framework required the development of new approaches for disaster management. The next events to influence the direction of disaster management were a series of socio-technical system failures when concern for the safety of the environment and the sudden and preventable loss of life had a profound effect on public and political opinion. These included: • • • • • • • •

Flixborough, UK, 1974 and Seveso, Italy, 1976: chemical plant explosions. Canary Islands, 1977: two passenger planes collide on a Tenerife runway. Mississauga, Canada, 1979: train laden with chlorine derails. Three Mile Island, Pennsylvania, USA, 1979: Level 5 nuclear reactor meltdown. Bradford, UK, 1985: football stadium fire. Zeebrugge, Belgium, 1987: car and passenger ferry capsizes when leaving the harbour. Clapham, London, UK, 1988: two passenger trains collide just outside a station. Medan, Indonesia, 1997: passenger flight crashes into mountainous woodlands.

Detailed analysis of these and other events led to an enhanced understanding of the importance of infrastructure, especially utilities. There was a growing realisation that society and the economy were becoming increasingly dependent on very complex and poorly understood interwoven webs of infrastructure. The complexity of modern systems has further contributed to our vulnerability to disasters. To ensure continuity and sustainability, thinking shifted towards prevention, and the cornerstone of prevention is the identification and mitigation of risk. Risk management therefore became critical to business and community planning, leading governments to implement risk management standards. Comprehensive disaster management enabled thinking about approaches beyond response and relief. The other important shift was the recognition that a whole-of-government and whole-of-

Concepts & principles   39

community approach was crucial to dealing with complex problems, including disaster management. By the 1980s it was clear that community involvement in all aspects of disaster management would improve outcomes. This trend has accelerated rapidly over the past decade. The relatively recent adoption of the concept of ‘resilience’ as a critical component of community sustainability and effective disaster management enables organisations and communities to adapt to disasters. Likewise, the considerable increase in business continuity strategies indicates that organisations acknowledge they need to take responsibility for managing at least some aspects of disaster impacts. Business continuity is discussed in detail in Chapter 7.

Understanding disaster management Disaster management in its broadest understanding incorporates not only the breadth of interrelated concepts, but also the continuum of activities before, during and after events. It brings together a range of complementary concepts that contribute to our understanding of its complexity and scope. The most important characteristic of disasters is that they happen infrequently. However, they are large and complex, and require non-routine activity from individuals, organisations and communities. Figure 3.1 demonstrates the conceptual relationship between the elements that contribute to the impacts of disasters. Disasters cause significant damage to, or removal of, normal infrastructure; therefore establishing access to the necessities of life is critical. To do this requires planning and preparation including mitigation strategies and a robust recovery plan relevant to the context of the disaster and the community affected. It requires an all-inclusive,

Social impact Recovery preparedness

Recovery Physical impact

Disaster preparedness

Response

Hazard identification & mitigation

Disaster Pre-impact conditions Hazard exposure

Physical

Social

Vulnerabilities

Figure 3.1 The elements that contribute to the impact of disasters (adapted from Lindell 2013).

40  B. Aimers & L. Winn

cohesive, whole-of-government/community approach to management. This will include all stakeholders from government, NGOs (non-governmental organisations), the private sector and the community. In other words, anybody who lives, works, participates or has an interest in the community is included in all phases of the PPRR cycle. The fundamental concept behind disaster management is that the normal structures, capabilities and processes within and around the affected community are inappropriate to deal with a radically changing environment. That is why, fundamentally, disaster plans are ‘roadmaps’ guiding how a system must be adapted to operate in an innovative way. This is imperative as the BAU (business as usual) approach is inadequate to cope with an unfolding disaster. Good governance and effective management requires developing the knowledge and skills necessary to identify and respond to disasters in an appropriate way. It is an important aspect of any organisation’s survivability. While day-to-day operations can be managed through normal processes and plans, disasters such as cyclones, epidemics, floods, critical infrastructure failure, exotic animal disease outbreak and many others require significant reorganisation to deal with the situation. Extremely large disasters will require substantial scaling-up of organisational approaches, systems and processes to manage the response. Attempting to manage the situation without the ability to scale-up would be impossible and potentially counterproductive. For example, hospitals across any jurisdiction will have a scalable escalation plan to cover short-lived surges in demand for services isolated to the emergency department, through to protracted surges in demand covering the entire hospital and/or wider health service. It is important for escalation plans to align with the organisation’s strategic plan, business objectives and key performance indicators. They must identify escalation points (triggers), identify the level of response required and from whom, and what (if any) involvement from outside agencies is required. Escalation plans requiring involvement from outside agencies must be developed in consultation with those agencies. There are general principles or ideas that underpin all crisis or disaster management structures, but the approach has to reflect the type of organisation, its culture and environment. Many organisations, both private and government, use a three-tiered approach to disaster management: strategic, tactical and operational (as detailed further in Chapter 16). This hierarchy is not dissimilar to that used in organisational management more generally, as outlined in Table 3.1. Table 3.1 Levels of management. Platinum Gold Silver Bronze

Board of directors Sets the future direction of the organisation and its objectives Senior executive management Links the aims and objectives of the organisation to its activities Multi-site regional business units Sets out short-term linkage of resources to the daily activities that comprise the broad strategies Single-site business unit Task-focused achievements

Visionary Strategic Tactical Operational

Concepts & principles   41

The challenge is: how transferable is this system to other organisations, or groups of organisations working together in a unique or sudden-onset disaster? To determine when to activate response teams and escalation plans, the situation needs to be impacting on the ability of the organisation to achieve critical objectives. The escalation process is a very important part of any disaster management system. Sometimes the indicators or signals in the environment are very obvious; a flood for example. However, indicators may not be obvious, e.g. the Sarin attack on the Japanese subway, where railway employees, hospital staff and emergency departments were contaminated before the gas had been identified.

Core principles of disaster management The core principles that underpin modern disaster management have developed across many countries through experience from both communities and organisations. FEMA (2007) identified eight principles to use to guide development of doctrine of emergency management. These are: 1 Comprehensive: emergency managers consider and take into account all hazards, all phases, all stakeholders and all impacts relevant to disasters. 2 Progressive: emergency managers anticipate future disasters and take preventive and preparatory measures to build disaster-resistant and disaster-resilient communities. 3 Risk-driven: emergency managers use sound risk management principles (hazard identification, risk analysis and impact analysis) in assigning priorities and resources. 4 Integrated: emergency managers ensure unity of effort among all levels of government and all elements of a community. 5 Collaborative: emergency managers create and sustain broad and sincere relationships among individuals and organizations to encourage trust, advocate a team atmosphere, build consensus and facilitate communication. 6 Coordinated: emergency managers synchronize the activities of all relevant stakeholders to achieve a common purpose. 7 Flexible: emergency managers use creative and innovative approaches in solving disaster challenges. 8 Professional: emergency managers value a science and knowledge-based approach built on education, training, experience, ethical practice, public stewardship and continuous improvement. For further explanation of the FEMA principles, refer to Principles of Emergency Management (2007) available at: www.fema.gov/media-library/assets/documents/ 25063. However, there are alternative perspectives and the principles may be broadly described as taking a comprehensive, integrated and coordinated, risk-based approach which is community led and builds on community resilience. Comprehensive disaster management Comprehensive disaster management implies that management approaches should encompass the cycle of PPRR. While there has been some debate about the ongoing

42  B. Aimers & L. Winn Table 3.2 Strategies to deal with threats throughout the disaster management cycle. Timelines

Phase

Examples of strategies

Pre-event

Systemic preparedness

Planning Education and training Land use and construction standards Mitigation Resource evaluation Risk mitigation Refresh training Protection Evacuation Preposition resources

General alert preparedness Specific alert preparedness

During event

Rescue Relief Continuity

Post event

Rejuvenation: Restoration of functionality Reconstruction Adaptation

Urban search and rescue Public health measures, food, clean water, waste disposal Disaster assistance teams Clean up Rebuilding infrastructure Community relocation

appropriateness of the PPRR terminology, this text will use the PPRR cycle or similar language to emphasise the cyclical nature of comprehensive disaster management and the continuum of management efforts before, during and after disasters. Prevention focuses on hazard reduction and mitigation to minimise the effects that disasters may have. Preparation involves building resilience, surveillance, early warning and planning for specific risks. It is often considered that the process of planning is more significant than the plan itself. The response phase commences immediately after the event and is often led by key response agencies. Recovery will follow the immediate response. These concepts will be discussed in detail in later chapters. Table 3.2 outlines the disaster management cycle and examples of strategies to deal with the threat. The key activities in the PPRR cycle can be summarised as follows: •

•

Prevention/mitigation activities: seek to eliminate or reduce hazards and/or to increase the resilience of the community. The concept of prevention is well known to health management and public health protection remains the cornerstone of preventing epidemics. Preventing man-made disasters is underpinned by industrial and road safety programs and by design and construction standards. Where disasters may not be prevented, mitigation can reduce their impact. Preparedness activities: seek to establish arrangements and plans and to provide education and information to prepare the community to deal effectively with emergencies and disasters. Surveillance and early detection are well-known public health strategies designed to enable early intervention. These same concepts

Concepts & principles   43

• •

have considerable value outside of the infectious disease control environment. Preparedness also involves the marshalling of relevant resources to enable effective response. These activities require stakeholder engagement, planning, education, exercising and training. Response activities: requires the activation of preparedness arrangements and plans to effectively manage emergencies and disasters if and when they occur. An inadequate response will prolong recovery, particularly psychosocial recovery. Recovery activities: seek to assist the community affected by an emergency or disaster in reconstructing physical infrastructure and services, and to restore emotional, social, economic and physical wellbeing.

A prepared resilient community requires its citizens to be alert, informed and actively involved in all phases of PPRR. It requires support for voluntary organisations, an active and involved local government, and coordination between the ‘prepared community’, all levels of government and relevant organisations and agencies (EMA 2004). This concept identifies that the initial responsibility for responding to an emergency rests with the affected community. When the emergency requires resources beyond the capacity of the local community, support is escalated to districts or regions and jurisdictions, and if necessary, to a national level (AEMI 2011). Integrated disaster management For a comprehensive approach to disaster management to be workable, there must be effective arrangements for the coordination of the activities of governments and the large number of organisations and agencies that need to be involved in PPRR activities. The core underpinning principle is the all-hazards, all-agencies approach. This implies that regardless of the hazard or risk, the approaches should be similar and that all organisations involved should be able to operate in a consistent and collaborative manner. These arrangements need to be set within a legislative and public policy framework and based upon a solid doctrinal base. The role of governments in providing an effective disaster management framework in Australia is considered further in Chapter 4. Achieving an integrated disaster management framework and a robust community safety partnership requires commitment and active involvement of all levels of government and statutory agencies, NGOs, private and public business sectors and individual communities. Integrated approaches also reflect the need for cohesion in policy development. Many effective prevention and preparedness activities are not seen as disaster policies. For example, public health standards are considered health protections rather than disaster preparedness. Nevertheless, future approaches need to ensure a more integrated approach to public policy in which disaster preparedness implications are seen as an integral part of all policy analysis. Similarly disaster response arrangements must build on and leverage off existing activities. This is not a time to learn new things. The concept of ‘familiarity’ is a much sounder basis for crisis response than even the most effective preparedness training.

44  B. Aimers & L. Winn

Risk-based disaster management Disasters are social phenomena spanning most functional groupings of government and crossing all levels – Commonwealth, state and local. When managing risk associated with disasters, what processes might society or communities use to make decisions about uncertain and complex issues? For example, what is an appropriate land management regime? Given this topic is highly contested, and at times emotive, how then can robust and sustainable decisions be made in the context of a complex and highly uncertain situation? There is now a growing body of knowledge and experience in the application of risk management to disasters. Disaster risk management is a field that has evolved to address part of the risk spectrum associated with low-probability, high-consequence events and situations. The disaster management sector uses the term ‘disaster risk management’ to describe the adaptation of the standard to the disaster management context. This process of contextualisation was a conscious decision by Standards Australia. During the third United Nations World Conference in Sendai, Japan, in March 2015, contextualising the term was also noted as the most significant shift in the risk management of disasters. The Sendai Framework for Disaster Risk Mitigation, ratified at the world conference, has a strong focus on health resilience and natural and man-made hazards, and related environmental, technological and biological hazards and risks. While there has been some excellent work done on developing approaches to disaster risk assessment and mitigation, there is a real possibility this good work will be wasted due to knowledge gaps in creating policy frameworks to support effective disaster risk management. It is important to get sound information about the risks, but there are also an array of issues about process and relationships crucial to achieving effective outcomes. Further development of disaster risk management in an environment with very high levels of uncertainty will mean that the communication of risk may conflict with other objectives and values. It is important to understand that not all risks can be fully mitigated. Corrective disaster risk management seeks to correct or reduce identified risks and the probability of further risks developing, the latter being achieved through policies and procedures. Compensatory disaster risk management involves a series of activities designed to strengthen the social and economic resilience of individuals and communities in the face of residual risks that cannot effectively be eliminated or reduced. In summary, disaster risk management is a subset of the risk spectrum; it generally involves low-probability, high-consequence events. Non-routine problems require different organisational functions/operations if they occur and often require whole-ofgovernment and/or organisational approach. Coordinated disaster management Coordinated approaches require diligent attention to all-agency and all-hazards not only in the preparedness and planning environment but also to response. Chapter 16 details the concepts of incident management systems required to achieve coordinated approaches to response. The need for a coordinated approach throughout the PPRR cycle will be discussed in detail throughout this text.

Concepts & principles   45

Community-led disaster management Effective integrated approaches recognise the fundamental role of the community in determining its own arrangements and rebuilding or adapting its future. Challenging traditional responder approaches, the community-led approach is another core principle of effective disaster management. These concepts will be further explored in Chapter 9.

Conclusion When disasters occur, many organisations are required to become involved. Throughout all phases of the PPRR cycle, disaster managers work to improve the ability of individuals and groups to manage and overcome risks during disasters. However, this cycle is never-ending and ever-changing. Problem-solving capacity is enhanced by utilising concepts that can collect, organise and allocate information and resources, identify problems, determine objectives and priorities, and assign available resources. These arrangements are built through a regular process in which various agencies interact to identify hazards, develop plans and training programs, establish communications and support facilities, and practise through drills and exercises. As the planet continues to warm, global population grows, and disasters increase, more people will be exposed to disasters. This will undoubtedly require new approaches to manage the consequences of disasters and people cannot solely rely on governments to ‘fix the problem’. Nevertheless, governments and other response agencies can make their jurisdictions more resilient.

Key readings (All sites accessed on 16 April 2016.) Etkin D, Davis I. ‘The search for principles of disaster management’ [A draft working paper] International Journal of Accounting and Financial Management (IJAFM). Universal Research Group (www.universalrg.org), July 2013, ISSN: 2322–2107, Vol.12. FEMA. Principles of Emergency Management Supplement. 2008. http://training.fema. gov/hiedu/emprinciples.aspx

Activities • •

Identify how current concepts of disaster management are challenged in the current global environment. Consider how the principles of disaster management may be applied to the protection of a community against a pandemic.

References AEMI (Australian Emergency Management Institute). Disaster Health: Handbook 1. Australian Emergency Management Handbook Series. Canberra: Commonwealth of Australia; 2011. EMA (Emergency Management Australia). Emergency Management in Australia. Concepts and Principles: Manual 1. Australian Emergency Manual Series. Canberra: Commonwealth of Australia; 2004.

46  B. Aimers & L. Winn FEMA (Federal Emergency Management Agency). Principles of Emergency Management Supplement. Washington: FEMA; 2007. www.fema.gov/media-library-data/20130726-182225045-7625/principles_of_emergency_management.pdf (accessed 27 April 2016). Lindell M. ‘Disaster studies’ Current Sociology Review. 2013; 61(5–6): 797–825. Neal DM. ‘Reconsidering the phases of disasters’ International Journal of Mass Emergencies and Disasters. 1997; 15(2): 239–264.

Part 2

Key elements of disaster management

Chapter 4

Disaster management systems Peter Channells and Graeme McColl

Introduction and objectives Disaster management involves far more than skilled managers who can organise and coordinate the application of resources to respond to an incident. It requires managers who can achieve outcomes throughout all phases of the PPRR cycle. It also requires the organised systems and structures needed to support managers and ensure positive outcomes are achieved for individuals, agencies, government and, above all, the community. Systems are the processes that organisations use; their standard operating procedures, data systems and governance processes. Structures are the organisational arrangements that are necessary to achieve outcomes including boards of governance, consultative committees and monitoring bodies. Such systems and structures must be independent of specific individuals and collaborative in nature. Any management task requires both systems and structures. The aim of this chapter is to identify the systems and structures required to support disaster management throughout the PPRR cycle and to identify the roles and responsibilities of the various organisations and individuals involved in disaster management. On completion of this chapter you should be able to: • • •

Clearly define the organisational and other structures relevant to your jurisdiction, including their roles and responsibilities. Understand the factors that influence the establishment, operations and effectiveness of those organisational structures. Identify the activities required to ensure the systems and structures are rapidly mobilised and effective.

Organisational systems and structures Organisational systems are the processes used; and organisational structures are the inter- and intra-organisational arrangements necessary for the organisation to achieve its objectives. Figure 4.1 demonstrates the relationship between organisational systems and structures. Disaster management systems and structures are scalable arrangements within each organisation or agency specifically established and resourced to manage the situation within their charter (e.g. ambulance service provide pre-hospital emergency patient

50  P. Channells & G. McColl

Inter-organisational 0 R

Organisational systems

Standard operating procedure: data systems, training & governance processes

G A N

w TSN

A T 1

Achieve outcomes, assign roles & responsibilities, provide chain of control & coordination, reporting linkage for staff to follow

Organisational structures

O

N

Intra-organisational

Figure 4.1 The relationship between organisational systems and structures.

care; fire service respond to building fires; and police service uphold law and order). As the complexity of the disaster increases, the systems and structures must be able to cater for multi-agency, multi-jurisdictional responses; this may include international support or assistance (see Chapter 17). Recognising the complexity and urgency of any situation, disaster management response and recovery arrangements generally involve the establishment of a special single purpose organisation, e.g. a disaster management committee. This special purpose organisation must include the structures (governance and coordination committees), and the systems supporting those structures such as Coordination Centres. These organisations necessarily comprise multiple other organisations (e.g. response agencies) that have their normal mandate for action but bring to the collaborative effort not only those normal responsibilities but also the ability to scale up to meet extraordinary challenges and to alter their operations to provide mutual aid and support. Thus these temporary systems and structures may cut across existing structures and priorities of the organisations involved. Planning for the creation of these special purpose response teams should be part of routine planning and preparedness across all agencies. These teams are similar to the ‘task force’ approach taken towards planning and preparation for major events. To ensure maximum efficiency and effectiveness, existing systems and structures should be utilised where possible in these special single purpose structures and systems. The systems and structures also need to fit within a broader environment defining, for example, why those systems and structures exist; what they are trying to achieve; the roles and responsibilities of those involved; the social, economic and environmental context; and a description of the risks and priorities. This is encapsulated in a strategy, whether at an organisational or government level. Once developed, a strategy is supported by an implementation plan that includes flexible systems and structures that are capable of fulfilling the specific actions to be undertaken.

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It is worth emphasising again that these systems and structures must cover all aspects of the PPRR cycle. A key factor for success is engagement of the organisation’s senior executive and all relevant stakeholders.

International perspectives International arrangements for disaster management are complex. Many wealthy countries will be called upon to render aid in the event of incidents affecting their area of influence. Such assistance may fall into several broad categories: security, health and resources. Thus it is important that disaster managers, even those who work for national agencies, are aware of the international governance structures and the roles and responsibilities of leading international authorities and organisations involved in disaster response. The principal organisation of international cooperation remains the United Nations (UN) and its subsidiary and affiliated organisations including the World Health Organization (WHO). The UN is a large and complex organisation which provides a forum for member states to express their views. While best known for peacekeeping, peacebuilding, conflict prevention and humanitarian assistance, the UN’s mandate also includes to serve as the focal point for the coordination of disaster reduction and to ensure synergies among the disaster reduction activities of the UN and regional organisations. To support this, the UN established the Office for Disaster Risk Reduction in response to the Hyogo Declaration (2005a) and the Hyogo Framework for Action 2005–2015: Building the resilience of nations and communities to disasters (2005b). Additionally the UN established the Inter-Agency Standing Committee (IASC) to foster coordination and cooperation between the UN and non-UN humanitarian partners. The IASC was established in June 1992 as the primary mechanism for inter-agency coordination of humanitarian assistance. The UN High Commissioner for Refugees (UNHCR) is a notfor-profit organisation dedicated to providing humanitarian support to refugees and other displaced and stateless people. In addition to the UN, many regions such as the European Union have established cross-national structures to support risk reduction, disaster preparedness and response coordination. For example, the European Community Humanitarian Office (ECHO) was created in 1992 and became the Directorate-General for Humanitarian Aid in 2010. Many nations also maintain international response arrangements which build on existing humanitarian and development aid. These include funding schemes to assist with development and mitigation efforts (e.g. USAid: United States Agency for International Development, AusAID, etc.), as well as response arrangements including USAR (urban search and rescue) and DMAT (disaster medical assistance team), along with pre-deployed and pre-determined resource caches. Non-government agencies (NGOs) There are a vast range of international NGOs and it is not possible to list them all. We include here examples of NGOs that demonstrate the range of roles played by these agencies:

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• •

• • • •

• •

The Centre for Research into the Epidemiology of Disasters (CRED) provides data on disaster trends to support preparation and evaluate the effectiveness of risk reduction strategies. The International Committee of the Red Cross (ICRC) and the International Federation of Red Cross and Red Crescent Societies (IFRC) have the capability of providing people, resources and equipment, and thus play a prominent role in international responses. Médecins Sans Frontières (MSF) provides medical and health responses in major incidents. The International Emergency Management Society (TIEMS) is a non-profit NGO that provides opportunities for the exchange of information and innovation in disaster management. The International Association of Emergency Managers (IAEM) aims to provide members with the opportunities to exchange information and to build a network to advance the profession of emergency management. The World Association for Disaster and Emergency Medicine (WADEM) is a multidisciplinary professional association whose mission is the global improvement of pre-hospital and emergency healthcare, public health, and disaster health and preparedness. The World Bank contributes funding to disaster risk mitigation projects through the Global Facility for Disaster Reduction and Recovery (GFDRR) which is established in partnership with other agencies. Mercy Ships is an international charity providing free healthcare, community development projects, community health education, mental health programs, agriculture projects, and palliative care for terminally ill patients.

International support strategies All disaster management begins locally. However, in the era of instantaneous communication, a rapid escalation of interest from national and international organisations is inevitable. In addition disasters often disproportionally impact on countries that are resource poor. Thus, international interest in and support for active direct involvement in disaster responses is becoming more common. Some disasters will attract more donations than others. In general, bushfires will raise double the amount of money floods do. This has a lot to do with images presented in the media. There are frequent problems with equitable distribution of donations and support, and with the management of donated goods and volunteers. There are key international strategies and programs underway to try to regularise the provision of international assistance; this is covered in detail in Chapter 17. There is also considerable effort being directed towards the management of international volunteers. Volunteers may be organisations and individuals which, if experienced, form a critical component of the international aid effort. On the other hand, volunteers may be disruptive, diverting resources from the aid effort to the management of volunteers. There are numerous volunteer organisations, including government and nongovernment organisations as well as international and national organisations. Some of these organisations are highly structured, well-resourced and experienced; while

Disaster management systems  53

others may lack such resilience infrastructure. The expansion of volunteer groups has led to a call for registration on an international level to ensure legitimacy and standardisation (see Chapter 17).

National disaster management structures It is not possible to detail the national disaster management arrangements for all countries, as there is incredible variety in the arrangements of individual countries. However, there are some similarities in the principles that govern the nature of those systems and structures. Those core principles include: • •

A legislative framework that includes both specific and applicable statutes as well as common law and regulatory arrangements, as detailed in Chapter 5. Governance and planning of organisational structures, as detailed in Chapter 13.

The governance and planning organisations are specific to the individual countries and to their political and constitutional arrangements. However, as a general rule, they include a whole-of-government coordinating committee usually led by the president or chief minister, a head of agency level committee intended to advise ministers and domain subcommittees (such as health) and technical advisory structures. These arrangements are often replicated at regional and local level and systems put in place to coordinate between the various levels of jurisdiction. To demonstrate the complexity and to provide an example of these arrangements we present a case study of the Australian disaster management arrangements. We do not hold this out to be an exemplar, but rather an example of the complexities required for national arrangements. Australian disaster health arrangements Australia has three tiers of government, each independently elected and answerable to the others only in broad terms defined by the constitution, relevant legislation, financial accountability or by political considerations. Disaster management is the constitutional responsibility of the state and territory (hereafter referred to as states) governments with some aspects delegated to local government. Despite this constitutional accountability, disaster management arrangements in Australia are largely based on local government controlling the initial response. The Australian Government (Commonwealth) generally provides both financial and non-financial assistance under the Commonwealth Disaster Plan (COMDISPLAN) when requested by the states or territories, but also provides a leading role in prevention, preparedness and recovery. Roles and responsibilities can be defined as follows: •

Australian Government: national standards, policies, strategies and plans; coordination and inter-operability between all states and agencies; and national responsibilities including:



– national security (international responses, border control and quarantine); – provision of Commonwealth assets (primarily defence) to aid in response and recovery when requested;

54  P. Channells & G. McColl



– financial assistance to individuals, provided through Natural Disaster Relief and Recovery Arrangements (NDRRA).

•

Australian state and territory governments: state legislative and planning frameworks for disaster management; state disaster management infrastructure including police, ambulance, health, etc.; coordinated planning, including all-agency state disaster committees such as the State Disaster Management Group (SDMG); and state risk mitigation. Australian local governments: (within jurisdictional boundaries) planning and preparedness, operational response, risk mitigation, some volunteer infrastructure and recovery. Most states have a system of disaster management whereby districts (regions) consist of several local governments or councils. This provides a system and structure for local governments to assist each other when a situation is beyond the capacity of one local government, but not large enough to escalate to state level.

•

National coordination of disaster policy and preparedness is achieved under the umbrella of a broader policy integration structure, the Council of Australian Governments (COAG). COAG is a meeting of the Prime Minister and state and territory chief ministers to develop agreed national approaches. COAG is supported by domainbased ministerial councils which are in turn supported by committees of officials. Thus in this context, Emergency Services Ministers from the Australian Government and state and territory governments meet to discuss policy and common issues, and are supported by the Australia–New Zealand Emergency Management Committee (ANZEMC). Within the health context, similar supportive arrangements apply. Health is generally the constitutional responsibility of the states and territories, although the Australian Government does have specific responsibilities such as quarantine. During the preventative and preparedness phases, the Commonwealth works with states and territories to develop a range of protocols, procedures and plans to manage health incidents or to provide health support in other incidents. Finally, the Australian Government has a supportive role to states on request for assistance in response and recovery phases. Thus the national committee of health ministers is supported in this domain by a specific purpose advisory committee, the Australian Health Protection Principal Committee (AHPPC) which provides overarching national leadership through crossjurisdictional collaboration on health protection matters. The AHPPC is chaired by the Chief Medical Officer and has as its core members, senior Commonwealth officers (including military) and the Chief Health Officers of each state or territory. Roles include: • • • •

Providing leadership on national policy development and implementation on emerging health threats related to infectious diseases, the environment, and natural and technological disasters, including long-term threats. Leading the management of health protection incidents and coordinating the national health response to incidents of national significance. Preparing national health systems for responding to emerging health threats and disasters, including exercises and planning. Ensuring consistent, timely and accurate communications between jurisdictions and other relevant organisations.

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Health incident management in Australia The agreed system for incident management in Australia is the Australasian InterService Incident Management System (AIIMS) (version 4). (Note that New Zealand uses a slightly different version, the Coordinated Incident Management System: CIMS.) AIIMS and CIMS are not unlike other incident management systems used throughout the world and will be discussed in detail in Chapter 16. A ‘hierarchical escalation’ system applies to disaster health response, where one level can seek assistance from adjacent areas or escalate to the next level, e.g. local to district to state to national levels, or even to international level. Escalation is based on resources at each level being exhausted before assistance is sought. However, this does not prevent one level signalling a possible request where there are predictions of a severe event, e.g. a cyclone. Incident coordination is crucial: each level has a coordination structure and system that is fully scalable depending on the severity of the disaster. In summary, there will be a forward command/coordination operations centre close to the incident. This is then replicated through the district and state, then to national level with the strategic focus increasing at the state and national levels. There is a wide range of strategies and response plans maintained at each level. Large private sector organisations also adopt management systems based on AIIMS, and it is common for companies to establish a memorandum of understanding (MoU) with other organisations to provide support during emergencies or disasters. For example, a residential care facility may agree to take another facility’s residents if a situation required evacuation. Operations centres are key to all response systems and structures. The successful management of disasters requires coordination of the efforts of all agencies and the resources (organised as per AIIMS/CIMS or similar) within each agency. Such centres operate at the multi-agency and single agency level from the incident scene up to national level. Operation centres are covered in Chapter 16. Training must be in line with current best practice, policies and procedures, and be carried out regularly to ensure knowledge and standards are maintained. Training and exercising builds resilience within and between organisations. It improves organisational ability to withstand shocks and continue to function with a capacity for adaptation and crisis management. Training must be endorsed and encouraged at managerial and executive levels to ensure an organisation has the best opportunity to achieve its objectives and responsibilities when confronted with the uncertainty and chaos a disaster brings.

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Case study 4.1: Hurricane Katrina, 29 August 2005 Despite warnings a hurricane would make landfall in the region of New Orleans in the US, it appeared no one was listening. Evacuation orders were not issued and pre-event preparedness was virtually non-existent. Hindered by wideranging uncertainty and inconsistency in the way government officials responded, the initial response following the hurricane was slow. The scale of the disaster overwhelmed Louisiana local governmental agencies and a state of emergency was not declared. The slow, ad-hoc response by all levels of government intensified the pain and suffering of those impacted by the hurricane and led to a breakdown in social order which authorities struggled to restore (Treaster 2005). The Governor declined an offer by the White House to put federal government controlled National Guard troops in New Orleans (Luo 2005) and the federal government showed an unwillingness to intervene. The New Orleans Mayor issued a desperate plea for help to which the federal government responded with troops and supplies. It was five days after the hurricane before the situation began to stabilise (Dao and Kleinfield 2005). All levels of government failed to observe the existing inter-governmental disaster management and administrative procedures, which are so critical in the early stages. Governmental failures led to an unprecedented response from NGOs, with 14 international NGOs responding to a disaster inside the US for the first time (Eikenberry et al. 2007). Commenting on the government response to Hurricane Katrina, New Orleans Congressman Charles W. Boustany Jr. stated ‘we needed direct federal assistance; command and control and security – none of the three were present’ (White and Whoriskey 2005).

Key readings Abraham J. ‘Disaster management in Australia: The national emergency management system’ Emergency Medicine. 2001: 13(2): 165–173. AIIMS. The Australasian Inter-Service Incident Management System. 4th ed. Melbourne: Australasian Fire and Emergency Service Authorities Council: 2013. Association of Academic Health Centers. Managing Emergency Preparedness: Health centres organize and innovate. 2008. www.aahcdc.org/policy/reports/aahc_ emergency_prep_08.pdf (accessed on 27 April 2016). Department of Health and Ageing. Australian Health Management Plan for Pandemic Influenza. Canberra: Commonwealth of Australia: 2008. Emergency Management Australia. Critical Infrastructure Emergency Risk Management and Assurance Handbook. 2nd ed. Canberra: Commonwealth of Australia: 2004. (Especially Chapters 6 and 7.) Pan American Health Organization. Humanitarian Supply Management and Logistics in the Health Sector. Washington, D.C.: 2001.

Disaster management systems  57

Activities • •

What would be the advantages and disadvantages of applying existing formal organisational structures to the structure required for an emergency response? Think of an organisation you are familiar with based on key elements outlined in this chapter: prepare an organisational structure to cover the likely functions required when responding to an identified risk.

References Dao J, Kleinfield NR. ‘More troops and aid reach New Orleans; Bush visits area; Chaotic exodus continues’ New York Times [Internet]. 3 Sep 2005. http://query.nytimes.com/gst/ fullpage.html?res=9C0DE3D91431F930A3575AC0A9639C8B63&pagewanted=all (accessed 17 April 2016). Eikenberry A, Arroyave V, Cooper T et al. ‘Administrative failure and the international NGO response to Hurricane Katrina’ Public Administration Review. 2007: 67 (Special Issue): 160–170. Luo M. ‘The embattled leader of a state immersed in crisis’ New York Times [Internet]. 8 Sep 2005. www.nytimes.com/2005/09/08/us/nationalspecial/the-embattled-leader-of-a-storm battered-state-immersed-in-crisis.html?_r=0 (accessed 17 April 2016). Treaster JB. ‘At stadium, a haven quickly becomes an ordeal’ New York Times [Internet]. 1 Sep 2005. www.nytimes.com/2005/09/01/us/nationalspecial/superdome-haven-quicklybecomesan-ordeal.html (accessed 17 April 2016). UN (United Nations). Hyogo Declaration. World Conference on Disaster Reduction, 2005a. www.unisdr.org/2005/wcdr/intergover/official-doc/L-docs/Hyogo-declaration-english.pdf (accessed 12 May 2016). UN (United Nations). Hyogo Framework for Action 2005–2015: Building the resilience of nations and communities to disasters. World Conference on Disaster Reduction, 2005b. www.unisdr.org/2005/wcdr/intergover/official-doc/L-docs/Hyogo-framework-for-actionenglish.pdf (accessed 12 May 2016). White J, Whoriskey P. ‘Planning, response are faulted’ Washington Post. 2 Sept 2005.

Chapter 5

Legal and ethical aspects of disaster management Fiona McDonald, Michael Eburn and Erin Smith

Introduction and objectives Law and ethics have an important role to play in emergency management. In addition to coordinating functions, legal frameworks at the international, national and subnational level provide a structure establishing who can lawfully act, what can and cannot be lawfully done, and the manner in which actions should be taken. Law also plays an important role in specifying that in the midst of an emergency situation the vulnerable should be protected, and human rights respected. With a foundation of respect for the dignity of individuals and communities, ethics is equally important as it informs decision-making around what should be done and the manner in which it should be done. This chapter provides an introduction to key elements of the legal framework at the international and domestic levels, followed by an introduction to some of the most significant ethical issues in disaster management for health professionals. On completion of this chapter you should be able to: • • •

Analyse both domestic and international law as it pertains to disaster management, particularly response to disasters. Identify the instruments and covenants that support and guide an international response to disasters. Demonstrate an understanding of the ethical challenges and professional responsibilities of response agencies and their staff.

International law arrangements While disasters have the capacity to cross national borders, there is no single comprehensive international treaty directly addressing how the international community could or should respond. The major obstacle to this is the concept of national sovereignty – that a nation state should govern itself without interference from other nations or international bodies. The international legal framework for disaster management is therefore fragmented with a variety of relevant hard laws (legally binding law, such as covenants) and soft laws (quasi-legal instruments that are not legally binding or which are only weakly binding; for example, United Nations (UN) resolutions that are directly or indirectly relevant), as well as multi- and bi-lateral agreements between nation states and within or between non-governmental organisations (NGOs). General human rights

Legal & ethical aspects of disaster management   59

instruments, such as the International Covenant on Civil and Political There is no single comprehensive Rights (ICCPR) (UN 1966a) and the international treaty directly International Covenant on Economic, addressing how the international Social and Cultural Rights (ICESCR) community could or should respond (UN 1966b), for example, the right to to disasters that cross boarders. food and water, will also be relevant in disaster contexts. Some of the most significant instruments for disaster management are discussed below. Prevention The main strategic framework for disaster reduction and mitigation is the Sendai Framework for Disaster Risk Reduction 2015–2030 (UN 2015). This framework aims to encourage the integration of disaster risk considerations (including risk reduction strategies) into emergency preparedness, as well as response and recovery planning and policy, and to develop and strengthen capacity. Coordination There are a number of actors in international disaster management, including UN agencies, regional organisations, nation states, private companies and NGOs. Effective coordination is therefore important but difficult to achieve. The main frameworks are: •

•

•

UN: In 1991 the UN General Assembly passed a resolution (UN 1991) to strengthen its role in coordinating disaster response efforts of the international community. With the aim of improving coordination, the UN created the InterAgency Standing Committee (IASC) and the position of the Emergency Relief Coordinator (ERC). IASC is composed of representatives from the UN, the International Organisation for Migration (IOM), the Red Cross and various NGO consortia. Regional and bilateral agreements: There are a number of regional and bilateral agreements between national states that aim to improve cooperation and smooth barriers to a regional or bilateral response to a disaster. For example, the Association of South East Asian Nations (ASEAN) Agreement on Disaster Management and Emergency Response (AADMER) (ASEAN 2005). NGOs: The 1997 Seville Agreement (ICRC 1997) specifies which arm of the Red Cross movement becomes lead Red Cross agency in disasters. NGOs may also coordinate their operations and share information through the creation of networks, such as the Asian Disaster Reduction and Response Network (ADRRN).

Entry, operations and exit Ensuring international aid and personnel can rapidly reach areas and people affected by disasters, and can operate with relative impunity (for example, doctors can provide medical care without a license to practice in the host country) is another priority to

60  F. McDonald, M. Eburn & E. Smith

enable international disaster management. Bi- and multi-lateral agreements usually specify rules in respect to the entry, exit and operation of organisations and their employees within disaster areas, as well as relief supplies needed to carry out their functions. International Conventions apply in respect of UN agencies (e.g. the Convention on the Safety of UN and Associated Personnel) and other international or regional organisations (UN 1994). The UN General Assembly has also adopted a resolution (UN 2003) urging states to reduce customs and administrative procedures related to the use of air space, and the entry, transit, stay and exit of international search and rescue teams and their animals, equipment and materials (for more detail, see Chapter 17). Human rights In addition to general human rights protections accorded by the Covenants (UN 1966a, 1966b), several international instruments focus on maintaining and promoting human rights in a disaster context. In the Convention on the Rights of Persons with Disabilities (UN 2006), Article 11 specifically addresses the obligations of states to provide for the protection and safety of persons with a disability in situations of risk. This includes humanitarian emergencies and natural disasters. The need for states to protect vulnerable people including the disabled, the elderly, women and children in a disaster context is also explicit in the Guiding Principles on Internal Displacement (GPID, 1998) (UN High Commissioner for Refugees 2004) and the IASC Guidelines (2011) for the protection of persons in natural disasters (ICRC 1997). The IASC Guidelines recommend displaced persons (including women and disabled persons) should be involved in the design and management of camps and food distribution systems. Key principles in the GPID stipulate: • • • •

Principle 6.2: people should only be displaced if evacuation is required to maintain their safety or health. Principle 7.2: displaced people should, to the greatest extent possible, be provided with accommodation, nutrition, health services (see also Principle 19.1) and hygiene; and families should not be separated. Principle 18: people should be provided with clean drinking water and clothing. Principle 23: education should be provided as soon as conditions permit.

In 1994 the Red Cross developed a voluntary Code of Conduct for The International Red Cross and Red Crescent Movement and NGOs in Disaster Relief (IFRC and ICRC 1994). This Code also emphasises human rights: to provide assistance in an impartial, neutral, humane and respectful manner and in a way that maximises the benefits to affected populations and minimises harms and risks. (For more information, see Chapter 17.) Infectious diseases One area in which there is binding international law is in response to disease outbreaks that have the capacity to constitute global public health threats, e.g. the 2014–2015 West African Ebola epidemic. The main features of the International Health Regulations (IHR) (WHO 2005) are:

Legal & ethical aspects of disaster management   61

• • • •

The requirement of nation states to report to the World Health Organization (WHO) all diseases (infectious or otherwise) that might constitute a public health threat. The imposition of more detailed reporting requirements. The requirement of nation states to develop their capacity to detect and to respond to diseases. The power of WHO to issue non-binding recommendations, to require nation states to provide additional information, and to share information without the consent of the nation state, amongst other things.

Domestic law arrangements The primary responsibility for managing the response to any disaster or emergency lies with the government of the affected state (here referring to ‘state’ as a nation state rather than sub-national states or provinces) (UN 1981, 1991; Fidler 2005). Nation states have options as to how they make their emergency management arrangements, and it is a significant matter for some national governments, for example: Canada (Emergency Management Act, SC 2007, c 15; Emergencies Act, RSC 1985, c 22 4th Supp); New Zealand (Civil Defence and Emergency Act 2002); and the UK (Civil Contingencies Act 2004). In some jurisdictions, for example, Australia, responsibility for managing the response to disasters is vested in the states, and the national government’s role is limited to providing assistance at the request of the states (e.g. Australian Government 2012, 2014). The US gives primary responsibility for emergency management to local governments but management can be moved up to state and then to federal government depending on the size and impact of the event (Robert T. Stafford Disaster Relief and Emergency Assistance Act, Public Law 93–288, as amended, 42 U.S.C. 5121 et seq.). Most jurisdictions have specific disaster (emergency) management legislation which identifies principally when a disaster is declared. However, many other items of legislation contain specific provisions that apply in the event of a disaster and, with few exceptions, other legislation will continue to apply even during a disaster. Thus emergency managers need to have a broad understanding of the legislative environment in which they work. The role of domestic law Where there is an international obligation, for example to facilitate the entry of relief personnel and to allow licensed health professionals to practice in the affected country, then it is the responsibility of the state to ensure that their domestic laws give effect to those international obligations (IFRC 2007). Domestic laws are essential to create appropriate organisations such as national emergency management offices, as well as local fire brigades and rescue services (Fire and Rescue Services Act 2004 (UK); Fire Service Act 1975 (NZ); Fire Services Act [RSBC 1996] Chapter 144 (British Columbia, Canada); Health and Safety Code, Division 12 Fires and Fire Protection [13000– 14960] (California, US); Fire Brigades Act 1989 (New South Wales, Australia)). Laws also define who is responsible for formulating emergency plans and for giving agencies both the authority, and the obligation, to take part in disaster planning (Emergencies

62  F. McDonald, M. Eburn & E. Smith

Case study 5.1: SARS management, Singapore, 2003 The political response to SARS in Singapore fostered a spirit of public collaboration and solidarity which contributed to the control of the virus. Recognising early that containing SARS was the only way of restoring the confidence of tourists and trade partners, and thus gaining economic recovery, control and containment efforts were made a priority of government at the highest level. Strong public partnerships were fostered between the government and the people largely due to the frank, open, complete and constant information which was being disseminated to the public (WHO 2004: 14). Singapore’s high vigilance in initiating containment measures to control the outbreak of SARS meant the disease was only prevalent in the country for less than four months. Specific SARS ambulances transported patients to dedicated SARS hospitals which were closed to visitors. Frequent and regular temperature monitoring (with every household being issued thermometers), early case identification, isolation of patients, contact tracing and home quarantine of contacts were integral in controlling the outbreak. Movement of healthcare workers, patients and visitors within and between hospitals was restricted and the military in Singapore were deployed to assist with contact tracing and to enforce quarantines. Education of healthcare workers and audits of infection control practices were also implemented. Cross-border transmission was monitored with incoming travellers from SARS affected areas completing health declarations and all outgoing travellers monitored for fever. The public was urged to restrict non-essential travel to SARS affected regions, schools were closed and sporting activities suspended. Increased public education programs on good hygiene were implemented and information was made readily available to the public. There were mandatory biosafety precautions for laboratories testing for SARS virus culture and all laboratory workers were counselled on biosafety guidelines (Chan 2005: 255).

Act, RSC 1985, c 22 4th Supp (Canada); Civil Defence and Emergency Act 2002 (NZ); Civil Contingencies Act 2004 (UK); Australian Government 2014; State Emergency and Rescue Management Act 1989 (NSW, Australia)). Responding to a disaster may require decisions to be made to benefit the community, even though this may cause individual losses. During the immediate response to a disaster, emergency managers may require the power to enter or commandeer private property, to restrict freedom of movement, to require people to undergo decontamination and to either stay in, or leave, defined areas. Domestic laws are required to set out the powers that may be employed to control an emergency (Emergency Management Act, SC 2007, c 15 (Canada); Australian Government 2012; Lee 1984). When faced with an emergency or disaster, decisions have to be made with both limited time and limited knowledge. In the post-incident review it may be thought that the decision was not the best that could be made, or that it resulted in poor outcomes. Laws are required to ensure that a responder:

Legal & ethical aspects of disaster management   63

. . . is not to be charged with negligence if . . . faced with a situation which requires immediate action of some sort and if, in the so-called ‘agony of the moment’, he [or she] makes an error of judgment and takes a step which wiser counsels and more careful thought would have suggested was unwise. (Leishman v Thomas [1958]) Judge-made law The common law tradition is a legacy of English colonial imperialism and is shared with other former English colonies including the US, Canada and New Zealand. The essential feature of the common law is that judges who deliver detailed reasons when deciding cases that come before them develop the law. The earlier decision of a superior court such as a Court of Appeal or the national Supreme or High Court defines the law that other subsequent courts must follow. In the area of disaster and emergency management, common law courts have been sympathetic to the dynamic and information-poor environment in which decisions have been made (Eburn 2013). Litigation against those that respond during a disaster to provide emergency assistance is rare and has been unsuccessful to date (Capital and Counties v Hampshire Council [1997] QB 2004; Electro Optic Systems Pty Ltd v NSW [2014] ACTCA 45). Medical emergencies Even though there has been no successful litigation against people stepping forward to provide emergency medical care at an accident or in a disaster (Graham et al. 2015; Ipp 2002), there is an expressed fear that people will be subject to some legal liability for their actions, taken in good faith to assist others. Most states now have ‘Good Samaritan’ laws (named after the biblical parable), to protect a person who steps forward to provide emergency medical care (Social Action, Responsibility and Heroism Act 2015 (UK); Good Samaritan Act, RSBC 1996, c 172 (British Columbia, Canada); Civil Code, Division 3 Obligations Part 3 Obligations Imposed by Law [1714.2– 1714.23] (California, US); Civil Liability Act 2002 (NSW, Australia) s 57). The importance of law in emergency management should be remembered. The presence of international and domestic laws should remind those involved in planning for and responding to emergencies that they do not operate in a legal vacuum. It is not the case that law does not, or should not, apply during an emergency; rather that laws should be designed, and implemented, before a disaster to ensure appropriate arrangements are in place to maximise the effectiveness of any response. People and organisations involved in the disaster management process need to be aware of the relevant international and domestic laws that apply to facilitate disaster assistance. At the same time they should have little concern that they will be sued or found liable for their honest attempts to deal with the situation that presents itself.

Ethical challenges Disasters place unprecedented demands on health systems and expose emergency healthcare workers to a range of risks. Despite this challenge, legal guidelines and

64  F. McDonald, M. Eburn & E. Smith

emergency service professional codes of ethics are largely silent on the issue of professional obligations during disasters. This provides little to no guidance on what is expected of healthcare workers or how they ought to approach their duty to treat in the face of risk. Professional responsibilities In 2003, the outbreak of SARS infected approximately 8,400 people worldwide. The epidemic caused 813 deaths and billions of dollars in economic damage (Emmanuel 2003). Exposing the vulnerabilities of healthcare systems, health professionals bore the brunt of the outbreak and were the most-at-risk population for SARS, accounting for 45% of probable or suspect cases in Toronto, Canada, and 21% of all cases worldwide (WHO 2003). In every affected country, healthcare professionals had to choose between providing care and protecting themselves – crystalising an ethical challenge and fundamentally changing our assumptions about duty and risk (Rothstein et al. 2003). The professional obligation to face this risk has been referred to as part of a larger duty to care (Annas 1988; Daniels 1991). Contemporary ethical standards offer some guidance on treating patients during emergency siuations, but they are largely silent on the issue of healthcare worker professional responsibility (Ruderman et al. 2006) and the ramifications of failing to fulfil this responsibility. Healthcare professionals are arguably not required to accept life-threatening risk whilst caring for patients, but there appears to be no uncontroversial way to establish a threshold at which risk acceptance becomes a duty (Iverson et al. 2008). Morally speaking, when does the right to protect oneself from serious risk outweigh the duty to care for patients in need? Healthcare workers hold similar values when it comes to professional responsibility and duty of care, and this duty is an integral part of what it means to be a health professional. Alongside professional integrity, duty of care is largely based on patients’ rights, professional virtue, beneficence and social utility. However, despite these various ethical reasons to uphold a duty of care in all circumstances, both historic and recent events have highlighted that not all healthcare workers will be willing and ready to respond during a disaster. Will professionals work? Reports from the US, Canada, Asia, Israel, Germany and Australia highlight that emergency healthcare workers will not always be willing to report to work during disasters. A study of Israeli healthcare workers reported that 58% of respondents were not willing to report to work during a non-conventional missile attack (Shapira et al. 1991). A Hawaiian study which examined the willingness of doctors and nurses to work in field hospitals during mass casualty events identified that respondents were more likely to be willing to work during natural disasters, with willingness influenced by perception of risk, perceived knowledge and self-perceived ability to provide the type of care required (Lanzilotti et al. 2002). A number of studies following the 9/11 terrorist attacks investigated the ability and willingness of emergency healthcare workers to work during disasters and terrorist events. Barriers to being willing and able to work during these events included childcare, eldercare, transportation, personal and family health concerns, compensation

Legal & ethical aspects of disaster management   65

(Qureshi et al. 2002, 2005), fears for personal and family safety (DiMaggio et al. 2005), perception of inadequate or too little training and education, and the lack of necessary equipment to respond to large-scale events (Reilly et al. 2007). Furthermore, emergency healthcare providers report a decreased willingness to work during a prolonged disaster situation, and at no time will 100% of all personnel rostered to work actually report for duty (Syrett et al. 2007). Similar barriers to willingness to work have been identified in the Australian context, where paramedic willingness to work during a disaster is influenced by perception of risk regarding injury, exposure, infection, illness, death and a difficulty in finding a balance between safety and duty of care (Smith et al. 2008; Tippett et al. 2007). Should professionals work? A debate about duty to treat in the context of disaster response asks whether it is fair to expect health workers to take on a risk of personal injury or death, and the burden of psychological stress associated with that risk, in order to provide care. Much of the existing discussion on this topic has its roots in ethical considerations and medical professionalism. While the obligation to continue caring for patients in the face of personal risk is not found in the Hippocratic oath, it has been a central tenet of medical professionalism since 1847. In the American Medical Association’s (AMA) first Code of Ethics (Zuger and Miles 1990; Huber and Wynia 2004), it was written that when pestilence prevails, it is: [the professionals’] duty to face the danger and to continue their labours for the alleviation of suffering, even at the jeopardy of their own lives. This statement helped formalise a sense of physician duty that was sustained until the 1950s and 1960s. When domestic threats of infectious diseases – such as smallpox and polio – dissipated, such heroic statements vanished from the AMA Code (Huber and Wynia 2004; CMA 2004). Decades later, the HIV threat motivated changes in the Code, and language was added in 1986 suggesting that treating HIV positive patients was required only if the physician was ‘emotionally able to do so’ (Iverson et al. 2008). This statement proved controversial and was revised six months later to: A physician may not ethically refuse to treat a patient whose condition is within the physician’s current realm of competence solely because the patient is seropositive. (Huber and Wynia 2004) Updated following the 9/11 terrorist attacks and subsequent anthrax threat, the AMA’s new Social Contract with Humanity now includes a Declaration of Professional Responsibility that is more reminiscent of the AMA’s 1947 Code: We, the members of the world community of physicians, solemnly commit ourselves to . . . apply our knowledge and skills when needed, though doing so may put us at risk. (AMA 2001)

66  F. McDonald, M. Eburn & E. Smith

The AMA Code now states that: . . . because of their commitment to care for the sick and injured, individual physicians have an obligation to provide urgent medical care during disasters. This ethical obligation holds even in the face of greater than usual risks to their own safety, health or life. (AMA 2001) However, although the AMA has outlined a professional obligation, it fails to transparently detail how failure to comply with these obligations will be managed. The Canadian Medical Association (CMA) released a revised Code of Ethics one year after the SARS outbreak in 2004 (CMA 2004). The Code is largely silent on the issue of professional obligations and acceptable standards of care, despite their direct experience with managing the SARS outbreak. One key revision of the 2004 Code was the inclusion of a ‘Fundamental Responsibilities’ section. This section fails, however, to substantively address the issue of duty to respond, or to provide transparent guidelines.

Conclusion This chapter has provided an introduction into key elements of the legal framework of disaster management at the international and domestic levels, followed by an introduction into some of the most significant ethical issues for health professionals in disaster management contexts. It has demonstrated that law and ethics are an important aspect of disaster management practices both domestically and internationally and, as such, knowledge of both is an important part of professional practice.

Key readings Eburn M. ‘Disaster risk reduction in the shadow of the law’. In: AE Collins, S Jones, B Manyena et al. (eds). Hazards, Risks, and Disasters in Society. Cambridge: Academic Press; 2015: 255–271. Kayman H, Radest H, Webb S. ‘Emergency and disaster scenarios’. In: P Singer and A Viens (eds). The Cambridge Textbook of Bioethics. Cambridge: Cambridge University Press; 2008: 281–288.

Activities • •

Detail the legislative arrangements in a jurisdiction with which you are familiar. What do you see are the weaknesses in this framework?

References AMA (American Medical Association). Declaration of Professional Responsibility. 2001 [updated 2015]. www.ama-assn.org/ama/pub/physician-resources/medical-ethics/declarationprofessional-responsibility.page? (accessed 18 April 2016). Annas G. ‘Legal risks and responsibilities of physicians in the AIDS epidemic’ Hastings Centre Report. 1988; 18(2): 26–32.

Legal & ethical aspects of disaster management   67 ASEAN (Association of South East Asian Nations). ASEAN Agreement on Disaster Management and Emergency Response. 2005; Vientiane, Laos. Australian Government. Comdisplan 2014: Australian Government Disaster Response Plan. Canberra: Commonwealth of Australia; 2014. Australian Government. National Disaster Relief and Recovery Arrangements: Determination 2012. Canberra: Commonwealth of Australia; 2012. Capital and Counties v Hampshire Council [1997] QB 2004. Chan K. ‘Control of severe acute respiratory syndrome in Singapore’ Environmental Health and Preventative Medicine. 2005; 10: 255–259. Civil Code, Division 3 Obligations Part 3 Obligations Imposed by Law [1714.2–1714.23] (California, US). Civil Contingencies Act 2004 (UK) Civil Defence and Emergency Act 2002 (NZ) Civil Liability Act 2002 (NSW, Australia) s 57 CMA (Canadian Medical Association). CMA Code of Ethics. 2004 [updated 2015]. http:// policybase.cma.ca/dbtw-wpd/PolicyPDF/PD04-06.pdf (accessed 18 April 2016). Daniels N. ‘Duty to treat or right to refuse?’ Hastings Centre Report. 1991; 21(2): 36–46. DiMaggio C, Markeson D, Loo GT et al. ‘The willingness of U.S. emergency medical technicians to respond to terrorist incidents’ Biosecurity and Bioterrorism: Biodefense Strategy, Practice and Science. 2005; 3(4): 331–337. Eburn M. Emergency Law. 4th ed. Annandale: The Federation Press; 2013. Electro Optic Systems Pty Ltd v NSW [2014] ACTCA 45. Emergencies Act, RSC 1985, c 22 (4th Supp) (Canada) Emergency Management Act, SC 2007, c 15 (Canada) Emmanuel EJ. ‘Lessons of SARS’ Annals of Internal Medicine. 2003; 139(7): 589–591. Fidler, David P. ‘Disaster relief and governance after the Indian Ocean tsunami: What role for international law?’ Melbourne Journal of International Law. 2005; 6(2): 458–473. Fire and Rescue Services Act 2004 (UK) Fire Brigades Act 1989 (NSW, Australia) Fire Service Act 1975 (NZ) Fire Services Act [RSBC 1996] Chapter 144 (British Columbia, Canada) Good Samaritan Act, RSBC 1996, c 172 (British Columbia, Canada) Graham R, McCoy MA, Schultz AM. Strategies to Improve Cardiac Arrest Survival: A time to act. Washington, DC: National Academies Press; 2015. Health and Safety Code, Division 12 Fires and Fire Protection [13000–14960] (California, US). Huber SJ, Wynia MK. ‘When pestilence prevails . . . Physician responsibilities in epidemics’ The American Journal of Bioethics. 2004; 4(1): W5–W11. IASC (Inter-Agency Standing Committee). Operational Guidelines on the Protection of Persons in Situations of Natural Disasters. Washington, DC: Brookings; 2011. ICRC (International Committee of the Red Cross). Agreement of the Organization of the International Activities of the Components of the International Red Cross and Red Crescent Movement – The Seville Agreement. 1997; Sevilla, Spain. IFRC (International Federation of Red Cross and Red Crescent Societies). Law and Legal Issues in International Disaster Response: A desk study. Geneva: IFRC; 2007. IFRC (International Federation of Red Cross and Red Crescent Societies) and ICRC (International Committee of the Red Cross). Code of Conduct for the International Red Cross and Red Crescent Movement and NGOs in Disaster Relief. 1994. Ipp D. Review of the Law of Negligence. Canberra: Commonwealth of Australia; 2002. Iverson KV, Helne CE, Larkin GL et al. ‘Fight or flight: The ethics of emergency physician disaster response’ Ann Emerg Med. 2008; 51(4): 345–353.

68  F. McDonald, M. Eburn & E. Smith Lanzilotti S, Galanais D, Leoni N et al. ‘Hawaii medical professionals assessment’ Hawaii Medical Journal. 2002; 61(8): 162–173. Lee HP. Emergency Powers. Sydney: Law Book Company; 1984. Leishman v Thomas [1958] 75 WN (NSW, Australia) 173, 175. Qureshi K, Gershon RRM, Sherman MF et al. ‘Health care workers’ ability and willingness to report to duty during catastrophic disasters’ Journal of Urban Health: Bulletin of the New York Academy of Medicine. 2005; 82(3): 378–388. Qureshi K, Merrill J, Calero-Breckheimer A. ‘Emergency preparedness training for public health nurses: A pilot study’ Journal of Urban Health: Bulletin of the New York Academy of Medicine. 2002; 79: 413–416. Reilly MJ, Markenson D, DiMaggio C. ‘Comfort level of emergency medical service providers in responding to weapons of mass destruction events: Impact of training and equipment’ Prehospital and Disaster Medicine. 2007; 22(4): 297–303. Robert T. Stafford Disaster Relief and Emergency Assistance Act, Public Law 93–288, as amended, 42 U.S.C. 5121 et seq. Rothstein MA, Alcalde MG, Elsert NR et al. Quarantine and Isolation: Lessons learned from SARS: A report to the centers for disease control and prevention. Louisville, Kentucky: Institute for Bioethics, Health Policy, and Law, University of Louisville, School of Medicine; 2003. Ruderman C, Tracy CS, Bensimon CM et al. ‘On pandemics and the duty to care: whose duty? who cares?’ BMC Medical Ethics. 2006; 7(5): 1–6. Shapira Y, Marganitt B, Roxiner I et al. ‘Willingness of staff to report to their hospital duties following an unconventional missile attack: A state-wide survey’ Israel Medical Science Journal. 1991; 27(11–12): 704–711. Smith E, Morgans A, Quershi K et al. ‘Paramedics’ perceptions of risk and willingness to work during disaster’ Australian Journal of Emergency Management. 2008; 23(2): 21–27. Social Action, Responsibility and Heroism Act 2015 (UK) State Emergency and Rescue Management Act 1989 (NSW, Australia) Syrett JL, Benitez JG, Livingston WH et al. ‘Will emergency healthcare providers respond to mass casualty incidents?’ Prehospital Emergency Care. 2007; 11(1): 49–54. Tippett V, Archer F, Kelly H et al. The Australian Prehospital Pandemic Risk Perception Study and an Examination of New Public Health Roles for Ambulance Services in Pandemic Response. Brisbane: Australian Centre for Prehospital Research, Queensland Ambulance Service; 2007. UN (United Nations). Sendai Framework for Disaster Risk Reduction 2015–2030. Geneva: UN; 2015. UN (United Nations). Convention on the Rights of Persons with Disabilities. 2006. UN (United Nations). General Assembly Resolution 57/150 Strengthening the Effectiveness and Coordination of International Urban Search and Rescue Assistance. 57th session; 2003; New York, US. UN (United Nations). Convention on the Safety of United Nations and Associated Personnel. 1994. UN (United Nations). General Assembly Resolution 46/182 Strengthening of the Coordination of Humanitarian Emergency Assistance of the United Nations. 78th Plenary Meeting; 1991; New York, US. UN (United Nations). General Assembly Resolution 36/225 Strengthening the Capacity of the United Nations System to Respond to Natural Disasters and Other Disaster Situations. 36th session; 1981; New York, US. UN (United Nations). International Covenant on Civil and Political Rights. 1966a. UN (United Nations). International Covenant on Economic, Social and Cultural Rights. 1966b.

Legal & ethical aspects of disaster management   69 United Nations High Commissioner for Refugees. The Guiding Principles on Internal Displacement. 2004. WHO (World Health Organization). International Health Regulations. 2005. WHO (World Health Organization). Outbreak Communication: Best practices for communicating with the public during an outbreak. Report of the WHO expert consultation on Outbreak Communications, Singapore, Sept 2004. Geneva: WHO; 2004. WHO (World Health Organization). Consensus Document on the Epidemiology of Severe Acute Respiratory Syndrome (SARS). Geneva: WHO; 2003. Zuger A, Miles SH. ‘Physicians, AIDS, and occupational risk. Historic traditions and ethical obligations’ Health Policy. 1990; 14(1): 56–57.

Chapter 6

Risk and its management Mike Tarrant and Carl Gibson

Introduction and objectives Chapter 3 identified risk, and its management, as a core principle of disaster management. A simple definition of risk is something that will have an impact on the organisation or community’s objectives. It is very important to understand that risk is not only negative; it is about both threat and opportunity to achieve objectives. This provides a much better way of approaching the problem that disruptions and disasters pose to economies and societies globally. Risk management is the process by which resources are allocated to manage the uncertainties around achieving community or organisational objectives and this approach is invaluable in enhancing disaster management. The aim of this chapter is to outline the concept of risk and the principles and practice of risk management in the context of health-related disasters. On completion of this chapter you should be able to: • •

Demonstrate a detailed understanding of disaster health-related risk and the application of risk management as a means of achieving community and organisational objectives in the context of disasters. Identify and analyse some of the national/state/local approaches to making decisions about assessing and reducing disaster health-related risk.

What is risk? The terms ‘risk’ and ‘risk management’ have now become central to the lexicon of just about every field. Risk has been conceptualised and studied by a wide range of disciplines, from engineering through to anthropology, with each bringing their own frame of reference and concepts to thinking about risk. Key researchers and thinkers (Bernstein 1998; Beck 1992; Smith et al. 2000; Douglas 1992; Lupton 1999; Slovic and Johnson 1995; Fischhoff 1995; Kasperson et al. 1992) have published a significant amount of literature about risk and its social theories (Krimsky and Golding 1992). Krimsky and Golding (1992) have produced excellent overviews of the social theories of risk, which is particularly useful for disaster managers. Slovic (1999) emphasises that while danger is real, there is no such thing as ‘real risk’ or ‘objective risk’. Risk is a judgement about how objectives are affected by a situation. Simply put, hazards are facts and risk is a conclusion about how a hazard may affect objectives.

Risk & its management  71

Historically, significant resources have been allocated to hazard analysis and Hazards are facts. Risk is a conclusion assessment, but very few resources alloabout how a hazard may impact cated to how the problem is actually objectives. going to be managed and risk reduction implemented. A theme often discussed in disaster management is the lack of community and organisational responsibility in managing risk. Why don’t people see the risks the way others do and invest time and resources in making themselves safe? If there is an expectation by disaster management agencies of significant changes in behaviour by individuals, then risk assessment and/or risk management will have to move beyond the idea that risk is something independent of minds and cultures, waiting to be measured. Unless an approach is developed that moves beyond technical assessments, we are doomed to be met with either apathy or occasional aggression by the public when attempting to engage them in managing risk. Subjectivity permeates low-probability, high-consequence risk assessments due to the high levels of uncertainty and complexity. Risk assessments rely on limited data, therefore significant judgements are required at every step of the process. This is particularly true for comparative work where judgements have to be made regarding allocating resources. At the core of this perspective is expected utility theory. It is generally assumed that people will follow the rules if they have sufficient information and time to dwell on the consequences of different paths (Krimsky and Golding 1992). It is essential to have a sound scientific perspective but it is not sufficient. There is a significant body of research that challenges the assumption that people desire the most accurate and precise information possible (Smithson 1989). The objectivist approach to risk is too limited a perspective on which to deal with complex policy problems such as disasters (Beck 1992). If a goal of public policy is active participation by the public and organisations in managing risk, then a richer understanding of the influence of the social contexts in which ideas or beliefs about risk are constructed is needed.

Challenges of managing disaster health-related risk Disaster-related risk is typically outside of the experience of most individuals, organisations and communities. A helpful way of understanding disasters, and the conditions leading up to them, is to consider four characteristics of disaster-related risk: volatility, uncertainty, complexity and ambiguity; often referred to as ‘VUCA’ (see Figure 6.1): 1 Volatility: all aspects of disaster-related risk change rapidly. 2 Uncertainty: there is a lack of understanding regarding the nature of current and future conditions, particularly regarding the predictability of events, consequences and their likelihoods. 3 Complexity: the nature of inter-relationships makes it difficult to define causal pathways, relationships and consequences, and to identify optimal risk-modification options. 4 Ambiguity: the potential for differing interpretations of sources of risk, consequences and modification of risk exists. Recognisable patterns are difficult to identify and it is difficult to gain sufficient clarity.

72  M. Tarrant & C. Gibson

NEGATIVE EFFECT Volatility / Uncertainty i Complexity I AmbiguityN

Strategic & operational objectives

POSITIVE EFFECT

Risk

^Flexibility LKnowledge Adaptability I Capability

Decision-making

Successful outcomes

Enaction

Unsuccessful outcomes

Figure 6.1 The effect of VUCA on achieving successful outcomes in disaster management.

A robust risk management framework provides the means of reducing the effects of VUCA for disaster management by establishing a systematic approach for individual and shared sense-making, decision-making and action. In a disaster environment, risk management needs to be flexible and to ensure multiple perspectives of stakeholders and disciplines are effectively integrated into decision-making. Flexibility is especially important where risk strategies may need to be adjusted to address disruption-related risk in response to an uncertain environment and a changing understanding of risk. One of the key outcomes of effective risk management is behaviour change driven by stakeholder understanding and acceptance. Effective risk management requires behaviour change driven by stakeholder understanding & acceptance.

Risk management and disaster management Originating as the Australian standard AS/NZS 4360: 2004, this standard emphasised management of risk, rather than management of hazards. Australian emergency management recognised the value of this approach and in 2000 risk management was contextualised sector wide. Comprehensive emergency management enabled thinking about approaches Risk management standards provide a that extend beyond response and relief. common conceptual framework & The use of risk management was crucial language for emergency management in providing a common conceptual sectors to engage across both the framework and language for the emereconomy & society. gency management sector to engage more widely across the economy and

Risk & its management  73

Incident

Routine

Disaster

Emergency

RISK

Non-routine

Crisis Business as usual

Business continuity

Figure 6.2 The risk spectrum.

society. Titled ‘emergency risk management’, it was flexible enough to cope with a wide range of contexts. It was common practice at the time to use the word ‘emergency’ and ‘disaster’ interchangeably (see Chapter 1). Critical to risk management is a systematic process to ensure limited resources are best allocated for an entity to deal with the uncertainty associated with achieving objectives. An entity can be a single person, a local government or a large multinational corporation. If there are objectives to be met, then risk management is necessary to ensure they are achieved. For example, while the concepts and principles remain the same, the detail around the way risk management is applied in a small rural health clinic will be different to that in a large tertiary hospital. Emergency risk management is a field that addresses part of the risk spectrum covering risks associated with low-probability high-consequence situations (see Figure 6.2). These non-routine risks may be distinguished from the more predictable routine risks that form part of the daily challenges of life and make up virtually all the work of public safety agencies. Emergency risk management is very well articulated in the nationally agreed National Emergency Risk Assessment Guidelines (EMA 2015) and this is an essential reference for this field. The flexible approach of risk management can be used in any context because it is defined by the need for a part of the system to run in a non-routine way. For example, a storm in a remote rural community may require the local system to move to non-routine operation, whereas in a large urban area, this situation could Disaster is not an absolute concept. be handled through business as usual It is a function of the rate of change it (BAU) processes. Disaster is not an brings to the impacted area. absolute concept; it is a function of the rate of change it brings to the area affected.

Disaster health risk management process The process for managing disaster health-related risk is based upon the internationally recognised standard ISO 31000: 2009. The process is adapted to better address the challenges presented by the non-routine nature of disaster health-related risk (see Table 6.1). AS/NZS have also produced a Standard AS/NZS 5050: 2010

74  M. Tarrant & C. Gibson Table 6.1 Alignment of the disaster health-related risk process with ISO 31000. Disaster health risk management

ISO 31000 Risk management process

Understanding context Understanding risk Hazard identification and mapping Vulnerability analysis Describing risk Prioritising risk

Establish the context Risk assessment

Modifying risk Monitoring risk and its modification Reviewing the risk management process Stakeholder consultation and communication

Risk treatment Monitoring and review

Risk identification Risk analysis Risk evaluation

Communication and consultation

(Business Continuity – Managing disruption-related risk) to try to better address the complexities of non-routine risk. The disaster health-related risk management process is an iterative cycle supported by continuous monitoring and review, and stakeholder consultation (see Figure 6.3). The risk management process can be used to manage risk as part of preparedness before a disaster occurs, or in reducing harm and improving decision-making in support of managing an actual disaster.

Understanding context Review process monitor risk

Changing risk landscape

Review process monitor risk

Stakeholder consultation & participation Review process monitor risk

Review process monitor risk

Modifying risk

Understanding risk Hazard mapping & assessment

Vulnerability analysis

Describing risk

Ranking risk

Prioritising risk

Figure 6.3 The health disaster risk management process.

Risk & its management  75

Step 1: Understanding context Understanding the context involves firstly defining the scope which establishes the boundaries within which the risk management process will be undertaken. This involves: • • • • • •

Examining the physical, natural, social, political, economic and cultural aspects of the environment in which the disaster(s) may occur or has occurred. Identifying key stakeholders affected by or involved in the potential or actual disaster. Determining the capabilities of communities and organisations potentially affected by the disaster. Establishing the capabilities and constraints of the organisations contributing to the management of disaster-related risk. Clarifying and allocating roles and responsibilities for the risk management process. Selecting and customising the risk management process and methodologies to meet the needs of the specific context. This will include deciding on the criteria by which risk will be ranked and prioritised.

Step 2: Understanding risk Risk arises from an interaction between hazards and the vulnerabilities of communities and organisations, depending on the context. Hazard identification and mapping Identifying and mapping sources of risk is a key aspect of understanding risk. Hazards have varying levels of predictability and different patterns of impact. Identification requires a systematic and comprehensive all-hazards approach to ensure that all disaster-related risk is considered: see the examples in Table 6.2. Hazards will have a range of effects on different societal levels and functions, which may change over the duration of a disaster. These may include direct and indirect

Table 6.2 Examples of sources of risk: an all-hazards approach. Hazard category

Examples of hazard

Natural

Earthquakes, landslides, tsunamis, cyclones/hurricanes, flood, drought, extreme temperatures, forest fires, famine. Building fires, structural collapses, chemical substances, radiological agents, transportation crashes. Epidemic disease in humans, animals or plants; pandemic diseases; infestations of pests. War, conflict, stampedes, acts of terrorism, mass population dislocation, civil unrest, economic collapse.

Technological Biological Societal

Source: Based on Guha-Sapir et al. (2009); Below at al. (2009); IRDR (2014).

76  M. Tarrant & C. Gibson

impacts that degrade existing functionality and exacerbate already failing systems, including: • • • • • • •

Degradation of the capability and performance of health systems, facilities and services. Impairment of infrastructure and the provision of essential services, such as water, food, sanitation and shelter. Disruption of economic, social and governmental mechanisms and services. Death and injury including psychological and social behavioural disorders. Population displacement. Increased incidence and severity of Key to success is to manage the risk, disease. not the hazard. Degradation of disaster management capability.

Vulnerability assessment Vulnerability is an expression of the population’s or organisation’s susceptibility to hazards and includes their capacity to anticipate, to cope with, to resist and to recover from impacts. This involves a complex mix of issues and factors that vary according to hazard, community, organisation and social change. In assessing vulnerability, the full range of types should be considered as defined by the context (see Table 6.3) in aligning vulnerability with specific stakeholders, Table 6.3 Examples of vulnerability types. Vulnerability type

Examples

Physical

Properties of built environment. Critical infrastructure and assets including plant and machinery. Lack of governance, effective institutions and the rule-of-law. Health of economy including private enterprise. Capabilities of NGOs and civil society. State of infrastructure and lifelines. Beliefs and customs. Social equality. Continuity of employment. Access to essential services. Access to information, resources and commodities. Community cohesiveness and coping capacity. Personal factors:   Gender – female   Age: < 5 years and > 65 years   Education level. Health status. Social status:   Single-parent family   Social isolation/exclusion   Low socio-economic status.

Politico-socio-economic

Community

Human

Risk & its management  77

locations, jurisdictions and socio-economic groups. Comprehensive vulnerability assessment is essential to achieve a robust risk assessment. Describing risk Describing risk involves examining the interaction of hazards and sources of risk and how this is modified by vulnerabilities. The same hazard may pose very different risks to communities and organisations depending on their vulnerability (De Chesnay and Anderson 2016). Hazards may combine in different ways to produce highly complex consequences. Describing risk is best based on input from both expert and community/ organisational representatives. Different participants will likely have very different views on risk. This can be driven by prior experience, knowledge and biases. In describing risk, a substantial practical problem often arises: a very large number of hazards, vulnerabilities and consequences make subsequent analysis a daunting, if not near impossible task. Risk scenarios provide a useful technique to limit the number of possible interactions under consideration and make the risk management process manageable. A risk scenario is a sample of all the potential interactions between hazard and vulnerability that generate risk. The key steps in developing a risk scenario are: 1 Review the range of hazards identified in Step 1, and confirm their potential occurrence. With available resources, select the significant hazards for detailed analysis. 2 For the list of hazards, establish an intensity range, and select a limited representative sample of intensities. For example, select upper limit of the intensity range, the reasonably expected intensity and the lower limit of the intensity range. Sensitivity analysis can be applied to ensure that selected samples are representative. 3 Once intensities have been established, it is then possible to define and describe the resulting consequences by referring to the vulnerability analysis. A risk register is a very useful methodology for recording and documenting the risk management process. Ranking risks Ranking risk assists in subsequent decision-making by assigning a level of risk for each risk description. This is the key step in providing information for prioritising risk. Ranking risk involves assigning some value or descriptive level to each of the risks or risk scenarios. These values or levels are based upon criteria developed as an outcome of Step 1 (understanding context), and should be revisited and reviewed given the increased understanding that will have arisen during all the steps. Risks can be analysed and ranked qualitatively or quantitatively depending upon the needs of decisionmakers, the nature of the context, and the type and quality of available information. Prioritising the risks Risk ranking provided a list of risks based on their level, together with a rich narrative about the nature and importance of those risks. The next task is to produce a prioritised list of risks to guide the allocation of resources to modifying the risks.

78  M. Tarrant & C. Gibson

Step 3: Modifying risk Modifying risk involves identifying, developing and implementing appropriate actions for managing risks. The first task after reviewing the assessment is to develop options to modify the high priority risks. There are a number of ways by which the risk can be reduced to meet the resources and capacity of the community or organisation: • • • •

Avoid the risk (e.g. banning the widespread use of a chemical). Changing the likelihood (e.g. land-use planning). Changing the consequences (e.g. warning systems). Sharing the risk with another party (e.g. insurance).

The selection of risk-modification activities should reflect the values and perceptions of the community, organisation and key stakeholders to ensure the activities are acceptable and credible. These actions are then documented into a plan containing: • • • • •

Why the actions for modifying risk were selected. Who will be accountable and responsible for implementing the plan. What resources are needed. Schedule and timing for implementation. Reporting and monitoring requirements.

Activities supporting the risk management process There are very important sets of activities which enable the risk management process. Monitoring the process A crucial part of the risk management process is to ensure any changes that may have occurred are reflected in the outcomes of the process. Regular monitoring and review is an integral part of the risk management process that ensures the risk is being modified in line with available resources and the needs of the community or organisation. Some keys areas to be considered are: • • • •

Is there any new evidence or research? Are the controls for modifying risks working as planned? Have new risks emerged? Has vulnerability changed?

Communication and consultation The high uncertainty and complexity associated with disaster-related risk means that communication and consultation are vitally important and involve a wide-range of stakeholders. Each stakeholder or stakeholder group may have very different knowledge, understanding and views on the risks they face. Effective risk management requires the sharing of information and perspectives on risk with the goal of achieving

Risk & its management  79

a better allocation of scarce resources to enhance organisational performance or community wellbeing. This is particularly the case when dealing with low-probability high-consequence risk, which is not amenable to typical statistical analysis, such as road accidents. In most cases, risk treatments will depend on the willingness of organisations and community members to commit time or financial resources to managing risk. Risk assessment is a critical process in building understanding and a commitment to act. While the technical aspects of risk assessment are essential, effective communication and consultation underpins every aspect of the process. Even when risk can be managed through very direct treatments such as legislation and regulation, their effectiveness still largely depends on stakeholder support and acceptance.

Conclusion A risk management approach makes a very important contribution to the field of disaster management. It provides an internationally recognised methodology which is used widely in all aspects of society and the economy and provides an excellent opportunity to not only guide more effective disaster management, but also to nurture a common approach to managing disaster-related risk.

Key readings All the emergency risk management handbooks can be downloaded for free from the Commonwealth government at www.ag.gov.au/EmergencyManagement/Pages/ default.aspx. The Australian Standards Handbook HB 327: 2010 Communicating and consulting about risk (Sydney: Standards Australia; 2010) offers a good general coverage. EMA’s Implementing Emergency Risk Management: A facilitator’s guide to working with committees and communities: Manual 6 (Canberra: Commonwealth of Australia; 2001) is a useful guide for people working with all aspects of emergency risk management.

Activities • • •

Identify and evaluate the risk confronting the immediate community in which you live. Identify strategies to minimise the impact of those risks. How would you identify vulnerable groups?

References Beck U. Risk Society: Towards a new modernity. London: Sage; 1992. Below R, Wirtz A, Guha-Sapir D. Disaster Category Classification and Peril Terminology for Operational Purposes [Working Paper]. Brussels: CRED; 2009. Bernstein PL. Against the Gods: The remarkable story of risk. 2nd ed. New York: John Wiley & Sons; 1998. De Chesnay M, Anderson B. Caring for the Vulnerable: Perspectives in nursing theory, practice, and research. 4th ed. Burlington: Jones & Bartlett Learning; 2016. Douglas M. Risk and Blame: Essays in cultural theory. New York: Routledge; 1992.

80  M. Tarrant & C. Gibson EMA (Emergency Management Australia). National Emergency Risk Assessment Guidelines, Handbook 10. Australian Emergency Management Handbook Series. 2nd ed. Canberra: Commonwealth of Australia; 2015. Fischhoff B. ‘Risk perception and communication unplugged: Twenty years of process’ Risk Analysis. 1995; 15(2): 137–145. Guha-Sapir D, Below R, Hoyois PH. EM-DAT: The CRED/OFDA International Disaster Database – www.emdat.be. Brussels, Belgium: Université Catholique de Louvain; 2009. International Standards Organisation. ISO 31000: 2009: Risk Management – Principles and guidelines. Geneva. IRDR (Integrated Research on Disaster Risk). Peril Classification and Hazard Glossary. Data project report no. 1. Beijing: IRDR; 2014. Kasperson RE, Golding D, Tuler S. ‘Social distrust as a factor in siting hazardous facilities and communicating risks’ Journal of Social Issues. 1992; 48(4): 161–187. Krimsky S, Golding D. Social Theories of Risk. Westport: Preager; 1992. Lupton D. Risk. New York: Routledge; 1999. Slovic, P. ‘Trust, emotion, sex, politics, and science: Surveying the risk-assessment battlefield’ Risk Analysis. 1999; 19(4): 689–701. Slovic P, Johnson BB. ‘Presenting uncertainty in health risk assessment: Initial studies of its effects on risk perception and trust’ Risk Analysis. 1995; 15(4): 485–495. Smith D, Tomb S, Coles E. Advances in Natural and Technological Hazards Research. Boston: Kluwer Academic Publishers; 2000. Smithson M. Ignorance and Uncertainty: Emerging paradigms. Springer-Verlag: Berlin; 1989. Standards Australia, Standards New Zealand. AS/NZS 5050: 2010: Business Continuity – Managing disruption-related risk. Standards Australia, Standards New Zealand. AS/NZS 4360: 2004: Risk Management.

Chapter 7

Business Continuity Management David Parsons and Peter Brouggy

Introduction and objectives All organisations are potentially at risk of disruption as a result of disasters. However, healthcare organisations, along with other emergency service organisations, often face the additional challenge of surging their operations to meet sudden increases in demand at the same time as they may face the consequences of the event on their ability to continue operations. This challenge leads to the essence of business continuity planning and preparedness and seeks to identify ways in which any organisation can continue to operate despite the impacts a disaster may have. Healthcare organisations are subject to disruption risks including direct physical damage, restricted resources (including personnel and supplies), loss of power and restricted access. To ensure continuity of services at all times, these risks must be managed through the application of business continuity principles and processes. The aim of this chapter is to examine the principles and practices of good Business Continuity Management (BCM). At the end of this chapter, you should be able to: • •

Clearly define business continuity and its components. Identify and understand the steps to develop and maintain a Business Continuity Plan (BCP) for a healthcare organisation.

Business continuity: Its application The ISO 22301 International Standard for Business Continuity Management Systems – Requirements is considered to be the best framework for managing business continuity in an organisation. This chapter draws on the business continuity process as outlined in this standard. Business continuity is defined as: . . . capability of the organisation to continue delivery of products or services at acceptable pre-defined levels following a disruptive incident. (ISO 22301: ‘Terms and definitions’: 2012: p.2) A BCP is defined as: . . . documented procedures that guide organisations to respond, recover, resume and restore to a pre-defined level of operation following disruption. (ISO 22301: ‘Terms and definitions’: 2012: p.2)

82  D. Parsons & P. Brouggy

BCPs typically address, but are not limited to, the following seven types of major disruptive events: 1 2 3 4 5 6 7

Loss of people. Denial of access to facilities. Loss of technology. Failure of suppliers. Failure of internal or external dependencies. Loss of telecommunications facility. Failure of special requirements specific to a function of the business.

When invoked, BCPs focus on the impact of a major disruption, not the cause of the disruption. For example, a flood, fire or police exclusion zone due to criminal activity or terrorist attack could cause denial of access to facilities. The impact that needs to be addressed by the BCP is being unable to access the facility, not the actual flood or terrorist attack. It is important to make the distinction between operational robustness and business continuity. Figure 7.1 is a typical business continuity continuum and depicts the range of responses that may occur at any given incident. The level of response is governed by the nature and impact of the incident. The impact of disruptive events can vary significantly. Minor incidents may disrupt an organisation but the impact can be readily addressed through pre-defined procedures or operating arrangements. Whilst this may be considered business continuity in the sense that there are documented procedures that guide the organisation to absorb the impact of the disruption and to continue to operate using alternate means, this is in fact incident management.

Operational management Emergency response Return

Im pact resolved

and/or Incident response

or

To Business as usual

C risis m anagem ent Business Continuity Plan invoked

Operate under recovery arrangements

T im e

Figure 7.1 The business continuity continuum.

Im pact resolved

Business Continuity Management  83

Examples of incident management in a hospital environment include: • • • •

Disruption to electricity supplies. Loss of parts of a hospital complex due to fire or water ingress. Extended disruption to potable water supplies. Unexpected patient surge.

BCPs may involve operating out of different premises/locations and reducing the range of functions performed to the most critical/bare minimum or redirecting functions to be performed by other teams in the organisation operating from different locations not affected by the disruption. Operating under invocation of business continuity is considered short-term until the return to business as usual (BAU). Examples of business continuity invocation in a healthcare environment include: • • • • • •

Disruption to medical gas supplies. Air conditioning failure. Disruption to staff rostering systems. Failure of communications systems. Disruption to catering services. Disruption to electronic patient records.

Implementation of business continuity systems The principles of setting up and managing a Business Continuity Management System (BCMS) as outlined in ISO 22301 (2012), also apply in the context of the healthcare environment. This standard emphasises the importance of: 1 Understanding the organisation’s needs and the necessity for establishing BCM policy and objectives, 2  Implementing and operating controls and measures for managing an organisation’s overall capability to manage disruptive incidents, 3 Monitoring and reviewing the performance and effectiveness of the BCMS, and 4 Continual improvement based on objective measurement. (ISO 22301: ‘Introduction’: 2012: p.5) When initiating, developing and managing a successful BCP, there a number of key considerations specific to the organisation: its context, leadership and commitment, policy and objectives, and resources and education/knowledge. Context of the organisation When developing and implementing a BCP that will enable an organisation to recover from a disruption, it is necessary to establish the context of how the organisation operates and the environment in which it operates. This requires an understanding of the organisation’s functions, activities, products, services and supply chains, as well as partnerships and relationships with interested parties, and the legal and regulatory

84  D. Parsons & P. Brouggy Table 7.1 Defining context of a healthcare organisation. Context to define

Examples

Core functions and services

Obstetrics Outpatients Emergency department Mental health etc. Electricity Water Sanitation Communications systems Patient records Catering Security etc. Healthcare accreditation Patient confidentiality Electricity Medical gases Laundry services Catering Regulatory requirements Board of directors Other healthcare providers

Key resources required to operate

Regulations standards and legal obligations Dependencies on key suppliers or service providers

Governance structure

context in which it operates. Furthermore, it requires a comprehensive understanding of the links between the business continuity policies and procedures and the organisation’s objectives and risk management strategies. The organisation must identify all internal and external issues that may have the potential to impede its ability to achieve its objectives. Criteria must be established for the level of risk the organisation can accept and still maintain services before crucial action is required (e.g. evacuation or removal of services) (ISO 22301: 2012). Table 7.1 provides some considerations for a healthcare facility when developing a BCP. Leadership and commitment One of the greatest enablers for implementing an effective BCMS within an organisation is executive sponsorship. Executive support legitimises the process, makes it a priority in the organisation and combats complacency. Examples of how leadership and commitment to business continuity is demonstrated include: • •

Defining responsibility with the appropriate level of authority and accountability across the organisation; e.g. an executive owner is identified and incorporated into managers’ performance agreements. Aligning policy and objectives with strategic direction and governance structure; e.g. BCMS is integrated into business plans and reporting.

Business Continuity Management  85

• • • • • • • •

Full integration with the organisation’s processes; e.g. requirements for business continuity included in contracts, building design and staff training. Making resources available, as needed. Communication is cascaded down through the organisation regarding the importance of, and compliance with, the BCMS. Providing direction and support for all staff, ensuring commitment to the BCMS. Monitoring effectiveness of the BCMS, ensuring objectives are met. Actively engaging in testing and exercising the BCMS. Regular audits and reviews of the BCMS. Promoting continual improvement of the BCMS (ISO 22301: 2012).

Policy and objectives The above information is generally captured in the BCMS policy. The business continuity policy must be appropriate for the purpose of the organisation and provide a framework for the objectives the BCMS must achieve (ISO 22301: 2012). The policy should include, but is not limited to: • • • •

Definition of the type of disruptive events that are considered in and out of scope of the BCP; e.g. in scope: patient call system failure/out of scope: pandemic. Reference to applicable standards or regulatory/legal requirements; e.g. healthcare accreditation standards. Resources, roles and responsibilities needed to achieve the objectives; e.g. business continuity executive owner, business continuity planner and/or business area managers. How objectives will be measured; e.g. milestones and targets for plan completion and testing.

Resources, education and awareness, knowledge management There are various models for resourcing business continuity within an organisation. Larger organisations have a team that manages the BCMS and is supported by staff across the organisation that may have part responsibility to manage the BCP for their functional area. Smaller organisations may allocate all responsibilities to one person or make it a part role with another position in the organisation. It is common to embed responsibility for business continuity across the organisation, with managers being responsible for their functional area. Consequently it is important to ensure that the following elements are in place:

•

Job descriptions that formally define the business continuity role and responsibility, and allocation of time to perform this role when shared with other responsibilities. Training delivery programme including, but not limited to:



– – – –

•

risk management fundamentals; conducting a business impact assessment; developing and maintaining a BCP; testing a BCP and BCP conducting exercises.

86  D. Parsons & P. Brouggy

• •

Competency development, including written and oral communication skills, and influencing skills. Robust documenting and auditing process to ensure all BCPs and training are formally managed and maintained including, but not limited to: – – – – –

being kept up-to-date; version control; formal approval; change tracking; controlled distribution.

Operational planning and control of business continuity systems ISO 22313 (2012) Business Continuity Management Systems – Guidance comprises five key elements in business continuity management, as shown in Figure 7.2. Operational planning and control is essentially programme management and control of the business continuity process within the organisation. This includes defining the methodology and implementation plan and appropriate controls to ensure the BCMS meets the organisation’s objectives. Business impact analysis and risk assessment The business continuity cycle starts with the business impact analysis (BIA). This allows the organisation to identify the functions or processes including dependencies (internal and external resources and suppliers that support its key products or services), as well as the impact over time of not performing these functions or processes. The BIA also allows the organisation to define the timeframe within which these functions or processes must be restored, referred to as the ‘recovery time objective’ (RTO) (ISO 22301: ‘Terms and definitions’: 2012: p.7), before the impact of them not being available would be unacceptable, referred to as the ‘maximum acceptable

Business impact analysis & risk assessment

Business continuity strategy

Establish & implement business continuity procedures

Exercise & test

Operational planning & control

Elements of business continuity management

Figure 7.2 Key elements in business continuity management (adapted from ISO 22313, 8.1.1 ‘Elements of BCM’: 2012: p.15).

Business Continuity Management  87 Table 7.2 A BIA template. Business function

Impacts 1–4 hours

1 day

2–7 days

2–4 weeks

Highest impact

Maximum acceptable outage

Internal short-term workarounds

Comments

outage’ (MAO) (ISO 22301: ‘Terms and definitions: 2012: p.5). Table 7.2 provides an example of suitable headings for a BIA. Identifying the types of risks and determining the likelihood of occurrence and impact to the business informs appropriate mitigation/treatment actions or the most appropriate recovery strategy should the risk occur. Decisions as to the level of investment in mitigation/treatment actions or recovery strategies are driven by the level of ‘risk appetite’. A low appetite for risk means that a greater investment is made in mitigation and recovery. For example, in a hospital setting, it may be acceptable to lose the public cafeteria for an extended period; however, a disruption to medical gases would not be acceptable for any duration. Business continuity strategy The business continuity strategy defines the most appropriate way to reduce the impact of, or to recover from, a disruption. It is directly informed by the outcome of the BIA

Case study 7.1: Eruption of volcano Eyjafjallajökull, 20 March 2010 After the eruption of volcano Eyjafjallajökull, an ash cloud hung over Iceland for three weeks. Then, on 14 April 2010, the ash cloud moved over northern Europe, where it remained for eight days. What was initially a local crisis with localised effects rapidly transformed into a complex cascading international crisis with global effects. The European aviation transport system was crippled. Globally, medical supply chains including vaccines, trade in manufactured goods and perishables including flowers, fish and fresh fruit, as well as tourism, were all affected by this crisis. Concerns were raised for both the environmental risks and for public health and the quality of food and water in the affected regions. In total 113,000 flights were cancelled and in excess of 10 million passengers left stranded. While the true social and economic cost to the global economy may never be known, the crisis cost the aviation industry $AU2.2 billion. This event demonstrated the vulnerability of our highly interdependent society. The crisis also exposed the disjointed coordination and cooperation arrangements and lack of interoperability between the 27 national airspaces affected by this disaster. Source: Parker (2015)

88  D. Parsons & P. Brouggy

and risk assessment including risk appetite, and drives the level of investment the business continuity strategy requires. Consider the example quoted earlier of a denial of access to facilities due to a flood, fire or police exclusion zone. Business continuity strategies combined with a risk treatment may consider ensuring that critical facilities such as emergency power generators or data centres are not located in building basements due to risk of flooding. Discussions could be held with police or fire authorities so that they have a better understanding of the organisation’s critical operations and the impact that an exclusion zone or fire response may have. This level of preparation and investment in building relationships and mutual understanding of key actions and priorities can significantly reduce the impact of a disruption. Considerations for business continuity strategy involve decisions regarding whether to invest in protective treatments that may reduce the likelihood or duration of a disruption. Other strategies are to assume that the impact of the disruption falls outside of the level for investment in risk mitigation/treatments and that the function must be recovered or resumed using resources not impacted by the disruption, often from another location. It is necessary to have a very clear understanding of the resources required to support the function. There is a distinction between the resources required when operating in BAU and the resources required under business continuity. Often decisions are made to only provide a subset of functions or services when operating under business continuity arrangements; hence it is only these resources that need to be identified in a BCP. This includes, but is not limited to: staff, technology, physical facilities, specialised technologies or facilities, transportation, key suppliers and internal dependencies. Examples of business continuity strategies in a healthcare context may include providing: Business continuity focuses on the impact of the disruption, not the cause.

• •

Manually operated resuscitation equipment for electricity disruptions. Portable gas bottles for medical gas disruption.

Business continuity procedures This relates to controlling the response to a disruptive incident. Business continuity teams work very closely with an organisation’s incident management team (IMT). The role of the IMT is to manage the overall incident. During a major disruption event, these teams work together to manage the recovery of the key functions of the organisation to the point they can return to BAU. BCPs usually follow a formal protocol to be invoked by the organisation’s leadership, following a major disruptive event and an assessment that the organisation cannot continue to operate via existing BAU operating facilities as a result of the disruption. Some organisations may automatically invoke a BCP in response to a large-scale disruption with formal notification back to the IMT that business continuity has been activated for the impacted area of the business. The key tool used is a BCP. This is often a printed document but may also be a website supported by specialised BCM software. The BCP addresses (but is not limited to) the following key components:

Business Continuity Management  89

• • • •

Description of the business function being addressed by the plan. Defined roles, responsibilities and authority for people enacting the plan to recover the business function. Resources required to recover the business function. Procedures to follow in the event of a disruption including:



– engagement with IMTs; – contact details to determine the welfare of staff and patients; – options and guidelines to respond to the disruption and prioritised actions.

•

A communications plan for staff, management, internal and external dependencies, and key suppliers. Procedures to recover operations under business continuity arrangements and to return to BAU when appropriate.

•

Exercising and testing An important element of planning and control is exercising and testing the BCP. This process is the key control measure to ensure that BCPs can be relied upon to recover from a disruption within the specified recovery times. BCPs should be tested annually at a minimum. A variety of methods are used to test, including: • •

•

Desktop walk through: BCP owners are presented with a scenario and they walk through their plans to check that they appropriately address the scenario. Facilities test: Special recovery facilities such as equipment at back up or recovery locations are tested. Sometimes equipment is stored at the location and needs to be set up when recovery is required. Facilities testing provides ideal training for staff and ensures the equipment is maintained, working properly and has up-todate software. Full recovery tests: Conducted when the risk appetite is such that partial testing (e.g. desktop walk throughs or facilities tests) is not deemed sufficient. Whilst a full recovery test ensures that all staff, stakeholders and equipment or facilities required for a recovery are fully tested, there can be a level of disruption to the business.

Many organisations conduct a combination of these tests in order to minimise disruption to the business and to ensure all key stakeholders are involved in the process. Performance evaluation and continuous improvement As with any management process, the BCMS needs to be constantly monitored to ensure efficiency and effectiveness, and to identify opportunities for improvement. Characteristics of a performance evaluation and continuous improvement process may include: •

Review of performance against a set of metrics such as:



– completing the development, review and testing of BCPs within specified timeframes;

90  D. Parsons & P. Brouggy



– evidence of test results; – evidence of achieving recovery within recovery time objectives.

• • •

Evidence of meeting compliance or legal obligations where appropriate. Identification and implementation of opportunities for continuous improvement. Independent review of performance metrics by senior management and internal audit. Annual or bi-annual updates of the BCM policy, framework and procedures.

•

Business continuity: Coordinating incidents The response to a disruptive event in a healthcare organisation may require the implementation of BCPs for multiple business services and systems. The disruption could be caused by an event external to the healthcare organisation such as a flood or hurricane. The healthcare organisation may be required to interact with the local community’s disaster response agencies. To effectively coordinate internal resources, a healthcare organisation requires a method of establishing a quick decision-making team. The team collects and assesses information, liaises with external agencies, decides course of action, and tasks business units in a coordinated manner. Where there is a requirement to work in an integrated way with community disaster responders, it is an advantage to use a response system they will understand, such as the incident management system (IMS). Components and functions of the IMS are discussed in detail in Chapter 16.

Conclusion This chapter has provided a detailed overview of the nature and purpose of business continuity, when it is applied and how it interacts with the IMT. Business continuity is a professional discipline with formal accreditation offered by a number of institutions. Below is some recommended reading for those seeking to gain a better understanding of this discipline.

Key readings •

Standards:



– ISO 22301: Business Continuity Management Systems – Requirements. – ISO 22313:2012: Business Continuity Management Systems – Guidance.

•

Organisations:

– Business Continuity Institute Good Business Guide: www.thebci.org.

Activity •

Consider a healthcare organisation with which you are familiar and identify strategies that could be used to maintain its services in the event of a major disaster.

Business Continuity Management  91

References ISO 22301 Business Continuity Management Systems. The British Standards Institution; 2012. www.bsigroup.com/en-AU/iso-22301-business-continuity/ (accessed 21 April 2016). ISO 22313:2012 Societal security–Business continuity management systems–Guidance. International Organization for Standardization; 2012. www.iso.org/iso/catalogue_detail? csnumber=50050 (accessed 21 April 2016). Parker CF. ‘Complex negative events and the diffusion of crisis: Lessons from the 2010 and 2011 Icelandic volcanic ash cloud events. Geografiska Annaler: Series A, Physical Geography. 2015; 97(1): 97–08.

Chapter 8

Risk and crisis communication during health disasters Amisha Mehta, Bob Jensen, Ingrid Larkin and Robina Xavier

Introduction and objectives Communication plays an essential role in encouraging preparedness for health, natural and organisational disasters, and in guiding the response to, and recovery from, these disasters. Influenced by stakeholders including media, politicians, the private sector, faith-based and community organisations, and community members, the way organisations communicate during health disasters is critical. Disasters in the health context can emerge directly from events such as pandemics and outbreaks of disease or infections (for example, Legionnaires’ disease or highly resistant staphylococcus aureus in hospital settings). Alternatively, they could be linked to effects of other natural, organisational or human-led disasters such as terrorist events. Interspersed with examples from Australian and international health disasters, this chapter aims to identify key concepts that have led to the current best practice in risk and crisis communication. At the end of this chapter, you should be able to: • • • •

Discuss the main foundation for effective risk and crisis communication. Outline the importance of establishing and maintaining strong relationships prior to disasters. Identify key players in response-phase risk and crisis communication who set the context for disaster planning, effective message design, and execution. Understand the challenges and opportunities impacting risk and crisis communication during health disasters.

Trust and engagement before health disasters Trust can be defined as: The willingness of a party to be vulnerable to the actions of another party based on the expectation that the other will perform a particular action important to the trustor, irrespective of the ability to monitor or control that other party. (Mayer et al. 1995: p.712) Trust is an essential part of relationships and it is often tested during crises and disasters. Recently, four domains were developed for the public health disasters trustscale (Eisenman et al. 2012):

Risk & crisis communication during health disasters  93

1 2 3 4

Honesty (truthful information). Fairness (acting in others’ interests). Competency (technical proficiency). Confidentiality (maintaining privacy).

Interestingly, much of the crisis literature examines how effective communication can enhance organisational or corporate reputation and image (Coombs 2006; Benoit 2004). Although outcomes such as reputation and image are essential for businesses that operate in competitive environments where consumers may choose alternative providers, they may not be as relevant in the context of health disasters. Organisations, governments and authorities that feature during health disasters often lack direct competitors and involve community members who lack the ability to choose services. In this chapter, trust is presented as an appropriate alternative outcome to reputation, and as the essential condition for enabling stakeholders to take actions to help prevent or respond to a crisis. Trust generally increases over time; therefore, it is important to establish, build and maintain trusting relationships between organisations, communities and businesses before, during and after disasters. A fundamental communication strategy to support this process is community engagement. A strong relationship between and among key parties before, during and after disasters creates social capital, thereby enabling public relations and communication activities to achieve positive social outcomes (Taylor and Kent 2014). From a more strategic perspective, favourable relationships with stakeholders have been strongly linked to a positive reputation (Coombs and Holladay 2001). There are multiple ways to engage communities and other stakeholders from deep integration into decision-making, to policy commitments or publicfacing activities such as the communication of information (Sloan 2009). The value of long-term community relations programs is their ability to build community capability when disasters occur (Heath and Palenchar 2000). Engagement is a two-way process and organisation staff and leadership need to understand the concepts of active listening to help foster a strong relationship. Disasters bring uncertainty, which can test and challenge relationships and trust. At a broad level, health disasters can create concern and sometimes panic in communities. At the same time, healthcare providers and organisations often face the dual task of learning and upskilling about the disaster, as well as managing ongoing care (MedfordDavis and Kapur 2014).

Key communication stakeholders in disasters There are a number of stakeholders critical to organisations involved in health disasters. Traditionally, relationships have been viewed by placing the core organisation as the central actor for all other stakeholders (see Figure 8.1). Although the hub and spoke model is a simple way to identify stakeholders, it is important to keep in mind that relationships exist between and amongst all stakeholders. Following from the identification of stakeholders, it is useful to view key communication stakeholders as a series of networked relationships or ‘a web of complex relationships’ (Allen and Caillouet 1994: p.44) where the actions of multiple stakeholders can either add pressures, or support each other as well as the core organisation.

94  A. Mehta, B. Jensen, I. Larkin & R. Xavier

Emergency services organisations

Utility & water companies Business

Community

Media

Politicians

ORGANISATION

Governments & government departments

Figure 8.1 Identifying key communication stakeholders.

This perspective is particularly relevant for engagement and communication before, during and after health disasters, because risk and crisis communication and protective behaviours become a shared responsibility for all stakeholders. Furthermore, different stakeholders can communicate with different levels of impact and relevance.

Media as a key communication stakeholder Understanding the dynamic landscape of media is essential for disaster managers. There are many types of media, which can be broadly categorised as direct (straight from the journalist) or mediated by ‘gatekeepers’ such as editors, who set the agenda for stories and content. Across both categories, media comprises print, electronic, online, and mixed or complementary channels. Within these channels are varying sources from experienced and trained journalists who commit to abiding by codes of conduct and ethics, to individual bloggers who may have substantial followings, but may lack formal training in journalism and broadcast communication. Both traditional and social media are an important source of information for a range of issues and current affairs. In disasters, they play a critical role in informing communities. However, traditional media have the potential to sensationalise information in news coverage (Dahlstrom et al. 2012), and social media have the potential to be a platform for both verified and unverified content. Both sensationalism and unverified content can challenge the accuracy of risk information about disasters, and bias the way people assess and respond to the risks they face. During disasters, media becomes an important channel to communicate with communities. Therefore it is imperative to understand how the media works, and how people use media before and during disasters.

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Media type and reporting roles Each media type approaches news and reporting in a different way. Generally, print and online text-based media are able to present detailed information that provides backgrounds to complex events. Television, image and video-based online media have the potential for emotional impact by portraying images, whereas radio can provide ways to engage multiple community members in audio-based communication and analysis of an issue. During disasters, radio is one of the channels that can operate without power and telecommunications. Others include direct person-to-person communication, town halls, posters, direct mail or handouts, and other print products. Digital/social media platforms Digital or social media platforms are an integral channel for communication during disasters. Social media comprise a number of digital platforms and applications including Twitter, Facebook, YouTube, Reddit, Instagram, Vine, Snapchat and Meerkat. Social media take on a number of functions for multiple users during disasters; signalling and detecting events, working as a platform that connects multiple users to share information about disasters and recovery processes (Houston et al. 2015), and gathering information whilst sharing and observing emotions (Neubaum et al. 2014). The functions of social media in all disaster stages, from pre- to post-event, are identified in Figure 8.2. Additionally, social media provide five primary functions that cross multiple levels of analysis: interpersonal communication, group communication, mass media, information sharing and information gathering (Jung and Moro 2014).

Pre-event to event Signal & detect disasters

Post-event Discuss socio-political & scientific causes, implications' of & responsibility for events Reconnect community

Event Send & receive requests for help Advise appropriate behaviours Inform others & learn about disaster-affected areas

Event to post-event Share disaster response & recovery information Donate & identify ways to help Provide & receive physical & mental health support

Figure 8.2 Functions of social media in disasters (adapted from Houston et al. 2015).

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News consumption by media type From a theoretical perspective, the way people consume news has changed significantly over time, with patterns of multiple media use or convergence now commonplace, rather than a preference for single media selection (Yuan 2011). Media convergence challenges traditional theories such as agenda-setting by proposing that consumers integrate multiple media platforms to form complex patterns of media use and understanding of news (Yuan 2011). Put simply, media convergence theory impacts the way people consume information from the media and shifts the power balance in journalism (Jenkins 2004). Media convergence theory has implications for organisations involved in health disasters, including audience segmentation approaches. Immediate and constant access to multiple media channels on multiple devices impacts how people seek, consume and share information. However, in disaster settings this access may be restricted or eliminated. Organisations responding in disaster settings must navigate the challenges of the ubiquitous access to rich and varied media, and balance this with the possibility of access being eliminated, and thus the need to return to communication via non-digital channels.

Community as a key communication stakeholder Disasters affect communities directly and indirectly and bring high levels of uncertainty and variance in warning times, providing significant challenges to responding

Case study 8.1: Ebola outbreak, US, 2014 During October 2014, information about Ebola cases in the US heightened public anxiety about the spread of the virus (Fung et al. 2014). The Centre for Disease Control (CDC) was quick to respond with information and illustrations about the virus, how it is spread, and how people can and cannot contract the virus. However, according to Fung et al.’s research, news about Ebola cases in the US triggered a marked number of tweets still reflecting public anxiety about the contagion and spread of the virus. The role of rumours and misinformation following the report of Ebola cases in the US was the subject of much media analysis. One of these articles includes the following insights from the CDC: ‘Rumours move much more quickly in the social media space than they would have otherwise,’ says Barbara Reynolds, head of public affairs for the CDC. ‘People want information and one of the best things we can do is give them information in a way that they can take it in and manage their emotions.’ (Luckerson 2014) Social media platforms like Twitter can provide a quick indication of public anxiety and fear levels that can therefore guide medical and public health responses to disasters (Fung et al. 2014).

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organisations as well as stakeholders. For disasters with longer lead times, gaining and maintaining the attention and trust of community members is critical to their perception of, and response to, the imminent though uncertain risk (Laughery and Wogalter 2014). Communities comprise individuals and groups (e.g. households and community groups), as well as businesses. People in communities have diverse experiences, interests and backgrounds. People will engage with, and respond to, risk information depending on their individual characteristics, including demographics (age, gender, social and economic status, and education), personality, self-concept, social identity, self-efficacy and past experiences (Cialdini and Goldstein 2004; Fitch 1994; Glik 2007), as well as their learning style (Sellnow et al. 2014). In addition, the specific features of the disaster will influence how people engage. For example, people who have experienced similar disasters with some regularity are more likely to understand the value in preparing for these events. Understanding these individual differences has the potential to guide communication. Traditionally, community is seen as the primary target of emergency services organisations, and this perspective is reflected in research that shows how the majority of online government communication focuses on ‘push strategies’ (Waters and Williams 2011), where information is delivered to specific recipients, rather than an audience accessing this information at their discretion and priority. However, to be most effective, risk communication should be a two-way process of interpretation and meaning creation, incorporating feedback and input from the community. Community members who become both the source and recipient of critical information during disasters more commonly model these experiences. Existing research shows that people found local sources of information more persuasive than media appeals (Brenkert-Smith et al. 2012). At the same time, the accuracy of this information is critical. In response to the 2014 Ebola outbreak, a number of resources were developed for different audiences in different regions of Africa. For example, the United Nations International Children’s Emergency Fund (UNICEF), CDC and the World Health Organization (WHO) created a series of factsheets for school administrators, school students and community members in West Africa that included key messages about what people should know, do and tell others (see: www.cdc.gov/vhf/ebola/outbreaks/2014-westafrica/communication-resources/index.html). There are also resources to support family members of first responders (see: www.cdc.gov/vhf/ebola/families/index.html). Understanding and working within the networks of communities is an important way to enhance relationships between emergency services organisations and community members before, during and following disasters.

Communication processes and planning Health disasters affect lives and relationships, along with community and economic resilience. The potential damage from disasters has encouraged organisations to focus on crisis planning and pre-disaster decision-making. To maintain trust, confidence and support of its stakeholders, an organisation needs to consider carefully its response to disasters. In doing so, an organisation must recognise the importance of not only its own view on its response but the perceptions of its stakeholders (Dowling 2004).

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Penrose (2000) highlights the importance of the public perception of a crisis, suggesting that, ultimately, such public perception is reality. Communication with key stakeholders is one of the most important functions of any disaster management plan. Roles need to be clearly described, especially who will be the lead spokesperson and how information flows from the operational side to be released to stakeholders, including media and the public. Input from stakeholders is also a key element to planning and response during the actual disaster and needs to be included in the communication planning.

Risk and crisis communication Risk and crisis communication primarily occurs at a time when people are vulnerable. The organisation and key communicator’s philosophy or rationale behind risk and crisis communication is as important as the message. While each organisation and individual will have their own approach, advice from leading experts in this area highlights the value of empathy and a genuine connection and commitment to the affected community, which is best summarised in this quote: . . . Vincent Covello, for example, argues that caring/empathy accounts for 50 percent of trust; the other 50 percent, he says, is shared about equally by dedication/commitment, honesty/openness, and competence/expertise. People (especially people who are upset) don’t care what you know until they know that you care. (Sandman 2008: p.1) Following the philosophical approach, the content and methods of communication can take a more strategic approach and align with the phases of disaster. The primary challenge is to gain the attention of community members about an imminent event. Once a disaster is known, communication can comprise three types of information: instructing, adjusting and internalising (Sturges 1994). Instructing information contains content that advises people about how to physically react to the event and is often delivered as a warning or instruction that notes specific and immediate behaviours (Sturges 1994). Instructional messages can be framed in multiple ways with appeals that are direct and rational, threat/fear-driven, positive (to reward compliance), normative (to appeal to social consensus), or based on selfconcepts (see Mehta et al. 2014). Instructions are more common during the response and early recovery phases of disasters. Adjusting information includes content that helps people to psychologically cope with the event (Sturges 1994). This might include information that enhances people’s ability to respond to the event and reassures community members about the presence of emergency services personnel. It can be delivered through social media, mass media and interpersonal channels. This kind of information is usually seen as secondary content during disasters and primary content following disasters. Finally, internalising information helps people to formulate an image about the organisation (Sturges 1994). It is more commonly recognised in the public relations literature as a means to help restore or improve the post-disaster image or reputation of emergency services organisations.

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Risk communication message design and dissemination There are many principles that guide the development of risk communication Adapt core messages to gain including precision and self-efficacy. attention & motivate responses from As noted above, messages should create community members. accurate risk perceptions or assessments and avoid panic. One way to achieve this is by being precise. Precise messages include details about the disaster, location, required actions and timing that are communicated to personalise risk and influence protective action (Mileti and Peek 2000; Stein et al. 2013). To enhance protective actions, messages can also be designed to integrate self-efficacy. Organisations can To design effective messages, tailor messages to enhance the inditranslate operational information viduals’ perceptions of self-efficacy by to suit the needs of community personalising and boosting confidence members. about their ability to undertake the required self-protective actions (Verroen et al. 2013; Macinnis et al. 1991). For example, Schoolies is an event where final year graduating students from across Australia celebrate the end of high school on Queensland’s Gold Coast. In anticipation of the event, the Queensland Ambulance Service (QAS: @QldAmbulance) tweeted the following: #Schoolies tip: planning a big night? Pace yourself and stay hydrated by alternating with water. 40% of jobs we attend are for intoxication. A recent study of the content of public health tweets following a flood event in the US showed that people were seeking a variety of information from the safety of drinking water to the effects of floodwater exposure as well as updates about cleaning/ sanitation and sewage/wastewater (Sutton et al. 2015). While information and/or instructions can be summarised in tweets, links can also provide further details or visual cues to guide protective action. The tools and channels used to disseminate messages must be carefully selected to reach different audiences so that these audiences effectively engage with the message and take subsequent actions. Organisations must fully consider the challenges of media convergence and multiple channels, as well as the potential consequences of a disaster that may impact or eliminate access to media (e.g. power or telecommunication failure). It is important to plan for, and to expect, these circumstances and so to use multiple channels of communication to ensure messages get through.

Disaster management review Following a disaster, an organisation should take the time to review disaster management and communication approaches in order to identify areas of strength, and those in need of improvement. Ideally, this process should integrate different stakeholders to provide multiple viewpoints and combine formal and informal research. These findings will highlight potential issues about the decisions or reactions of decisionmakers internal to organisations, as well as external issues such as a fall in public

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trust or confidence. Both internal and external issues have the potential to influence responses to future disasters and the programs of organisations and governments.

Challenges and opportunities There are many challenges and opportunities in risk and warning communication that are the focus of specific inquiry for organisations, researchers and educators in this field. Some of the key areas to consider during the planning and execution phases are: •

•

•

•

•

Avoid assumptions: It is best not to assume that all audiences receive the same message and interpret the message in the same way. Individuals bring different lenses and experiences or biases to information, leading to different interpretation and response. Organisations can address this by planning communication in multiple ways at multiple times to multiple audiences. Trust, but verify: Be aware of the ways to verify information in online communication and its implications for crowdsourcing and myth-busting activities by emergency services organisations. This process can take time and resources and be challenged by individual community members. Create connections but expect non-compliance: Perfect compliance together with safe and swift responses to disasters are ideal but rarely occur. Some people still refuse to be vaccinated (Velan et al. 2011), or fail to follow medical treatment procedures, potentially risking their life and the lives of others. One way to communicate with diverse and disengaged audiences is to create connections with trusted opinion leaders who might add an alternative but valuable perspective to the more traditional voices and arguments during disasters. Expect and respond to stress: Uncertainty and stress impacts decision-making of the community and of emergency services personnel and communicators. Organisations must prepare for the impact of uncertainty and stress by designing messages with clarity, and considering repetition and reinforcement. Make messages accessible: Organisations should consider the range of audiences with different language and cultural backgrounds, or disabilities that influence access to or comprehension of communication. Multiple tools and channels are Be prepared for your own reaction likely to address requirements of all to emergencies. audience members.

Key readings Alexander D. ‘Social media in disaster risk reduction and crisis management’ Science and Engineering Ethics. 2014; 20: 717–733. Houston JB, Hawthorne J, Perreault MF et al. ‘Social media and disasters: A functional framework for social media use in disaster planning, response, and research’ Disasters. 2015; 39:1–22. Kent M, Ellis K. ‘People with disability and new disaster communications: Access and the social media mash-up’ Disability & Society. 2015; 30(3): 419–431.

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Lorenzi D, Chun S, Vaidya J et al. ‘PEER: A framework for public engagement in emergency response’ International Journal of E-Planning Research. 2015; 4(3): 29–46. Nowell B, Steelman T. ‘Communication under fire: The role of embeddedness in the emergence and efficacy of disaster response communication networks’ Journal of Public Administration Research and Theory. 2014; 25: 929–952. Spence P, Lachlan K, Lin X et al. ‘Variability in Twitter content across the stages of a natural disaster: Implications for crisis communications’ Communication Quarterly. 2015; 63(2): 171–186. Steelman T, McCaffrey S, Knox Velez A et al. ‘What information do people use, trust and find useful during a disaster? Evidence from five large wildfires’ Natural Hazards. 2015; 76: 615–634.

Activities •

The Bureau of Meteorology is predicting a cyclone will cross the coast in the next 24 hours. It is currently a Category 1 system moving at 25 kilometres per hour. The local disaster management group is on alert and you are the nominated spokesperson for communication to your community, which has been previously affected by cyclones.



– What information will you provide and what instructions will you ask of the community? – What communication channels will you use to share this information? – How will you tailor this information and select channels to suit non-English speaking residents, people with hearing and/or visual impairment, young people and older people?



•

Below are some examples of tweets issued by Queensland Fire and Emergency Services and Queensland Police following the alert of Tropical Cyclone Marcia in February 2015. How do your responses to question one compare? What would you retain or change based on your experiences and learning in this chapter?

Tweets (at Twitter handle QLDFES) 1 Prepare now as #TCMarcia approaches http://t.co/42v0byWOl4 http://t.co/ MGfhVu8vyX. 2 #TCMarcia upgraded to a Category 2 system, still on track to cross the Capricorn Coast early Friday morn http://t.co/ujkD7EnnhC. 3 @BOM_Qld have forecast #TCMarcia to bring damaging storm tides for areas of central and south east coast #GetReadyQld http://t.co/7jFtYCRkEg. 4 Our swift water rescue techs are ready for #TCMarcia, deployed to at-risk areas #ifitsfloodedforgetit http://t.co/5hZEeKlvMp. Tweets (at Twitter handle QPSMEDIA) 1 Bundy Police: Prepare your emergency kit, home, pets & check on neighbours #TCMarcia http://t.co/rEWskzbEpZ http://t.co/hYQcVEmX74.

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2

The Bruce Hwy, sth of Rockhampton will soon be closed at Midgee for 15 minutes as cattle are moved to higher ground #TCMarcia #SteerClear. 3 Police are encouraging QLDers to sign up to Red Cross’ service so they can be reunited with family after #TCMarcia http://t.co/saiRoHpM9v. 4 #TCMarcia press conference due to start shortly http://t.co/Nf8kO9q6Mr.

References Allen MW, Caillouet RH. ‘Legitimation endeavours: Impression management strategies used by an organisation in crisis’ Communication Monographs. 1994; 61(1): 44–62. Benoit WL. ‘Image resotration discourse and crisis communication’. In: Millar DP, Heath RL, editors. Responding to Crisis: A rhetorical approach to crisis communication. Mahwah, NJ: Lawrence Erlbaum; 2004. Brenkert-Smith H, Dickinson KL, Champ PA et al. ‘Social amplification of wildfire risk: The role of social interactions and information sciences’ Risk Analysis. 2012; 33(5): 800–817. Cialdini RB, Goldstein JJ. ‘Social influence: Compliance and conformity’ Annual Review of Psychology. 2004; 55: 591–621. Coombs WT. ‘The protective powers of crisis response strategies: Managing reputational assets during a crisis’ Journal of Promotion Management. 2006; 12(3–4): 240–260. Coombs WT, Holladay SJ. ‘An extended examination of the crisis situations: A fusion of the relational management and symbolic approaches’ Journal of Public Relations Research. 2001; 13(4): 321–340. Dahlstrom MF, Dudo A, Brossard D. ‘Precision of information, sensational information, and self-efficacy information as message-level variables affecting risk perceptions’ Risk Analysis. 2012; 32(1): 155–166. Dowling GR. ‘Journalists’ evaluation of corporate reputations’ Corporate Reputation Review. 2004; 7(2): 196–205. Eisenman DP, Williams MV, Glik D et al. ‘The public health disaster trust scale: Validation of a brief measure’ Journal of Public Health Management Practice. 2012; 18(4): E11–E18. Fitch KL. ‘A cross-cultural study of directive sequences and some implications for compliancegaining research’ Communication Monographs. 1994; 61(3): 185–209. Fung I C-H, Tsz Ho Tse Z, Cheung C-N et al. ‘Ebola and the social media’ The Lancet. 2014; 384(9961): 2207. Glik DC. ‘Risk communication for public health emergencies’ Annual Review of Public Health. 2007; 28(1): 33–54. Heath RL, Palenchar M. ‘Community relations and risk communication: A longitudinal study of the impact of emergency response messages’ Journal of Public Relations Research. 2000; 12(2): 131–161. Houston JB, Hawthorne J, Perreault MF et al. ‘Social media and disasters: A functional framework for social media use in disaster planning, response, and research’ Disasters. 2015; 39(1): 1–22. Jenkins H. ‘The cultural logic of media convergence’ International Journal of Cultural Studies. 2004; 7(1): 33–43. Jung J-Y, Moro M. ‘Multi-level functionality of social media in the aftermath of Great East Japan Earthquake’ Disasters. 2014; 38(2): s123–s143. Laughery KR, Wogalter MS. ‘A three-stage model summarizes product warning and environmental sign research’ Safety Science. 2014; 61: 3–10. Luckerson V. ‘Fear, misinformation, and social media complicate Ebola fight’ Time Magazine. 8 Oct 2014.

Risk & crisis communication during health disasters  103 Macinnis DJ, Moorman C, Jaworski BJ. ‘Enhancing and measuring consumers’ motivation, opportunity, and ability to process brand information from ads’ Journal of Marketing. 1991; 55(4): 32–53. Mayer RC, Davis JH, Schoorman FD. ‘An integrative model of organizational trust’ Academy of Management Review. 1995; 20(3): 709–734. Medford-Davis LN, Kapur GB. ‘Preparing for effective communications during disasters: Lessons from a World Health Organization quality improvement project’ International Journal of Emergency Management. 2014; 7(1): 1–7. Mehta A, Greer DA, Dootson P et al. Making Smart Decisions: Key steps towards a typology for emergency communication during natural hazards. Brisbane: Digital Transformations; 2014. Mileti DS, Peek L. ‘The social psychology of public response to warnings of a nuclear power plant accident’ Journal of Hazardous Materials. 2000; 75(2–3): 181–194. Neubaum G, Rosner L, Rosenthal-Von Der Putten AM et al. ‘Psychosocial functions of social media usage in a disaster situation: A multi-methodological approach’ Computers in Human Behavior. 2014; 32: 28–38. Penrose JM. ‘The role of perception in crisis planning’ Public Relations Review. 2000; 26(2): 155–171. Sandman PP. ‘Handling explosive emotions demands five acts of empathy’ ISHN. 2008; 42(1–1): 24–26. Sellnow DD, Lane D, Littlefield RS et al. ‘A receiver-based approach to effective instructional crisis communication’ Journal of Contingencies and Crisis Management. 2014; 23(3): 1–10. Sloan P. ‘Redefining stakeholder engagement’ Journal of Corporate Citizenship. 2009; 36(1): 25–40. Stein R, Buzcu-Guven B, Duenas-Osorio L et al. ‘How risk perceptions influence evacuations from hurricanes and compliance with government directives’ Policy Studies Journal. 2013; 41(2): 319–342. Sturges DL. ‘Communicating through crisis: A strategy for organisational survival’ Management Communication Quarterly. 1994; 7(3): 297–316. Sutton J, League C, Sellnow TL et al. ‘Terse messaging and public health in the midst of natural disasters: The case of the Boulder Floods’ Health Communication. 2015; 30(2): 135–143. Taylor M, Kent ML. ‘Dialogic engagement: Clarifying foundational concepts’ Journal of Public Relations Research. 2014; 26(5): 384–398. Velan B, Kaplan G, Ziv A et al. ‘Major motives in non-acceptance of A/H1N1 flu vaccination: The weight of rational assessment’ Vaccine. 2011; 29(6): 1173–1179. Verroen S, Gutteling JM, De Vries PW. ‘Enhancing self-protective behavior: Efficacy beliefs and peer feedback in risk communication’ Risk Analysis. 2013; 33(7): 1252–1264. Waters RD, Williams JM. ‘Squawking, tweeting, cooing, and hooting: Analyzing the communication patterns of government agencies on Twitter’ Journal of Public Affairs. 2011; 11(4): 353–363. Yuan E. ‘New consumption across multiple media platforms’ Information, Communication & Society. 2011; 14(7): 998–1016.

Chapter 9

Community engagement Ghasem-Sam Toloo and Marie Fredriksen

Introduction and objectives One of the fundamental shifts that has occurred in disaster management over recent decades has been a change in emphasis from an almost complete focus on response agencies towards a more holistic approach that involves all aspects of community working in partnership to achieve improved whole-of-community outcomes. This greater involvement of the community directly permeates all aspects of disaster management throughout the PPRR cycle. The concepts that underpin this chapter are derived from those of disaster resilience, and building a resilient community through engagement. Community engagement is important as it enhances resilience and longterm sustainability of the community by building trust and sharing the knowledge, experience, decision-making and burden among the citizens and authorities. On completion of this chapter you should be able to: • • •

Understand the concept of community engagement throughout every stage of PPRR. Identify the elements of community that contribute to effective PPRR. Discuss the mechanisms of evaluating effective community engagement.

What is a community? It may be useful to clarify the concept of community within the disaster management context. Defining community and its characteristics can be complicated. Communities can be regarded as a source of strong values and spirit, of complex social units and systems operating within specific boundaries, often with a shared sense of identity, meaning and common interests. Within the context of disaster management, the definition of community used throughout this chapter will be that of MacQueen et al. (2001): . . . a group of people with diverse characteristics who are linked by social ties, share common perspectives, and engage in joint action in geographical locations or settings. This definition is useful for our purpose as it encompasses the major characteristics that are important for engaging with heterogeneous communities in disaster

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management. This includes socio-demographic differences (e.g. age and gender), cultural diversity (e.g. ethnicity) and shared perspectives (e.g. religious). Effective community engagement practices during disaster PPRR should draw upon these characteristics to enable participation of all its members, whereby leading to longterm resilience. In this sense, communities are seen as stakeholders in the PPRR process and a valuable source of information on which disaster-planning authorities can capitalise.

Community as stakeholders Community engagement is closely linked to seeing the people or citizens as stakeholders. The concept of stakeholders is equally difficult to define despite the constancy of reliance on ‘stakeholder engagement’ as a cornerstone of modern management principles, particularly in disaster management. While literally meaning those ‘holding a stake in the outcome’, some distinguish stakeholders from service providers or emergency responders, while others limit the use of the term to community representation. As mentioned above, community is a diffuse and movable concept, but regardless how a community is defined, it is inevitably a composite of all its component parts. This includes its citizens, response organisations, government representatives and officials. One significant aspect of seeing community as stakeholders is shared decisionmaking. Community decision-making is not the same as individual decision-making. An individual can weigh up the alternatives and make a best-case decision. But decision-making processes at the community level are much more complicated, and this is further aggravated by the complex nature of communities. Additionally, individual and community priorities before an event may differ significantly after the event (Cox 2012). A broken piece of china seems far less important when you have lost your home to fire or flood. Collective decision-making may result in decisions that are combinations of elements from various perspectives that ultimately may not be favoured by all. To reduce conflict, it is important to reach a common ground to ensure decisions made provide the greatest good for the greatest number. For example, a part of the flood mitigation strategy in the Netherlands involves deliberately inundating some populated areas in order to prevent flooding in the wider community. The Dutch government carried out extensive consultation with landholders and whilst those who will be directly affected may prefer a different strategy, the cost–benefit analysis ensures the greatest good for the greatest number (for more information, visit www.technologyreview.com/news/531131/sharing-flood-mitigation-strategies-withat-risk-countries). Community consultation was a critical part of the Dutch strategy. However, Kuziemsky and Varpio (2010) warn that reaching common ground does not develop immediately. It requires an all-inclusive approach to engage with the community and an interactive cycle of continual consultation, information exchange, networking and collaboration.

Factors affecting community engagement There are many interrelated factors that will impact effective community engagement, including socio-demographics, social capital and leadership.

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Socio-demographic characteristics and vulnerability Disasters affect individuals, families and communities in many different ways. An important consideration for disaster management is the composition of the population in a given area impacted by a disaster. Developing an understanding of the community/ societal context is critical to understanding the impact of disasters and the potential for recovery. The key focus of disaster management involves meeting people’s changing physical and social needs (e.g. food, shelter, safety, connections, income), as well as their physical health and psychological needs. Disasters have a cumulative or compounding effect on community functioning, as the economic, physical, and health and wellbeing consequences interrelate. This also helps to inform the particular vulnerabilities of individuals and community groups that may require special consideration in all phases of the disaster management continuum. Vulnerability is the pre-event, inherent characteristics or qualities of social systems that create the potential for harm. It is a function of the exposure (who or what is at risk) and sensitivity of the system (the degree to which people and places can be harmed), and is defined as: . . . the characteristics of a person or group and their situation that influence their capacity to anticipate, cope with, resist, and recover from the impact of a . . . hazard. (Wisner et al. 2004: p.11) Some socio-demographic characteristics that may impact on the vulnerability of communities in disasters include: special needs groups, communication barriers, socioeconomic status, cultural differences and mass population movement. However, vulnerability and resilience are not solely related to age, disability, poverty, lack of education, health, geographic location or the inability to speak the predominant language; it is also a consequence of lifestyle. It is important to understand the qualitative nature of communities and how these qualities may vary not only over time as a consequence of broader social and economic changes, but also when communities are placed under stress. As Marsh (2001) warns, communities are not static and any destabilisation can severely impede their ability to ‘bounce back’. Special needs groups The community affected by a disaster comprises individuals, groups and organisations with differing needs. Some may be directly affected, injured, deprived of access to normal supports or bereaved. Others may be indirectly affected either as responders or supporters. Some will be particularly vulnerable due to their special circumstances and needs such as children, the elderly, women, people with physical/intellectual disability or mental illness, those restrained (e.g. prisoners), alternate sexual orientation, and indigenous communities (AEMI 2011). These communities and groups can be easily excluded due to limited mobility or access to information, services and support (financial, physical, emotional and social). Influenza pandemics and heatwaves often differentially impact on the elderly and children. Women are more vulnerable as they often fulfil a protective family function

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which complicates their ability to escape. In many societies, a woman’s relative lack of education and economic capacity reduces their resilience even further. People with restricted mobility (e.g. disabled or imprisoned) may not be able to evacuate or escape. Residents in remote areas may not receive timely updates or appropriate support in preparing for and dealing with disasters. Disaster managers must engage with these communities to ensure they are included in all stages of PPRR. Communication barriers Community engagement should take into consideration language and educational differences within the community. Where different languages are spoken, including sign language, or people with varying levels of literacy, multiple strategies for engagement are required to ensure the entire community has the opportunity to be involved in all aspects of disaster management PPRR. These may range from simple face-to-face contacts to multilingual information brochures or complex interactive computer programs and games. Socio-economic status Lower socio-economic status is associated with higher vulnerability. The effect on these groups is more severe during disasters. Affluent communities have the ability to recover and ‘bounce back’ quickly following a disaster. In general, these communities will have individually and collectively prepared for, and are able to adapt in the lead up to a disaster. They possess a strong local community and a robust and mostly trusted governance structure, with effective, well-trained essential service organisations, and a comparatively low level of social inequality (Walters 2015). By contrast, communities without a trusted governance structure and effective well-trained response organisations generally do not have the ability to ‘bounce back’ as quickly (Walters 2015). Case studies of Cyclone Nargis (9.1), Burma, and Cyclone Yasi (9.2), Australia, provide a comparison of two countries with vastly different governance and disaster PPRR structures. Cultural differences Well-established communities will often have knowledge of, and experience with, disasters. Generational knowledge handed down through stories and rituals in many indigenous communities is valuable to PPRR. However, some beliefs or practices (e.g. fatalistic ideas or belief in metaphysical powers) may impede effective PPRR. It is important that disaster managers acknowledge and work with all religious, cultural and ethnic beliefs and practices. Engaging with communities as stakeholders fosters connectedness and a sense of coherence and belonging, which strengthens and empowers communities to build resilience (Morgan and Ziglio 2010). Mass population movement Displaced communities, similar to the large movements of refugees across Europe, Africa and the Middle East throughout 2015, are particularly vulnerable to disasters.

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Case study 9.1: Cyclone Nargis, May 2008 The former government of Burma (now Myanmar), a military junta, spent less than 2% GDP on health and education combined, while military expenditure was 40% GDP (Willis 2012). Following Cyclone Nargis in the Irrawaddy Delta region in 2008, the government was accused of crimes against humanity (Coppola 2011). Warnings from the Indian Meteorological Department on 29 April 2008 that a cyclone would make landfall on the Irrawaddy Delta region were issued to the Burmese Department of Meteorology and Hydrology (HRW 2010). Despite this, the then Burmese government failed to act; communities in the region were not advised and no preparations were made (HRW 2010). The cyclone made landfall on 2 May 2008, killing more than 150,000 people with a further 2.4 million people severely affected. Destruction was widespread: 50% of the schools and 75% of the region’s healthcare facilities were destroyed or damaged (Willis 2012). Following the cyclone, the military regime prevented thousands of bilateral and international non-governmental humanitarian responders from entering the country (Pearson 2010). Furthermore, the government of the day failed to provide the basic necessities of life (including food, water and shelter), restricted access to information, seized control of foreign aid, distributed aid based on ethnicity and religion, forcibly relocated survivors, and confiscated land (Haacke 2009). A limited number of NGOs from within the region were granted access almost three weeks after the cyclone, whereby enabling some assistance to be provided (Coppola 2011).

In addition to socio-cultural differences, they may suffer increased incidence of health conditions including mental illness associated with exposure to traumatic events. Despite their vulnerability, these communities may also possess survival experience and knowledge, which can assist disaster managers. The huge influx of refugees imposes added demand for services including sustenance, sanitation, housing, health, employment, and education and integration programs. These services place extra pressure on the budget of the host community. Given the infrequency and unpredictability of natural disasters, this may potentially shift funding away from disaster management programs. To strengthen resilience, it is imperative that host communities maintain effective PPRR, ensuring this vulnerable population is fully engaged in the process. Social capital The concept of social capital is a core component of community engagement and resilience. Cheers et al. (2007) define social capital as: . . . a measure of the communal trust, cooperation, and reciprocity components of community capacity. Social capital is a community asset that can be accumulated,

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Case study 9.2: Cyclone Yasi, February 2011 Australia has a democratically elected system of federal, state and local governments. Throughout 2011–2015, Australia’s spending on health was 9.4% GDP (World Bank 2015a), education was 4.9% GDP (World Bank 2015b), and military expenditure was 1.8% GDP (World Bank 2015c). Australian states maintain comprehensive, all-hazards disaster management arrangements with extensive consultation between governments and communities in all aspects of PPRR. On 3 February 2011, far north Queensland was hit by Category 5 Cyclone Yasi. Prior to the cyclone making landfall, cyclone warnings and information on cyclone preparations were widely distributed through a variety of mediums and they were continually updated (Olsson 2014). Additional emergency services personnel and critical infrastructure technicians were positioned close to the region out of the impact zone so they could respond rapidly once the immediate threat had passed. Evacuation procedures involved 30,000 people, including patients from Cairns Base and Private Hospitals and dialysis patients, being moved before Cyclone Yasi hit (Johnson et al. 2013). The official death toll from Cyclone Yasi was one (CRED 2015). Following the cyclone, response was swift, power and other essential services were restored quickly to most areas, and within four days, 70 of the evacuated patients had been repatriated back to Cairns (Johnson et al. 2013). The remaining renal patients were repatriated within two weeks after the cyclone made landfall (Johnson et al. 2013).

but when it is low it can reduce the strength of local social fields, including the community field, and be a barrier to the development of community activities and structures. Poortinga (2012) described the factors that contribute to social capital as: bonding and bridging strategies, social cohesion, civic participation, socio-economic relationships and political efficacy. Townshend et al. (2015) found a significant positive correlation between social cohesion and resilience in a community’s ability to ‘bounce back’ following disaster. However, social cohesion reduces when marginalisation increases. Figure 9.1 depicts the constituent dimensions of social cohesion and the factors that reduce social cohesion within a community (Jenson 1998). Leadership and governance Societal changes and historical trends have influenced the way many communities are governed. Governments can no longer be expected to be the sole agent responsible for protecting their citizens from the consequences of disasters. Governance structures need to be set up in a way that fosters participation and decision-making throughout the community. An all-inclusive comprehensive approach to PPRR requires a shift from top-down to bottom-up decision-making processes. However, success of this

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Belonging Inclusion Participation Recognition Legitim acy

Isolation Exclusion Non-involvement Rejection Illegitimacy

Figure 9.1 The dimensions of social cohesion (adapted from Jenson 1998).

hinges on the leaders’ ability to engage with the community. Leaders who do not have the trust or respect of their constituents will not be effective in building sustainable community resilience.

Community engagement principles and mechanisms As the number of disasters increases and the population grows, the need to ensure sufficient funds to keep the community safe puts added pressure on both government and non-government organisations. Now more than ever it is important that individuals and the community in which they live have the capacity to be actively involved in all aspects of PPRR and to learn how to be resilient. This has led to the need to develop appropriate programs to effectively engage communities in disaster PPRR. Cox and Hamlen (2015) state that these programs must be flexible, location-based and context-specific with up-to-date assessment tools (e.g. disaster plans and hazard risk assessments). The principles underpinning these programs include: • •

Strong partnerships between local leaders, response agencies and authorities (Thornley et al. 2015). Sharing information and understanding all needs and perspectives (AEMI 2013).



– Develop awareness and common ground (Carroll et al. 2006, 2009; O’Sullivan et al. 2013).

•

Effective participation, building involvement and connected networks (AEMI 2013).



– Community engagement must foster shared knowledge and connectedness (Norris et al. 2008; Chandra et al. 2011; Poortinga 2012; Edwards 2013).

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•

Consultation with, and inclusion of, all communities (AEMI 2013).



– Integrative process which will involve, support and empower the entire community (Cox and Hamlen 2015). – Procedures responsive to the individual, contextual and cultural factors (Cox and Hamlen 2015). –  Ensure unifying messages and involvement of all faith and non-faith organisations (Joakim and White 2015).



•

Collaboration and partnering with communities (AEMI 2013).



– Community-led action (Thornley et al. 2015) and incentives (Cox and Hamlen 2015). – Engage with, and acknowledge the role of, community organisations and groups (Abara et al. 2014).



•

Capacity-building skills and empowering individuals and communities (AEMI 2013).



– Understanding the current level of community resilience at every phase of PPRR (Manyena and Gordon 2015).

•

Building on existing assets and resources (AEMI 2013).



– Adequate financial and human resources with a supporting legal framework (Cox and Hamlen 2015). – Provide opportunities for innovative thinking and developing appropriate goals for collaborative initiatives (Robinson and Berkes 2011; McKnight 2010). – Infrastructure to support community resilience (Thornley et al. 2015), e.g. evacuation centres.



To achieve resilient communities through the principles outlined above, robust methods and mechanisms are required. These include (AEMI 2013; Johnson 2004; Hashagen 2002): • • •

•

Public consultation: used to elicit community views and perspectives on a range of issues, through social and market research techniques, e.g. opinion polls, surveys, workshops and focus groups. Direct involvement: shared decision-making through formal and informal deliberative processes, e.g. local councils and social forums. Target groups engagement: respected leaders and elders can utilise their authority to encourage their communities to engage in disaster PPRR, e.g. faith, ethnicity, disability, elderly and LGBTIQA (lesbians, gays, bisexuals, transgenders, intersexes, queers and allies). Community assets utilisation: recognises and capitalises on community assets and resources, both physical and human, to maximise control over, and benefit from, them.

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• •

Education: including training, employment and personal development to build and support the skills and confidence of community members. Service delivery mechanisms: mobilises the community to respond to gaps in public service provision or local needs (e.g. environmental clean-ups, transport, and emergency support); volunteerism can play an important role in this process. They can be formal government and NGOs (e.g. State Emergency Services and Surf Life Saving in Australia), or informal (e.g. Brisbane’s Mud Army in 2011) (Bekkers 2008).

In practice however, organisations may need to adopt a mixed model approach to effectively engage communities. Furthermore, the part that traditional and modern mass media (including electronic social forums such as Facebook and Twitter) play in the PPRR cycle is considerable (see Chapter 8). Community engagement is not an easy task; it requires continuity and currency, and involves challenges at all stages of PPRR. Given the fluid nature of many disasters, it may not be possible to fully prepare and plan in advance or to respond and recover as quickly and efficiently as expected or desired. Also, communities change both naturally and as a consequence of disasters, as do the type, frequency and intensity of disasters. Therefore, it is important to continually monitor changes, evaluate the programs’ effectiveness, and revise, improve and update as required. Evaluation of community engagement is: . . . a process of assessment used to generate information about the way in which an activity or program of activities is undertaken (process) and the results of the activity or program (outcomes). (Johnson 2004) Evaluation draws upon social sciences research and methodology and involves development of a conceptual framework, devising and testing data collection instruments, collecting and analysing data, and interpreting, sharing, reporting and responding to findings (Stern 2004). Evaluation is an opportunity to validate PPRR strategies. It should promote inclusive debriefing with the aim of identifying both successful and unsuccessful practices, thereby identifying lessons to be learnt. It should also promote further engagement by involving the communities in the process. Due to the complex nature of communities, human behaviour and disasters, evaluating community engagement programs across the PPRR cycle is an ongoing, reiterative and costly process. It requires context-trained and experienced evaluation researchers (Sundnes and Birnbaum 2003). Figure 9.2 (opposite) demonstrates the process for strengthening community resilience (White et al. 2015).

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RESILIENCE ASSESSM ENT Perform an all-hazards resilience assessment Develop a current community profile

CONTINUED EVALUATION & REVISION OF THE COMMUNITY’S RESILIENCE PROGRAM/PLAN Monitor & evaluate progress Test community’s resilience Reassess community resilience post-disaster

SHARED COMMUNITY VISION

EN G A G E C O M M U N ITY LEA D ER S & K E Y ST A K E H O LD ER S

Develop shared community vision Engage the community, seek feedback

Establish the foundation for strategic planning towards empowering a resilient community Develop engagement and awareness strategies

ACTION PLANNING Develop a prioritised action plan Endorse & authorise ESTABLISH SUSTAINABLE MECHANISMS TO IMPLEMENT ACTION PLAN & ENSURE CONTINU ITY OF THE PROGRAM Define ownership for action plan & resilience program Establish implementation work groups Begin formal reporting process

Figure 9.2 The process for strengthening community resilience (adapted from White at al. 2015).

Key readings Ellemor H. ‘Reconsidering emergency management and indigenous communities in Australia’ Environmental Hazards. 2011; 6(1): 1–7. Enarson E, Fordham M. ‘Lines that divide, ties that bind: Race, class, and gender in women’s flood recovery in the US and UK’ Australian Journal of Emergency Management. 2001; 16: 43–52. Engelman A, Ivery S, Tseng W et al. ‘Responding to the deaf in disasters: Establishing the need for systemic training for state-level emergency management agencies and community organizations’ BMC Health Services Research. 2013; 13: 84.

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Evan J. ‘Mapping the vulnerability of older persons to disasters’ International Journal of Older People Nursing. 2010; 5: 63–70. Hazeleger T. ‘Gender and disaster recovery: Strategic issues and actions in Australia’ Australian Journal of Emergency Management. 2013; 28(2): 20–25. Mathbor G. ‘Enhancement of community preparedness for natural disaster. The role of social work in building social capital for sustainable disaster relief and management’ International Social Work. 2007; 50(3): 357–369. Spence PR, Lachlan KA, Griffin DR. ‘Crisis, communication, race, and natural disasters’ Journal of Black Studies. 2010; 37(4): 539–554. Twigg J. Characteristics of a Disaster-resilient Community: A guidance note. Interagency Group. 2009. http://discovery.ucl.ac.uk/1346086/ (accessed 14 May 2014).

Activity •

Identify a community with which you are familiar.



– How would you describe it? – Who are the key informal leaders of the community? – Are there people within the community who are particularly vulnerable?

References Abara W, Wilson S, Vena J et al. ‘Engaging a chemical disaster community: Lessons from Graniteville’ International Journal of Environmental Research and Public Health. 2014; 11(6): 5684–5697. AEMI (Australian Emergency Management Institute). Disaster Health: Handbook 1. Australian Emergency Management Handbook Series. Commonwealth of Australia; 2011. AEMI (Australian Emergency Management Institute). National Strategy for Disaster Resilience. Community Engagement Framework: Handbook 6. Australian Emergency Management Handbook Series. Commonwealth of Australia; 2013. Bekkers R. ‘Volunteerism’. In: Darity WA Jr, editor. International Encyclopaedia of the Social Science. 2nd ed. Detroit: Macmillan Reference USA; 2008. Carroll JM, Rosson MB, Convertino G et al. ‘Awareness and teamwork in computer supported collaborations’ Interacting With Computers. 2006; 18: 21–46. Carroll JM, Rosson MB, Farooq U et al. ‘Beyond being aware’ Information and Organization. 2009; 19: 162 –185. Chandra S, Acosta J, Stern S et al. Building Community Resilience to Disasters. Santa Monica, CA: RAND Cooperation; 2011. Cheers B, Darracott R, Lonne B. Social Care in Practice in Rural Communities. Leichardt, NSW: The Federation Press; 2007. Coppola D. ‘Investigation of the political implications of disasters requiring international assistance.’ Federal Management Agency and Emergency Management Institute; 2011. https:// training.fema.gov/hiedu/highpapers.aspx (accessed 14 May 2016). Cox L. ‘Community resilience and decision theory challenges for catastrophic events’ Risk Analysis. 2012; 32(11): 1919–1934. Cox R, Hamlen M. ‘Community disaster resilience and the rural resilience index’ American Behavioral Scientist. 2015; 59(2): 220–237. CRED (Centre for Research into the Epidemiology of Disasters). EM-DAT: The OFDA/CRED International Disaster Database. www.emdat.be. Brussels, Belgium: Université Catholique de Louvain; 2015.

Community engagement  115 Edwards FL. ‘All hazards, whole community: creating resiliency’. In: Kapucu N, Hawkins C, Rivera FI, editors. Disaster Resiliency: Interdisciplinary perspectives. New York: Routledge; 2013. Haacke J. ‘Myanmar, the responsibility to protect, and the need for practical assistance’ Global Responsibility to Protect. 2009; 1: 156–184. Hashagen S. ‘Models of community engagement’. 2002. www.lcsansw.org.au/documents/ item/463 (accessed 22 April 2016). HRW (Human Rights Watch). ‘“I Want to Help My Own People”: State control and civil society in Burma after Cyclone Nargis’. 2010. www.hrw.org/report/2010/04/28/i-want-help-my-ownpeople/state-control-and-civil-society-burma-after-cyclone (accessed 22 April 2016). Jenson J. Mapping Social Cohesion: The state of Canadian research. Ottawa, CA: Renouf Publishing Co. Ltd; 1998. Joakim EP, White RS. ‘Exploring the impact of religious beliefs, leadership, and networks on response and recovery of disaster-affected populations: A case study from Indonesia’ Journal of Contemporary Religion. 2015; 30(2): 193–212. Johnson AL. Engaging Queenslanders: Evaluating community engagement. Brisbane: Department of Communities; 2004. Johnson D, Hayes B, Gray N et al. ‘Renal services disaster planning: Lessons learnt from the 2011 Queensland floods and North Queensland cyclone experiences’ Nephrology. 2013; 18(1): 41–46. Kuziemsky C, Varpio L. ‘Describing the clinical communication space through a model of common ground: “You don’t know what you don’t know”’ AMIA Annual Symposium Proceedings Archive. 2010; 2010: 407–411. MacQueen KM, McLellan E, Metzger DS et al. ‘What is community? An evidence-based definition for participatory public health’ American Journal of Public Health. 2001; 91(12): 1929–1938. Manyena SB, Gordon S. ‘Bridging the concepts of resilience, fragility and stabilisation’ Disaster Prevention and Management. 2015; 24(1): 38–52. Marsh G. ‘Community: The concept of community in the risk and emergency management context’ Australian Journal of Emergency Management. 2001; 16(1): 5–7. McKnight J. ‘Asset mapping in communities’. In: Morgan A, Ziglio E, editors. Health Assets in a Global Context: Theory, methods, action. London: Springer; 2010. Morgan A, Ziglio E. ‘Revitalising the public health evidence base: An asset model’. In: Morgan A, Ziglio E, editors. Health Assets in a Global Context: Theory, methods, action. London: Springer; 2010. Norris FH, Stevens SP, Pfefferbaum B et al. ‘Community resilience as a metaphor, theory, set of capacities and strategy for disaster readiness’ American Journal of Community Psychology. 2008; 41: 127–150. O’Sullivan TL, Corneil W, Kuziemsky C et al. The EnRiCH Community Intervention: Collaborative asset-mapping to enhance resilience for high-risk populations. Ottawa, CA: EnRiCH Collaboration; 2013. Olsson E. ‘Crisis communication in public organisations: Dimensions of crisis communication revisited’ Journal of Contingencies and Crisis Management. 2014; 22(2): 113–125. Pearson E. ‘Agence France Presse: Myanmar aid barriers hinder cyclone recovery’. 2010. www. burmanet.org/news/2010/04/29/agence-france-presse-myanmar-aid-barriers-hinder-cyclonerecovery-hrw/ (accessed 14 May 2016). Poortinga W. ‘Community resilience and health: The role of bonding, bridging, and linking aspects of social capital’ Health and Place. 2012; 18(2): 286–295. Robinson L, Berkes F. ‘Multi-level participation for building adaptive capacity: Formal agency community interactions in northern Kenya’ Global Environmental Change. 2011; 21: 1185–1194.

116  G-S. Toloo & M. Fredriksen Stern E. Evaluation Research Methods. 4th ed. London: SAGE Publications; 2004. Sundnes KO, Birnbaum ML. ‘Health disaster management: Guidelines for evaluation and research in the Utstein Style’ Prehospital and Disaster Medicine. 2003; 7(3): s1–s14. The World Bank. ‘Health expenditure, total (% of GDP)’. 2015a. http://data.worldbank.org/ indicator/SH.XPD.TOTL.ZS (accessed 22 April 2016). The World Bank. ‘Government expenditure on education as % of GDP (%)’. 2015b. http:// data.worldbank.org/indicator/SE.XPD.TOTL.GD.ZS (accessed 22 April 2016). The World Bank. ‘Military expenditure % of GDP’. 2015c. http://data.worldbank.org/indicator/ MS.MIL.XPND.GD.ZS (accessed 22 April 2016). Thornley L, Ball J, Signal L et al. ‘Building community resilience: Learning from the Canterbury earthquakes, Ko-tuitui: New Zealand’ Journal of Social Sciences Online. 2015; 10(1): 23–35. Townshend I, Awosoga O, Kulig J et al. ‘Social cohesion and resilience across communities that have experienced a disaster’ Natural Hazards. 2015; 76: 913–938. Walters P. ‘The problem of community resilience in two flooded cities: Dhaka 1998 and Brisbane 2011’ Habitat International. 2015; 50: 51–56. White R, Edwards W, Farrar A et al. ‘A practical approach to building resilience in America’s communities’ American Behavioral Scientist. 2015; 59(2): 200–219. Willis N. ‘Natural disaster, national sovereignty and state negligence: An international law analysis of the denial of emergency relief after Cyclone Nargis in Myanmar (Burma)’ University of Tasmania Law Review. 2012; 31(2): 134–154. Wisner B, Blaikie P, Cannon T et al. At Risk: Natural hazards, people’s vulnerability, and disasters. 2nd ed. London: Routledge; 2004.

Part 3

Healthcare considerations

Chapter 10

Health systems and disaster management Charles Blanch, Gerard O’Reilly and Natasha Murray

Introduction and objectives The link between disaster management and health systems is twofold. Firstly, a disaster will have a major impact on a health system: directly increasing the disease burden, through illness or trauma caused by the hazard; or as a result of secondary hazards confronted during response and recovery phases, exemplified by outbreaks of infectious disease or mental illness. Secondly, the health impacts can also be indirect, where the capacity of the health system to respond to disease is impeded due to infrastructure damage or loss of resources, including staff. Health Disaster Risk Management (DRM) is an ‘all of health, all of system’ activity. All disaster managers should (ideally) develop an understanding of their respective health systems and the way they respond to disasters. This is not so as to understand the clinical care of patients, but rather the management and coordination of processes that are necessary to ensure those patients are cared for efficiently and effectively. The aim of this chapter is to outline the systems of public and acute healthcare that are required to protect the community. On completion of this chapter, you should be able to: • • •

Define the health system and its role in disaster management. Outline the frameworks for health DRM. Discuss mechanisms and system activities for coordination and control to implement effective health DRM.

Defining health systems The World Health Organization (WHO) defines a health system as follows: A health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health. This includes efforts to influence determinants of health as well as more direct health-improving activities. A health system is therefore more than the pyramid of publicly owned facilities that deliver personal health services. It includes, for example, a mother caring for a sick child at home; private providers; behaviour change programmes; vectorcontrol campaigns; health insurance organizations; occupational health and safety legislation. It includes inter-sectoral action by health staff, for example, encouraging

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the ministry of education to promote female education, a well-known determinant of better health. (WHO 2007) The WHO further defines health as a ‘complete state of physical and mental wellbeing’, not just the absence of disease (WHO 1946). This broader view of health calls upon health systems to extend well beyond narrow perspectives of the treatment of the sick and injured. Health systems should aim for integrated health service delivery, which includes: . . . a continuum of health promotion, disease prevention, diagnosis, treatment, disease-management, rehabilitation and palliative care services, through the different levels and sites of care within the health system over the course of a lifetime. (WHO 2015a) This has significance for health DRM, which should similarly focus not only on the treatment of the sick and injured, but also on the promotion of resilience for both the individual and the system. As both health systems and DRM move to a communitybased approach, it is necessary to ensure that the community and all health stakeholders are involved in health DRM. Health systems vary across the globe reflecting the level of development, funding models, levels of access, and resources available for the delivery of services. WHO supports countries in moving their health systems towards universal health coverage, through increased access to safe, high quality, effective, people-centred and integrated services (WHO 2015a). So far as the principles and practices of disaster risk management need to be applied in any country or region (group of countries), it is very important to understand that health systems vary enormously from one setting to the next.

Frameworks for health DRM There are frameworks for health DRM at the global, regional, country and local level. Global level Contemporary approaches to health DRM, including the impact and role of health systems, have extended beyond an historical focus on response, to incorporate prevention, mitigation and recovery activities. These provide a significant opportunity to avoid the impact of a hazard entirely, or at least mitigate its impact. In 2005, the second World Conference on Disaster Reduction developed the Hyogo Framework, which identified five priority areas to achieve substantial reduction of disaster losses in lives and in the social, economic and environmental assets of communities and countries. These assets include components of the health system. These themes continued in the third World Conference, which produced the Sendai Framework for Disaster Risk Reduction 2015–2030 (United Nations 2015). This sets four specific priorities for action, all of which have application to health agencies and health disaster managers. These are:

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1 2 3 4

Understanding disaster risk. Strengthening disaster risk governance to manage disaster risk. Investing in disaster risk reduction for resilience. Enhancing disaster preparedness for effective response, and to ‘build back better’ in recovery, rehabilitation and reconstruction.

The 2011 World Health Assembly resolution 64.10 (WHO 2011) provides a global mandate for health DRM. This resolution urges member states to ‘Strengthen allhazards health emergency and Disaster Risk Management (DRM) programmes’, integrate this planning into national and sub-national plans, and support these arrangements institutionally. This may include: to establish relevant offices or functions; to develop safe and prepared healthcare facilities able to withstand local hazards and to respond to internal and external emergencies; to collaborate and strengthen the health workforce in health emergency management. Many countries have developed national legislation encompassing common elements of the Hyogo and Sendai DRM frameworks, such as the comprehensive PPRR cycle and all-hazards approach. When these elements have been applied to the health system, they provide a contemporary framework for health to develop resilience alongside other sectors. Other international instruments, such as the International Health Regulations, require countries to strengthen core surveillance and response capacities for public health emergencies. Whilst the focus of the regulations is on ‘preventing, protecting, controlling and providing an appropriate public health response to the international spread of disease’ (WHO 2008), such arrangements provide capability to coordinate responses to a wide range of hazards. Regional level The WHO is organised across six global regions (the Americas, Africa, South East Asia, Europe, Eastern Mediterranean and Western Pacific). Each region runs a range of programmes, as well as supporting individual member states. The WHO Western Pacific region has six of the ten most vulnerable countries in the world according to the 2014 World Risk Report (WRR) (United Nations University, Alliance Development Works 2014) (based on risk to natural hazards against exposure, susceptibility, coping capacity and adaptive capacity with a wide range of hazards including tropical cyclone, earthquake, tsunami, volcano, drought and sea-level rise), impacting countries from a population of 1,200 (Niue) to over 1.3 billion (China). Following consultation, a regional framework for health DRM was adopted in 2014 that identifies four key components as critical: the development of governance, policy, planning and coordination; the provision of information and knowledge management; the implementation of health and related services and resources; and the support of all-hazards disaster health management (WHO 2015a). Country level Disaster managers must be familiar with the roles and responsibilities, legislative mandate, and respective powers of their health system. In many instances health will

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be a support agency and national disaster management strategies will be implemented by the National Disaster Management Agency (NDMA). Health will be responsible for ensuring the ongoing delivery of health system functions at all levels during an emergency. It may also be the lead agency for human health emergencies such as pandemic influenza. Disaster managers need to have considered how health will provide leadership and response coordination in these circumstances. National health legislation usually provides a mandate for roles and responsibilities that are applicable in a disaster or an emergency. Depending on the jurisdiction, these may define: the functions of the Ministry or Department of Health; sub-national health functions, such as districts or commissioning or funding agencies; and the role of public health services, particularly around infectious disease control and environmental health risks. Other sectors’ legislation may also provide tools to support health DRM. For example, legislation relating to building codes or resource consent may be developed to ensure ‘safer hospitals’ by ensuring that healthcare facilities are not built in hazard zones or meet minimum seismic standards (WHO 2015b). For a more extensive discussion around legislative frameworks, see Chapter 5. Jurisdictions may also have a framework of contracts, services or standards for healthcare providers. Providers can be incentivised to undertake specific activities, such as participation in health DRM exercises or initiatives, including developing contingency capability. For example, having a business continuity management framework could be a contractual requirement. This is mutually beneficial in that the provider is able to remain in business whilst the affected community can continue to access health services. Local level Mixes of private and public providers typically deliver health services. In any area, these may be coordinated by a sub-national entity such as a health district, or by a voluntary or corporate group. Understanding the relationship between different providers, especially around finite acute capacity such as operating theatres or intensive care unit beds, is critical. It is also important to ensure that community providers, including those funded through the social sector, are also considered. Providers such as aged care or disability providers can help reduce the impact on vulnerable people. Avoiding the evacuation or relocation of residents from a care facility through good preparedness will reduce the impact on all responding agencies. It is important to recognise that during a disaster, previously unknown vulnerable populations may emerge and the demand for some services, such as mental health services, may significantly increase.

Health DRM systems coordination and control The legislative and policy frameworks described above will usually provide for the roles and responsibilities of health and other agencies in both routine emergencies and disasters. The development of plans for surge capacity, continued service delivery (business continuity) or leadership may be a mandatory requirement or may be directed and required by a policy framework. These plans need to describe the system of command, control, coordination and communication that will be used (in an

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emergency or disaster), and enable local solutions to be developed that meet its intent. One solution is unlikely to work across all parts of a country. Typically, legislative and policy frameworks will include: •

•

•

•

•

•

Legislative framework for disaster management, national security or civil defence. These will typically outline Ministry or Department roles and responsibilities, often by hazard or consequence. Increasingly these are being applied across PPRR functions, though there is still often a focus on response. Advisory committees or working groups within the health system. If one of these is not specifically focussed on emergency or disaster management, it may be possible to ensure that disaster management requirements are addressed in other areas, such as quality improvement or patient safety programmes. Roles and responsibilities of various bodies in health DRM. These will be reflected at regional and local levels. Jurisdictions may have different approaches with regard to the hazard and consequence management lead. The response to the Ebola Virus Disease (EVD) in West Africa in 2014–15 saw the overall response coordination allocated to central departments such as the Prime Minister, President, NDMA or Defence; however, health remained responsible for managing the impact on the health system. Regulatory bodies responsible for registration. This applies to the registration of health professionals, medical pharmaceutical, consumable and device licencing, and consumer advocacy. These interested parties may have roles such as supporting increased scopes of practice, facilitating the import and use of new treatments, or enabling the access and registration of emergency foreign medical team members. Key role of professional clinical associations and unions. While protecting their members’ interest, safety and livelihood, with early engagement these bodies can also provide assistance in developing and supporting official policies and occupational health and safety. During preparedness activity for EVD, the professional bodies of several unaffected countries provided interpretation and dissemination of official advice, as well as identifying emerging issues to policy makers. Many reiterated clinicians’ obligations to provide care where a safe system of work had been assured. Training and the ongoing development of health professionals. Provided by associations and colleges, many working groups focus on disaster medicine or mass casualties. There is a role for colleges in providing stewardship and enhancing the capability of their professionals. They are often a key stakeholder in reaching health professionals and their population.

A considered approach to health DRM demands a comprehensive understanding of key stakeholders in the jurisdiction, as these will be influential in setting policy direction and in sustaining major responses. Identification of these stakeholders and their roles and responsibilities is a critical component of planning and preparedness activities.

A considered approach to disaster health management demands a comprehensive understanding of key stakeholders, as these will be influential in setting policy direction & in sustaining major responses.

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Public health and emergency health services in disaster management An all-of-health system approach to health DRM is necessary. Jurisdictions need to consider how certain services, such as public health and emergency health service requirements, may need to be escalated from routine (including acute service provision) in a disaster situation. Public health services A long-standing definition of public health is: The science and art of preventing disease, prolonging life and promoting physical health and efficiency through organized community efforts for the sanitation of the environment, the control of communicable infections, the education of the individual in personal hygiene, the organization of medical and nursing services for the early diagnosis and treatment of disease, and the development of the social machinery which will ensure to every individual a standard of living adequate for the maintenance of health; organizing these benefits in such a fashion as to enable every citizen to realize his birth right of health and longevity. (Merson et al. 2001) The primary focus of public health services in jurisdictions is usually the cost-effective prevention of death, disease and disability in populations, and the promotion of health. These core activities of public health have relevance for health DRM. A broader role of public health services in health DRM is to reduce the overall level of risk to the community during all phases of PPRR. This is particularly relevant in the post-disaster phase when normal public health protections may be damaged, increasing the risk of infectious disease outbreaks and other environmental hazards. Activities to reduce risk include: • •

• • • •

Programmes that reduce the vulnerability of a community to environmental hazards through the control of dangerous goods, vector control, air quality, food safety, potable water and effective sewerage management. Infectious disease surveillance systems routinely used for early identification, investigation and management of specific diseases. Surveillance programmes may need to be enhanced and delivered in different areas or with different partners following a disaster (for example, military environmental health teams) as part of an early warning and response system (WHO 2012). Outbreak control, including early detection and appropriate management. Public information on potential health impacts, and personal and community measures to prevent disease. Promotion of healthy options to build individual resilience; for example, dual benefit projects such as incorporating urban cycle-ways on top of raised levees. Developing personal skills and strengthening community action.

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Acute health systems Routine acute health systems are sometimes termed emergency healthcare systems (EHS). They exist to provide timely access to emergency care for time-critical disease and injury, in order to save lives and reduce morbidity. Emergency medicine, the core business of an EHS, has been defined as: A field of practice based on the knowledge and skills required for the prevention, diagnosis and management of acute and urgent aspects of illness and injury affecting patients of all age groups with a full spectrum of episodic undifferentiated physical and behavioural disorders; it further encompasses an understanding of the development of pre-hospital and in-hospital emergency medical systems and the skills necessary for this development. (IFEM 2008) A developed EHS consists of the following components: • •

A pre-hospital service with well-equipped vehicles, trained staff, and clear triage protocols to ensure the transport of the right patient to the right healthcare facility in the shortest time (Eastman et al. 1987; Atkin et al. 2005). Healthcare facilities, including primary care, with appropriate equipment and well-trained staff to provide timely triage and management of ill and injured patients.

Emergency departments and receiving healthcare facilities must have plans to rapidly increase their capacity in the event of a disaster and thus maintain their ability to provide definitive care for ill or injured patients. Additionally, healthcare facilities without an emergency department, such as primary care, medical and surgical facilities, must consider their likely role in a disaster either as a primary reception point or as a complement to more traditional acute care services. Staff need to be appropriately trained and exercised for their role. They should To be able to maintain health services know whether they report immediately & provide definitive care to the sick & if off-duty, or wait to be rostered on injured during a disaster, emergency for subsequent shifts. These actions departments & receiving healthcare may vary depending on the hazard. For facilities must have plans to rapidly example, a cyclone or hurricane landfall increase their capacity. on a community will (usually) provide some pre-warning which could allow staff to ensure their families are prepared before staff ‘shelter in place’ in the healthcare facility, ready to provide immediate surge staffing. In a no-notice event, such as a multi-casualty incident, staff recall via normal on-call systems can allow for a more organised approach, to establish surge staffing and preserve staff for secondary events. Appropriate procedures to reflect local hazards need to be developed and staff trained accordingly. Coordination and communication structures need to be appropriate to the size of the facility. It may be appropriate for a large hospital to have an incident management

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team and emergency operations centre, but coordination with a primary care facility may only be via radio or phone to a single person. A system-wide structure for communication between facilities and with disaster management agencies will be required. Different communication modes, including runners, radio, satellite and cell phone, and email and data transmission may be useful in different environments. Systems such as bed management systems or emergency management systems all have appropriate roles and should be tested and exercised. A range of clinical staff may deliver emergency care depending on the jurisA system-wide structure for diction and setting. Pre-hospital providcommunicating between facilities & ers will normally be the first trained with disaster management agencies health professionals at the scene, but the is needed. This requires different, capacity and capability will vary across & at times, innovative communication jurisdictions. A response in an urban modes, including runners, 2-way centre may see a joint response between radio, satellite & cell phone, & email paramedic and emergency medicine & data transmission including inter/ specialists able to provide a high level intranet & facsimile. of trauma intervention at the scene. Conversely, many rural communities may be served by small numbers of volunteer or co-responding personnel (e.g. Fire). Health organisations need to have considered how other providers such as community rescue teams, Red Cross teams or private providers, who are not routinely involved in pre-hospital medicine, but will be present in the community, are utilised in a disaster and ensure they are appropriately engaged in planning, training and exercising. Some rural communities have progressive clinical practice models such as nurse practitioners or rural health medical specialists who have experience across acute and long-term condition management. These health professionals are well equipped to support their community in a disaster. Some jurisdictions use hospital-based teams that deploy in a pre-hospital role (Hirsch et al. 2015). This should be carefully planned, so as not to place hospital staff in an unfamiliar role and environment, and also to avoid reducing the capacity at the receiving facility. Regardless of the role, any such teams must be prepared, appropriately trained, equipped, coordinated and requested by the pre-hospital clinical lead. A special example of these teams is a disaster medical assistance team (DMAT), which is a multidisciplinary team comprising task-specific mixtures of primary care, acute care and public health capabilities. This is covered in detail in Chapter 17. Although response pathways in a disaster should be very similar to normal pathways (just faster and with more capacity), some disasters may require significant reconfiguration of the emergency healthcare services. This is particularly so when the system is likely to be overwhelmed. For example, during the outbreak of an influenza-like illness (ILI) when large numbers of patients may be affected but only a small proportion will require active clinical intervention. In this circumstance, community-based triage, telephone referral, public information and other techniques may be used to direct patients with ILI through a dedicated referral pathway such as ‘flu centres’. This is intended to protect critical infrastructure including staff and other patients, whilst maintaining access to acute care for non-affected patients. It requires effective coordination of public health and emergency healthcare services (pre-hospital and hospital).

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It is clear that EHS, with a focus on the rapid and organised access of patients to the healthcare they need, will be the principal source of organised emergency healthcare support in the case of a disaster. However, this will be complemented by the level of readiness within the community. Initial responders will always be the affected community and first-aid competency and access to basic supplies should be encouraged. Following the bombings in London in 2005, survivors testified in the inquiry that they had to improvise first-aid supplies whilst clinical help arrived. Health agencies in London subsequently installed mass casualty first-aid kits, consisting of quantities of basic dressings and stretchers in underground and railway stations across London. The Coroner’s report on the London bombings can be found at www.gov.uk/ government/publications/coroners-inquests-into-the-london-bombings-of-7-july2005-review-of-progress.

Key readings Murray V, Aitsi-Selmi A, Blanchard K. ‘The role of public health within the United Nations post-2015 Framework for Disaster Risk Reduction’ International Journal of Disaster Risk Science. 2015; 6(1): 28–37. Redlener I, Reilly MJ. ‘Lessons from Sandy – Preparing health systems for future disasters’ New England Journal of Medicine. 2012; 367(24): 2269–2271.

Activities • •

What do you see is the role of primary care (e.g. General Practice) in the continuum of health DRM? If you were asked to coordinate the redevelopment of health services for a small island nation devastated by a cyclone, what components would you wish to include and what priority would you give to each?

References Atkin C, Freedman I, Rosenfeld JV et al. ‘The evolution of an integrated State Trauma System in Victoria, Australia’ Injury. 2005; 36(11): 1277–1287. Eastman AB, Lewis FR Jr, Champion HR et al. ‘Regional trauma system design: Critical concepts’ The American Journal of Surgery. 1987; 154(1): 79–87. Hirsch M, Carli P, Nizard R et al. ‘The medical response to multisite terrorist attacks in Paris’ The Lancet. 2015; Nov 24: 1–4. IFEM (International Federation of Emergency Medicine). ‘IFEM definition of emergency medicine’. 2008. www.ifem.cc/about-us/ (accessed 23 April 2016). Merson MH, Black RE, Mills AJ. International Public Health: Diseases, programs, systems and policies. Maryland, USA: Aspen Publishers; 2001. United Nations. Sendai Framework for Disaster Risk Reduction 2015–2030. Geneva: UN; 2015. United Nations University, Alliance Development Works. World Risk Report 2014. Berlin: Alliance Development Works, Bonn: United Nations University – Institute for Environment and Human Security; 2014. WHO (World Health Organization). Western Pacific Regional Framework for Action for Disaster Risk Management for Health. Geneva: World Health Organization; 2015a.

128  C. Blanch, G. O’Reilly & N. Murray WHO (World Health Organization). Safe Hospitals Initiative. Comprehensive safe hospital framework. Geneva: World Health Organization; 2015b. WHO (World Health Organization). Outbreak Surveillance and Response in Humanitarian Emergencies: WHO guidelines for EWARN implementation. Geneva: World Health Organization; 2012. WHO (World Health Organization). World Health Assembly Resolution 64.10: ‘Strengthening national health emergency and disaster management capacities and resilience of health systems’. 2011. http://apps.who.int/gb/ebwha/pdf_files/WHA64/A64_R10-en.pdf (accessed 17 May 2016). WHO (World Health Organization). International Health Regulations. 2nd ed. Geneva: World Health Organization; 2008. WHO (World Health Organization). Everybody’s Business: Strengthening health systems to improve health outcomes: WHO’s framework for action. Geneva: World Health Organization; 2007. WHO (World Health Organization). Preamble to the Constitution of the World Health Organization. As adopted by the International Health Conference, New York, 19–22 June, 1946.

Chapter 11

Healthcare considerations in disasters Andrew Johnson, Michael Aitken and Peter A. Leggat

Introduction and objectives Disasters pose significant challenges to the provision of health services; both direct and indirect. The direct impacts on health infrastructure including staff, resources and patient load, may challenge the capability of health services to deliver on core expectations. Indirect impacts result from changes in function to other elements within the community such as: interruption to transport affecting resupply and staff availability; inability for parents to attend work when childcare facilities and schools are closed; or loss of financial viability. To deal with these challenges, it is important for healthcare leaders and disaster managers to understand the way their system works; not a hierarchical, top-down system, but rather an organic, evolving and ever-changing interconnected world that responds to leadership and behaves unreliably to traditional command approaches. Understanding these concepts builds resilience within the healthcare system; that is, the capacity to adjust and deal with threats and challenges and still achieve required outcomes. Health leaders also need to develop plans that will guide their responses in the context of the local environment. The plans for one service may be quite different from another and need to reflect the hazards and threats in their community, and the local capacity and resources to respond. A disaster will challenge healthcare providers to look for ways to cope with rapidly evolving changes over which they have little control. This will impact on the availability of staff, the skills required, and changes to work practices. Consideration of these matters in advance and, as far as possible, ensuring that everyone knows and understands their roles will allow a far more resilient response and better outcome. The aim of this chapter is to explore the health system’s role in disasters. On completion of this chapter you should be able to: • • •

Identify and discuss the impacts that disasters have on the health system. Critically evaluate strategies required to build health system resilience. Discuss the strategies required to enable the health system to respond to disasters.

The impact of disasters on health systems Health systems are almost always affected by disasters of any cause. The range of ways in which those impacts occur depends on many factors including the source of the

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disaster, the damage caused, the loss of function that results, and the degree to which efforts in prevention, preparedness and response can mitigate the result. Examples of direct and indirect impacts are explored below. Direct impacts •

•

•

•

Damage to critical infrastructure: When considering the nature of Direct impact of disasters on health disasters, the reality is that for many, systems: including both man-made and •  Damage to critical infrastructure. natural disasters, the health system is •  Injury to staff. in the disaster zone. On occasions, •  Loss of resources. elements of the health system may in •  Increased number of patients. fact be the source of the disaster, for example a hospital fire or terrorist attack. In these circumstances, the hospital and health services may need to deliver healthcare in improvised environments, adapting to the available resources. This was certainly the case in the aftermath of Hurricane Katrina, where makeshift hospitals had to be established in alternative venues that offered the best fit for purpose, such as airports and community halls (Lister 2005). On occasions, elements of hospital infrastructure may be damaged or destroyed, such as power generation or distribution, communications infrastructure failure, or water service failure. The all-hazards approach allows flexibility in diagnosis and management of issues in the context of the disaster. Injury to staff: One of the most challenging aspects of disasters for healthcare systems is the loss of its own people to the disaster. Not only does this have direct impact on the capacity and capability of the service to respond, but it has a huge impact on the psychological wellbeing of the remaining staff. For example, early in the SARS epidemic in Hong Kong, key personnel, including the medical and nursing staff leading the response, fell ill and some staff died. This can impact the willingness of staff to attend and continue to provide care. There may be an impact on both staff who were present and staff who ‘missed out’ due to appropriate rostering practices. These concepts will be discussed in more detail in Chapter 19. Loss of resources: As with loss of critical infrastructure, the supply caches of the health system may be impacted by the disaster, or the source of the disaster as discussed previously. In a major centre, with greater redundancy, this may be less of an issue; however, in more remote population centres this can become a very significant problem. It is also impacted by ‘just in time’ delivery and stock holding policies. Increase in patient load: In a disaster, regardless of its nature, there is commonly a surge in demand. Each form of disaster brings with it its own form of challenges. For example, a bomb blast or explosion will generate penetrating injuries, often multiple, and may be complicated by burns and smoke inhalation. Whereas a natural disaster such as a storm may give rise to blunt trauma, lacerations and, commonly, significant injury from clean-up efforts, for example contaminated lacerations, falls from rooftops, and chainsaw injuries (Aitken et al. 2015).

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Indirect impacts •

•

•

Indirect impact of disasters on health Decreased availability of staff due to systems: loss of community infrastructure: Health service managers rapidly •  Decreased availability of staff due to discover how dependent they are on loss of community infrastructure. a complex interlinking of community •  Failure of resupply due to loss of resources when those resources are supply lines. challenged. For example, in the lead •  Loss of financial viability. up to a natural disaster such as a cyclone, non-essential services may be suspended. This allows people to establish and reinforce their own safety. However, this can have profound impact on health service staffing availability. The closure of schools and childcare facilities which are often critical in allowing parents to work limits their availability unless alternative arrangements can be made. Similarly, loss of public transport systems can affect how people get to and from work and play a role in decreasing attendance rates of staff. Finally, health systems can suffer decreased availability in staff in the wake of a disaster, paradoxically as a result of external disaster support. Foreign aid agencies arriving on disaster relief missions may take on local staff (both clinical and non-clinical staff such as drivers, interpreters, etc.) to augment their response at the expense of local efforts. This represents a significant challenge to the delivery of both aid and normal services. Failure of resupply due to loss of supply lines: Whilst destruction or contamination of stores and provisions can be seen as a direct impact, the capacity for resupply may be challenged. This is particularly the case for areas with poor transport infrastructure, or where transport mechanisms are disrupted. This is most notable, for example, after a tsunami where there can be a near total loss of supply lines; port infrastructure, airports, roads and rail can all be destroyed in one event, whilst the health service infrastructure on high ground may be spared. Loss of financial viability: Health systems are part of the economy, just like any other facet of society. They need money to run; to pay for staff, power, supplies and infrastructure. One of the early impacts of a disaster, or indeed the source of the disaster, can be financial crisis. For example, a private sector health service may be starved of revenue due to a collapse of the market in high-dividend elective surgery, which may result in service failure. Similarly primary care services may lose income by the provision of free care by international relief agencies.

Health system resilience Each of the direct and indirect impacts described above is, to a greater or lesser degree, predictable. This means they can be anticipated and planned for, and hence more effective care can be delivered despite those issues arising. This contributes to what is known as system resilience. In recent years, leading researchers in healthcare (Braithwaite et al. 2015; Hollnagel et al. 2013; Wears et al. 2014) have written about the concept of resilient health care (RHC) outside of the context of disaster health. Their definition of RHC has evolved and resonates with the definition of resilience used in Chapter 1. A RHC system can

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adjust its functioning prior to, during, or following changes and disturbances, so that it can sustain required operations, under both expected and unexpected conditions (Hollnagel et al. 2013). The very qualities that make a health system robust and capable in normal times, are the qualities required in the context of disaster. Key elements of RHC are essential to reflect in disaster health, including healthcare as a complex adaptive system, safety-one and safety-two, and work-asimagined vs. work-as-done (Hollnagel et al. 2013). A resilient healthcare system is one that can anticipate & plan for the direct & indirect impacts of a disaster & still maintain an effective level of care despite these impacts.

Healthcare as a complex adaptive system (CAS) Braithwaite et al. (2013) challenge the orthodox linear thinking that prevails in healthcare. Health workers and managers often quote the dictum of primum non nocere, or ‘first do no harm’. This drive to eliminate unwanted outcomes or ‘harm’, and to improve the efficiency of the healthcare system, has led healthcare system leaders over the last 30 years to adopt a ‘managerialism’ approach to the delivery of healthcare, breaking care down into small, measureable and reproducible components which can then be standardised, thus eliminating variation. This has met with resistance from frontline workers who will often opine that standardised care cannot be achieved when the patients themselves are not standardised. Suggesting an organic model of healthcare, Braithwaite et al. (2013) describes a complex adaptive system that adjusts and evolves to meet the extant circumstances. A systematic review undertaken by Clay-Williams et al. (2014) explored how organisational and cultural factors influence hospital-wide patient care interventions, and the effects these interventions have on patients. The study examined organisational determinants including: staff morale and organisational climate; organisational and patient safety culture; clinical and organisational leadership; and education, training, promotion and awareness of interventions. Whilst the range of studies was limited, findings suggest there is potential to improve patient outcomes by changing organisational and/ or cultural determinants. System-wide change can be most influenced by effective leadership, adequate funding and professional development, and career advancement opportunities (Clay-Williams et al. 2014). According to Rouse (2008), a CAS has a number of key features: • • • •

It is nonlinear and dynamic and does not inherently reach fixed-equilibrium points. As a result, system behaviours may appear to be random or chaotic. It is composed of independent agents whose behaviour is based on physical, psychological or social rules rather than the demands of system dynamics. Agents’ needs or desires, reflected in their rules, are not homogeneous, and so goals and behaviours are likely to conflict. In response to these conflicts or competitions, agents tend to adapt to each other’s behaviours. Agents are intelligent. As they experiment and gain experience, agents learn and change their behaviours accordingly. Thus overall system behaviour inherently changes over time.

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• •

Adaptation and learning tend to result in self-organisation. Behaviour patterns emerge rather than being designed into the system. The nature of emergent behaviours may range from valuable innovations to unfortunate accidents. There is no single point(s) of control. System behaviours are often unpredictable and uncontrollable, and no one is ‘in-charge’. Consequently, the behaviours of a complex adaptive system can usually be more easily influenced than controlled.

Before elaborating on these characteristics in the context of healthcare, it is useful to reflect on an overall implication for systems with these characteristics. One cannot command or force such systems to comply with behavioural and performance dictates using any conventional means. Agents in complex adaptive systems are sufficiently intelligent to game the system, find workarounds and creatively identify ways to serve their own interests. They will do so under both routine and non-routine challenges (such as disasters); for both positive and negative purposes. Safety-one and safety-two Hollnagel is a systems engineer who devoted much of his career to designing safety systems for industry, and most recently for health. He has come to recognise the intense scrutiny applied to the rare failures that occur within our systems, rather than recognising and seeking to understand what goes right. Hollnagel et al. (2013) describes the pursuit of eliminating variation and risk as ‘safety-one’, and the broader focus on understanding what happens to make things go right as ‘safety-two’. The implications of this for disaster health practitioners are profound. Rather than focusing only on where things go wrong, and in taking a linear reductionist approach to understanding failure, analysis needs to look at what goes well, so this can be maximised when the system is stretched. Work-as-imagined vs. work-as-done The implications of the ‘work-as-imagined’ and ‘work-as-done’ concepts are profound when taken to the amplified context of disaster health. The non-linear, highly complex and heterarchical reality of the health system means that it is not predisposed to work well when a hierarchical command and control disaster management approach is superimposed. An underpinning requirement in RHC is to recognise that the way work is actually delivered on the ground may bear little resemblance to the way that leaders and managers think it is being done. Hence, policies, procedures and plans, written by middle managers, may bear little resemblance to what is and can be done in the workplace. For those who may lead in disaster health, this reinforces the need to ensure the engagement of the frontline workers in designing and implementing solutions to emergent problems. In health, unlike most industries, the most qualified and highly experienced people are often at the frontline, and they understand the work they do better than anyone else. To be effective, the disaster health leader needs to lead and not manage or direct, communicating outcomes desired rather than methods and processes to get to the outcomes.

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Management of surge One of the most predictable effects of a disaster is the surge in emergency health activity that this produces. Emergency medical systems (EMS) worldwide, although very different in their structures, approaches and service delivery, share a common feature: they are overloaded in normal times, let alone in a disaster. This can lead to significant ‘brittleness’ and vulnerability within the system. A key in the response to a surge is recognising that this is not just an issue for EMS but rather the broader health system and the entire community. Mobilising community response can take the load off the over-stretched health system and allow it to function optimally. This can include such things as: schools and childcare services working extra hours to look after the children of key staff; families or friends taking home patients not requiring acute care who are waiting for aged care placement; and other government agencies assisting with transporting stores. Health is a key priority for the community, and they will want to help, if given permission to do so and a role to play. In order to achieve the required objectives, the disaster health manager within an already stretched system is going to require changes to priorities, flows and the approach to care. In the reality of healthcare as a CAS, it is important to recognise the significant variation between the context of a hospital and EMS. Consider for example the variability between a regional and a metropolitan centre: not only will the regional centre have fewer resources available directly, but it will also lack access to other facilities that may characterise a metropolitan area. Therefore it is better to work on principles and concepts of operation, rather than tightly defined rules and practices. One such common approach applies to surge management. The well-drilled department will be able to ‘flip into disaster mode’ without the need for external authority, Managing surge requires: and will take a number of actions imme•  Space. diately. Disaster mode may require •  Staff. rapid expansion of capability that can be •  Stuff (supplies). usefully considered under the categories •  Systems flow. of space, staff, stuff and systems (Koenig et al. 2006). Space Often the first warning of a major event may be the arrival of patients at health services. Walk-in patients can arrive even before the first ambulances, and things can get very chaotic and very crowded extremely quickly. The leadership on the ground needs to have the delegated authority to initiate actions across the system. This will involve the creation of space to triage, assess and manage patients, and to provide for definitive care. This is a whole-of-system issue, not just an EMS response, and can be based on the concept of ‘divert, decant, absorb and expand’. For example: • •

Deferring all non-emergency patients or diverting them to community-based services. Decanting the acute health system by discharging everyone who is unlikely to come to harm, or by moving patients to outgoing care. Inpatient teams should

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• •

• •

conduct urgent discharge rounds. Consideration may be given to altering discharge criteria from ‘ready for discharge’ to ‘unlikely to come to harm if discharged’. Absorbing additional patient numbers may require increased capacity within the available space regardless of normal capacity constraints. Moving screening functions such as triage outside the emergency department to expand space, and annexing nearby clinical spaces that can be used for ambulant patients, e.g. outpatient clinic areas. These areas may also be used for ‘cohorting’ of friends and relatives. Deferring all non-emergency surgery and intensive care unit admissions, and preserving critical internal infrastructure. For example, designating a number of theatres for trauma reception. Where patients are awaiting aged care placement and not requiring acute care, family may be called to take them home for the duration of the disaster or utilise facilities such as schools or hotels commissioned for this purpose.

Rapidly changing the mindset of the organisation and allowing people to consider risk in the new context can create much space very quickly. Staff Arguably, augmentation of staff may come first in a surge, but in reality increasing patient and staff numbers generally occur in unison. Without staff with the right skills, it is not possible to deal with a surge in attendances. The people who know best how to manage patients in a surge are those who work in the emergency environment every day. They need to be preserved to do the things that only they can do, and use others to undertake supportive tasks. Considerations include: • • • • •

Closing clinics and elective care areas, and redeploying staff to assist in preparation for surge. ‘Buddying’ extra staff with specialty staff to maximise staffing numbers and to reduce disorientation for those staff working outside their usual area of expertise. Calling in staff whose specialised skills may be required, including the leadership team. This needs to be balanced with the requirement to maintain capacity over time and not ‘burning out’ all human resources in the initial response. Cancelling non-essential tasks such as training or projects. Utilising partly trained support personnel such as students.

Stuff (supplies) This is a catch-all expression to group the other resources required. Some elements are essential to cache and have at the ready; others can be sourced just-in-time. One essential to consider for caching is medical records. Early notification and mobilisation is essential for just-in-time resources. Resources to consider include blood and blood products, sterile supplies, intravenous fluids and giving sets, patient trolleys (gurneys), linen, disposables, gloves, gowns, masks and pharmaceuticals.

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Systems flow Maintaining the flow of patients is essential to normal business of EMS. Patients should proceed in a single streamlined way from one point of care to the next. In any system, there are always bottlenecks, the rate-limiting component of care. Commonly these will be found in a resource intensive, expensive component of care such as diagnostic imaging or operating theatre access. In maintaining flow in disasters, it is critical to ensure that patients only receive diagnostics that will inform or alter their care, and they should not be detained waiting for results unless that affects the direction of their care. For example, while ordering a CT scan for a patient with minor head injury may lead to a definitive diagnosis, in the disaster context, if it is not going to alter the care provided, then it is not sustainable.

Preparing the health system Of course, the usual world of healthcare does not turn off in the event of a disaster and deferred care will need to be addressed. Thinking through in advance how this may be approached will assist in getting the best outcomes for the community. Critical to success is the forward planning that allows staff and leaders (and the community) to assume roles that are familiar to them and use concepts, principles and practices that they understand well enough to be able to adapt them. Plans should not be rigid. While it is possible to anticipate likely problems and to document an approach to deal with them, no disaster is the same. It is important the health plan delineates the desired outcomes and the principles and concepts needed to achieve the outcomes, allowing flexibility in application. The essential suite of plans A number of international groups, including the World Health Organization (WHO), have developed guidelines and systems to be considered in disasters and emergencies, and these have been described in Chapters 5 and 10 (WHO 2015). Disaster planning, however, tends to be local and will be discussed in this context. Planning is discussed in detail in Chapter 13; but there are components of the health planning environment worthy of emphasis here. Disaster management plan Many organisations will have a basic disaster management plan, which will outline the overarching ‘doctrine’ adopted and provide detail of the structure of responses, responsibilities and delegations. This plan will normally take an all-hazards approach and whilst there should be analysis of likely risks, the plan will form the basis of an understanding of how to address disasters regardless of the nature of the event. The plan will also outline the steps available to the health service during the different phases of a disaster evolution. These phases may be summarised as alert, lean forward, stand up, and recover and stand down, as shown in Table 11.1. Incident management will be discussed in detail in Chapter 16.

Healthcare considerations in disasters  137 Table 11.1 Levels of activation in a disaster management plan. Level of activation

Definition

Alert

A heightened level of vigilance and preparedness due to the possibility of an event in the area of responsibility. Some action may be required and staff capable of assessing and preparing for the potential threat should monitor the situation. An operational state prior to ‘stand up’ characterised by a heightened level of situational awareness of a disaster event (either current or impending) and a state of operational readiness. Disaster coordination centres are on stand-by; prepared but not activated. The operational state following ‘lean forward’ whereby resources are mobilised, personnel are activated and operational activities are commenced. Disaster coordination centres are activated. Transition from responding to an event back to normal core business and/or recovery operations. There is no longer a requirement to respond to the event and the threat is no longer present.

Lean forward

Stand up

Stand down

Source: From Queensland Government (2015).

The alert phase represents the first notification of a possible event that may impact the health service. It may take the form of: • • • •

Notification of an incident from ambulance or other emergency service. Weather bureau information regarding a possible extreme weather event. Television or social media feeds about an incident. The first patients presenting to a health service, who have left the scene rapidly and bypassed the normal emergency service transport routes.

During this time, a health service should be thinking about how they will respond, and attempting to gather more information regarding the nature and severity of the event. Leaning forward is a concept that gained significant currency after Hurricane Katrina. This is an opportunity for a heightened state of readiness; for example if a storm event is 12–24 hours from landfall, or rain deluges high up a river catchment create downstream flood risk. In this phase, there is opportunity to: set up an incident management team; advise all staff of the threat and planned response; prepare the physical infrastructure; consider closing down elective care; and evaluate and reinforce stock levels. Essentially, this is about pre-empting the nature of the threat, its potential impact, and taking early steps to mitigate the risk. An excellent example of leaning forward was the global response to the Ebola Virus Disease (EVD) epidemic in Africa in 2014/15. During that time, efforts were concentrated not only in dealing with the disaster in Africa, but also in preparations across the world to respond if a case emerged locally. Alternatively, on a more local level, informed of a mass casualty event, a health service may take initial steps to create capacity and begin setting up their disaster response in acute services and key support services such as radiology, pathology and pharmacy. Stand up is where the formal disaster response kicks in. In situations with prior warning, this will occur prior to the event’s occurrence; however, in other circumstances,

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such as a terror attack, there may be no warning and this may be the starting point for the response. In this phase, the emergency operations centre (EOC) is established and the disaster response is underway. Recovery and stand down have historically been less well developed in health services plans. However, they are the essential steps in getting the health service back to a normal footing and they require just as much planning and control effort as the initial response. Recommencing services can be a real struggle in a situation where staff are emotionally and physically exhausted. Significant health issues will surface in the recovery phase, and the health needs of the community will shift to late complications of acute injury; acute exacerbation of chronic illness where care has been lacking during the emergency response; and critical mental health issues becoming evident. Mass casualty plan (MCP) An MCP is a common endpoint for health services for most forms of disaster. Some health services will see this as the entirety of the disaster plan, but this reflects a narrow interpretation of disaster health management. While it is essential that there is an overarching approach to planning, it is also vital that key areas are involved in the initial response to a mass casualty incident (e.g. the emergency department, theatre and intensive care unit), and that they have their own dedicated sub-plan that outlines their own individual actions. These should be based around surging their usual practices as a disaster is not the time to be doing something completely different. Deceased plan Management of the deceased is a critical factor, not only for the physical management of the bodies, but also for the recovery phase and achieving ‘closure’ for individuals and the community. Additional capacity for storage of the deceased may be necessary, and access to similar facilities (e.g. anatomy teaching facilities) or refrigerated vans has been commonly utilised. Cultural and religious considerations as well as accurate disaster victim identification are critical to effective long-term management. Modern techniques using DNA sampling of victims, whilst time-consuming to process, may allow for body disposal by burial or cremation, whilst maintaining the opportunity for subsequent identification. Family reunion plan In the confusion that often reigns in the aftermath of a disaster, where there are people missing, friends and families will try to track them down. These people may congregate at health facilities and crowd control can become a real issue, as well as communication with concerned relatives and friends. Setting up a dedicated facility for friends and families where they can be supported, register their interests and facilitate reunion can go a significant way to maintaining respect and order. Childcare plan Whilst this may seem to be outside the realm of a health service plan, ensuring provision of safe childcare may be critical to maintaining staff availability during a

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response. This does not need to be complex and can offer meaningful and valuable duties to staff who are expert in dealing with children. It may be accommodated in areas of a hospital such as meeting rooms, office areas or paediatric friendly areas such as outpatients spaces designed for children. Allowing interaction between staff member parents and their children offers a huge psychological boost to both parties.

Issues with the provision of healthcare in disasters There are many significant issues specific to health planning and to the provision of health services during disasters. Futile care In many catastrophic disasters, patients are identified as alive but requiring huge input for unlikely survival. It is always a challenging decision to take, but at times the dictum of ‘greatest good for the greatest number’ means that it may be considered unethical to expend extremely limited resources in likely futile care. Some health services address this through plans to identify and to provide comfort care to those identified with ‘non-survivable injuries’ in an area separate to the rest of the emergency response. Treatment is limited to oxygen therapy and pain control. As the disaster evolves, these patients will be reassessed and if their condition improves will be reconsidered for definitive care. Forensic considerations It is worth remembering that many major incidents also require forensic or criminal investigation and preservation of evidence. The general principles of ‘bag, tag, seal and secure’ should ideally be followed, but liaison with local police services to determine what they require is advised. The media It is important to consider how the health service will manage the media during the event. Having a designated area which is separate to, and away from, the relatives’ area, will help to control information that goes into the public domain and also avoids unnecessary harassment of families. The EOC needs to be aware of the media’s need for up-to-date information and should provide regular and timely media briefings to meet these needs and to avoid misinformation. Staff issues and availability In a disaster response, augmentation of staff can be critical. On most occasions, domestic and international external relief will become available if required, but this can take some time to emerge. Some considerations in the early phases include: •

Volunteers: Commonly there will be a flow of volunteers that can be a help or a hindrance. It is worth considering how their efforts may add value, freeing up

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•

•

•

•

skilled staff to do things that require their expertise. Building relationships with (organised) volunteer agencies, such as the Red Cross, may help to ensure volunteers are appropriately credentialed. Clinical governance: Clinical governance and credentialing of clinical staff is an essential feature of health systems. In the disaster context there is a need to ensure flexibility in response, and staff may be required at times to work outside their normal scope of practice. Volunteer clinicians are a common feature, including those arriving as part of a disaster medical assistance team. Health services need to consider how they will verify the bona fides of volunteer clinicians. Pets: For many staff, pets carry the same level of commitment and personal value as children and other dependents. If an effective mechanism for providing pet care can be established, it is likely that staff availability may well increase. As Cyclone Yasi approached Townsville in 2011, many staff smuggled pets into the campus because this was the only way they felt they could attend and meet their commitments. Bring your family: A key factor for staff making themselves available in a disaster is concern for the safety and protection of their family. An effective strategy used in many facilities in cyclone-prone areas of Australia is to allow staff to bring in their families during the event. They must be self-sufficient and depart the facilities as soon as it is safe to do so. Access (road closures and public transport): In fires, storms, earthquakes and other natural and indeed man-made disasters, simple issues such as road closures can mean the difference between having staff and not. Similarly, suspension of public transportation may restrict access. Engagement with other agencies such as municipal councils, emergency response agencies and the military may assist with transport in these circumstances.

Case-mix/skill-mix change In a disaster event, the nature of presentations will be significantly different from normal times, and the availability of resources may necessitate use of different treatment modalities. Rather than continuing to try to provide the same care as normal, practitioners may need to adapt to what is available. Additionally, professional standards may need greater flexibility. For example, an obstetrician and gynaecologist may be sufficiently skilled in basic surgical techniques such as laparotomy and haemostasis to be able to assist experienced trauma surgeons. Changes in work practice In a disaster, when resources, staff and time may be limited, the following changes in work practice may need to be considered as temporary measures to achieve objectives: •

Surgical approach (conservation surgery, delayed primary closure): Rapid progress of patients through operating theatres may be essential to avoid a critical bottleneck. Many of the presenting injuries may take several hours and enormous resources for definitive care. Initial stabilisation, haemostasis and wound toilet followed by delayed definitive care can expedite care and reduce resource

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• •

•

utilisation. This may be characterised as ‘damage control’ surgery and draws experience from a long history of military surgery. Crisis standards of care: Standards may need to vary from normal. Recently the concept of crisis standards of care has been explored as a means of describing altered clinical standards (Gostin and Hanfling 2009). Reduce, reuse, recycle: Reduction in use of resources is often achievable by rethinking our tolerance of ‘abnormal’ clinical parameters. For example, only a few years ago, blood and blood products were used much more freely and given to patients with much better haemoglobin levels than now tolerated. Many products designed for medical use are labeled ‘single use only’ when they can in fact, with appropriate care, be reused multiple times with effective cleaning and sterilisation. Innovative clinicians and technicians will often be able to repurpose discarded items and should be encouraged to do so safely. Rationing: Rationing is a word commonly brought into discussions of disaster healthcare. The ethical challenges are real and confront the clinician in the frontline who is charged with allocating scarce resources to people who may have competing needs. Such choices are invidious and are an extreme amplification of the daily dilemma faced by practitioners in many parts of the world. The process of rationing is generally achieved through triage and disaster triage and is a significant issue in disaster health management.

Community-based primary care service Community providers can be both a source of support and a source of added pressure on existing resources. In many cases general practitioners and community-based providers will be available to provide care, but may not be able to operate from their normal practice, or may have issues with supplies and resources. These are critical resources for a health service as they can help to provide care to people not requiring the specialised resources of a hospital, and they are responsible for long-term care of disaster victims. They are also the frontline of services during pandemics. The health system must engage with the primary care sector to ensure that they continue to function. Aged care Aged care is a significant component of modern health systems. Events that require evacuation of these facilities may put a great strain on an already overstretched acute health system. Prior planning with these facilities can avoid the use of hospitals as an evacuation centre. For example, the Townsville Hospital in North Queensland, Australia, has predetermined evacuation facilities, including geriatrician supervision, while other jurisdictions have worked closely with aged care facilities to develop their own evacuation and ongoing care options. Security In many cases, a hospital will be (literally) the ‘beacon of light’ in a ravaged community following a disaster. It will be amongst the first facilities restored to power, food

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supplies and safety. Additional security, including engagement with police or military, may be required to preserve access to the health service to those who truly need it. Public health response Public health preparedness has been covered in Chapter 10. Health protection has a critical role in disaster health management, particularly the traditional fields of environmental health (water, sanitation, vector control and shelter), communicable disease control, and epidemic management. This is particularly relevant in displaced populations where prompt provision of adequate quantities of water, basic sanitation, community outreach and effective case management of ill patients is required. Immunisation, provision of outreach medical/health services, and identification of hazards/risks are also important. There may be a requirement to scale up public health surveillance and monitoring to help inform response and health education/ health promotion. Public health services also contribute to system coordination and control (WHO 2016), and to inform response to pandemics; for example, the establishment of caches of oseltamivir in support of managing pandemic influenza outbreaks (Leggat 2011). Staff engagement: Needing leadership, direction and communication One of the most important issues for disaster health managers is to secure and maintain the engagement of staff critical to the response. Staff must be informed what it is the facility is trying to achieve and what is required of them. They also want to know what authority they have to come up with solutions. Communication to staff in a crisis is even more challenging than normal; the pace is often frenetic, and the gossip trail can often better define people’s understanding of what is occurring than is achieved through formal communication channels. Staff communication should be in real-time; giving an accurate picture of what is known, what is expected and what is being done. One of the simplest and most effective mechanisms is a public address system. This has the immediate benefit of getting everyone, including staff, patients and families, ‘on the same page’. This communication must be carefully constructed and delivered, to give purpose and to avoid a sense of distress and panic. A recognised authority figure should take the time to deliver the message. In protracted disasters, a more effective mechanism may be to use regular bulletins that include an up-to-date status report, and what has changed since the last reporting period (see Chapter 8). Communication needs to be delivered in a form and a vehicle that works for its intended recipients. Knowing that communication has been received and understood is critical to establish the effectiveness of that communication. Checking face to face with regular visits by senior staff across the organisation is one of the most effective mechanisms available. For example, the Townsville Hospital used links to a website to establish if staff had sufficient information and understood their roles during cyclones. This enabled the incident management team to tailor further communications to address information needs. An interesting facet was that administrative staff opened email communications most quickly and were then asked to ensure that subsequent

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communications were then printed out, prominently displayed and put in front of the clinicians who most needed to be informed.

Key reading Hollnagel E, Braithwaite J, Wears RL. Resilient Healthcare: The resilience of everyday clinical work. 2nd ed. Farnham, UK: Ashgate; 2015.

Activites • •

What are the phases of disaster response in a health service? You are the emergency physician on duty in your busy department at 6pm on a Friday evening. You are notified by the ambulance service that there has been an accident involving a bus full of schoolchildren and a train.



– What are your immediate actions? – You get a further call after 30 minutes telling you that there are 15 dead, 10 critical including 5 major burns, and 10 with minor injuries. Are there any further considerations? – As Health Incident Controller, how will you communicate with your hospital staff?

•

Think about your community and the types of disaster it is most likely to experience.



– Describe a disaster’s potential effects on the health and wellbeing of the community. – Identify the potential public health consequences.



References Aitken P, Franklin RC, Lawlor J et al. ‘Emergency department presentations following Tropical Cyclone Yasi’ PLOS ONE. 2015; 10(6): 1–12. Braithwaite J, Clay-Williams R, Nugue P et al. ‘Healthcare as a complex adaptive system’. In: Hollnagel E, Braithwaite J, Wears RL, editors. Resilient Healthcare: The resilience of everyday clinical work. Farnham, UK: Ashgate; 2013. Braithwaite J, Wears R, Hollnagel E. ‘Resilient health care: Turning patient safety on its head’ International Journal for Quality in Health Care. 2015; 27(5): 418–420. Clay-Williams R, Nosrati H, Cunningham FC et al. ‘Do large-scale hospital and system-wide interventions improve patient outcomes: A systematic review’ BMC Health Services Research. 2014; 14: 1–13. Gostin LO, Hanfling D. ‘National preparedness for a catastrophic emergency crisis standards of care’ JAMA. 2009; 302(21): 2265–2366. Hollnagel E, Braithewaite J, Wears RL. Resilient Healthcare: The resilience of everyday clinical work. Farnham, UK: Ashgate; 2013. Koenig KL, Cone DC, Burstein JL et al. ‘Surging to the right standard of care’ Academic Emergency Medicine. 2006; 13(2): 195–198. Leggat PA. ‘Oseltamivir and its role in influenza prevention and treatment’ Annals of The Australasian College of Tropical Medicine. 2011; 12(2): 61–63. Lister SA. Hurricane Katrina: The public health and medical response. Washington, DC: The Library of Congress; 2005.

144  A. Johnson, M. Aitken & P.A. Leggat Queensland Government. 2015 State Disaster Management Plan. The State of Queensland (Queensland Police Service). May 2015. www.disaster.qld.gov.au/Disaster-Resources/CDMP/ default.html (accessed 18 May 2016). Rouse WB. ‘Health care as a complex adaptive system: Implications for design and management’ The Bridge (National Academy of Engineering). 2008; 38(1): 17–25. Wears RL, Sutcliffe KM, Van Rite E. ‘Patient safety: A brief history’. In: Zipperer L, editor. Patient Safety: Perspectives on evidence, information, and knowledge transfer. Farnham, UK: Gower; 2014. WHO (World Health Organization). Framework for a Public Health Emergency Operations Centre. Geneva: WHO; 2015. WHO (World Health Organization). ‘Disasters and emergencies’. 2016. www.who.int/surgery/ challenges/esc_disasters_emergencies/en/ (accessed 24 April 2016).

Part 4

Getting ready

Chapter 12

Prevention and mitigation Gerry FitzGerald

Introduction and objectives Chapter 3 outlined the evolution of thinking about disasters and the shift from a principal focus on response to a more comprehensive all-hazards approach throughout the pre-event, event and post-event continuum or the PPRR cycle. The evidence of the value of this approach is unquestioned and highlighted at the macro-community level when damage is minimised in well-structured communities, while the same event can be catastrophic in less well-developed societies. Building resilient community infrastructure and resilient communities is the best protection that may be offered to a community against the ravages of disasters. The by-product of this investment is improved living standards more generally. Of course, the latter is the more impactful on everyday society, as disasters are rare. Therefore much public policy is directed towards preventing disasters. When they cannot be prevented, the focus is on mitigating their impact. However, most policies that achieve prevention and mitigation are not recognisable as disaster prevention. Rather they are directed towards broader community development goals. The aim of this chapter is to outline the concepts and strategies underpinning disaster prevention and mitigation. On completion of this chapter you should be able to: • • •

Identify and analyse the principles of disaster prevention and mitigation. Discuss the range of strategies utilised to build resilience. Evaluate public policy options in regard to their disaster mitigation impact.

Prevention and mitigation: Building resilience Prevention implies the hazard may be controlled and the event prevented or at least reduced in frequency or severity. Prevention strategies may be diverse, comprehensive and integrated with broader policy initiatives. For example, the accepted social niceties of not spitting in public or covering your mouth when sneezing may be alternatively viewed as pandemic prevention. Building better roads to speed the flow of traffic implies greater safety and reduced risk of major accidents. Safer security systems may reduce the ability of terrorists to cause disruption. Finally, dams built for water supply may aid with flood mitigation.

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However, prevention may be not possible, too costly or not achievable because of the influence of other imperatives. Earthquakes may not be preventable. Building the ultimate safe road may exceed the community’s economic capacity. Consider the considerable resistance to strategic approaches to reduction of carbon emission resulting from fears of the impact such initiatives may have on the economy and quality of life. Where disasters cannot be prevented, it is often possible to take actions that reduce or mitigate the impact of hazards. Mitigation strategies include those taken by the individual, the organisation or the community and may be directed at both individual and community infrastructure. At the individual level, behaviours that avoid the risk may be encouraged. Communities can reduce the risk of exposure to volcanoes by not building near them, and houses built on high ground reduce risk of flooding. Prevention and mitigation strategies may also be viewed as structural and nonstructural: • •

Structural measures are those directed towards the design and engineering of structures. These include building dams, levees and seawalls, windbreaks, freeways with flexible joints to permit some movement, and diverting water flows. Non-structural measures include policy and guidelines to influence not only the design and construction of physical elements but also the design and performance of non-physical elements such as standard operating procedures, governance structures or response arrangements.

However, modifying structures is not sufficient as the only mitigation strategy. Physical barriers can create a false sense of security: see, for example, the tsunami barriers in Japan or the levees in New Orleans. Often the community believes the construction of defences is an absolute protection, when really at best it can reduce the frequency of impact. The combination of structural and non-structural measures may result in a more comprehensive approach. Van den Brink et al. (2013) describe the ‘adaptive capacity wheel’ in which an array of strategies fit within six fundamental domains described as: leadership, governance, resources, variety, learning and autonomous change. Categorisation of prevention and mitigation strategies may assist with understanding their range and scope. Day and Disaster prevention & mitigation Fearnley (2015) categorised mitigation strategies: strategies firstly into those that are •  Strategies directed at the host permanent, responsive to hazard alerts, reduce risk-taking human or anticipatory of risk. Secondly they behaviours. provide a means of evaluating strategies •  Strategies directed at the agent on the basis of those that may be ‘brittle’ reduce risks posed by hazards. (sustainable to a level of impact, then •  Environmental strategies ensure fail) or those that are ‘flexible’ (continue physical infrastructure supporting to sustain to some extent, regardless of communities is resilient. the level of impact). •  Social environment strategies build Understanding prevention strategies community resilience. may also borrow from Haddon’s Matrix used in injury prevention research to

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describe the inter-relationship between the host, agent/vehicle, physical environment and social environment throughout the pre-event, event and post-event cycle. Prevention and mitigation strategies are diverse and permeate through the host, agent, and physical and social environment perspective of Haddon’s Matrix. Strategies directed at the host are those aimed at human behaviour to reduce the likelihood of behaviours that may cause disasters. At its most strategic level, this may focus on the collective use of energy which fosters greater consumption of the earth’s resources and greater production of carbon dioxide which in turn impacts on climate change. More directly these strategies may focus on risk-taking behaviours or on deliberate action designed to cause terror. The scope of these strategies is well beyond this text’s capacity to detail. They may also focus on preventing vulnerability of individuals through physical protections (e.g. safety helmets) or through personal resilience (e.g. immunisations). The strategies aimed at human behavioural modification may be broadly categorised as restrictive, educational or informational. Societies will act to eliminate behaviours that place the community at risk through legal enforcement actions. They may also seek to inform individuals of the consequence of their action or to educate them to enhance awareness and understanding. Strategies directed at the agent are generally those aimed at reducing the presence or risk posed by hazards. For example, containing chemicals and ensuring safety in their accessibility, handling and application may reduce the likelihood of chemical events. Safety systems built into transportation systems will reduce the likelihood of collision. Strategies focused on the environment are directed towards ensuring the physical infrastructure that supports communities is resilient. Such strategies include building standards and land-use planning. Fire risks can be minimised by vegetation planning, and fuel load reduced through controlled burning or vegetation clearing. Similarly firebreaks, levees and evacuation pathways and centres can help protect the people from the impact of disasters and thus mitigate their effect. Strategies focused on the social environment are directed towards building community resilience to either prevent or mitigate the impact disaster has on society. Strategies may focus on both the hard (physical) and soft (systems) infrastructure and target building connectedness and support. Prevention and mitigation measures may occur at all levels of society and at the strategic as well as the operational and tactical levels. On a national level, governments might implement large-scale mitigation measures. They may also be taken at the international level. If achieving domestic cooperation is difficult, gaining international cooperation is extremely challenging. Mitigation measures may also be internally conflicting. For example, the light wooden style of houses traditional in Japan is less dangerous in earthquakes but is not resistant to tsunami. Preventive or mitigation strategies can take different forms to deal with different hazards specific to the local community. Tropical areas may impose cyclone resistance standards that are inappropriate in temperate areas. Tactical measures include rapidly mitigating the impacts of an earthquake or cyclone by shutting down electricity grids to prevent fires, turning off gas supplies, or building shelters. Protective measures include building sprinkler systems to protect houses in fire-prone areas, and having a generator available to ensure water pressures can be maintained. More resilient societies are those often with stronger economies. They are able to build stronger and more costly systems, including the rule-of-law and the putting in

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place of organisational or governance arrangements. More resilient societies are those that are more interconnected with strong social support systems such as family, religious and social connections. Building societal systems helps build resilience and thus mitigate the impact of disasters. Similarly, public and private organisations, service delivery agencies and productive industries need to attend to building their resilience. Disasters are low-probability, high-consequence events; therefore organisational resilience is necessary to ensure continued functioning required to sustain communities. An Australian government paper on organisational resilience (Ernest & Young 2013) emphasised that resilience is an outcome, not a process, and is related to the ability of organisations to maintain effective business as usual, the capacity to change and adapt, and the ability to shape the environment. Prevention and mitigation strategies also intersect with the concept of infrastructure protection, which describes the range of strategies required to protect critical community infrastructure. Such strategies can include security, surveillance, and rapid response, building around the concept of critical infrastructure protection. This is discussed in detail in Chapter 14.

Driving change The old medical adage that ‘an ounce of prevention is worth a pound of cure’ equally applies to disaster management. Prevention and mitigation not only reduces the human impact, but is also shown to repeatedly reduce the economic costs of response and recovery. However, there are practical and political constraints to these simple cost– benefit analyses. For example, while insurance companies may be most adversely affected by events, they are generally not in the position to pay for mitigation or protective works, as these are not the purpose for which people pay their premiums. The policy drivers of mitigation and prevention, particularly in democracies, are often indirect and difficult to link to direct action. While government may be able to direct initiatives they fund, they are generally not in a position to direct the actions by private individuals and organisations. Evidence suggests that people are prepared to spend more on prevention and mitigation, and that financial incentive directed towards the individual may deliver benefit in excess of the costs to the public purse (Donahue 2014). It should be noted that the majority of critical community infrastructure is held by the private sector. Prevention and mitigation measures may need to be encouraged by governments or communities through strategies that are more indirect. These may be broadly grouped into five categories: 1 Legislative and other legal measures: either requiring or forbidding certain actions. These may range from direct legislative imposition of certain actions, through to the creation of standards forming benchmarks against which commonlaw judgments may be made. Examples include land-use planning legislation, construction standards and road safety activities. 2 Financial incentives: either through taxation or price mechanisms, making it financially attractive to take certain measures. Or, on the contrary, the imposition of financial penalties such as higher insurance premiums or direct fines for actions that are not appropriate.

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3 Information and awareness: programs that ensure people know and understand the consequences, allowing for necessary protective actions to be taken. 4 Direct action: governments may determine the actions taken by agencies it directly controls, or by the community through collaborative community-based activities. 5 Political and commercial pressure: may be exercised on governments (by the people) or by governments on other instrumentalities. This may involve the media and may include commercial pressure when governments take action against companies that devalue the safety of workers. The difficulties confronting implementation of prevention and mitigation Indirect prevention & mitigation strategies is the multiplicity of agencies strategies: involved in those strategies and the •  Legislative & other legal measures conflicting and confounding imperatives. requiring or forbidding certain For example, the finance department actions. may be pushing for increased efficiency •  Financial incentives/penalties making it to improve productivity, while injury attractive/unattractive to do certain prevention advocates (and unions) may activities. speak to safer production. The employ•  Information & awareness ensuring ment department may wish to lower people know & understand occupational health and safety (OH&S) consequences, & adopt safer injuries whilst consumers are begging for practices. lower costs. •  Direct action whereby governments The challenge of modern societies is to determine actions taken by their determine how mitigation strategies may agencies, or by the community via fit within the complex and competing collaborative community-based priorities and influences. How does a activities. community exact prevention and miti•  Political & commercial pressure gation strategies and where is the exercised on governments by the authority for, and the sustainability of, people, or by governments on such decisions? other instrumentalities. For example; people in floodable areas have previously built their house on stilts to allow water to circulate relatively harmlessly under the house without damaging content. Greater prosperity, the loss of historical knowledge through the passage-of-time and the false or inappropriate belief that modern systems will prevent any illeffect has meant subsequent property Greater prosperity, the loss of owners have built-in under the house historical knowledge through to expand the useable family space. the passage-of-time, & a false or However, this makes the property more misguided belief that modern systems vulnerable to the impact of flooding. will prevent any ill-effects of a disaster How can vulnerability be addressed have caused many communities to in the light of competing demands and adopt high-risk land management a reluctant community? Implementing practices. coordinated approaches to disaster prevention and mitigation against conflicting

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interests is difficult not only within government, but across the entirety of society. Communities are likely to be tolerant of measures that address their own risk, but less so of measures to reduce the risk to others. How can individual interests be balanced against the greater good? The NIMBY (‘not in my back yard’) perspective limits the creation of mitigation initiatives that disadvantage anyone. Societies often demand greater protection as long as someone else pays for it and it does not interfere with an individual’s sense of comfort. Comprehensive multimodal approaches are necessary as no single strategy is likely to be successful. Using floods as an example, vulnerability can be addressed through land-use planning, housing design and operational strategies such as alerts and evacuation. Furthermore, collective strategies to minimise the hazard may include: • • •

Storage of excess rainwater in dams or flood protection ponds. Channelling of water away from vulnerable areas by the use of diversion channels or levees. Such channels need to be maintained to ensure they remain free of obstruction. Water flow management ensuring absorptive land is maintained.

Consider also a comprehensive strategic approach to drought management. This may include water conservation as well as soil conservation and management to prevent erosion through crop or plant selection. Finally, community lifelines are an essential component of disaster mitigation ensuring reduced impact on the community. For example, resilient design and construction will ensure less vulnerable infrastructure, allowing continued supply and evacuation of communities. Safe houses or evacuation centres may be required to provide protection in the event of a disaster.

Vulnerability The concept of vulnerability is often seen as the counterpart of risk. Disasters are a social phenomenon and vulnerability can be expressed in terms of the individual, organisational or community’s susceptibility to the impact of hazards. However, the definition of vulnerability is unclear. Indeed it could be posited that vulnerability, like disaster, is a relative term. Even the best swimmers may be vulnerable to the tsunami, while some severely disabled individuals are heavily reliant on support at all times and thus highly susceptible to any changes in that equilibrium. There is clearly a range of vulnerability that balances the capability of the individual, organisation or community against the extent and nature of the challenge confronting it. The vulnerability of people may be considered to comprise several interconnected components or perspectives: • • •

Individual vulnerability relates to the personality and coping mechanisms of the individual and their capacity to resist and respond to challenges. Social vulnerability refers to the extent of social support the individual may have. Physical vulnerability concerns the level of physical disability and the system and structural supports available.

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•

•

Biophysical/medical vulnerability concerns the extent of ill health and the need for ongoing medical support. For example, a person with renal failure is highly vulnerable to the loss of transportation denying access to the dialysis machine, or to the loss of power preventing the machine from operating. Economic vulnerability refers to the individual’s access to physical and financial support and the ability to purchase assistance when required.

According to Cutter (1996):

Perspectives of vulnerability: •  Individual vulnerability – individual’s personality, coping mechanisms & capacity to resist & respond to challenges. •  Social vulnerability – extent of individual’s social support. •  Physical vulnerability – level of physical disability & the support systems available. •  Biophysical/medical elements – extent of ill health & need for ongoing medical support. •  Economic vulnerability – individual’s access to physical & financial support & ability to purchase required assistance.

This perspective highlights the social construction of vulnerability, a condition rooted in historical, cultural, social and economic processes that impinge on the individual’s or society’s ability to cope with disaster and adequately respond.

Social and economic vulnerability is aggravated by the increasing complexity of modern society where interconnectivity of human social systems becomes more vulnerable to failure of component pieces. In particular, modern Western societies are particularly vulnerable to power failure which impacts much of our social system functionality from telling the time to communication and mobility. An individual in a wheelchair may be reasonably mobile in highly developed Western societies until the power fails and they cannot use the elevator. Weichselgartner (2001) defines two models: 1 The pressure and release model: vulnerability is contributed to by the intersection between the hazard event and the processes that give rise to unsafe conditions. 2 The access to resources model: vulnerability is contributed to by the interplay of political and economic forces which contribute to social vulnerability.

Mainstreaming mitigation and prevention Isolated discussion around prevention and mitigation implies these strategies occur in isolation of other public policy or social development. However, non-routine and rare events can never be the basis of social and economic development. After the 2011 Japanese earthquake and tsunami, people asked why they built those fishing villages in a tsunami-prone area. The nearness to the fish obviously outweighed any risks known or unknown of tsunamis. This concept of greater good must necessarily be taken into consideration in social and economic decisions. Most public policy decisions, as with most individual and organisational decisions, balance the risks

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of adversity against the risk of benefit. Mines are built in dangerous and isolated places because that is where the minerals are found. Human populations inhabit the alluvial (floodable) land because that is where the rich soil to support food production is found. The cost effectiveness of mitigation measures in their broadest sense must also be considered by balancing the economic and social perspectives: • •

Economic consideration: building high-level concrete houses to withstand the annual floods is optimal, if the community can afford them. Social consideration: some people enjoy the riverside aspects and are prepared to accept the risk of flooding.

Except in the most high-risk areas, there is rarely a role for standalone approaches to mitigation but rather there is a constant need to take disaster mitigation and prevention into consideration in all public policy initiatives. This mainstreaming of policy approach means not only that it is more likely to ensure consideration is given, but also that the consideration is taken into the broader perspective of the potential risks, costs and benefits. Land-use planning is a classic example. As new development occurs, disaster impacts should be part of the contextual analysis. This mainstreaming of mitigation helps with a balanced consideration. The consideration of investment in a strong high-level bridge should take into account not only the longevity and productive capacity of the bridge, but also its role in maintaining communication and access to vulnerable communities.

Case study 12.1: Tasman Bridge disaster, January 1975 In Hobart, Tasmania, on 5 January 1975, the bulk iron ore carrier Lake Illawarra collided with several pylons of the Tasman Bridge when travelling up the Derwent River. Two piers of the bridge collapsed, along with 127 metres of bridge decking. Four cars careered into the Derwent River killing all five occupants. Seven crewmen from the Lake Illawarra were also killed. The disaster severed the main link between Hobart and its eastern suburbs with a population of approximately 40,000. This disaster is notable for the social impacts resulting from the loss of such an important road artery, as most of the city’s hospitals, schools, businesses and government offices were located on the western shore. A temporary one-lane bridge was constructed within a year; however, it was 34 months before the Tasman Bridge was reopened. Hence the disaster hastened development of commercial and public facilities in the eastern suburbs.

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Key readings Kieny M P, Dovlo D. ‘Beyond Ebola: A new agenda for resilient health systems’ Lancet. 2015; 385(9963): 91–92. Kruk ME, Myers M, Varpilah ST et al. ‘What is a resilient health system? Lessons from Ebola’ The Lancet. 2015; 385(9980): 1910–1912.

Activities • • •

Produce a table summarising strategies that may prevent or mitigate the impact of bushfires on a rural community. In doing so, consider using the framework of host, agent, environment and society. Consider the legal, economic, physical and social strategies that may help mitigate the effect of a tsunami on a coastal region. Evaluate the costs and benefits of imposing lower speed limits on a highway.

References Cutter SL. ‘Vulnerability to environmental hazards’ Progress in Human Geography. 1996; 20(4): 529–539. Day S, Fearnley C. ‘A classification of mitigation strategies for natural hazards: Implications for the understanding of interactions between mitigation strategies’ Natural Hazards. 2015; 79(2): 1219–1238. Donahue AK. ‘Risky business: Willingness to pay for disaster preparedness’ Public Budgeting & Finance. 2014; 34(4): 100–119. Ernest & Young, Australian Government. Organisational Resilience: The relationship with risk related corporate strategies. Canberra: Ernest & Young, Commonwealth of Australia; 2013. van den Brink M, Meijerink S, Termeer C et al. ‘Climate-proof planning for flood-prone areas: Assessing the adaptive capacity of planning institutions in the Netherlands’ Regional Environmental Change. 2013; 14(3): 981–995. Weichselgartner J. ‘Disaster mitigation: The concept of vulnerability revisited’ Disaster Prevention and Management: An international journal. 2001; 10(2): 85–95.

Chapter 13

Planning Mark Cannadine and Rosemary Hegner

Introduction and objectives The effective management of disasters begins well in advance of any event. Getting ready includes preventing and mitigating the risks to which the community is exposed but it also involves organising the resources required including the people and their capabilities. Indeed, in the absence of frequent events, the only thing we can measure is the degree of preparedness. Preparedness involves a range of strategies that in general aim to prepare for response and recovery. Key to preparation is the process of planning. Disaster planning should not occur in isolation of normal business planning. Modern organisations and communities have exposure to a range of risks including those associated with major incidents. Disaster planning should be part of the normal preparedness of organisations and communities to confront not only the routine risks associated with normal operations but also the major non-routine risks that challenge the whole community. The aim of this chapter is to address the issue of disaster planning for health services and to outline the principles and practice of planning. On completion of this chapter you should be able to: • • •

Identify and critically discuss the value and importance of planning. Demonstrate an understanding of the principles of disaster planning and its context. Describe the process of planning and the activities required to achieve effective planning.

Disaster planning in the health context Good disaster management is about effectively coordinating and directing resources to achieve the greatest good for the greatest number when normal systems and processes are stretched to, or even beyond, capacity. Planning is the process of designing and documenting how an organisation or facility will respond to, and manage, a disaster to achieve the desired health outcomes. For many health services, a disaster response will be very complex and involve a diverse group from differing functional areas of health. This coordinated and joint approach must start in the planning process by identifying and engaging all those

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who will add value to, and sustain an effective response and recovery during, a Good disaster management is the critical period. ability to effectively coordinate Engagement of the wider health system & direct resources to achieve during business as usual (BAU) presents the greatest good for the greatest its own challenges as most health services number when normal systems work at, or close to, capacity most of & processes are stretched to, or the time. This leaves little time to dedicate beyond, capacity. to planning. Ironically, the healthcare culture of continuing to serve and care no matter the circumstance can almost become an obstacle to effective planning. The argument ‘why should we plan, we always cope?’ can almost be made, when a focused and dedicated workforce constantly adapts and overcomes in the face of adversity. With changing demographics, cultures and climate and the heightened expectations amongst communities in the effectiveness of response to disasters, failing to plan can ultimately put at great risk well-intentioned health workforces who have limited time to meet and plan. So it is never truer than in the health context that ‘failing to plan is planning to fail’ both our people and our communities.

Planning principles There are many and varied definitions of planning but most will probably agree that it is an analytical and consultative process to help organisations or governments manage the risks presented from both common and extraordinary hazards. Modern health services are under considerable stress, struggling to cope with No amount of disaster planning, the increasing demand for services within education & exercising will resource constraints. Health services can compensate for the confusion also be quite fragmented organisations created by the departure from with conflicting priorities, meaning that normal business or professional any planning activities which are counter practice in the face of adversity. to, or create challenges for, normal business, will struggle to gain traction. This is one reason why consulting early with the business is a key principle in achieving the level of engagement critical to successful disaster planning. Equally important, however, is embedding normal business at the heart of our response to disasters. No amount of disaster planning, education and exercising will compensate for the confusion created by the departure from normal business or professional practice in the face of adversity. Normal business may need to be augmented or supplemented of course, but familiarity in the planning of disaster systems and arrangements will enable health services to manage the surge in demand which accompanies any disaster. Disasters present unique challenges to health services, but can also present opportunity. Of course disasters place systems under enormous stress, placing extraordinary demands on staff and services. However, they can also present opportunities to step outside of normal boundaries and conventions, forging new relationships and arrangements borne of necessity. These opportunities must be anticipated in the planning

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process though, particularly if the principle that disaster planning must be rooted in normal business is to be applied. For example; where limitations in human, financial or technical resources are known, planners can anticipate the options that would normally be ‘off the table’, such as accessing private health services or modifying capacity or staffing ratios. Disaster health plans will therefore strive to achieve a balance between the well-practiced and understood, and permission to go beyond.

Planning context Fundamental to the planning process is establishing and communicating the context within which the planning occurs and the plan will operate. Central in establishing this context for health services is authority and governance. The authority for the proposed plan will be relative to its strategic, tactical or operational application, but regardless, there must always be appropriate oversight and governance to ensure efficacy of process, and accountability for development and delivery. At a jurisdictional level this may be informed by legislation outlining statutory obligations to plan, which in turn may inform government, department, health service or business unit planning. The mandate may not be legislated but may relate to organisational aims and objectives or public health priorities. Wherever the mandate originates, it is essential to identify the authority to plan, the governance body with oversight, and the group or individuals responsible for delivery of the plans. Nor are these considerations for only the start of the planning process. Throughout the journey the governance body will need to be consulted to approve finance and resources, stakeholder groups, endorsement of draft content and approval of finished plans. They will also have a crucial role in bringing the planning process full circle by: • • •

Setting review periods and exercising or training programs. Ensuring lessons identified during exercise or activation are incorporated into the plan. Informing the revision and update of the plan.

Therefore, identifying the appropriate governance body to provide oversight and direction is a critical early consideration. Establishing and understanding the planning context will therefore help to clarify the ultimate objective and required output of the planning process. It may even change the initial perception of the plan’s purpose and intent, but ultimately the finished product must address the issues that it needs to without over-reaching, must have oversight from those accountable for it and, most importantly, must add value to those who need it.

The planning process Whilst arguably Dwight D. Eisenhower’s quote ‘Plans are nothing, planning is everything’ is a rather bleak assessment of the finished product, it is undeniable that the planning process itself is an enormously beneficial and educative process. By stepping through the planning process, planners and stakeholders will almost certainly build their organisational awareness, renew their links and relationships within their organisation, and

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have a better understanding of its capabilities, vulnerabilities and limitations. It may also be the case that where the disaster plan is perceived to be of little use, this could be due to unclear context, lack of appropriate governance or scope, inability to engage the right stakeholders, or ambiguity in its aims and objectives. Before progressing further in the Dwight D. Eisenhower said: ‘Plans are planning process, the first step is to plan nothing, planning is everything’. the plan! Having obtained authority to plan, a project plan must be established with agreed deliverables, i.e. the plan’s constituent parts. This chapter will not address the principles of project management, but a rudimentary understanding and application of these principles will not only be important in achieving a successful outcome to the project (i.e. delivering the plan in the agreed timeframe and budget), but will also inform the planning process and deliver a better finished product. There are a number of key stages in the planning process, as outlined below. Engage key stakeholders and participants Most health services, whether local, Key stages in the planning process: regional or jurisdictional in size, are •  Engage key stakeholders & complex organisations with many participants. internal and external relationships and •  Establish scope & limitations; dependencies. Attempting to plan without identify clear aims & objectives. first understanding the organisation and •  Undertake hazard identification & the stakeholders who will either be risk analysis. essential to the process, or who will be •  Create document plan ensuring impacted by the application or activation compliance with agreed objectives. of the plan, can at best result in ineffective •  Socialise, refine & confirm. plans, and at worst, create division and •  Formally endorse the plan. barriers which can delay or derail the planning process. Obtaining authority to plan through an appropriate governance body can help with this process, but the planner should not assume that this is so. Time spent in mapping out stakeholders and participants and those who will benefit or be affected by activating the plan will help to draw out all those who should be engaged with, or who should contribute to, its development. Establish scope and limitations; identify clear aims and objectives Having identified key stakeholders and participants, the next question is how (or how much) should they and their service or business be incorporated into the planning process. Limitations in scope can be related to resources: • • • •

Are there enough people to do this? Can this be done in time? Is this strategy affordable? Is there the authority to do this?

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Whatever the limitations are, they need to be understood. This will save wasting time and effort developing an unworkable plan. As an example, a national disaster plan may include contingencies which will be activated at a national level, but which rely entirely on resources that are controlled by multiple jurisdictions. If the jurisdictions and/or their resources are not well prepared or resourced, the national plan is unreliable. Logistical, financial, human resource or political issues may limit or deny the inclusion of key elements in the plan. If this is the case, the level of risk this presents to the plan and its success will need to be considered early in the planning process. Critically, the scoping process must identify the aim and objectives for the plan. Confusion between these two concepts is common, with many and varying definitions. Simply put: the aim of the plan is a broad statement of the plan’s purpose or intent (i.e. the aim of this plan is to outline the health services strategy and arrangements for responding to, managing, and recovering from, a natural disaster). The objectives thereafter provide detailed explanation of how to achieve that aim. A list of objectives for the above aim might include: • • •

To maintain an effective command and control structure with clear communication, notification and escalation processes for identifying and responding to disasters. To establish effective incident response procedures to ensure the organisation is aware of and can respond to a disaster, including details of all departments and services involved in the response and their relationship to incident command. To outline a recovery strategy to help the organisation recover from the impacts of the disaster and to return to normal functioning, to identify lessons and opportunities from the disaster and to build capability through reviewing and updating the disaster plan.

Undertake hazard identification and risk analysis Emergency risk assessments including hazard identification are well documented in international and national standards. Understanding hazards is an important element in health emergencies and clarity regarding the hazard(s) in the context of planning for emergencies affecting health services is essential. For example, ‘Hospital Emergency Plan’ is a very broad definition potentially encompassing many hazards including fire (both internal and external to the facility), bomb threats, medical emergencies, etc. Nevertheless, in the context of health disaster management, the hazard or source of potential harm is of less significance. The key considerations become the impacts of a disaster on the health facility or service, and planning the health facility’s or services’ response to, and management of, the disaster. For example, is the plan addressing the effects an earthquake will have on infrastructure and disruption to services, or how to deal with the impact the disaster has on a community and thereby the potential patient surge or increase in demand for health services? Business disruption and recovery strategies are most often documented within business continuity plans (as discussed in Chapter 7). Ultimately though, by understanding the hazards, developing both an earthquake plan and a cyclone plan, for example, may be unnecessary and duplicitous if the impact on the ability to provide health services is the same and can be addressed in one consolidated plan.

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Document the plan compliant with agreed objectives; socialise, refine and confirm Returning to the examples of objectives for a disaster plan above, the next step is to expand the detail of each objective and the processes and arrangements needed to help achieve them and make the plan work. For example, the first objective above (‘To maintain an effective command and control structure with clear communication, notification and escalation processes for identifying and responding to disasters’) can be broken down as follows: • • • •

Command and control structure. Incident notification pathways – internal and external. Escalation processes. Incident command centres and incident management teams.

This process then informs the list of contents for the plan with the objectives being broken down into their constituent parts, and detail on how to achieve them. Formally endorse the plan As each objective is addressed in the planning process, the key stakeholders will be able to provide agreement on content and informal endorsement of each element. Formal endorsement must be completed before the plan can be released and become a functional part of business practice. The governance body identified whilst establishing the context for the plan will have agreed upon the appropriate administrative endorsement process and this must now be undertaken. Version control for disaster plans is extremely important. Identifying a source of truth for a health service or organisation is critical to ensure that those who activate the plan will be working with up-to-date and relevant documents and processes. This can also be part of the endorsement process and as a result of making this the business of the governance body or committee rather than a bespoke group established solely for the planning process. The plan will benefit from well-understood administrative procedures and oversight.

Planning frameworks The purpose of a planning framework is not only to establish a hierarchy of plans but also to ensure understanding of the relevance of each plan and its relationship to the planning framework as a whole. National, jurisdictional, regional and local plans can often be developed in relative isolation and with little reference to the suborEffort can often be wasted or dinate or superior arrangements and duplicated without first establishing systems. Without good linkage between the planning framework & where the vertical levels, a national plan, for consolidated arrangements can be example, may include objectives only developed & shared. achievable with resources controlled at the jurisdictional level. Equally, regional

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plans and services supporting local/hospital arrangements will fail if the horizontal interdependencies and relationships fail to be understood. Effort can often be wasted or duplicated without first establishing the planning framework and where consolidated arrangements can be developed and shared. Visual representation of planning frameworks can be a powerful tool in clarifying these vertical and horizontal relationships, as in Figure 13.1. The example in Figure 13.1 shows that the national health disaster plan at the strategic level can only function if the constituent jurisdictions understand their responsibilities in the national context. Equally they must be consulted in its development, if their capability and capacity are to be understood and integrated effectively. Thereafter the jurisdictions’ health disaster plan must outline in tactical terms how they will respond to activation of national arrangements and to a jurisdictional event. The jurisdictions must consult with their regional health services so the regions can develop sub-plans/guidance to inform the whole-of-jurisdiction approach. Finally, hospitals will then be able to plan their operational approach, including supporting the regional and jurisdictional response, but importantly these operational plans will be consistent, informed by the work done at the jurisdictional and regional level. For example, workforce health plans can be developed by the jurisdiction to ensure consistent application of personal protective equipment (PPE) across all regions, operationalised by hospital service units and staff. If communicated clearly and consistently, this approach ensures effort is not duplicated in policy development at the hospital and operational level, where attention and time can then be focused on the formulation of specific hospital clinical and administrative arrangements and plans. In this way, understanding the interrelationships in the planning framework and knowing that these relationships work both ways (i.e. not only in a strictly top-down hierarchical sense), will ensure effort is expended in a more efficient and productive way.

Structure and content of plans There is no magic formula or rigid structure for what should be in a plan. The aim and objectives of the plan are a good place to start in understanding whether what is written (the contents) and how they are laid out (the structure) effectively achieve the objectives in a logical and workable order and thereby, hopefully, achieve the aim. It can be difficult sometimes to know from the outset whether all the key elements of the plan have actually been captured in the contents list and it is tempting (because they are usually located at the front of the document) to write the perceived contents list first, then flesh them out in the body of the plan. This can, of course, work if a clear and comprehensive picture of what is to be achieved, and how, already exists, but it is not necessarily a hard and fast rule. A perfectly reasonable approach would be to set out the administrative elements of the plan, already outlined when establishing the context, then apply some basic structure around which to frame the operational elements of the plan. For example: • • •

Authority and governance. Scope. Risk assessment/hazard identification.

Service Unit

Ambulance - Transport

Horizontal integration ensures interdependencies & relationships across geographical areas, services & specialties can be incorporated into & inform all levels of plans

Service Unit

Service Unit

Service Unit

Infection Control

Protective EauiDment

Workforce Health

Mental Health

Environmental Health

Allied Health

Community Health

Public Health

Service Unit

Service Unit

Service Unit

Hospital Plan

Service Unit

Service U nit

Service Unit

Service Unit

Service Unit

Hospital Plan

Figure 13.1 Vertical and horizontal integration of disaster plans.

Vertical integration ensures each plan references & supports that above & is supported by that below

Regional Plan

Jurisdictional Plan

National Health Disaster Plan

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• • • •

Aims and objectives. Information/background. Method – operational guidance on how you will complete the objectives and achieve the aim. Glossary of terms.

Then just start writing! Almost certainly when stakeholders are engaged, discussions progress, and the plan takes shape, new information will come to light about the perceived scope and limitations. The plan is bound to take more than one turn or new direction. The value in this kind of dynamic writing process is that it will confirm or change the understanding of the original intent, and thereby result in a more accurate and robust final product.

Translating plans into action Confirming or dispelling the perception that plans are nothing, but planning is Translating plans into action: everything happens at this stage. Adding •  Embed, socialise & educate. a plan or policy to an organisation’s •  Establish the exercise, validation library, a shared drive, or a document & review cycle. repository, does not add value where needed: instead, it only validates the common perception that ‘it will be put on the shelf with the others!’ There are some key considerations when translating plans into action, as discussed below. Embed, socialise and educate The planning process itself can be educative for those who undertake it, or participate in it, but now it must be determined who are the education and socialisation audience. Many health services and large organisations will have communications departments to help with this and raise awareness of the disaster plan and its development. Whilst the audience may vary and many will have an interest, the plan’s aim and objectives will determine the people who really need to know about it and who must be reached. The focus ought to be on those who will need to use it, have a role in it, or who will rely upon it during a crisis. Expecting the organisation to passively adopt and embrace a plan which has not been well communicated to the right audience will fulfil the prophesy of planning to fail! Establish the exercise, validation and review cycle Belief that there is no value in plans is only true of the paper and plastic gathering dust on a shelf. The true value of a plan can only be measured in its application and validation and whether it lives in the minds of those who one day may have to use it. Therefore a crucial component of the plan, which must be included in the endorsement process, is the exercise, validation and review cycle. Exercising can take many forms; field, functional, table top or discussion, and will be addressed in Chapter 25. All have value and potentially any or all can be included

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in the exercising and evaluation cycle of the plan. However, scale and complexity can often result in long gaps between exercises as they require planning time and release of resources. Smaller compartmentalised exercises focusing on key elements or sections of the plan (e.g. command and control, notification and escalation, or emergency department clinical response) can then be considered together to validate the plan as a whole and can be much easier to achieve. This brings us full circle: back to the context and governance body. In establishing the authority to plan, the frequency of exercise, validation and review must be considered. This must be documented, mandated and regulated by the appropriate body or committee. The exercising process must also be managed and communicated carefully. Often executives, senior clinicians and administrators will be required to participate in disaster exercises as they have a role in the disaster plan. Yet this is frequently by virtue of their position in the organisation, rather than any particular knowledge or experience in disaster response. This can result in avoidance and delays in the exercising cycle, perhaps not through indifference or neglect, but because nobody wants to fail, or to be seen to struggle, and this must be anticipated when planning and communicating exercises. Adherence to the principle of embedding normal business into the heart of the plan ought to reassure those who have a part to play, because all that is being asked of them is to do what they do every day, only with slightly different structures, resources or guidelines to help manage the crisis. Thus the key players will understand that this is an opportunity to exercise the plan, and for the organisation to learn together, in a safe learning environment. It should not be regarded as a test of performance and knowledge. In this way, plans can be properly exercised and validated to determine where and how they need to be revised and improved. It is also natural for the planner to feel protective of their plan: after all, it is the product of much hard work. However, as has already been stated, the real value of the plan is when it lives in the minds of those who one day may have to use it, not in the words on the paper. Validating the plan and identifying areas for improvement and refinement during an exercise, can only serve to better prepare organisations Field Marshall Von Moltke noted: and their people for the day they need to ‘No plan survives contact with use it in a real disaster. the enemy.’ The plan is just that – a plan – not a hard and fast, inflexible document which must be adhered to at all costs. Organisations will have the best chance of operationalising their plan and effectively responding to, and recovering from, a disaster if they: • • • •

Engage with the right people. Understand how and when the plan is intended to be used. Make the plan reflect what the people who may need to use it do every day. Exercise the plan occasionally.

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Key readings Kahan. J. 2015 ‘Future of FEMA – Preparedness or politics?’ Homeland Security & Emergency Management. 2015; 12(1): 1–21. United Nations. Sendai Framework for Disaster Risk Reduction 2015–2030. Paper presented at the Third United Nations World Conference on Disaster Risk Reduction, Sendai, Japan. April 2015. www.wcdrr.org/uploads/Sendai_Framework_for_ Disaster_Risk_Reduction_2015-2030.pdf (accessed 25 April 2016).

Activities • •

Identify the key stakeholders from a community with which you are familiar, and consider how their disparate interests may influence the development of a community plan. What criteria would you use to ensure your planning process is effective?

Chapter 14

Preparedness Julian Meagher and Rosemary Steinhardt

Introduction and objectives While planning is the cornerstone of preparedness it is not its entirety. An understanding of the broader disaster management cycle is necessary to enable understanding of the various phases of disaster and the benefits that investments in those phases bring to community outcomes. A casual visitor to drought affected areas of central Australia may be puzzled to find boats stored at the local authority, yet this is an essential component of the preparedness arrangements built around the identified community risks. Preparedness involves a range of strategies and activities that contribute to understanding risk and enabling a community to be resilient and able to respond rapidly to disasters. Building resilience in individuals, community and the infrastructure that supports them contributes to preparedness. It considers how the development of strength in the design and maintenance of systems and structures may be complemented by the processes of surveillance, and by having pre-positioned resources and equipment potentially critical to the required flexibility, responsiveness and adaptability. Finally it concerns the preparation of people; building their personal resilience and strength by pre-arming them with the knowledge required to defend and respond appropriately. Additionally it concerns the identification, training and availability of help through both paid and volunteer organisations and individuals. The aim of this chapter is to explore the requirements for preparedness needed to ensure that the community is ready to respond to disasters. On completion of this chapter you should be able to: • • • •

Understand the concepts underpinning disaster preparedness. Identify what constitutes resilience of individuals, communities and organisations, and how to build resilience. Evaluate the strategies required to be ready. Discuss concepts of infrastructure protection and business continuity.

The role of preparedness within the disaster management cycle An understanding of the course disasters take, or the cycle that they go through, is as important as understanding the terms and language used. The traditional mantra of

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‘prevention, preparedness, response, recovery’ (PPRR) is often quoted as the disaster management cycle; however, these terms often have differing definitions and relate more to the phases that are applied to preparing for, responding to, and recovering from disasters. A more contemporary view emerging is to describe activities as being associated with the before, during or after phase of a disaster. There are various definitions applied to terms used, but most importantly they describe phases that are not linear in nature, but should be seen as overlapping. We have previously detailed the processes of risk assessment and treatment as part of the process of communities ‘getting ready’. Similarly we have detailed the planning process and its importance in disciplining the process of community preparedness. The portion of activities undertaken in preparation is often now simplified as ‘getting ready’, and this may be considered in two phases: general preparedness that reflects the development of community structures and systems that build community resilience; and immediate preparedness that encompasses the preparation of people and resources to confront an imminent threat. Preparedness is not easily disconnected from the next phase that some see as ‘crisis management’, involving the scaling up of response, where resources are marshalled and tasked. Of most interest in contemporary times, however, is the emergence of ‘consequence management’ as a defined component of any disaster. An understanding of the likely or potential consequences will need to be managed and thus consideration must be given to what to prepare for, and the resources required for response, relief and recovery. Figure 14.1 seeks to contextualise this. With any disaster, the initial focus is on meeting the broader community needs that provide for, protect, and assist it to survive in a population sense. Broadly, at a minimum, this ought to include consideration of shelter, safe food, safe water, sanitation, and disease vector control. Initially the focus is at a basic level to support the affected population and prevent starvation and spread of disease. The focus can then shift to include, where available, access to health and medical care, and financial support, etc. Once the basic level needs for the broader community have been established, the shift to restoration of other supporting infrastructure (i.e. utilities) and rebuilding begins. There is a degree of predictability in terms of the impacts a disaster may bring. As an example, earthquake brings destruction and damage to buildings and key community infrastructure; and trauma and injury go hand-in-hand, therefore injuries such as fractures, crush injuries and lacerations are some of the consequences that need to be managed. Disruption to water and sewerage systems bring disease potential to the broader community, and power loss impacts food storage systems, also increasing risk to the community. Similarly, tsunami brings predictable patterns of injury and risk of secondary wound infection complications along with respiratory issues that can be associated with immersion and near drowning events. This provides the opportunity in preparedness to consider risks faced by communities and what may be required to address them. There are guidelines and standards that should also be considered irrespective of whether the disaster is impacting a developing, or a developed nation. The Sphere Project (www.sphereproject.org) is one that seeks to set in place a humanitarian charter and minimum standards for response, defining the accountabilities associated with responding to disaster. Another instrument to help guide effective responses in

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Before

A fte r Consequence Management

Crisis Management

During

Risk Assessment

DISASTER

Figure 14.1 The disaster management cycle: before, during and after.

humanitarian health action, and to incorporate a registration and assurance process, is the World Health Organization/Emergency Medical Teams guidelines (www.who. int/hac/techguidance/preparedness/foreign_medical_teams/en/). These guidelines establish standards to be met in terms of the nature and level of assistance provided by other nations. Consideration of the range of guidelines is part of the contribution to preparedness.

Resilience The definition of resilience is refined to mean the ability to survive and cope with a disaster with minimum impact and damage. It incorporates the capacity to reduce or avoid losses, contain the effects of disasters, and recover with minimal social disruptions. Until recently, resilience has primarily focused on engineered and social systems including pre-event measures to prevent hazard-related damage and losses (preparedness) and post-event strategies to help cope with and minimise disaster impacts (Cutter et al. 2008).

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The use of resilience as an outcome or a process also varies. For example, resilience is considered an outcome when defined as the ability to ‘bounce back’ or cope with a hazard event. Process-related resilience is defined more in terms of continual learning and taking responsibility for making better decisions to improve the capacity to handle hazards. Determining whether resilience is an outcome or a process is an important step towards its application to disaster reduction. When compared to the global change perspective, adaptive capacity or mitigation is often embedded within resilience (Norris et al. 2008). Norris et al. (2008) identified a set of ‘adaptive capacities’ as including: • • • •

Economic development. Social capital. Information and communication. Community competence.

The resilience of a community is dependent on both hard and soft elements: the strength and design of physical infrastructure; the systems and processes necessary to maintain the community; and the knowledge, skills and attitudes of its members. Resilience is conceptualised as the ability of both physical and social systems to withstand earthquake-generated forces and demands, and to cope with disaster impacts through situation assessment, rapid response, and effective recovery strategies. This is measured in terms of reduced failure probabilities, reduced consequences, and reduced time to recovery. Bruneau et al. (2003) attests resilience for both physical and social systems can be further defined as consisting of: • • •

•

Robustness: strength, or the ability of elements, systems and other units of analysis to withstand a given level of stress or demand without suffering degradation or loss of function. Redundancy: the extent to which elements, systems or other units of analysis exist that are substitutable (i.e. capable of satisfying functional requirements in the event of disruption, degradation or loss of functionality). Resourcefulness: the capacity to identify problems, establish priorities and mobilise resources when conditions exist that threaten to disrupt some element, system or other unit of analysis. Resourcefulness can be further conceptualised as consisting of the ability to apply material (i.e. monetary, physical, technological and informational) and human resources to meet established priorities and achieve goals. Rapidity: the capacity to meet priorities and achieve goals in a timely manner in order to contain losses and avoid future disruption.

Critical infrastructure protection In the past, key infrastructure items were physically independent, but growing complexity of modern societies and advances in technology have made the interconnections automated and often invisible. While this has made systems more efficient, it also makes them more vulnerable to failure in any component part. A risk assessment and evaluation assessing continuity of supply is a crucial consideration.

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Critical infrastructure (CI) refers to the core physical and social means on which communities rely. The Australian Government (Commonwealth of Australia 2015) defines CI as: . . . physical facilities, supply chains, information technologies and communication networks that if destroyed, degraded or rendered unavailable for an extended period would significantly impact on the social or economic well-being of the nation or affect Australia’s ability to conduct national defence and ensure national security. Primarily, private companies’ investment and ownership of Australia’s CI (including electricity, transport, gas, water, waste and telecommunications) is significantly larger then government ownership (Commonwealth of Australia 2015), therefore it is difficult for governments to directly influence its protection. Attempts to achieve this strategically through partnerships and support arrangements, including the IAAG (Infrastructure Assurance Advisory Group) and the CIAC (Critical Infrastructure Advisory Council), compels CI owners to secure their assets, apply risk management techniques, develop and test business continuity plans and conduct regular reviews. CI protection describes the range of strategies including security, surveillance and rapid response needed to protect critical community infrastructure. As lessons identified from major events have demonstrated how complex and interconnected systems are, the concept of critical infrastructure protection has become especially important. Particular components of society and its infrastructure are essential to the development of resilience and to the sustainability of the community throughout the response and recovery phases. For example, a computer virus that damages the IT system of a bank may have massive consequences throughout the economy as payrolls are frozen. Consider the

Case study 14.1: Damage to undersea cables, Europe, Asia and Middle East, 2006 Global communication systems rely on vast networks of undersea cables which are vulnerable to natural and technological disasters both deliberate (e.g. sabotage) and accidental (e.g. shipping and fishing activities). Earthquakes off the coast of Taiwan in 2006 and in the East China Sea in 2006 and 2009 have caused unprecedented cable failures resulting in millions of customers in dozens of countries throughout Europe, Asia and the Middle East losing access to communication networks. In many cases, damage often takes weeks, or even months to repair. This can have devastating consequences on a country’s economy (Ross 2014). Primarily controlled by a consortium of private companies, no single company or country has ownership over this vast network of undersea cables and communications infrastructure which adds to the vulnerability of the system. Authority falls under both national and international laws and relies on cooperation and coordination between companies and countries to facilitate repairs and maintenance (Ross 2014).

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widespread impact of power shortages resulting from the closure of the Fukishima power station in Japan, where effects were felt in a diverse array of industries including vehicle manufacture. The interconnectivity is such that the consequences will not be limited to a single locality, region or even nation. Many countries have initiated special programs aimed at identifying CI; to ensure systems build resilience and are protected from malicious or natural assault. However, an organised and strategic approach to infrastructure protection faces the barriers of a lack of understanding of the interconnections, as well as dissipated responsibility. CI sectors may include: • • • • • • • •

Banking and finance. Transportation. Power. Information and communications. Government agencies; particularly emergency services, police and health. Public works including water supplies and drainage. Agriculture and food supplies. National monuments and icons.

CI, particularly iconic structures, is increasingly vulnerable to both natural failures (e.g. human error, or weather and seismic events) and to external attack, including cyber-attacks. This vulnerability has been exacerbated by the trend to break up major public utilities and privatise them. The process of infrastructure protection involves the following steps: 1 Identification of CI. 2 Assessment of vulnerabilities. 3 Identification of risk. 4 Mitigation of risk. 5 Protection. The process of CI protection is an interactive process throughout the cycle of getting ready, responding and recovering. Adapted from the US Department of Defense, Figure 14.2 demonstrates the component phases.

Reconstitution

Pre -event

Post-event Event

Figure 14.2 The critical infrastructure protection cycle (adapted from the US Department of Defense).

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It is not possible to defend every critical asset in every location. Responsibilities need to be delegated to individual asset owners and their operators. The components of approaches to CI protection include the following: • • • • • •

Analysis and assessment: identifies the critical assets, their vulnerabilities and risks. Remediation: involves taking precautionary measures. Indications and warning: involves monitoring threats and vulnerabilities. Mitigation: involves actions taken to reduce the potential impact. Incident response: comprises the strategies required to control the extent of damage. Reconstitution (or recovery): involves the actions required to stabilise, rebuild or restore a critical asset’s capability.

The response and recovery phases of CI protection interlink with business continuity, particularly for service-orientated industries. For example, the maintenance of health services requires not only protection of the physical asset, but also the protection of management systems and the people required to maintain services. Business continuity requires an advanced understanding of the organisation’s objectives and resources. The public sector has to balance the drive to maximise return for tax-payers’ funds, with the need to have a certain level of capacity in the event of a disaster.

Surveillance Surveillance is an important component of preparedness as it sets up systems and structures that monitor trends and identifies risks within the community. Traditionally, the term ‘surveillance’ was the domain of public health agencies and used locally to identify people who needed treatment, prophylaxis or education. Since the late 1800s and early 1900s health authorities within multiple countries established processes for physicians to report specific communicable diseases to enable local prevention and to control activities. This included quarantine of exposed persons or isolation of affected persons. Important refinements in the methods of notifiable diseases reporting have occurred over time and have led to changes in surveillance practice. This enabled a shift of public health response and resources. Whilst compulsory reporting of certain diseases allows monitoring of the trends and patterns, and support to early recognition and intervention, the formal reporting systems tend to be slow. Recent attempts have been made to develop more timely surveillance through monitoring of emergency health service data or using the public to participate in regular health surveys, especially during influenza season. To facilitate better communication about influenza with the public health community, clinicians, scientists and the general public, the Australian and US CDC’s FluView maintain an interactive website that monitors and provides weekly reports about influenza. In Australia the public are encouraged to enrol in an online health surveillance system called Flu Tracking. This system is used to monitor effectiveness of influenza vaccine, onset of influenza, severity of circulating virus and changes to influenza strains. More broadly, surveillance occurs throughout the disaster management cycle to inform and manage the disaster response. The use of proactive risk surveillance in the

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community is based not only on the history of what has occurred, but also on the monitoring of current and predicted events around the world. Lessons identified through surveillance are used to improve and modify disaster management responses. Surveillance also involves monitoring the impact of disasters, and seeking to identify potential adverse consequences including those that may emerge after the event; for example, infectious disease outbreaks and long-term health consequences including mental health. The issues associated with surveillance are the balance between information needed, and the limitations in data collection, analysis and reporting. As an ongoing process, there is a requirement for long-term cooperation amongst participants and agencies at varying levels. Expectations of participants and the inability to demonstrate usefulness of the data that they collect threaten optimal surveillance systems and waste valuable resources. Partnerships with other agencies are also important. Current systems are relatively cumbersome and new systems are being explored that are more ‘real time’ and cost effective.

Preparing people Building disaster management capability is a critical component of disaster preparedness. Capability comprises both capacity and ability. It is built around identifying key individuals who will lead disaster management for an organisation or community, building their ability and that of the other key officials. Most large organisations have recognised the risks of internal disasters and have in place individuals responsible for policy advice, planning, training and coordination. Large hospitals, local governments and private sector industries will have one or more emergency management specialists responsible for facilitating training of key personnel, advising on policy, leading planning activities and ensuring systems are in place to ensure coordination in the event of a disaster. Broader capability development is based on training and other individuals whose normal responsibilities may extend to disaster management. This may include individuals whose normal role will be useful in a disaster (e.g. paramedics) along with individuals whose normal role may not be essential but who may be called upon to play a critical support role in a disaster. In health services, for example, part of the breadth of training of clinicians may include the extension of their clinical role to practise in a resource-constrained environment both during major events and in rural or international environments. Equally, others may need to be trained to take up roles in a coordination centre. The difficult task for major organisations is to meet these developmental needs within the constraints of a challenging economic environment. The educational needs will be addressed in more detail in Chapter 25, but it is worth considering how any organisation or community would ensure sufficient personnel are trained to take up roles in a disaster. Exercises are a way of testing these preparedness arrangements and contributing to the educational needs of the organisation.

Preparing resources Equipment, including the means for their operations (e.g. fuel and power), that may be required in a disaster should be deduced from the risks likely to be faced. These

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may need to be pre-positioned or supply maintained to be readily accessible when required. Such equipment needs to be evaluated for its appropriateness in a disaster and positioned either on a standing arrangement or during a time of heightened risk. For example, in the event of an impending cyclone, sandbags, flood boats or helicopters may be repositioned closer to the impact site so that they are ready to respond, but at the same time far enough away to be safe from damage. The community will be expected to clean up around their homes and generally prepare for impact. In some instances this may include evacuation or relocation to purpose built cyclone shelters. Consumables will also be necessary to ensure business continuity and responsiveness. The supply chain of consumables will need protection in a disaster and preplanning should address the resilience of the supply chain. Consumables and equipment may need to be stockpiled so that they are ready and protected, or arrangements made to ensure ready access and continued resupply when in use. Consideration of the nature, location and protection of such stockpiles is a necessary component of the preparedness planning process. In medical terms, the first line of defence is the imbedded stockpile of consumables and equipment located within many health services. This stockpile is the essential component of first response and needs to be identified, maintained and protected so that it can facilitate the response phase. This is a challenge for the ‘just-in-time’ supply chain. Preparedness focuses on preparing equipment and procedures for use when a disaster occurs. Preparedness measures can take many forms including the construction of shelters, implementation of an emergency communication system, installation of warning devices, creation of back-up lifeline services (e.g. power, water and sewerage) and rehearsal of evacuation plans. Planning for all different types and magnitudes of events and consideration of likely risks is of utmost importance so when a disaster does occur, responders know exactly what their role and responsibilities will be. For evacuation, a disaster supplies kit ought to be prepared, and for sheltering purposes a stockpile of supplies may be created. Authorities often advocate the preparation of a survival kit such as a ‘72-hour kit’. These kits may include food, bottled water, medications, battery operated radio and spare batteries, flashlights, money, and specific items depending on the individual/family (e.g. baby or pet food). Putting valuable items in a safe area is also recommended, as is carrying some form of identification at all times.

Public health preparedness issues Understanding the context of the disaster and its impact on a community is important for the recovery process. There needs to be an appreciation of the risks faced by communities along with an understanding of the existing strengths and capacity – including that derived from past experiences. Often a key factor is recognition of the complexity of the situation. Information on impacts will generally be limited at first, meaning that is will be difficult to assist the diverse needs of the community. In addition needs will evolve and change rapidly as the recovery phase unfolds. The key is to initiate quick actions to address immediate needs and engage with the community in planning ahead at the earliest possible time. This will facilitate a smoother transition into the recovery process. Conflicting knowledge, values and priorities in a community will usually create tensions. Emergencies create a stressful

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environment where grief and blame also affects those involved. Recovery is therefore a long and challenging journey. Recognising the significance of community knowledge and values will assist in the journey, especially where these are in contrast to the assumptions of the outside community. Public health preparedness requires strengthening the system’s response, thorough planning and added resources to implement non-therapeutic countermeasures. These include adequately trained staff, quarantine and containment, infection control strategies, surveillance and contact tracing, social separation and dealing with international boundaries and foreign nationals. There are key issues that emerge in preparing communities to respond to disasters. Attention to these issues prior to the event helps build resilience and preparedness. Therapeutic issues Consideration needs to be given to the provision of ongoing therapy for people with acute and chronic disease and to the care of patients with illnesses or injuries arising from the disaster. There are issues to be resolved in regard to the ongoing provision of therapeutic services and resources. Attention needs to be given to redundancy in vital lifesaving therapies such as dialysis and home oxygenation. Similarly, consideration needs to be given to the determination of therapeutic policies following a disaster; how much care is to be offered to whom and where. Ethical issues Inevitably ethical issues arise, particularly in a catastrophic disaster, about who is to be offered care. But this is also true during preparedness, when decisions have to be made in regard to how much protection is provided and balancing investments in protection and preparedness against the provision of routine medical care. In 2004 the influenza vaccine shortfall was around 30 million for high-risk cases, thus creating prioritisation decisions of who gets vaccinated first. These types of decisions require the application of standard ethical principles along with clarity of communication and transparency in their application. These legal and ethical issues have been covered in Chapter 5. Surveillance and contact tracing: Privacy vs. protection Most of the modern strategies for pandemic control arise from experiences with SARS. Identification of SARS cases by name was a central feature of all national responses. There were varying levels of aggression in contact tracing. In Singapore, the military was used, in Hong Kong the police, and in Canada, hospitals. Surveillance in the case of SARS was more intrusive than simply reporting names. It involved daily temperatures, health questionnaires and complete daily certificates. Contact tracing will inevitably lead to identification. Protecting the physical security and confidentiality of surveillance records is both an ethical responsibility and a requirement of maintaining the trust of participants. Personal identifying information is needed to facilitate contact tracing, collection of follow-up information, provision of services to individuals and identification of data issues (e.g. duplicate records).

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Agencies collecting surveillance data need to determine the level of patient identifying data required. For example, in the US, local and state health departments collect patient identifying HIV and AIDS data to facilitate follow-up and to investigate the circumstances of exposure. De-identified notification reports are then forwarded to the CDC. The four critical questions asked were (Gostin 2008): 1 What limits on privacy are justified by surveillance? 2 What limits on bodily integrity are justified by testing, physical examination and treatment? 3 What limits on liberty are justified by isolation/quarantine? 4 What restrictions on movement and economic liberty are justified by travel advisories? In Singapore, the names of many of the SARS super-spreaders were made public, resulting in privacy issues. In Toronto, hospital employees were ‘identified by association’ when their hospital was closed, and this led to them being ostracised within the community. In North America, discrimination and racism resulted from the negative stereotypes of SARS’s origins in China. In recent decades, the only significant legal or ethical challenge to surveillance and contact tracing has been HIV, which suggests name-based HIV surveillance is recognised as an acceptable limit on privacy. Advocates of name-based surveillance contend there are wider benefits to the community that transcend the risks to an individual’s privacy (Sweeney et al. 2013). The state should meet standards relating to surveillance. The state should respect the public’s right-to-know, should take decisions openly, consult with the relevant communities and use data only for legitimate purposes. Surveillance without names is far less effective. Physicians and hospitals have a moral obligation to report all notifiable conditions to ensure the most effective public health interventions are taken, and that the benefits and burdens of privacy invasions are equitably distributed. In many countries, these obligations may be enforced by law. Isolation and quarantine Isolation is the separation, for the period of communicability, of known infected persons. Isolation takes place under conditions to prevent or limit the spread of infection. Quarantine is the restriction of activities of healthy persons following exposure to a communicable disease. The aim is to prevent disease transmission during the incubation period if infection should occur. Public health officials usually have powers to enforce public health regulations. However, they generally prefer voluntary measures and only resort to mandatory measures as a last resort. Voluntary measures promote better cooperation and improved results of contact tracing, but are dependent on the public’s awareness and willingness to comply with recommended containment measures. Key to this is often demonstrating that people will be supported should home isolation or quarantine be recommended. Mandatory enforcement will usually come at a higher cost, divert resources, cause confrontation and undermine public cooperation.

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All legal systems and international human rights permit governments to infringe on personal liberty in certain circumstances. However, there must be a scientific assessment of risk targeting the restrictive measures, a safe and humane environment, fair treatment and social justice, procedural due process, and the least restrictive alternatives chosen. Public officials, and society in general, have a duty to protect the needs and interests of those who are identified as sick or otherwise vulnerable. This may require consultation with representatives of the communities most at risk to ensure correct measures to protect mental and physical welfare are implemented. A US court overturned an early 20th century quarantine in San Francisco that operated exclusively against the Chinese community. The court concluded public health officials had operated with an ‘evil eye and unequal hand’.

Key reading Prosser B, Peter C. ‘Directions in disaster resilience policy, Attorney-General’s Department, Emergency Management Policy Branch’ The Australian Journal of Emergency Management. 2010; 25(3): 8–11.

Activities • • •

Identify three critical infrastructures in your community and describe in broad terms how you would ensure that they are protected. What strategies would you consider essential in preparing an organisation for disaster response? How would you develop an educational strategy for an organisation with which you are familiar so that it would be better placed to respond to a disaster?

References Bruneau M, Chang SE, Eguchi RT et al. ‘A framework to quantitatively assess and enhance the seismic resilience of communities’ Earthquake Spectra. 2003; 19(4): 733–752. Commonwealth of Australia. Australian Infrastructure Audit. Our Infrastructure Challenges. Report–Volume 1. Canberra: Infrastructure Australia; 2015. Cutter SL, Barnes L, Berry M et al. ‘A place-based model for understanding community resilience to natural disasters’ Global Environmental Change. 2008; 18(4): 598–606. Gostin LO. ‘Public health’. In: Crowley M, editor. From Birth to Death and Bench to Clinic: The Hastings Center bioethics briefing book for journalists, policymakers, and campaigns. Garrison, NY: The Hastings Center; 2008. Norris FH, Stevens SP, Pfefferbaum B et al.’ Community resilience as a metaphor, theory, set of capacities, and strategy for disaster readiness’ American Journal of Community Psychology. 2008; 41(1): 127–150.

Preparedness  179 Ross M. ‘Understanding interconnectivity of the global undersea cable communications infrastructure and its implications for international cyber security’ The SAIS Review of International Affairs. 2014; 34(1): 141–155. Sweeney P, Gardner LI, Buchacz K et al. ‘Shifting the paradigm: Using HIV surveillance data as a foundation for improving HIV care and preventing HIV infection’ The Milbank Quarterly. 2013; 91(3): 558–603.

Part 5

Incident management

Chapter 15

Incident assessment and evaluation Gerry FitzGerald

Introduction and objectives Efficient and effective management of any incident depends, in the first instance, on a careful and detailed assessment of the event and its impact. During exercises or practice, there is often the presumption that full knowledge of the extent and impact of the disaster will be immediately available. The reality is that during a disaster, there will be initial chaos. Information will be incomplete at first. There is also limited capacity of those directly affected to be able to step outside of their immediate priorities of preservation of life to undertake a comprehensive analysis and evaluation of the situation. This is compounded by disruptions to communication systems and networks. Often bystanders can be critical of this initial confusion. In reality, this will always be so, particularly in major catastrophic incidents. For example, it may be difficult to distinguish an explosion as a terrorist act from an accident (e.g. gas explosion) until forensic examination has occurred. Analysis and evaluation is necessary to provide clarity regarding the extent and nature of the impact, and of the need for assistance. There is an imperative to reduce confusion by undertaking a careful assessment of the incident, and providing that information to those tasked with the authority to organise the necessary responses. Put simply, we need the capacity to assess what is going on, evaluate it in terms of what it means, and then determine what must be done about it. The aim of this chapter is to develop an understanding of the approach to assessment and evaluation of an incident, and the processes required to initiate and manage responses. On completion of this chapter you should be able to: • •

Demonstrate a detailed understanding of the factors that need to be considered in evaluating the impact of a disaster, and in determining the support required. Identify a structured approach to incident assessment and reporting which will help define and initiate assistance.

The context Assessment and evaluation of the incident must take into context the environment in which the incident occurs as well as identification (within the limits of incomplete initial information) of the impact and the capacity of the community to respond. It must be emphasised that this initial assessment will always be limited. The extent of

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the impact will not be known, often for years afterwards. It is important initially to identify what is known but also to identify the limits of knowledge. The background to an initial assessment is a clear understanding of the context. The context assessment may be structured into an understanding of the legislative, policy, planning, organisational, social, political and operating environment in which the incident has occurred. This should be determined during the planning and preparedness phases. When responding in familiar territory, much of this will be known to those tasked with the initial assessment. However, if providing assistance to another community, responders may not understand intuitively the detailed context and thus identification of this context is a critical part of the initial assessment. The policy and legislative environment It is important to know and understand the policies and commitment of authorities to the preparation and management of an incident. At its most overt level, government policies will be expressed as legislation, although additional common-law and other subsidiary influences must also be taken into consideration. In addition to the statutes of government, it is also critical to identify and comprehend the policy direction as articulated by public statements and the organisational arrangements that government and government agencies may have established to provide incident governance and authority. Furthermore, it is important to understand the standards expected by authorities and by the communities they serve. These standards may govern response arrangements and expected outcomes, and be the basis for post-hoc evaluations. The planning environment It is also critical to identify and understand the hierarchy of plans that are in place. The planning hierarchy has been dealt with in Chapter 13; but in summary, the assessment of context must take into consideration the relevant international plans and their translation into national and local plans. Additionally, it is important to understand the impact and effect of special plans and the roles specified in those plans of various agencies and organisations. The organisational environment In order for government to exact its responsibilities, it needs to establish the systems and structures required to plan and prepare for disasters, and to respond when required. These include the consultative and planning approaches, as well as the command, control and coordination structures. Understanding the organisational environment requires an understanding of these structures and systems. Considerations include: • • •

What are the consultative and coordination committees? Where have control centres been established? How will control centres link to each other and to the various response agencies?

In the interests of optimal clarity of communication and of effective response management, it is critical that these structures are respected and supported. It is also

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critical to identify and understand the roles and responsibilities, and resources and capabilities of the various organisations, both government and non-government, who are involved in the disaster response. The social environment A critical aspect of the context evaluation is to understand the nature and structure of the society within which the incident has occurred. This assessment is best structured in a coordinated manner around the following elements: • •

•

• •

What is the level of social cohesion and how will the community work cooperatively together and ensure fair treatment and justice in the distribution of assistance? How stable is the community and what is the degree of social control? Is the community compliant and willing to accept instruction and direction? Or is there a degree of disrespect of governance and governments to the extent that this limits the capacity of a structured response? How does communication occur within the particular society? Specifically, what is the relative value of existing formal and informal communication linkages? To what degree does the community trust the formal communication channels, or does the community rely on rumours? What are the predominant attitudes and beliefs of the community? What is the primary culture and religion, and how will these influence the behaviour and receptiveness of people to assistance? What is the extent of international interest? High-profile events with significant international interest will elicit more assistance than events that may have more significant impact, but lack an international profile. For example, a motor vehicle accident may be of little international interest unless it was to involve a visiting high-profile head-of-state. International political considerations may even influence the nature and extent of international assistance.

The political environment Many would say that a disaster is not the time to consider politics; but this would be particularly naïve, especially in a democracy. There are always political considerations, not necessarily at the level of party politics, but rather at the level of interplay of powerful people and the clash of ideas. It is important to understand the political environment as part of the evaluation of an incident and its impact. While this should be done in prospect, this may not always be possible, and sometimes rapid acquisition of an understanding of the political environment is critical, especially at an international level. The jurisdiction affected by the disaster must remain in charge. They have the legal and moral authority regardless of their perceived competence. The traditional or current international linkages forged around the common political interests will form the basis of international assistance or prove an impediment to it. Thus countries will misread or assume that assistance they receive from countries they see as adversaries is an attempt to undermine.

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Case study 15.1: Control of Toussaint L’Ouverture airport, 2010 Following the 2010 earthquake in Haiti, the US military requested and was granted operational control of Toussaint L’Ouverture airport in order to manage transport logistics and the humanitarian response. Following transfer of control of Haiti’s major international airport to the US, The Guardian newspaper (UK) reported that several other donor nations accused The Haitian government of ‘playing favourites’, and the French called the airport a ‘US annex’ (Rudy 2010). Rightly or wrongly, the consequences of the host government transferring control of critical infrastructure to a foreign sovereignty gave the impression the host government had lost situational awareness and control of the disaster response. The long-term consequences were reflected in the election result following the earthquake when the government was replaced (Coppola 2011).

Can adversaries be allies in times of natural disaster? Following the 1995 Sakhalin Island earthquake, Russia denied Japanese rescuers entry to the impacted region. It was thought the Russian government was concerned Japan would use its access to take control of the island. Source: Coppola, 2011

• • • •

The political perspective is no less important at the local level. All disasters are local as is all politics. An assessment of the political environment involves identification of the key stakeholders and the interest they have in disaster management, or in the impact of the disasters. The stakeholders in a disaster are multitudinous and may be broadly categorised as the community, affected people and response organisations. All stakeholders need to be assessed:

What are their views and how will they seek to protect their interests? What authority will they exert? What impact will they have? How can they be managed to support the strategy?

The key influential leaders are not necessarily those with formal authority. They could be religious or community leaders who may or may not hold official office but yet remain influential. Unless they are engaged in the solution, they have the potential to become an impediment. At its worst case, this may include those who seek to derive personal corrupt benefit from donations. It may also include those who seek political advancement through a high-profile disaster role. Even in highly developed countries political leaders will be aware of the political benefit of crisis leadership and may seek to obtain political advantage and recognition.

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The operating environment It is also critical to understand the operational environment of the disaster-affected community. This includes the range of organisations and their capacity. Considerations include: •

•

•

•

•

Understanding the available human resources including number, skills and capability is necessary to identify gaps and align assistance with those gaps. There is a tendency for external aid, particularly from highly developed nations, to supplant local resources which are sometimes deemed as less qualified and less capable. It must be remembered that there is always a necessary transition back to local resources, so they must remain the cornerstone of sustainability. Providing local resources with necessary relief, allowing them to attend to their own and family needs, but then working in collaboration with the international response will help ensure a sustainable transition back to local resources only. It is also necessary to identify the scope and range of local consumables including clinical (drugs and personal protective equipment), fuel, food and power. The supply chains for these consumables may be disrupted by the disaster and therefore attention may need to be focussed on restoring them to ensure sustainable resources and therefore functionality. Facilities may be disrupted by the event; buildings or access (roads) damaged and destroyed. Built infrastructure provides the most useful resource, and despite potential degrading, it is always preferable to portable or temporary structures. Understanding what is available, what may be restored to functional use, and what is required to achieve this, is an important first step in the assessment. This includes those facilities that are functionally important (e.g. hospitals), as well as other facilities that may be important to the recovery effort even if their function is altered. It is necessary to identify the available equipment necessary for recovery and which can be restored to functionality, including highly specialised equipment (e.g. hospital ventilators) or equipment necessary for restoring functionality (e.g. generators). Finally, information sources are a critical component of the operational evaluation. Who knows what is available and who is influential? Where are staff lists and contact details?

There is a tendency for external assistance to presume a zero local capability. This is not only unrealistic, but also potentially damaging to community recovery. Use of local resources not only ensures they are, and remain, relevant to the local community, but also aids with economic recovery. Local businesses damaged by a disaster may confront a second disaster when donated goods or external suppliers supplant their business. Thus the operational evaluation is about identifying what is available, what are the gaps, what strategies would be necessary to fill those gaps, what external assistance is required, and the timing of that assistance.

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A review in the Scandinavian journal Public Health (Sundnes 2014) identified a structured approach to the process of review:   1 Identify that you need to know the information and it is not otherwise available.   2 Define the goals and objectives of the assessment.   3 Select appropriate indicators including rapid assessment tools.   4 Define the methods.   5 Develop and test the data collection plan.  6 Train the data collectors.  7 Gather the data.  8 Analyse and synthesise the data.   9 Collate it into information. 10 Compare the information with the goals and objectives.

Working with or against local communities? Enticed by higher salaries, a large number of local Haitian medical personnel were ‘poached’ by international NGO humanitarian agencies following the 2010 Haiti earthquake. In a country where there are three physicians, one midwife & 50% women) did not have access to basic healthcare before the earthquake, this practice can severely weaken local services & long-term recovery following a major disaster. Sources: de Ville de Goyet et al., 2011; WHO, 2009

Incident evaluation After evaluating the context of the incident, the second stage is to detail what can reasonably be known about the incident and its impact. This will change over time as more information becomes available and thus more detailed analysis is enabled. However, there are principles behind this analysis and the reporting of the information, including: • • •

• •

Objectivity: to ensure any information is restricted to what is known and does not presume to speculate about things that are not known. Analytical: to ensure that where reasonable deductions can be made, they are done so on the basis of evidence available. Respectful: to the privacy of individuals and to the performance of other responders. It is rare that people at the time of an incident will have all the information necessary, but unguarded comments made about others can contribute to the adverse impact of disasters. Brevity: to aid rapid communication. Relevant and focussed: to what is known and what is needed to be known by those to whom the communication extends.

Evaluation of the incident needs to take a relatively structured approach. The exact structure may be locally determined and will vary with the nature, scope and extent of the event. A possible structured approach may include the following elements: •

The nature of the incident; what caused it and can the nature and extent be confirmed?

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• • •

The location and physical extent of the incident. The number of people involved in the incident (if known). What has been the impact of the incident on:



– community; – services; – people and society; – business and economy?

• • • •

How severe are the illnesses or injuries caused? What resources are available to deal with the incident and what are the evident gaps? What are the current levels of activity of responding agencies? Are there any safety or security concerns for those responding?

There will be intense interest in the number of people affected and the nature of that effect. What illnesses or injures has the event caused, how severe are they, and what has been done by way of treatment for the ill and injured individuals? Chapter 2 referred to the relationship between deaths and injuries and the fact that although the focus of much of disaster evaluation and reporting is on those who have died, the focus of the health sector is inevitably on those who are ill or injured and require treatment. The focus of the evaluation is therefore on identifying the number affected, type and severity of injuries, and the location of people who may require medical aid, including those who require public healthcare. The outcome of the incident assessment and evaluation is focussed on deterHealthcare sector evaluation in a mining what is required to be done and disaster focuses on identifying the how it should be achieved. Therefore number of people affected, type the situation analysis will focus on the & severity of injuries, & the location development of a clear understanding of people who may require medical of the event and its impact so as to inform aid, including those who may be in the development of a response strategy. need of public healthcare. Objectives must be fashioned for that strategy, along with particular issues of concern and the risks of the chosen strategies. A rapid initial assessment under the international UNDAC (United Nations Disaster Assessment and Coordination) format includes situation, resource and needs assessment in the early, critical stage of a disaster. It provides information about the needs, possible intervention strategies and resource requirements, and aims to identify: • • • •

The impact a disaster has had on a society and its infrastructure, and the ability of that society to cope. The most vulnerable sectors of the population needing assistance. The level of response by the affected country, its internal capacity to cope with the situation, and the level of response from the international community. The most urgent relief needs and potential methods of organising them most effectively.

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• •

Coordination mechanisms. Significant political, cultural and logistical constraints.

Increasingly, technological means are used to aid in impact assessment. Satellite imagery has been shown to be an efficient and useful resource for decision-makers (Liou et al. 2010). Unmanned aerial vehicles are being used to make detailed impact analyses (Griffin 2014), and crowd-sourced information is increasingly used with analysis of both images and text. Indicators used in disaster assessments should be observable, measurable and allow the team to arrive at conclusions regarding the response requirements. Commonly accepted indicators build confidence that the conclusions drawn in the assessment are a reflection of the real situation on the ground. Indicators should be agreed before the team conducts its assessment.

Evaluators It is important that the most experienced evaluators are used to assess an incident: individuals trained in the process. UNDAC is part of the international emergency response system for sudden-onset emergencies, although these methods and approaches may be helpful for more localised responses (UNOCHA n.d.). UNDAC teams can deploy quickly at the request of the disaster-affected country, arriving on site within 12–24 hours following the host country’s request. Working cooperatively alongside the local authorities, the UNDAC’s core role in an emergency response mission is the assessment, coordination and information management. The UNDAC (UNOCHA n.d.) system comprises four components: 1 Staff: experienced emergency managers made available for UNDAC missions by their respective governments or organisations. 2 Methodology: pre-defined methods for establishing coordination structures, and for organising and facilitating assessments and information management. 3 Procedures: proven systems to mobilise and deploy an UNDAC team. 4 Equipment: personal and mission equipment for UNDAC teams to be selfsufficient while on deployment. Most highly developed nations now maintain disaster evaluation capability. There are no standards that underpin such arrangements so they are largely domestically determined. Similarly, larger international aid agencies including non-governmental organisations (NGO)’s will also maintain a disaster evaluation and assessment capability.

Reporting During and after the event there is also a need to evaluate the effectiveness of the response, and to report on progress and outcomes. Such reports may be broadly categorised into progress reports and post-hoc evaluations (final reports): •

Progress reports (also known as situation reports or SITREPS) provide an assessment of what is currently known about the event, its impact and the response

Incident assessment & evaluation  191

•

activities. There is no agreed formula about such reports except within particular agencies. Therefore there is no standardised structure. Any reports should comply with local requirements for consistency and efficiency purposes. Final reports are compiled after the event and seek to address the nature and scope of the event and the lessons to be learnt as a result of the experience.

We have personal and professional responsibilities not only to report on what has occurred but also to evaluate the effectiveness of that response. That responsibility derives from our position as officials, to aid in informing any subsequent enquiry, to meet professional accountabilities, to help with incident management, and to inform future planning and preparedness. Reports will rely on the availability of reliable information. Data collection is often considered an irritable by-product of operational management. Therefore a system that ensures reliable data collection, and is the least invasive on the time and focus of those responsible for managing the response, will be required. Common elements of data may include patients seen and treated, resources utilised, adverse incidents and key lessons to be learnt. Data collection must not only be efficient but also as accurate as possible. Variable data causes confusion and a loss of community and political confidence. Inefficient systems of data collection will impose on the effectiveness of operational responses leading to irritation of both responders and victims.

Key readings Perry RW. ‘Incident management systems in disaster management’ Disaster Prevention and Management. 2003; 12(5): 405–412. van den Berg B, Grievink L, Gutschmidt K et al. ‘The public health dimension of disasters – Health outcome assessment of disasters’ Prehospital and Disaster Medicine. 2008; 23(4): s55–s59.

Activities • • • •

What are the key aspects of context necessary to enable a strategic evaluation of an incident to proceed? Identify the key components of a situation report. Describe the characteristics of the individual best suited to undertake an initial assessment of an incident. How could the UNDAC concept be operationalised at a national level?

References Coppola D. Investigation of the Political Implications of Disasters Requiring International Assistance. Washington, DC: Bullock & Haddow LLC; 2011. de Ville de Goyet C., Pablo Sarmiento J, Grunewald F. Health Response to the Earthquake in Haiti: Lessons to be learned for the next massive sudden-onset disaster. Washington, DC: Pan American Health Organization; 2011. Griffin G. ‘The use of unmanned aerial vehicles for disaster management’ Gematica. 2014; 68(4): 265–281.

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Liou Y, Kar S, Chang L. ‘Use of high resolution FORMOSAT-2 satellite images for postearthquake disaster assessment: A study following the 12 May 2008 Wenchuan Earthquake’ International Journal of Remote Sensing. 2010; 31(31): 3355–3368. Rudy C. ‘US accused of annexing airport as squabbling hinders aid effort in Haiti’ The Guardian. 17 Jan 2010. www.theguardian.com/world/2010/jan/17/us-accused-aid-effort-haiti (accessed 27 April 2016). Sundnes KO. ‘Assessments: Structure, concepts and methods’ Scandinavian Journal of Public Health. 2014; 42(Suppl 14): 87–101. UNOCHA (United Nations Office for the Coordination of Humanitarian Affairs). What is UNDAC?. n.d. (cited 10 Dec 2015). www.unocha.org/what-we-do/coordination-tools/ undac/overview (accessed 27 April 2016). WHO (World Health Organization). World Health Statistics 2009. France: World Health Organization; 2009.

Chapter 16

Incident management Marie Fredriksen, Justin Dunlop and Andrew Pearce

Introduction and objectives Much of the focus of emergency response agencies such as police and fire services is concentrated on the scene and its management. However, as discussed in Chapter 1, there are variables with all events, particularly given some events do not have scenes, or there are multiple or poorly defined scenes. For example, pandemics occur across the broad community and are often not localised. Similarly, heatwaves will affect the entire community. For events with a clearly defined scene (e.g. a bus crash) effective scene management and dispersal of the injured is critical to the optimal outcomes for those involved. Equally the systems and structures that underpin effective management must be familiar to the response agencies. Thus disaster incident management should be the same as routine incident management with capacity to surge response capability to meet the particular needs of an individual event. The aim of this chapter is to examine incident management and particularly scene management; the principles that underpin effective management of the scene and the issues that need to be understood and prepared for. On completion of this chapter you should be able to: • • •

Demonstrate an extensive understanding of incident management systems and their application to disaster management, in particular strategic, tactical and operational management structures and procedures. Discuss the principles and practices that ensure effective scene management. Identify obstacles to an effective incident management system, and strategies to overcome them.

The incident management system (IMS) Chapter 15 detailed the process and elements of incident assessment, involving a structured approach to understanding the nature, extent and impact of the disaster and the context within which it occurs. Also discussed was the response management framework which incorporates, in broad terms, the need to identify the authority, roles and responsibilities for response and recovery management, as well as evaluation and reporting. Incident management identifies core areas of focus such as community, control, command, coordination, collaboration, communication, clinical care, capability,

194  M. Fredriksen, J. Dunlop & A. Pearce

capacity, containment and continuity, known as the eleven ‘C’s’. The first step in incident management is to identify the authority, roles and responsibilities, response management systems and evaluation and reporting arrangements. This should be done prior to any event and would be informed by local legislation or regulations. • • •

Authority refers to who can act and the powers they can exercise governed by local legislation. Roles and responsibilities involves identification of the organisations involved and their roles. Often this will require negotiation. Key players should be identified and made aware of their responsibilities. Evaluation and reporting involves measuring the effectiveness of the response and reporting outcomes or progress. Evaluation will identify the levels of activity and data on the outcomes. It will also identify the impact of the event on society (which includes the community and their health), the built and natural environments, and the economy. Reporting can be via progress reports. These may be situation reports (SITREPS) on adverse events or background information. Final reports will then detail the extent, impact, outcome, lessons to be learnt and recommendations.

Within this broad conceptual understanding, a critical component of any response to an emergency or disaster is a systematic approach to the exercise of command and control. This systematic approach is broadly described by the concept of incident management systems (IMSs). IMSs derive their origins from military command systems and seek to apply an organised and systematic approach. They have been broadly adopted by all emergency services to organise day-to-day operations. This will then be scaled up during a major event but the principles remain broadly the same. It is important to note that in reviews of disaster responses, it has been identified that while having an IMS is important, a critical factor for success is having a leadership team that is well connected and familiar with each other. This is particularly important given the initial urgency of the situation, which requires real-time decisions to be made rapidly, often without all the facts. Rimstad and Solid (2015) analysed the response to the 2011 terrorist bombing in Norway to identify the underlying conditions that affect decision-making during a mass-casualty incident. They identified that most critical decisions are made within the first 30 minutes, with situational assessment and underlying uncertainties strongly affecting decision-making. However, the number and scale of these uncertainties primarily occur as the situation is evolving, and at a time when demand for resources exceeds resources available. Further studies revealed that the greater the depth of knowledge and experience a commander had, the easier they found it to pick up on sensory cues and translate these into situation assessments (Rimstad and Braut 2015). These findings support an analysis of the crisis and disaster management during the catastrophic bushfires that devastated parts of Victoria, Australia, in February 2009 (Boin and ‘t Hart 2010). Some basic principles of an IMS include shared situational awareness, flexibility, management by objectives, unity of command, functional modular management and span of control. Functions of the IMS can be scaled up or down depending on the size of the disaster, the needs and responsibilities of the agency, or the specific objectives of the response. Examples of some IMSs, and the countries in which they are used, are outlined in Table 16.1.

Incident management  195 Table 16.1 Examples of incident management systems. Incident management system

Country of origin

National Incident Management System (NIMS) Australian Inter-Service Incident Management System (AIIMS) Coordinated Incident Management System (CIMS) Joint Emergency Services Interoperability Programme (JESIP)

United States Australia New Zealand United Kingdom

Figure 16.1 shows an example of the structure an IMS could take during a major disaster. Key factors include: •

•

•

•

•

•

•

Planning involves an analysis of the internal and external situations and the consequences of the event to a number of parties including customers, the community, the environment and business operations. The plan includes performance monitoring, demobilisation and methods of investigation. Planning develops longterm and contingency plans, as well as assisting with planning the transition to recovery. Operations address the immediate issues and coordinate the day-to-day response activities. Operations must work closely with Planning to assist in the development of the action plan which Operations must implement. The operations team includes functional and structural coordinators, contractors and suppliers, liaison officers and logistics specialists. Operations also produce situation reports. Welfare addresses the immediate needs of the people, coordinates welfare resources and facilities, and manages the consequences of the disaster on individuals, families and communities. During small-scale disasters, Welfare may be a sub-function of the Operations cell. Logistics manage legal and financial matters, human resources including rostering, accommodation and telecommunications. Logistics procure and track resources and fill requests for resources. They are also responsible for essential services for the disaster response including IT support, catering, security, document and records maintenance, and facility maintenance. Public information (communication) is responsible for identifying stakeholders, managing and monitoring the media, development and issuing of key messages and official warnings, media conferences, site tours and any official visits as required. Investigation is responsible for seeking specific information related to the nature of the event. This may include interviewing people of interest and gathering statistical information to better understand the situation, its cause and potential consequences. Intelligence is responsible for gathering, analysing and modelling information about the current situation and making forecasts about future requirements. An important component of intelligence is the local knowledge contained within the impacted community. It may be appropriate to merge Investigation and Intelligence into one cell.

Action planning

Information including local knowledge

Long-term □lanninp

Volunteer coordination

Liaison

C

Figure 16.1 The structure of an incident management system.

Forecasting

Dlannin?

Contingency

Operations

Planning

Intelligence

Operational coordination

e xD e rtise

Technical

Safety & risk

Situation

c id e n t

Deputy commander

In

Catering

Personnel

Facilities & services

Donations

Care & protection services for vulnerable

Animal welfare

Administration & security

Financial assistance

Warnings & information

Shelter & accommodation

SUDDOrt

Psychosocial

Registration

W elfare

Community liaison

Media including social media

Com m unication & public information

Legal

Transport

IC T

Supply

Finance

Logistics

Personal assistant/s

o m m a n d er

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The outputs of an IMS should be clearly defined. These may include: • • • •

Defined incident mission and objectives. Plans of action. Briefings and situation reports. Optimal resource utilisation.

Incident management issues Within the broad strategic approach of an IMS, there are a number of issues that consistently challenge those responsible for incident management. There are no definitive answers to these issues; they all need to be addressed in the particular context of each jurisdiction. Who is in charge? There has been a surprisingly persistent debate regarding who is in charge underpinned by competing principles of familiarity and expertise. To oversimplify the debate, the police argue they should be in charge as they are in charge of other events (i.e. familiarity). Other agencies argue that the agency with relevant expertise (e.g. fire for fires or health for pandemics) should act as lead agency. Each jurisdiction must resolve this debate and reach a determined position prior to any disaster. Regardless of which agency acts as the lead, this does not detract from the expertise and the roles and responsibilities of all other agencies involved. Roles and responsibilities The roles and responsibilities of various agencies and individuals must be resolved either through negotiation or determination before the event. It is not appropriate to determine these at the time of an incident. Roles may evolve over time, but the initial response should be based on pre-determined agreements. Disaster management should have its foundations on existing systems and practices. Disasters are larger events, but the skills used in responding to an incident need to be scaled up to respond to a disaster. It is the required scale that needs well-exercised management. Well-documented plans can be used to achieve outcomes in large-scale disasters. Incidents usually need careful application of complex operational procedures and standards. Figure 16.2 depicts the levels of response indicative to every agency regardless of the incident. Safety and security Scene safety and security is a critical consideration, particularly where the danger is ongoing, such as a fire or terrorist attack. A highly disciplined approach to the safety of responders needs to be the first consideration. Examples where responders may be at risk include: • • •

Police responding to a mass shooting. Firefighters responding into a chemically contaminated zone. Search and rescue squads responding into unstable buildings.

198  M. Fredriksen, J. Dunlop & A. Pearce

Strategic T actical Decides strategic direction Coordinates response agencies Prioritises limited resources

Interprets strategic direction Coordinates activities and resources in the operational area

Operational Operationalises tactical plans Commands singleservice response

Police

Fire Ambulance

Other responders

Coordinates the scene

Figure 16.2 IMS levels of response: strategic (gold), tactical (silver) and operational (bronze).

Additionally, spectators and helpers will be attracted to such events and it may be difficult to distinguish these onlookers from the walking wounded. There is a tendency in developed countries for overwhelming responses as all agencies seek to be involved. This creates the very real danger of scene congestion, thereby denuding the remaining community of its emergency coverage. The media are vital for community messaging and can help with highlighting and recording events, but they will require active management. The media will seek immediate access and this may impede access by emergency responders. Left unmanaged, there is a risk the media could breach the privacy of those affected. There is a need to secure the site quickly and to restrict entry in the interests of safety and efficiency of response. Active scene management is critical to maintain access and egress. Volunteers It should also be recognised that the first responders to any event will be people in closest proximity, including those directly involved. In almost all circumstances these individuals will render aid within the limits of their ability. It is important for response agencies to understand that such actions are appropriate and potentially lifesaving and to be respectful to those concerned. It has long been recognised that out-of-hospital CPR performed correctly is associated with greater patient survival. A study by Bakke et al. (2015) found trauma patients receiving bystander-provided first-aid treatment is also associated with reduced mortality and morbidity. Other volunteer responders fall broadly into two categories. Those who form part of organised volunteer organisations, and those who spontaneously respond. The latter

Incident management  199

includes many well-meaning individuals who seek only to offer assistance; however, there are those whose enthusiasm for involvement in such events overwhelms not only their expertise, but also the need for safe and secure scene management. For this reason, incident managers need to consider how spontaneous volunteers can be utilised safely within the organised incident response. Surge capacity

Trauma patients in a pre-hospital setting who receive first-aid from bystanders have reduced mortality and morbidity. An 18-month study found: •  97% were provided with correct airway management. •  81% were provided with correct haemorrhage control. •  62% were provided with measures to prevent hypothermia.

Surge capacity describes the ability of Of the bystanders providing out-ofresponse agencies to expand capability at hospital first-aid, only 35% had some a time when there is significant increase in first-aid training. demand. Regardless of the agency, surge Source: Bakke et al., 2015 capacity is a critical principle that needs to be planned for and addressed. With demand for healthcare growing, especially in hospitals, access to healthcare globally is at crisis point. Research by Traub et al. (2007) has demonstrated that access to operating theatres, intensive care and radiography would be severely compromised during a mass-casualty event. Therefore it is imperative for healthcare facilities and response agencies to develop preparedness plans and benchmarks to ensure they have the surge capacity in the event of a mass casualty incident. It is equally imperative for governments to provide the necessary funding and infrastructure to ensure these benchmarks are sustainable. Healthcare at the scene Scene medical management is dependent on the availability of appropriate resources and expertise. Passing trained personnel will often offer help, although there are debates regarding the expectations that they do so and their vulnerability. Organised medical responses to the scene should leverage from normal community-based emergency health arrangements. Ambulance services will usually be the first health responders. It is critical that this be recognised and that any surge in health responses leverage from, and be controlled by, those first medical responders. Additional assistance may be obtained from specialist retrieval and urban search and rescue teams. The primary purpose of healthcare on the scene of a disaster is to triage, treat and transport patients to appropriate definitive care. The amount of care rendered will depend on the available resources, and the style of definitive care will depend on the local environment. Key concepts include: •

Triage: the process of sorting patients according to their urgency and severity into categories to determine their immediate health needs. There are two elements for triage; extrication priority and clinical triage:



– Extrication priority determines who is removed from the scene first. Those who are alive and mobile should be directed to a place of safety. Patients who

200  M. Fredriksen, J. Dunlop & A. Pearce

•

• •

require assistance in extrication are the next priority, and those trapped and requiring extrication will be retrieved only when they can be released. There are formal triage systems (e.g. START or Sieve). The principal of familiarity suggests conformity with normal practice is the most useful approach. – The second triage step involves the determination of urgency for treatment. This is usually based on a more thorough physiologic assessment (e.g. Sort). Forward aid: the stabilisation of the patient sufficiently to allow safe transport to a place of ongoing care. Healthcare on the scene should be provided in a safe environment and minimised to that essential to preserve life and limb. The scene is not an appropriate location to undertake advanced medical procedures because of the lack of infrastructure, infection control, and the ongoing risk to the patient and responders. Equipment and training: medical teams responding to the scene should be trained and equipped, and act in liaison with first responding professional health services (i.e. ambulance/emergency management systems). Appropriate dispersal: critical to optimal outcomes, a system-wide approach with central clinical coordination is necessary to disperse all patients. This ensures that the health system is managed strategically, and that individual health facilities are not overwhelmed.

Rescue In many countries search and rescue services have developed specialist programs to deal with particular hazards. These services are coordinated and directed through government agencies or non-governmental and volunteer-based organisations. Some examples of specialist rescue programs include: • • • • •

Road rescue: trapped within a vehicle. Rail, air or industrial rescue (RAIR): trapped in a complex environment involving special hazards. Urban search and rescue (USAR): trapped within collapsed buildings. Hazardous material response (HAZMAT): located inside a contaminated area. Wilderness/alpine response: located in an extreme environment.

Incident management elements: The eleven ‘C’s’ The management of the response and relief phase is complex, but may be structured into the eleven ‘C’s’ of response management:  1 Community: the importance of remembering that the primary goal of any emergency response is to preserve life and protect the community. It is also important to ensure that the community are engaged with the management of the incident. During large-scale events, community meetings and consultation are an important component of any incident management.  2 Control: the overall direction of emergency management activities in an emergency situation. Control arrangements operate horizontally across organisations and seek to ensure various organisations take a coordinated and collaborative

Incident management  201



approach to the response. Establishing command and control arrangements is a critical first step. It is imperative for effective disaster management that an appropriately skilled person is in charge, and is allowed to take charge.  3 Command: the direction that members of an organisation follow in the performance of roles and tasks. Command arrangements operate vertically within an organisation and ensure that the organisation’s resources can be directed to the delivery of its roles and responsibilities.  4 Coordination: the bringing together of organisations and elements to Command applies vertically ensure an effective response. to one agency Coordination is mainly concerned with the systematic acquisition and Control applies horizontally application of resources from various across all agencies agencies and locations. Coordination operates both vertically and horizontally as an adjunct to the authority to Coordination is assisted by clearly command and control. defined command & control  5 Collaboration: the required behavarrangements iour of all involved to work towards the mission in response to an emergency. It is not enough to simply control, command or coordinate. It is essential that all responders collaborate with each other and the community in order to achieve a successful outcome.  6 Communication: the provision of information, which facilitates an efficient and effective response. Communication refers to the design and development of the message, including its clarity, as well as the means of communication and its distribution. Most response personnel complain about breakdowns in communication in major incidents. In reality, communication is very difficult to maintain during a crisis. It is worth considering the vulnerability of normal means of communication and to have contingency plans in place. Many disasters have demonstrated the vulnerability of modern communications, with power failures affecting transmission towers, and systems overload etc. Often non-technological means, such as runners, may prove more reliable and resilient. Web-based platforms to share information across multiple agencies in real-time are available; however, they do require the technology and training to act as an enabler. Communication also implies information flow in two directions. Briefing upwards is important to ensure that the key political players are aware of what is happening. Briefing downward ensures the strategic intent and strategic decision are informed to those responsible for implementation.  7 Clinical care: the ongoing care for the ill and injured as well as the people in the vicinity of the event. Disasters may directly affect the health and wellbeing of individuals as well as disrupting the health infrastructure. A major event may impact on the capacity to provide ongoing clinical care. For example, chronically ill patients may lose access to specialised medical care, or be unable to obtain ongoing supply and prescriptions. The key strategic management issues to be addressed include: – Development of clinical standards preferably in advance of an emergency, or in response to any novel presentation.

202  M. Fredriksen, J. Dunlop & A. Pearce



– Clinical care in a disaster should be based on the principles of maximum benefit, so immediate interventions should be restricted to life and limb preservation, with deferred definitive care. –  Clinical documentation is essential: field triage tags can be useful as a method to identify, Sieve and Sort patients as well as providing information to ongoing carers; and initial documentation is essential to ensure the safety of ongoing care. –  Definitive diagnosis of the nature and extent of injuries or illness is essential to defining the healthcare requirements, particularly during pandemics. Accurate diagnosis is essential to inform the development of clinical standards and disease control strategies. Equally important is determining the requirements for decontamination and isolation. – It is also important to ensure care for family and contacts of those suffering directly from the event.  8 Capability: the ability of the organisation to deliver a particular service or function including the protection of critical health infrastructure and personnel through enhanced infection control, personal protective equipment (PPE), isolation of patients, and anti-viral agents (if indicated) as well as other recommended immunisations.  9 Capacity: the organisation’s resource needs and the ability to surge and maintain health services’ capability. In order to maintain health services, attention must be given to a number of significant issues including: –  Maintaining access to services; both physical access and service availability. –  Health business continuity throughout an event that may be impaired by damage to physical infrastructure, the lack of key personnel or the availability of critical resources such as communications, water, power and supplies (including fuel). –  Additional capability may need to be created. There is value in taking a hierarchical approach to the mismatch of demand for healthcare and the capability available. A simplified approach to understanding the need for additional infrastructure involves four tiers of response: (1) actions require concentration of expertise utilising existing infrastructure; (2) actions require preservation of infrastructure for the event by early discharge of patients and limiting non-urgent activity; (3) actions require expansion of health infrastructure through system-wide management, growing capacity and importing capacity (e.g. field hospitals); and (4) actions require rationing of access to health infrastructure through triage of patients and escalation involving international assistance. 10 Containment: the strategies required to limit the scope and spread of an event. The concept has most relevance for pandemic management, whereby strategies seek to limit the spread of an infectious disease through quarantine, isolation and containment. Containment in pandemic responses is achieved though isolation and quarantine, immunisation, and prophylactic use of antiviral or antibacterial agents. It may also include social distancing measures, such as school closure or

Incident management  203

Case study 16.1: Sarin nerve gas attack, 1995 Following the 1995 Sarin nerve gas attack on the Tokyo subway in Japan, emergency staff at St Luke’s hospital, unaware they were dealing with a chemical contamination, did not wear appropriate PPE. As a result, 46% of staff later reported symptoms of acute chemical poisoning due to secondary exposure (Okumura et al. 1998).

banning mass gatherings. Pandemics are covered in detail in Chapter 22. However, the concept is also relevant to other events where limiting the extent and impact of the incident is desirable. For instance, people involved in a major traumatic incident often depart independently from the scene. This makes it difficult to determine the extent of the problem and to ensure appropriate care. Often the walking wounded will crowd the nearest hospital, limiting the hospital’s capacity to deal with the critically ill and injured. This is also the case with patients injured or exposed to a major toxin. In these cases their departure from the scene continues the spread of the exposure and places the safety of hospital staff and the general public at risk. 11 Continuity: the strategies needed to maintain functionality. Generally, the three keys to continuity include people, facilities and systems:





– Keeping key personnel on duty is neither possible nor safe when events are long term. They need to be relieved, particularly if their own families are under threat, or they have suffered personally from the incident. Sometimes effort put into securing the safety of the families of key personnel will free them up to maintain activity. However, in addition to the workforce, continuity relies on other strategies including volunteers and the flexible use of other professional staff. Volunteer management is a critical aspect to maintain functions as a complement and aid to expert staff. Flexible use of other professional staff will also aid the experts. For instance, general practitioners may be useful as surgical assistants, to care for families or to provide vaccinations and counselling. However, allocating tasks to a group that is outside their normal day-to-day functions requires consultation and pre-planning, which needs to be done prior to a disaster. – Buildings and facilities may be damaged by the incident, and planning should consider the loss of the building or facilities. Similarly supplies need to be maintained through a prolonged event and supply and distribution systems are necessary. Supplies must be secured, as the imbedded stockpile will be consumed first and in an uncoordinated manner. – Data and information systems must be maintained. It is important to ensure that through sensible preparedness, facilities have access to documents needed to enable the response in the event of power failure (for instance, staff lists are generally stored on computer systems and hence it is also essential to have hard copy).

204  M. Fredriksen, J. Dunlop & A. Pearce

Coordination centres Throughout the duration of a major incident, there will be a need to establish, or scale up, coordination centres. Depending on the jurisdiction, these facilities have often been referred to as: • • • • •

Major Incident Room. Disaster Coordination Centre. Emergency Operations Centre. Emergency Coordination Centre. Emergency Control Centre.

An incident may have several coordination centres depending on the size, scale and complexity of the disaster, the level of response required, and the jurisdictional boundaries. For example, there will be a coordination centre in the field as well as at the local hospital, health services, or health department. There may be simultaneous centres established at district, regional and state levels. Fundamental to the success of the response, however, is that all these coordination centres maintain a constant flow of information within and between all involved. In the initial stage of a response, particularly for a disaster that has evolved rapidly with little or no forewarning, the coordination centre may be the bonnet (hood) of the car in which the first official responder drove to the scene. As events expand or are protracted, then purpose-built facilities may be used. If the coordination centre requires a large-scale operation involving numerous agencies and a large number of personnel, it is important to ensure the centre is large enough to accommodate all staff. Countries with well-developed PPRR approaches will have a pre-determined coordination centre, fully equipped, which can be scaled up as needed. However, while a pre-designated facility will always be the preferred option, a coordination centre may be in the form of a community hall or even a virtual location or house. It is important, however, that the centre has the necessary equipment, facilities and appropriately trained and skilled staff with the authority to commit resources and make decisions on behalf of their respective agency. Figure 16.3 shows how a multi-agency response might transition into a major incident requiring coordination to be moved off-scene.

Obstacles to effective IMS Every organisation involved in a disaster response brings with it its own organisational culture, language, policies, procedures and expertise. Large-scale events require a well-coordinated, multi-agency response. House et al. (2014) contend response agencies: . . . become a collective whole by sharing cognitive aspects relating to agencyspecific mental models (i.e. their knowledge and awareness of what the situation presents) and areas of expertise to produce a coherent and collaborative response. Figure 16.4 outlines the human factors that influence multi-agency incident management.

Incident management  205

On In

s c en e

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M ulti-agency coordination Incident com m ander Unified com m and

Liaison officer

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( m a io r

C

en t r e

in c id e n t )

Incident com m ander Unified com m and

em ergency operations centres Disaster management groups Departm ental operations centres

Figure 16.3 Transition of multi-agency response into a major incident (adapted from NIMS 2008).

A multi-agency response to a disaster requires a collaborative network of timely information exchange and coordination within and between all the actors involved. If response agencies are unknown to each other, the success of any response is potentially impeded due to a lack of inter-agency cooperation. Jung and Song (2015) argue these problems can be mitigated if a connectedness exists between organisations. Implementing multiple bridging strategies as part of disaster preparedness is essential to linking organisations and to creating diversity in disaster management networks. Training and experience are vital elements in the success of a multi-agency response during disasters. Jensen and Waugh (2014) avow there are three dimensions related to training and experience: frequency, depth and specificity. It is essential for the personnel that operate the IMS to fully understand their specific role, and to have a combination of training and experience not only with the IMS, but also with their own organisation and other organisations involved (Branum et al. 2010). Personnel must also have technical knowledge, in terms of both experience and through training, of the specific events that they will encounter in the IMS (Branum et al. 2010). Training and education is dealt with in detail in Chapter 25. To increase coherence in the IMS operations in complex environments requires analysis of each component, and implementation of effective strategies to ensure there is a resilient connection between each component (Hardy and Comfort 2015). The larger the scale of or number of levels within the IMS, the greater the need for there to be flexibility at every level of action, but sufficient order to hold and exchange

206  M. Fredriksen, J. Dunlop & A. Pearce

current best practice & best practices irganisational psychology skill mix

analysis of tasks & processes

environment

fire

social services/welfare

police

ambulance

local government

shared awareness

non-government

flow of knowledge & in frim n a tin n

understanding of different organisational structures of response agencies, their working culture, language, processes & resources

research opportunities knowledge & information sharing: who needs to know, what they need to know & delivery

support training solutions

Multi-jurisdictional collaboration

develop technological & non-technological toolset/s

Figure 16.4 Human elements in multi-agency incident management (adapted from ISCRAM 2006).

information in real time. Whilst the design of hierarchical organisations is to improve efficiencies and decrease the transaction of information, Hardy and Comfort (2015) caution this structure does in fact introduce errors and leads to inadequate decisionmaking due to biases and missing information. The problem is intensified in larger organisations and in large-scale disasters where there exists a rapidly evolving disaster event with significant environmental variables (Hardy and Comfort 2015) and observations may be indistinct and challenging to decipher (Rimstad et al. 2014). Information can often be unreliable, and information overload adds to the challenges faced by the IMS strategic direction and the tactical and operational response.

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To reduce the risk of confusion and loss of a sense of the situation (situational awareness) in these conditions, it is imperative the interoperability of the response agencies is solid. Furthermore, the IMS requires robust intelligence and planning, and flexible adaptation to comprehend and respond to any situation (Hardy and Comfort 2015). Ultimately, the success of any IMS requires a diverse array of multi-faceted conditions to be in place prior to its use in a disaster and during the response phase if the system is to effectively achieve the desired outcomes (Jensen and Thompson 2015).

Key readings Australian Government, The Department of Health. ‘Media Centre’. n.d. (cited 09 Aug 2015). www.health.gov.au/internet/main/publishing.nsf/Content/healthpubhlth-strateg-bio-index.htm (accessed 28 April 2016). National Critical Care and Trauma Response Centre. ‘What We Do’. n.d. www. nationaltraumacentre.nt.gov.au/what-we-do/disaster-management/ausmat (accessed 28 April 2016). Smith DM. A Study of Command and Control of Multi-Agency Disaster Response Operations. Phoenix, Arizona: University of Phoenix; 2010.

Activity •

Examine the Royal Commission report into the 2009 Black Saturday bushfires in Victoria, Australia. Discuss at the strategic, tactical and operational levels:



– How did the rapidly changing event, the structure of the IMS, and a constantly changing lead agency impact on the response? – How did other disasters in Australia that weekend, i.e. the heatwave in South Australia and Western Australia and the floods in Queensland, impact on operations in Victoria? – Can you identify additional improvements beyond those of the recommendations of the Royal Commission report?



References Bakke HK, Steinvik T, Eldissen SI et al. ‘Bystander first aid in trauma – prevalence and quality: A prospective observational study’ Acts Anaesthesiologica Scandinavica. 2015; 59(2015): 1187–1193. Boin RA, ‘t Hart P. ‘Organising for effective emergency management: Lessons from research’ Australian Journal of Public Administration. 2010; 69(4): 357–371. Branum A, Dietz J, Black D. ‘An evaluation of local incident command system personnel in a pandemic influenza’ Journal of Emergency Management. 2010; 8(5): 39–46. Hardy K, Comfort LK. ‘Dynamic decision processes in complex, high-risk operations: The Yarnell Hill Fire’ Safety Science. 2015; 71: 39–47. House A, Power N, Alison L. ‘A systematic review of the potential hurdles of interoperability to the emergency services in major incidents: Recommendations for solutions and alternatives’ Cognition, Technology & Work. 2014; 16(3): 319–335. ISCRAM (Information Systems for Crisis Response and Management). Human Factors Aspects in Multi-Agency Crisis Management. Special Session: May 2006. New Jersey Institute

208  M. Fredriksen, J. Dunlop & A. Pearce of Technology. https://web.njit.edu/~turoff/ISCRAM06/longdescription.htm#HumanFactors (accessed 18 May 2016). Jensen J, Thompson S. ‘The incident command system: A literature review’ Disasters. 2015; 40(1): 158–182. Jensen J, Waugh WL Jr. ‘The United States’ experience with the Incident Command System: What we think we know and what we need to know more about’ Journal of Contingencies and Crisis Management. 2014; 22(1): 5–17. Jung K, Song M. ‘Linking emergency management networks to disaster resilience: Bonding and bridging strategy in hierarchical or horizontal collaboration networks’ Quality and Quanity. 2015; 49: 1465–1483. NIMS (National Incident Management System). US Department of Homeland Security, Washington DC. 2008. www.dhs.gov (accessed 17 May 2016). Okumura T, Suzuki K, Fukuda A et al. ‘The Tokyo subway Sarin attack: Disaster management, Part 2: Hospital response’ Academic Emergency Management. 1998; 5(6): 618–624. Rimstad R, Braut GS. ‘Literature review on medical incident command’ Prehospital and Disaster Medicine. 2015; 30(2): 205–215. Rimstad R, Solid SJM. ‘A retrospective observational study of medical incident command and decision-making in the 2011 Oslo bombing’ International Journal of Emergency Management. 2015; 8(4): 1–10. Rimstad R, Njå O, Rake EL et al. ‘Incident command and information flows in a large-scale emergency operation’ Journal of Contingencies and Crisis Management. 2014; 22(1): 29–38. Traub M, Bradt DA, Joseph AP. ‘The Surge Capacity for People in Emergencies (SCOPE) study in Australasian hospitals’ Med J Aust. 2007; 186(8): 394–398.

Chapter 17

External assistance in disasters Charles Blanch, Ian Norton, Bronte Martin and Peter Aitken

Introduction and objectives The most timely and appropriate response to an affected community following a disaster is initially from the community itself and shortly thereafter from first responders and health staff at facilities within the affected area, who may themselves be affected by the disaster. As such, the resilience and preparedness of these communities, including hazard reduction activities, response capacity, and existing levels of care, are the principal factors in mitigating disaster morbidity and mortality. External assistance in the form of aid is available to assist countries build that resilience and preparedness. Nonetheless, in the aftermath of many disasters there will be immediate offers of external assistance, and in some circumstances external assistance may simply appear. Our inter-connectedness, globalisation, urbanisation, increased local and international awareness, including crowd-sourced information and social media coverage, will continue to increase the visibility of disasters to the global community. Assistance may take many forms including the provision of economic aid as well as both human and physical resources. Similarly health support may include health supplies and equipment as well as the provision of medical care in the form of medical assistance teams. The aim of this chapter is to examine and consider specific issues associated with the provision and organisation of external assistance. On completion of this chapter you should be able to: • • • • •

Demonstrate an understanding of the types of and priorities for external assistance. Critically analyse the international assistance coordination frameworks. Discuss how emergency medical assistance has evolved over the last 20 years and the issues facing both host countries and deployed teams. Describe the composition of international assistance and in particular emergency medical teams. Identify the core standards and guiding principles of emergency medical teams.

Need for external assistance Worldwide understanding of disaster management has changed in recent years with relief seen not as a charity but as a right and a humanitarian obligation (Gunn 2005).

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This is underpinned by the precept that health and security are a basic human right (Judd 1992; WHO 2005). However, assistance is not purely needed for the response: . . . less developed countries are increasingly requesting assistance in developing programs leading to improved disaster preparedness, prevention and mitigation. (Burkle 2001b: p. 144)

Types of assistance External assistance is any aid provided from outside of the affected community. This may be intra-state (from neighbouring communities), inter-state or national (from other states in the same country), or international. Obviously the greater the distance involved, the longer it takes for assistance to arrive, and often the greater the External assistance may be provided differences in language and culture. by way of direct financial assistance Cash is often promoted as the best as well as provision of essential form of aid as it enables autonomy of drugs, medical supplies, equipment the affected community, can be directed & personnel. to meet locally determined needs, and stimulates the local economy. However, to be effective it is reliant on an intact economy, infrastructure and logistic support, as well as sufficient numbers of locally available skilled personnel. There are many situations where this is not possible. Stockpiles Pre-positioned and pre-identified resources (stockpiles) are often made available to be dispatched immediately to a crisis location. The construct of these supply caches are based on the likely need within the immediate vicinity and the capacity of the donors. Considering the delays in dispatch and arrival of these resources, it is most likely that they will be required to address the ongoing survival needs of the displaced population. An example is the Interagency Emergency Health Kit (IEHK), which was first promoted by the World Health Organization (WHO) in 1984. The IEHK has been heavily revised and adopted by most relief organisations and national authorities. Needsbased supply is important: but although the IEHK is useful for the care of 10,000 displaced persons for three months seeking day-to-day care, it may not be appropriate for 10,000 trauma victims. However, stockpiles are difficult to justify and maintain as they consume resources, not only for the initial purpose and restocking, but also for their maintenance. A rational approach to the pre-positioning of these resources is necessary. The challenge of these stockpiles is to ensure their appropriateness and accessibility. Some nations seek not to stockpile resources, but rather to identify where stockpiles would normally be held and have in place operational mechanisms to rapidly construct a resource cache on the basis of a pre-determined list of appropriate items. This approach has the potential to reduce the risk of out-of-date stock, but may be slower to mobilise.

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Logistics Logistics is one of the most important elements of a relief operation. The ability to deliver supplies in the right amount in optimal condition, where and when required, is a must for effective emergency operations. Logistics responses include providing for limited needs such as medical items, communications, water supply repair, sanitation, electrical power, etc. The logistics response also includes moving bulk items such as food and shelter, as well as people. Pre-existing logistics infrastructure, political factors, the number of humanitarian actors, damage in the impacted region and security, will all limit or have an impact on logistics. Effective planning for logistics requires implementation and operations plans as well as information and control systems. Disaster relief logistics relies heavily on planning and anticipation, based on geological, technical, political and physical aspect knowledge. An implementation and operations plan will guide the process. Outbreak and pandemic logistics planning is vital, and is now occurring with involvement from the WHO, World Food Programme (WFP) and the World Economic Forum. Key areas of concern include the distribution of adequate personal protective equipment (PPE), treatment adjuncts, and vaccines, particularly to the low- and middle-income affected countries that cannot keep pace with inflating costs as stocks are exhausted. Public–private partnerships, scenario planning, and mass production and distribution agreements are now being developed to relieve the burden on these countries. External medical assistance Von Schreeb et al. (2008) describes a conceptual model for the burden of medical needs following a disaster: • • • •

The immediate reaction is that the elective surgical need and utilisation of hospital resources drop to zero when a disaster occurs. At the same time, trauma resource need and use spikes before eventually declining to baseline. Need and utilisation arising from the event has a long tail as a result of secondary cases, delayed presentations and complications. Subsequently a second spike of secondary non-trauma emergency demand, driven by infectious diseases, may also occur.

The relationship and scale of the disease burden will depend on the jurisdiction, hazard type and the effectiveness of the multi-sectoral response. This conceptual model is also specific to the location directly impacted. Many countries will respond as a network, therefore use and demand for elective cases may be absorbed by other parts of the system unaffected by the disaster. External medical assistance usually arrives only after immediate assistance and lifesaving trauma surgery has been provided by the local community and functioning health providers (von Schreeb et al. 2008; Bremer 2003; Roy et al. 2002). Figure 17.1 shows the difference in the number injured vs. number of deaths in natural disasters between 2003 and 2015.

Figure 17.1 Number injured vs. number of deaths in natural disasters, 2003–2015 (based on EM-DAT 2015).

Injured

Total deatns

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A review of the foreign field hospital (FFH) response to disasters in Iran, Haiti, Indonesia and Pakistan found that none of the 43 FFHs reviewed were operational early enough to provide lifesaving emergency trauma care. Findings suggest that deployed hospitals are better suited to meeting the ongoing medical needs of a community and substituting for existing damaged facilities, rather than the immediate trauma needs (von Schreeb et al. 2008). Nonetheless, the speed of deployment and time to becoming operational for responding emergency medical teams (EMTs) does appear to be improving. Within 24 hours of the earthquake devastating Nepal on 25 April 2015, foreign medical teams (FMTs) had on the ground: six Type 1 Fixed teams (outpatient facilities/tented structures), two Type 2 inpatient facilities with surgery, one Type 2 team with no facilities, and three Specialist cells. Five days after the earthquake, there were 136 FMTs operational throughout Nepal (FMT Coordination Team/WHO/UNDAC/MoHP 2015). Figure 17.2 shows the breakdown of FMT types five weeks after the earthquake. Improved coordination across responders and recognition of sovereignty of an affected country is required to ensure needs-based support is provided. Two days after the earthquake, the Nepal government requested non-deployed international urban search and rescue (USAR) teams to stand-down. Despite this, a further 54 teams, including 12 classified under the United Nations (UN) system, arrived. Their arrival restricted EMTs and resupply access due to the limited airport capacity in Nepal (Schmidt 2015). The logistics support of medical teams is a significant and challenging issue. Teams should be self-sufficient because imposing support of foreign teams onto an already devastated community with insufficient resources to support itself is unethical. Teams need to be self-sufficient in terms of accommodation, food and water to sustain their deployment, and the equipment and consumables that allow them to work. They also require security, as well-resourced foreign teams are occasionally targets in devastated communities who have lost everything.

Type I 48%

Type 2 14% Type 3 1%

Other 23%

Specialist cell 14%

Figure 17.2 FMTs present in Nepal on 1 June 2015, five weeks after the earthquake (adapted from FMT Coordination Team/WHO/UNDAC/MoHP 2015).

214  C. Blanch, I. Norton, B. Martin & P. Aitken

Effectiveness of external assistance External assistance is not always effective. The history of international medical assistance is full of examples of unnecessary and wasteful donations inappropriate to local needs, including expired drugs and equipment with which local staff are unfamiliar or that require unaffordable ongoing costs to use and maintain. The usefulness of international aid is also reduced by a lack of assessment of the real needs of the community, and by the dispatch of what is available rather than what is needed. The coordinator of the Swiss government’s aid response to the Asian tsunami, stated: Again, many well doers and uncoordinated, brainless ‘helpers’ arrived and were a burden for the country. This is not professional humanitarian aid. (Frisch 2005: pp. 22–23) This identifies the issue of ‘disaster tourism’ as described after the Gujarat earthquake (Roy et al. 2002). Worse, the 100,000 avoidable deaths in the Rwanda civil war were attributed to poor performance on the part of relief agencies (Hickson et al. 2001; Eriksson 1996). In addition, the 1994 wide-scale mismanagement of cholera by inexperienced relief workers in Zaire led to recognition of the need to improve professional standards and effectiveness of the response (Salama et al. 2001). International coordination Emergency managers should be cognisant of both national and international coordination frameworks for external assistance. These include the processes within a jurisdiction to request assistance, and the mechanism by which the relevant national authorities will determine whether this can be resourced domestically or by international assistance. Emergency managers need to be familiar with the process by which the relevant national authority will request and accept offers of external assistance, and how medical assistance will be requested and coordinated. This includes domestic resources, support from existing functioning facilities, and facilitating patient referral to unaffected parts of the country. The humanitarian and disaster-relief efforts of the UN system are overseen and facilitated by the Office for the Coordination of Humanitarian Affairs (OCHA), led by the UN Emergency Response Coordinator. The UN ‘cluster’ system is one of the outcomes of the humanitarian reform of 2005 aimed at improving capacity, predictability, accountability, leadership and partnership. It provides a common mechanism for national agencies to meet clear humanitarian needs by supporting coordination across numerous actors. The required clusters are determined by the host country and may include: • • • • • •

Logistics. Nutrition. Emergency shelter. Camp management and coordination. Health. Protection.

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• • • • •

Food security. Emergency telecommunication. Early recovery. Education and sanitation. Water and hygiene.

A specific mechanism for the rapid assessment of need and coordination of assistance exists through the use of UNDAC (United Nations Disaster Assessment and Coordination) under the auspices of OCHA. These teams are deployed rapidly in support of the country and the UN country team to assist in needs assessment and the operational coordination of arriving teams and resources. A key role of the team is to establish an onsite operations coordination centre (OSOCC). Used historically for arriving USAR teams, it was used successfully for the coordination of arriving EMTs in Nepal, after several years of planning. A coordination mechanism for arriving teams under the UN needs to quickly move into existing national structures of coordination. Otherwise, there is a risk of confusion through development of a parallel system. This is particularly important for medical teams so that continuity of care is ensured. The ministry of health has sovereignty before and after a disaster, while international teams only provide a temporary response. Roles and responsibilities of the affected countries Other than in limited circumstances of a failed state or in complex emergencies, the responsibility for managing the request or accepting international assistance is that of the affected country. UN General Assembly Resolution 46/182: Strengthening of the Coordination of Humanitarian Emergency Assistance of the United Nations (United Nations 1991) outlines an enhanced framework for humanitarian assistance. There are 12 guiding principles, including those related to the responsibilities and authorities of the affected states: • • •

Humanitarian assistance should be provided with the consent of the affected country. Each state has the responsibility first and foremost to take care of the victims of natural disasters and other emergencies occurring on its territory. States whose populations are in need of humanitarian assistance are called upon to facilitate the work of these organisations in implementing humanitarian assistance.

Often the roles and responsibilities of national and local agencies will be described in legislation or government mandate such as a National Civil Defence Plan, or National Emergency Plan. Most disasters will be managed by a non-health agency, typically the national disaster management authorities, but this function could be delivered by other agencies such as the Prime Minister or President’s office, or defence or police agencies. In most jurisdictions health agencies will be responsible for managing the health consequences of a disaster and will be expected to coordinate with the lead agency.

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In seeking and deploying external assistance, the degree of autonomy for support agencies will vary. Some disasters may see a wide mandate given by executive government for agencies to seek and manage external assistance within their areas of responsibility. For example, the Canterbury (New Zealand) earthquakes in 2010, with the epicentre 40 kilometres west of the city of Christchurch, and 2011, with the epicentre in the city of Christchurch, saw bi-lateral support provided to USAR, police, health and defence agencies from international partners. Other jurisdictions may require all accepted offers of international assistance to be signed-off by the executive government or lead agency. Emergency managers should understand and exercise the decision-making and approval frameworks that would apply within their own jurisdictions. The national disaster authorities will likely be working with the Ministry or Department of Foreign Affairs or equivalent. Foreign affairs will have a critical role in managing the political risks and implications for foreign policy in accepting or rejecting offers of assistance and managing issues on the ground. They may also provide advice to ensure teams from countries with historical conflict are deployed in either different areas of operation, or used in such a way as to avoid conflict between themselves and the affected country. In the 2005 South Asia earthquake, Foreign affairs will also be working to despite decades of ongoing violence ensure the diplomatic corps within the and tension in Kashmir, India & affected country is kept informed of Pakistan eased cross-boarder travel the situation, including any general or restrictions & ‘no-fly’ zones to allow targeted requests for assistance. Requests each other’s governments & citizens for assistance may be communicated to provide region-wide assistance in through embassies or overseas missions the disputed territory. in donor countries. Foreign affairs will Source: Coppola, 2011 also be working with external countries to manage the response to foreign citizens affected by the disaster. There is a risk that international assistance may be targeted to affected foreign citizens. Whilst there is a legitimate role in facilitating medical evacuation of expatriates in order to free-up hospital capacity, the role and function of these teams needs to be clearly understood and accepted. Regardless of the authorising agency, it is vitally important the lead agency is engaged in the coordination of the international response. International assistance may be entering the affected country through international airports and will be drawing on the same national resources to move forward to its area of operation. Incoming teams, regardless of function, will be competing for the same logistics resources including airport landing and apron space, customs and immigration clearance, freight forwarding, local transport providers and translation services. Even a fully self-sufficient team will require local support. External assistance will need to prioritise and allocate support across a range of different types of assistance. High-profile rescue teams may be competing for support against primary care teams that may have a much greater impact but do not make as compelling a media story. Support from law enforcement may be necessary for ensuring a safe operating environment. Other assistance, such as food distribution, may be assessed as more strategically important in terms of maintaining security and governance.

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Standards and laws Methodologies for quality management have been slowly developed (Sondorp et al. 2001), but there is still a need for agencies and governments to agree to benchmarks, standards and codes of practice for health disaster preparedness and response, and to guide recovery. There needs to be honest and transparent accountability, responsibility, and evaluation against agreed standards of performance (Nabarro 2005). An evidence-based grading system incorporating indicators to measure the effectiveness of a humanitarian response is required. Different methodologies may be needed to assess indicators in countries without access to data (Bradt and Drummond 2003; Burkle 2001a). The Sphere Project has been one of the first systematic efforts to improve accountability (The Sphere Project 2011). Sphere addresses key indicators for five sectors: water supply and sanitation, nutrition, food aid, shelter and site management, and health services (Sondorp et al. 2001), with clearly defined guidelines and minimum standards (Brennan and Nandy 2001). Reluctance in accepting these standards has arisen due to concerns about levels of flexibility and the potential use of minimum standards as a punitive tool, despite these being a collective expert opinion recognising context and constraints (Dufour et al. 2004; Salama et al. 2001). The debate should shift from potential threats to non-governmental organisations (NGOs), to the rights of people affected by disasters: Ultimately, all humanitarian organisations should be held accountable when they do not meet minimum standards when there is a reasonable expectation of doing so. (Salama et al. 2001: p. 532) A voluntary Code of Conduct was first developed in 1994 (Griekspoor and Sondorp 2001). More recently the Core Humanitarian Standard (CHS) on Quality and Accountability has been developed through a collaborative effort involving the Humanitarian Accountability Partnership (HAP) International, People In Aid and the Sphere Project. More than 2,000 humanitarian workers in head offices, regions and in disaster-prone countries were consulted across several hundred NGOs and networks, governments, the UN and donor agencies. The CHS draws together key elements of existing humanitarian standards and commitments as well as being underpinned by the International Bill of Human Rights. It sets out nine commitments that organisations and individuals involved in humanitarian response can use to improve the quality and effectiveness of the assistance they provide. Importantly, the CHS: . . . places communities and people affected by crisis at the centre of humanitarian action and promotes respect for their fundamental human rights. (Core Humanitarian Standard 2014) The Tsunami Evaluation Coalition found that many international agencies did not live up to their own standards with regard to respect and support for local and national ownership (Telford et al. 2006). The lack of quality enforcement mechanisms means

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the same problems keep reappearing. Telford et al. (2006) suggests this is due to the lack of external pressure for improvement in the humanitarian sector. Normally market forces lead to quality improvement in a consumer-driven market. Yet this does not apply in humanitarian aid and the failure of agencies to meet their formal commitments to Sphere or Good Humanitarian Donorship principles suggests that the various quality initiatives are not having sufficient impact (Telford et al. 2006). The Tsunami Evaluation Coalition feels that, if improvement is to occur, there is a need for a regulatory system to ensure agencies put the affected population at the centre of measures of effectiveness. Furthermore, detailed and accurate information needs to be provided to the donor public on assistance outcomes, including the affected populations’ views of that assistance (Telford et al. 2006). International classification and standards EMT is the collective descriptor of medical assistance known variously as FFH, DMAT (disaster medical assistance teams) and FMT. The number of medical teams responding to disaster-affected countries continues to increase and the challenges of coordination and the delivery of effective and timely assistance are well recognised. The deployment of EMTs has occurred globally in both high- and low-resource settings. The name change from ‘foreign’ to ‘emergency’ medical teams is an attempt by the global community and WHO to recognise that similar standards and coordination need to exist for national and international EMTs. Some also considered the name ‘foreign’ to have negative connotations. After earthquakes in Iran and Haiti, both the EMTs and the host nation governments experienced variable standards and lack of coordination in the external assistance. This prompted a number of initiatives towards the establishment of minimum standards, enhanced coordination, and ensuring delivery of appropriate, quality care for those impacted by the event. The WHO/Pan American Health Organization (PAHO) guidelines for the use of FFHs (WHO 2003) outlined the capability and capacity required of medical assistance

Case study 17.1: Earthquakes – Iran (2003) and Haiti (2010) In 2003, external assistance after the earthquake in Bam, Iran, involved 12 FFHs operated alongside 34 international urban search and rescue teams, providing support to an area where at least 80% of healthcare facilities were destroyed (Abolghasemi et al. 2006). In Haiti in 2010, an earthquake destroyed, or severely damaged, the majority of the secondary and tertiary hospital facilities. Thus 44 FFHs from more than 18 middle- and high-income countries were deployed (Gerdin et al. 2013). Additionally, up to 300 smaller, independent teams were also thought to have deployed with a wide variability in skills and abilities. In both Iran and Haiti, no formalised coordination or integration of arriving international FFHs and EMTs occurred with the existing national health systems and authorities.

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teams. These guidelines include a decision-making tool for national authorities to assess offers of assistance. The guidelines acknowledged that acute lifesaving surgery was most likely to be undertaken by existing resources or teams capable of deploying and becoming operational within 24 hours. The guidelines also outlined the need for deployment of subsequent teams focused on follow-up trauma and medical and primary care, as well as for the donation of long-term temporary hospital facilities to replace damaged facilities during early recovery (WHO 2003). However, despite the presence of these standards, the review of the health response to the 2010 Haiti earthquake found that: If the impact was unprecedented, the organisation of the response was not. It followed the same chaotic pattern as in past disasters . . . the humanitarian community failed to put in practice the lessons learned. (de Ville de Goyet et al. 2011) The Haiti review recognised an increased blurring between FFHs and fully equipped Despite there being a requirement EMTs that often delivered an equivalent for EMTs to register with the capability, yet operated in a different host country, only 50 of the 396 manner; one which did not fit the existing international agencies registered 2003 WHO/PAHO guidelines. The review with the Health Cluster were also set clear expectations that the WHO registered with Haiti’s Ministry of establish a Global Registry for FMTs and Health after the earthquake in 2010. FFHs, jointly now known as EMTs, as a Many organisations mistakenly basis for international accreditation. believed that once registered with Subsequently, a global writing team the Health Cluster, registration with developed a revised standard, published the government would be automatic. by the WHO Global Health Cluster in Source: de Ville de Goyet et al., 2011 2013 (Norton et al. 2013). These standards expect all EMTs to comply with a set of core standards and guiding principles. The EMT guiding principles describe the provision of safe, efficient, equitable and patient-centred care based on the actual identified needs of the population. They also emphasise the human rights approach and ethical considerations of that care and the need for coordination with domestic services and accountability (Norton et al. 2013). The EMT core standards note that international EMTs should expect to register with relevant national authorities, and only deploy on request of the affected government. Teams are to report to the relevant authority on arrival, at regular intervals and on departure at the end of their deployment. They are to maintain and provide clinical records to the patient and relevant national authorities, and operate as part of the health network, receiving and referring where appropriate. All staff must be licensed and registered in their own country, and have temporary permissions to practise in the affected country. They must be appropriately trained and operate within their scope of practice. Teams are to be self-sufficient in all regards (Norton et al. 2013). To further assist affected host nations to identify the capacity and capability of international emergency teams, a global EMT meeting held in 2015 developed a

220  C. Blanch, I. Norton, B. Martin & P. Aitken Table 17.1 Emergency medical teams (EMT) classifications. Type

Description

Capacity

1: Mobile

Mobile outpatient teams. Remote area access teams for the smallest communities. Outpatient facilities +/– tented structure. Inpatient facilities with surgery.

> 50 outpatients a day

1: Fixed 2 3

Referral-level care, inpatient facilities, surgery and high dependency.

Specialist cell (e.g. rehab, surgical, paediatric, infectious disease, etc.)

Teams that can join national facilities or EMTs to provide supplementary specialist care services.

> 100 outpatients a day > 100 outpatients and 20 inpatients 7 major or 15 minor surgeries daily > 100 outpatients and 40 inpatients 4–6 intensive beds 15 major or 30 minor surgeries daily Any direct patient care-related service can be termed a specialist cell EMT when given in emergency response by international providers/ clinicians.

Source: WHO (2015a).

classification system based upon services offered (WHO 2015). Table 17.1 outlines these classifications. Each classification is further supported by corresponding technical standards for key component, service delivery areas. Teams should strive to adhere to and meet all relevant operational qualifiers such as the ratio of post-operative inpatient beds to operating theatres. Further areas identified for expanded technical standards guidance are rehabilitation, surgical care extremities, maternal and child health, mental health, non-communicable diseases management, and isolation outbreak clinical care. Complementary operational, logistical and training technical standards are also in the developmental phase. These will support the minimum standards and deployment of self-sufficient, quality assured teams. It was the medical response to the Philippines after Typhoon Yolanda devastated the region in 2013 that signified an important milestone in the development of coordination and management mechanisms for EMTs. Over 150 teams deployed to the region (Blanch et al. 2015). The Philippines Ministry of Health, supported by the WHO Country Office, utilised the WHO Classification and Minimum Standards for Foreign Medical Teams in Sudden Onset Disasters (SODs) for the first time (endorsed May 2013). The standard provides reporting and a registration template to register teams prior to their arrival (88 in total), and to manage other teams already in the country. National teams deployed domestically were also concurrently managed. The response to the Nepal earthquake in April 2015 demonstrated that early deployment of EMT coordination, at the request of and in support of the affected country, along with better communication, enabled the effective registration and tasking of 98% of the 149 EMTs deployed (Norton 2015).

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Working with host governments Coordination will extend from the national to the local level. Ideally teams will be accepted and allocated to areas of operation at the national level based on local reporting of need. This is particularly important where a disaster has impacted more than one location. Typhoon Yolanda in the Philippines impacted nine government regions and approximately 14 million people; however, many international teams were focused on and concentrated solely in Tacloban. Whilst this regional city was directly under the path of the cyclone and affected by geography and tidal surge, these factors together with a functioning regional airport drew international media. This amplified the impact on the immediate area, making it the focus for responding teams. Support from foreign affairs will also be critical in managing deployed teams where the host nation’s Ministry of Health determines that a team should not be operating, because they have either self-deployed and refuse to be registered, or are not meeting minimum standards. Options for what to do with such a team already on the ground are limited. Key questions would be: • • •

Does the team meet the relevant standards for teams that have been requested or accepted? Is it performing a required function? Is the team willing to operate within the established coordination framework?

If the team is to remain operating, they will need to be integrated into the reporting structure and EMT coordination mechanisms, and steps taken to ensure all staff are appropriately registered and operating within their scope of practice. This could involve retasking or allocating tasks better suited to their skills. Alternatively, facilitating a dignified exit of the team may be required. Such issues occurred during the response to the Nepal earthquake in 2015 when medical capability within international USAR teams attempted to register and deploy as Type 1: outpatient teams. Where external medical assistance is required, the 2015 Global EMT meeting endorsed three options in order of preference: 1 Host government has pre-existing mechanism for EMT coordination at their (health) emergency operations centre. 2 WHO and UNOCHA will support host government to create a reception and departure centre and EMT coordination cell within existing health operations structures. 3 EMTs will be coordinated externally (e.g. in a health sub-cluster) in the case of host government capacity limitations. Diversification of roles and future directions Many of the elements that had been developed to facilitate the rapid and effective deployment of EMTs to disasters were repurposed for the international response to the Ebola outbreak in 2014. This included establishing coordination functions in partnership with the affected Ministries of Health, and ensuring deployed teams met reporting and registration requirements. Of particular note, rather than teams deploying with their own self-sufficient healthcare facilities, a range of government

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and NGO donors built and established the supply chain to establish the Ebola Treatment Centres (Gulland 2014). Experience with the Ebola outbreak led to emergency reform to address shortcomings identified internally and externally during the response. One of the themes of this reform is development of a Global Health Emergency Workforce and a key element is EMTs.

Conclusion External assistance should meet the needs of the affected population rather than being driven only by the desires of the donor, no matter how well-intentioned these are. Any assistance should also be safe, efficient, effective, appropriate and ethical and not pose an additional burden on the affected community. These competing demands will need to be considered by both donor and host country and by those involved directly in the deployment. Those funding EMTs must ensure their response is based on the request and is needs-led and appropriately resourced. EMTs themselves must ensure that they understand their own internal coordination mechanisms and approval processes for deployment. Special considerations apply to the donation of unused or surplus medical supplies and pharmaceuticals at the end of a mission. These should follow relevant international standards (WHO 1999) and be agreed with relevant authorities. The composition, capability and capacity of deployed teams must meet the need (disaster epidemiology), consider the existing health services and systems available in an affected area, and operate in collaboration and coordination with relevant global disaster response and management mechanisms in the affected region. Considering these issues will help ensure that requests for, and coordination of, external assistance is effective. Emergency medical teams should recognise that the deployment of self-sufficient medical support is complex, and the duration of the operation (at least 14 days) will be longer. Critical support functions including production of safe drinking water, medical waste management, and equipment sterilisation are complex and require detailed planning. Specialist logistics support and team management must take all this into account.

Key readings Norton I, von Schreeb J, Aitken P et al. Classification for Minimum Standards for Foreign Medical Teams in Sudden Onset Disasters. Geneva: World Health Organization; 2013. WHO have a range of up-to-date documents and information on the EMT initiative at www.who.int/hac/en/ where you can search ‘emergency medical teams’ (accessed 29 April 2016).

Activities Familiarise yourself with the WHO Classification and Minimum Standards for FMTs in a sudden onset disaster (SOD) (Norton et al. 2013).

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•

A small island nation has been devastated by a cyclone.



– What might be the priorities for external assistance, and how would you determine this? – Identify the construct of an EMT that may be required to respond immediately. – How would you ensure the EMT was suitably prepared to deploy at short notice?

•

Identify how you would integrate international and national EMTs from outside your jurisdiction into your area following a disaster.



– How would you coordinate with relevant national authorities to request assistance? – How would you manage EMT activity within your jurisdiction? How would you expect them to refer patients and to report their activity? – What information would you require, and what process would you expect EMTs to follow when they exit?



References Abolghasemi H, Radfar MH, Khatami M et al. ‘International medical response to a natural disaster: Lessons learned from the Bam earthquake experience’ Prehospital Disaster Medicine. 2006; 21(3): 141–7. Blanch C, Zagaria N, Peiris S. Initial Review of the Effectiveness and Coordination of Foreign Medical Teams in Response to Typhoon Yolanda. [After action report] In press: 2015. Bradt DA, Drummond CM. ‘From complex emergencies to terrorism – New tools for health sector coordination in conflict associated disasters’ Prehospital and Disaster Medicine. 2003; 18(3): 263–271. Bremer R. ‘Policy development in disaster preparedness and management: Lessons learned from the January 2001 earthquake in Gujarat, India’ Prehospital and Disaster Medicine. 2003; 184(4): 372–384. Brennan RJ, Nandy R. ‘Complex humanitarian emergencies: A major global health challenge’ Emergency Medicine. 2001; 13(2): 147–156. Burkle FM. ‘Complex emergencies: An introduction’ Prehospital Disaster Medicine. 2001a; 16(4): 182–183. Burkle FM. ‘Disaster management, disaster medicine and emergency medicine’ Emergency Medicine. 2001b; 13(2): 143–144. Coppola D. Investigation of the Political Implications of Disasters Requiring International Assistance. Federal Emergency Management Agency, Emergency Management Institute: 2011. Core Humanitarian Standard. Core Humanitarian Standard on Quality and Accountability. Groupe URD, HAP International, People in Aid, the Sphere Project: online: 2014. de Ville de Goyet C, Pablo Srmiento J, Grunewald F. Health Response to the Earthquake in Haiti: Lessons to be learned for the next massive sudden-onset disaster. Washington, DC: Pan American Health Organization: 2011. Dufour C, Geoffrey V, Maury H et al. ‘Rights, standards and quality in a complex humanitarian space: Is SPHERE the right tool?’ Disasters. 2004; 28(2): 124–141. EM-DAT. The International Disaster Database, Centre for Research on the Epidemiology of Disasters (CRED). 2015. www.emdat.be/ (accessed 18 May 2016).

224  C. Blanch, I. Norton, B. Martin & P. Aitken Eriksson J. ‘Humanitarian aid and effects’. In: Millwood D, editor. The International Response to Conflict and Genocide: Lessons from the Rwanda experience. Strandberg Grafisk, Odense: Steering Committee of the Joint Evaluation of Emergency Assistance to Rwanda: 1996. FMT Coordination Team/WHO (World Health Organization)/UNDAC (United Nations Disaster Assessment and Coordination)/MoHP (Government of Nepal Ministry of Health & Population). FMT Meeting Minutes from 1 June 2015. 2015. www.humanitarianresponse. info/sites/www.humanitarianresponse.info/files/201500601fmtmeetingminutes.pdf (accessed 18 May 2016). Frisch T. ‘The international aid perspective’ Crisis Response Journal. 2005; 1(2): 22–23. Gerdin M, Wladis A, von Schreeb J. ‘Foreign field hospitals after the 2010 Haiti earthquake: How good were we?’ Emergency Medicine. 2013; 30(1): 1–6. Griekspoor A, Sondorp E. ‘Enhancing the quality of humanitarian assistance: Taking stock and future initiatives’ Prehospital Disaster Medicine. 2001; 16(4): 209–215. Gulland A, BMJ. ‘UK built Ebola treatment centre opens in Sierra Leone’. 2014. www.bmj. com/content/349/bmj.g6704.full.pdf+html (accessed 29 April 2016). Gunn SWA. ‘The humanitarian imperative in disaster management – A memorial tribute to Professor Peter Safar’ Prehospital and Disaster Medicine. 2005; 20(2): 89–92. Hickson C, Schull M, Arias EH et al. ‘5th Asia–Pacific conference on disaster medicine. Theme 3. Sharing Pacific Rim experiences in disasters: Summary and action plan’ Prehospital Disaster Medicine. 2001; 16(1): 29–32. Judd P. ‘Disaster relief or relief disaster? A challenge to the international community’ Disasters. 1992; 16(1): 1–8. Nabarro D. ‘Putting it together: Stronger public health capacity within disaster management systems’ Prehospital and Disaster Medicine. 2005; 20(6): 483–485. Norton I. Personal email reviewing draft chapter on external assistance. 2015. Norton I, von Schreeb, Aitken P et al. Classification and Minimum Standards for Foreign Medical Teams in Sudden Onset Disasters. Geneva: World Health Organization: 2013. Roy N, Shah H, Patel V et al. ‘The Gujarat earthquake (2001) experience in a seismically unprepared area: Community hospital medical response’ Prehospital and Disaster Medicine. 2002: 17(4): 186–195. Salama P, Buzard N, Spiegel P. ‘Improving standards in international humanitarian response: The SPHERE project and beyond’ JAMA. 2001; 286(5): 531–532. Schmidt SJ, Miyamoto International Inc. ‘NEPAL QUAKE: Lessons learned and the way forward’ The Masterbuilder: India’s Premier Construction Magazine. 4 July 2015: 62–66. Sondorp E, Kaiser T, Zwi A. ‘Editorial: Beyond emergency care: Challenges to health planning in complex emergencies’ Tropical Medicine and International Health. 2001; 6(12): 965–970. Telford J, Cosgrave J, Houghton R. Joint Evaluation of the International Response to the Indian Ocean Tsunami: Synthesis Report. London: Tsunami Evaluation Coalition (TEC): 2006. The Sphere Project. The Humanitarian Charter and Minimum Standards in Humanitarian Response. 2nd ed. Rugby, UK: Practical Action Publishing, Schumacher Centre for Technology and Development: 2011. United Nations. General Assembly Resolution 46/182 Strengthening of the Coordination of Humanitarian Emergency Assistance of the United Nations. 78th Plenary Meeting; 19 Dec 1991: New York, United States. von Schreeb J, Riddez L, Samnegard H et al. ‘Foreign Field Hospitals in the recent sudden onset disasters in Iran, Haiti, Indonesia and Pakistan’ Prehospital and Disaster Medicine. 2008; 23(2): 144–151. WHO (World Health Organization). Guidelines for Drug Donations. 2nd ed. Geneva: World Health Organization: 1999.

External assistance in disasters  225 WHO (World Health Organization). WHO PAHO Guidelines for the Use of Foreign Field Hospitals in the Aftermath of Sudden Onset Disasters. Washington, DC: World Health Organization: 2003. WHO (World Health Organization). Strengthening Health Security by Implementing the International Health Regulations. 2005. www.who.int/ihr/en/ (accessed 24 June 2016). WHO (World Health Organization). Global Emergency Medical Team Meeting. 1–3 Dec 2015: Panama City, Panama. WHO (World Health Organization). Humanitarian Health Action Report: Emergency Medical Teams and World Health Organization. 2015a. www.who.int/hac/techguidance/preparedness/ emergency_medical_teams/en/ (accessed 18 May 2016).

Part 6

Recovering

Chapter 18

Community recovery Bob Lonne, Graeme McColl and Greg Marston

Introduction and objectives Disaster recovery is the most complex and often least understood of all the phases in the disaster management cycle. In Chapter 1 we outlined the discursive nature and lack of consensus of the definition of ‘disaster’; similarly, agreement is not assured concerning definitions of ‘recovery’, or when the actual recovery has been reached. One useful definition is: The coordinated process of supporting disaster affected communities in the reconstruction of the physical infrastructure and the restoration of emotional, social, economic and physical well-being. (AEMI 2011: p. 19) Recovery is a developmental and remedial process encompassing: • • • •

Minimising escalation of the consequences of the disaster. Regenerating social, emotional, economic and physical wellbeing of individuals and communities. Adapting to meet the future social, economic, natural and built environment needs. Reducing future exposure to hazards and their associated risks.

Recovery is a complex, multifaceted process involving many individuals, groups and organisations. Each may have different understandings of what is involved, and varying priorities as to what exactly should be done. In circumstances where social systems are severely impacted and everyday routines disrupted, coordination of recovery tasks is imperative. The development of a shared discourse is foundational to understanding the impacts of the disaster, ensuring effective communication, and making sound decisions that enable the community to cope and adjust. The aim of this chapter is to examine the recovery phase and to identify the principles and processes required to successfully manage recovery, and restore functionality. On completion of this chapter you should be able to: • •

Demonstrate an advanced understanding of the factors that need to be addressed to achieve improved social resilience during recovery. Evaluate community development processes and the role of non-governmental organisations, the community and community-based agencies in prevention, preparedness and management of major health incidents.

230  B. Lonne, G. McColl & G. Marston

• • • •

Describe the role of the community and strategies to strengthen community resilience. Identify the range of evaluation tools used after an incident, and review plans. Analyse the components and understand the purpose of the audit cycle (systematic critical analysis of medical care) in disaster response. Discuss the importance of evaluating effectiveness of aid.

Understanding recovery Communities have the potential to function effectively and adapt successfully in the aftermath of disasters. Community resilience emerges from four primary sets of adaptive capacities: economic development, social capital, information and community technologies, and community competence. Together these provide a strategy for disaster readiness. The disaster recovery phase begins with the incident that caused the The objective of recovery is to disaster, and may continue for many restore the community to a level months or years. Recovery begins with that implies some degree of normal preparedness and continues until recovery community function & control. transforms into ongoing community Where possible, this assumes development. Figure 18.1 summarises reconstruction or redevelopment will these disaster recovery phases. find, & build on, a reasonable balance Depending on the scale of the disaster, of what the community previously recovery entails immediate rehabilitation. had, what is left, & what can now be Individuals and organisations assess their achieved. situations and commence the survival process by gaining the necessities for life

Response Disaster event

Ongoing community developmen work

Long-term recovery

Relief ' Early recovery

Ongoing community development work

Time

Figure 18.1 Effect of disaster on ongoing community development, and interface with relief and recovery (adapted from AEMI 2011).

Community recovery  231

Realisation That there is:

Mitigation

Response

A new normal Coping period

EVENT

Preparedness

Maintenance

Rehabilitation

New priorities Survival Sufficiency of care Sufficiency of supplies

Recovery

Acceptance

Figure 18.2 The pause in the emergency management cycle between response and recovery (adapted from McColl and Burkle 2012).

(i.e. water, food and shelter). Most people require some time to process events and accept that a disaster has happened. This then enables a sustained movement into the recovery phase. Figure 18.2 outlines this pause in the emergency management cycle. The language used to describe this period is important. The term ‘recovery’ implies a return to the prior state with a new equilibrium achieved and a new normal evident. ‘Rehabilitation’ suggests restoration of normal function. ‘Resilience’ is important when the outcome is the re-establishment of pre-disaster levels of functioning. Resilience itself is not transformation or reformulation, but rather a facilitative capacity for achieving positive change. Terms such as ‘development’ are also used by some to emphasise the search for improvement. However, in the same way that disaster can be defined by individuals relative to their own conceptions of comResilience itself is not transformation munity functioning, so too can recovery. or reformulation, but rather a Whilst this variation in definition matters facilitative capacity for achieving little in many circumstances, some disaspositive change. ters are on such a high scale and scope of impact that consensus about terminology quickly ensues. However defined, the objective of the recovery phase is to restore the community to a level that implies some degree of normal community function and control. Where possible, this assumes reconstruction or redevelopment will find, and build on, a reasonable balance of what the community previously had, what is left, and what can now be achieved. For example, recovery can require complex planning and decisions early in the recovery phase whether to repair and restore, or whether to ‘build back better’. Building back better typically involves difficult decisions to abandon housing areas because of continuing danger from fires, earthquakes or floods, and revised building codes for greater future protection. These decisions should be communicated

232  B. Lonne, G. McColl & G. Marston

widely, with clear reasoning, and individuals likely to be affected given an opportunity to engage in a genuine community consultative process. As an integral part of the PPRR cycle, recovery plans often include actions to mitigate the impact of a disaster or future risks. Public health and mental health are key challenges to recovery and recovery processes. For example, Christchurch (New Zealand) experienced steep rises in the demand for mental health services after the 2010 and 2011 earthquakes (Hogg et al. 2014; Osborne and Sibley 2013). Thus, recovery plans need to not only address physical infrastructure needs, but also to incorporate processes to mitigate and address the likely public and mental health impacts of disaster.

Disaster recovery principles The overarching principle of the recovery phase is a restoration of an individual’s control over their own lives, which helps reduce dependency and encourages selfefficacy. Thus, genuine involvement in key decision-making processes, as in the build back better example above, is essential. The main principles of disaster recovery designed to achieve this objective have been summarised in the Australian Emergency Handbook Community Recovery (AEMI 2011). Community and support services will be most effective when: The overarching principle of recovery following a disaster is the restoration of an individual’s control over their own lives. This helps reduce dependency & encourages selfefficacy.

•

•

• • • •

Provided in a coordinated, timely and culturally appropriate manner. This is achieved by establishing a dialogue with community representatives, coordinating activities within the community to support structure, and developing common goals with recovery agencies utilising local expertise. Available for all those affected including individuals, families, communities, groups/organisations, emergency services and volunteers. An inclusive approach should be adopted, through a service delivery process that is relevant and responsive to changing and variable individual needs. They engage the affected community in the key decisions to maximise participation and self-determination. Key community members should be identified to facilitate this process. They facilitate sharing of information between agencies. This is foundational to the cooperative and collaborative provision of services. Open and effective communication is used across all areas to ensure that people receive accurate and current information about their situation and the services available. Integrated with all other recovery services, especially financial assistance. Interagency understanding of overall service provision and responsibilities should be facilitated where possible to ensure maximum integration of all service delivery. This should include ensuring that the affected community is aware of the criteria governing grants, loans and gifts.

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• • • •

Assistance and resources are provided to create, enhance and support community infrastructure. An integrated and cooperative approach is used to support and promote the economic base of the affected community. They recognise that cultural and spiritual rituals provide an important dimension to the community recovery process and should be encouraged and facilitated. They utilise personnel with the appropriate capacities, personal skills and knowledge. Personnel must have an awareness of the full range of services they provide as well as all those available, appropriate referral processes, and the ability to identify individual and community needs.

Disaster recovery processes The purpose of providing disaster recovery services is to assist the disaster-affected community towards management of its own recovery (AEMI 2011). The primary method is through community development, which strives to facilitate community change and advancement. Community development draws on a range of strategies and approaches that build social capital and community resilience, and which are consistent with the principles and processes of community-led recovery outlined below (see Kenny 2011; Taylor et al. 2008). The major processes in successful disaster recovery include: community involvement; management at a local level (community or affected area) that recognises differing effects or needs; a developmental approach that promotes empowerment, minimum intervention, recognition of resourcefulness, and planned/timely withdrawal; and accountability, flexibility, adaptability and responsiveness coupled with coordination and integration of services. Community involvement in all aspects of the recovery process is vital; however, capacity may be limited. The government and wider community may need to supplement local recovery initiatives and resources. Community recovery committees, incorporating local and external representatives, can be very useful for facilitating connections and communication with community members and stimulating their involvement. Advantages include a reinforcement of local and community orientation, recognition of common interests, ensuring equitable application of resources and services, identification and prioritisation of needs which can and cannot be met, and overall monitoring of progress. Beneficial approaches: • • • • • • •

Centre on the community and enable those affected to actively participate in their own recovery. Seek to address the needs of all affected groups and communities, and consider their values, culture and priorities. Allow individuals, families and communities to manage their own recovery. Use and develop community knowledge, leadership and resilience. Recognise that communities may choose different paths to recovery. Utilise adaptive policies, plans and services to build strong partnerships between communities and those involved in the recovery process. Ensure that their specific and changing needs are flexibly met.

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Management at a local level should take on as much responsibility as possible. Past experience has shown that locally based recovery programs tend to have greater success with increased community input and capacity for self-management. The local level is where state, national and international disaster recovery policies are interpreted and actioned. Disasters will often affect more than one government area and may sometimes affect people from multiple geographic areas (e.g. a mass gathering incident or events in a tourist region with foreign visitors). Depending on the disaster and its physical and emotional impacts, the capacity to restore losses and establish normal living patterns will vary greatly depending on the person’s or community’s capacity. However, outside assistance should not overwhelm those affected, detracting from their participation or preventing them from making their own decisions. Decisions not focused in this way can be seen as dictatorial and unacceptable. The management approach taken should supplement local involvement rather than supplant it. A development approach draws and builds on the resources within the community. Resourcefulness within the community during recovery is tantamount to a continued improvement once external resources are withdrawn. This withdrawal must occur at the appropriate time to ensure a void is not left. For example, where post-disaster specialist services have been provided, their withdrawal must occur following planning for local services to take responsibility for ongoing care. Such planning may require training locals or arranging long-term specialist support. Accountability, flexibility, adaptability and responsiveness are vital aspects of effective recovery management. Events unfold at vastly different speeds with the various elements accentuated by public, media and political reactions. Organisations need to be able to adapt and respond quickly to deal with these multiple pressures. Central to much of the criticism received about recovery processes are coordination and integration issues. Response and recovery activities should run parallel, requiring an integration of all services. This requires appropriate planning and effective liaison arrangements and networks. It is usually most effective when one single agency coordinates the provision of recovery services. The roles, responsibilities and processes of this coordinating agency must be clearly identified and articulated. The agency facilitates the regular involvement of individuals and groups in the community, and government and non-governmental organisations (NGOs) to address the physical, environmental and economic aspects, along with psychosocial wellbeing (see Chapter 19).

Elements for successful disaster recovery Effective recovery processes result in greater community resilience by improving previous conditions through the enhancement of social and natural environments, infrastructure and economies. The elements of successful recovery rely on understanding the context; recognising the complexity of the situation; using community-led approaches; ensuring coordination of all activities; and acknowledging and building capacity, which must be underpinned by effective communication (as discussed in Chapter 8). These concepts are explained as follows. Understanding the context of the disaster community is important for the recovery process because it enables appreciation of the risks faced by individuals, groups and communities. There is a particular need to identify those who are vulnerable,

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impoverished or face significant disadvantages. It requires developing an understanding of the social, economic, geographic and cultural dimensions of the disaster community. Understanding the context requires recognition of and respect for differences, including people’s culture, strengths, capacities, resources and experiences. Recognising the complexity of the individual and community experiences of disaster is essential to facilitating a smoother transition to the recovery process. Information on impacts is limited at first and changes over time. Affected individuals and communities have diverse needs, wants and expectations that are immediate and rapidly evolving. Quick action to respond to, and address, immediate needs is crucial. However, conflicting knowledge, values, and priorities among individuals, communities and organisations may create tensions. Emergencies create stressful environments, and grief or blame may also affect those involved. Comprehending the complexities helps us to acknowledge that the achievement of recovery is often long and challenging, and existing community knowledge and values may challenge our own assumptions. Community development and recovery processes utilise community-led approaches to ensure engagement and involvement of the community, and to facilitate restoration of local control. This element centres on ‘bottom–up’ strategies that help to rebuild community capacity and ownership of the recovery decision-making processes. Facilitating community-led approaches necessitates that those involved in the recovery, particularly those outside the affected area, embrace power-sharing methods that aim to enable those affected to actively participate in, and manage, their own recovery. Such approaches use and develop community knowledge and capacity, leadership and resilience, thereby building community capacity. In addition to the coordination and integration between recovery and response activities mentioned previously, the coordination of all activities constituting the recovery phase is required. This is to ensure effectiveness and avoid duplication, waste and inefficiency. This element should be guided by those with experience and expertise, using skilled and trusted leadership who undertake well-developed planning and detailed information gathering. As noted earlier, an understanding of the roles, responsibilities and authority of other organisations is necessary to coordinate across agencies and ensure minimal service disruption. Such approaches integrate responses and contribute to future prevention and preparedness. They require staff to be inclusive, while using relationships created before and after the emergency. Clearly articulated and shared goals based on desired outcomes are essential, along with clear decision-making and reporting structures. This element enables staff to incorporate the planned introduction to, and transition from, recovery-specific actions and services. Finally, the recovery phase should acknowledge and build capacity through respecting the community’s resilience and capacity (no matter how depleted it may be), and identifying the gaps and working towards closing these. Although it can be a slow process, supporting the development of self-reliance through identifying and mobilising the community skills, strengths and resources that are provided by a range of stakeholders helps to build community ownership and autonomy. This process needs to accommodate the reality that existing resources will be stretched and additional resources may only be available for a limited period. Sustainability needs to be addressed through approaches that share, transfer and develop knowledge, skills and training, and facilitate networks and partnerships to strengthen capacity.

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Leadership for community recovery It is clear that leadership in disaster and community recovery roles and organisations is an inherently difficult and complex task (which is discussed further in Chapter 23). On the one hand there may be immense pressure to ‘take charge’ and make decisions unilaterally and quickly in order to get things done. On the other hand, there will likely be resistance to approaches that disempower others, and restrict their involvement in decision-making which directly affects them. To follow the principles and processes of disaster recovery requires a leadership approach that is inclusive, open to feedback, and visionary about the necessary destination and journey. This must be provided while also attending to the operational and management aspects required to ensure that people’s needs and expectations are met within reasonable timeframes. A ‘command and control’ approach to leadership will generally be counterproductive in the recovery phase. The approaches to leadership we advocate (see Chapter 23) are necessary at all strategic and operational levels if community confidence is to be gained and maintained. Role of recovery manager It is important to establish an interim management structure to coordinate recovery measures for the participating organisations and agencies. This needs to be established in consultation with the relevant authorities. Goals and aims for the recovery process need to be determined (e.g. repair or enhance services and infrastructure). Essentially, the role of the recovery manager is to: • • • • • •

Enable the operation of agencies engaged in the recovery and coordinate their involvement. Facilitate the involvement of all affected parties in the development of long-term solutions that address priority issues. Disseminate relevant information, including critical steps, so all parties are aware of the scope and nature of the recovery process. Regularly report on the progress of recovery operations to national, state and local government organisations and agencies involved in the recovery process. Highlight important issues where required decisions go beyond current policies and procedures, and advise on recommended options. Provide a final evaluation report detailing the resources committed, actions taken, lessons learnt, and any recommendations for future operations.

Recovery guidelines Emergency Management Australia (EMA) has developed guidelines to inform all government departments, agencies and individuals involved in the disaster recovery process. EMA’s guidelines (EMA 2003) offer information on the desired community outcomes, indicators of need, funding and personnel, and specific initiatives and activities.

Community recovery  237

Controller

Response Manager

Recovery Manager Public Information

Planning & Intelligence Assessment Fwd planning Community planning

Infrastructure Manager W ater Sewage Roading

Finance Manaeer

Operations Manager

Budget Finance sourcing

Logistics Manager Supply Transport

Shelter & Housing Manager

Business Support Manager

Health Service! Manaeer

Shelter House repair House rebuild

Commercial property, repair & rebuild support

Primary Community Hospitals Mental

Figure 18.3 Sample recovery organisational structure.

Recovery organisational structure Like all phases of disaster management, recovery requires an organised approach assigning roles and responsibilities to ensure all needs are managed. The organisational structure must be based on the structure principles described in Chapter 4. It should be modular, flexible and adaptable so that it can respond to rapidly changing circumstances as well as differences in need and expectations. Roles in the structure are activated, or not, according to the needs, amount of damage and activity required, or staff available. Lines of accountability must be clear. The recovery manager must work closely with the overall controller and the response manager to ensure continuity and collaboration of roles and responsibilities. Figure 18.3 is an example of a recovery organisational structure adaptable for general use. Essential for the success of any organisational structure is the need for communication, coordination and collaboration between all levels and positions, particularly in assessment and planning. The realities, however, are that significant tensions are often evident in intra- and inter-organisational interactions. Operational and relational effectiveness is impacted by alliances, rivalries, and boundary and role issues. Leaders must devote attention to ensuring that these do not thwart the achievement of desired outcomes.

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Community recovery outcomes Disaster recovery processes are usually highly political due to the significant disruption to lives and community expectations of rapid improvement. Hence, managers, agencies and individuals need clear aims and scope of activity. While measures and outcomes are not usually the same across events, a common vision should be evident for an enhanced future addressing sustainability, social justice, the economic environment, and equity (EMA 2003). Key benchmarks include: • • • • • •

An informed and engaged community. Equitable access to services and facilities. A sense of community safety. Wide participation in community life through cooperative partnerships. Strong community identity incorporating tradition and history. Economic recovery through capacity development.

Utilisation of existing community resources enables the achievement of the outcomes of recovery management. Recovery managers need to accurately assess the disaster’s impact upon the affected community’s needs and the level of resources required to support necessary community development. EMA (2003) identifies five areas which indicate the level of need for community development activity and resources: 1 Event profile/scale is the disaster’s overall scale and public profile, which may be national and international with community and media attention complicating the recovery process. Indicators of scale include: the type of disaster; its unexpectedness and the extent of community preparation; the number of deaths/ injuries; the range of responses required; the point of coordination required; and a high media profile, with associated requests for information to and from the community. 2 Physical effects of the disaster significantly impact upon the capacity of the affected community and often require community development activities. Indicators of this need include: the scale of the disaster and loss of infrastructure; the proportion of the community displaced and for how long; increased requests for material aid and financial assistance; and time needed to restore services. 3 Psychosocial/emotional effects are usually more difficult to measure than physical ones. Importantly, service responses should be cognisant that people cope in a variety of ways. Indicators (as detailed in Chapter 19) include: increased anxiety, grief, loss and depression; a rise in domestic, family and community violence; motivation loss and apathy; decreased economic activity; an escalation in crime, antisocial behaviour, school absenteeism and substance misuse; and more requests for counselling (a greater use of counselling services can be anticipated). 4 Service capacity is the capacity of existing services to meet the additional demands generated by the disaster. Indicators include: disrupted communication systems; how well the available workforce can meet increased service complexity and demands; increased need for information on health and safety issues; and service disruptions. 5 General indicators of need for community development include: rising unemployment, and the relative disadvantage and impoverishment of the community

Community recovery  239

pre-event; increased community tensions and exacerbation of pre-existing community rifts; increased residential sales and relocations; increased church attendance; and a rising need for child health services and medical services.

Resourcing of recovery activities Timing of the disaster, along with political and media interest, have an impact on the availability and willingness to commit funds. Therefore, assessment of the need for additional resources should occur as early as possible and cover an extended period of 12 months or typically longer. Assessment should include statistical analysis of service demand and use, as well as intuitive assessment of experienced staff and community members. Local knowledge, experts and outreach programs should be the focus of consultations to assist in identifying which groups are vulnerable and why, and if the disaster exacerbated this. Recovery managers and staff should be employed as close as possible to the affected community. Funds can be sourced from governments, the community, or corporate sources. Funding submissions need to include detailed assessments of need, political and community expectations, and the benefits of expenditure. Submissions should also address likely activities and programs, and the integration of the community in recovery processes. There is often pressure to quickly appoint appropriate people so that the recovery process benefits from effective partnerships forming rapidly within the community. The recovery period requires continued funding and support, often for years, to address all aspects of infrastructure reconstruction, and public and mental health. This can be a significant problem. Financial aid is at its most abundant immediately following the disaster, but through the recovery phases there is usually less media and political attention with a consequent decrease in support and donations. Similarly different types of disasters can be more or less attractive to benevolent support.

Evaluation of recovery programs Evaluation is vital to assess the performance, effectiveness and value of comDisparity in donations is common. munity recovery programs. Evaluation In 2004, the Asian tsunami received acts as a learning tool, gives credibility over US$7,100 for every man, woman to and validates previous work, and & child affected. By contrast, spending shapes ongoing development of recovery for people affected by the 2004 processes. It is necessary for continued Bangladesh floods was US$3 or new funding. Evaluation seeks to per head. identify the actual outcomes with respect Source: Telford et al., 2006 to desired goals, objectives and expectations; how operations have been conducted; and where improvements are required. The focus is on achievements, processes and problem-solving. Quantitative measures include existing community capacity and activity, measuring the scope, utility, and quantifiable outcomes of recovery initiatives and community participation. Qualitative measures include a range of person-centred satisfaction and other assessments of how people are responding to,

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and perceiving, the recovery. Desired outcomes vary for different disaster types and community contexts, and will change over time, requiring re-evaluation. Remember, it is often difficult to define an end to the recovery phase: it tends to transform into a new reality. Evaluation reports should address: contextual issues; desired outcomes of the recovery process; strategies used; performance indicators; adherence to recovery principles and processes; data sources; findings; and recommendations. Key considerations in evaluations are: community participation, feedback and ownership; quantitative and qualitative approaches; appropriateness of evaluation tools; flexibility; opinions of stakeholders; and independence in evaluation. The evidence-based prevention and intervention strategies for disaster relief and recovery are based on the ‘medical audit cycle’ and epidemiological research on disasters as outlined in Chapter 24. For example, the World Health Organization (WHO) and international aid agencies have a

Case study 18.1: Asian tsunami, 2004 The scale of the 2004 Asian tsunami overwhelmed the international community and challenged their capacity to manage the huge surge of money and resources, and to deal with problems of coordination associated with agency proliferation. The Tsunami Evaluation Coalition undertook analysis of the recovery interventions 11 months after the disaster (Telford et al. 2006). The findings demonstrated patchy funding arrangements of response agencies prevented them having an adequate standing capacity, resulting in a shortage of trained staff on standby, and a lack of necessary financial tracking systems and working relationships. While funding was unprecendented, the standing capacity was not in place to deliver aid to the greatest effect (Telford et al. 2006). Telford et al. (2006) also concluded donor governments and international agencies: • • • • • • • •

Often overlooked the contribution of local communities and organisations. Failed to understand the local context and demonstrated a reluctance and/ or inability to consult with, and work through and with, local communities, groups and organisations. Did not adequately consult with, or even inform, the affected population about projects. Initiated inappropriate and poor quality programs and poorly executed aid projects, which in some cases acted against the best interests of affected people and even undermined the progress of local initiatives. Rarely allocated funds based on need, or used formal assessments of the needs of affected people, and did not undertake assessments jointly or share information. Failed to ensure adequate tracking of funds. Missed opportunities to strengthen and build local capacity. Did not establish firm foundations for building appropriate local capacity and longer term recovery.

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longstanding involvement and commitment to evaluation of disaster relief and recovery programs. The Sphere Project (2011) has provided a critical framework for assessing the operationalisation of the Humanitarian Charter, the Protection Principles, and the Core and Minimum Standards for disaster recovery interventions. The analysis of responses to disasters identifies valuable lessons to be learnt which underpin the development of more efficient and effective evidence-based recovery strategies. With the dignity of people threatened by disasters and subsequent recovery measures, those coordinating the recovery need to ensure collective efforts are achieving desired outcomes and building the community’s own capacity to manage its recovery and resilience.

Key readings Australian Emergency Management Institute. Handbook 2 Community Recovery. Australian Emergency Management Handbook Series. 3rd ed. Canberra: Commonwealth of Australia; 2011. Department of Homeland Security. The Federal Response to Hurricane Katrina: Lessons learned. Washington: US Government; 2006. Read Chapter 5. Emergency Management Australia. Guide 13 Community Development in Recovery from Disaster. Australian Emergency Management Manual Series. Canberra: Commonwealth of Australia; 2003. Read the appendices (case studies). Kenny S. Developing Communities for the Future. 4th ed. South Melbourne: Cengage Learning; 2011. Taylor J, Wilkinson D, Cheers B. Working with Communities in Health and Human Services. Melbourne: Oxford University Press; 2008. Examine the following websites and explore information that they can add to your understanding of incident management and disaster recovery (all sites accessed 9 Aug 2015): 3AWRadio. ‘Anna Bligh weeps for Queensland’. 2011. www.youtube.com/watch? v=l8b18Cv2cFE ENN. ‘Field exchange: Evaluation of international response to the tsunami’. 2007. www.ennonline.net/fex/30/evaluationofinternationalresponse Homeland Security. n.d. www.dhs.gov/ LGAQ. ‘Community development engagement initiative’. 2013. http://lgaq.asn.au/ cdei Public Health England. ‘Departments’. n.d. www.gov.uk/government/organisations/ public-health-england The Sphere Project. n.d. www.sphereproject.org/ Torrens Resilience Institute. ‘Community resilience toolkit’. 2009. www.torrensresilience. org/community-resilience-tookit

Activities •

How would you facilitate the development of healthy working relationships during the recovery phase of a major flood?

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• •

Identify and briefly describe the key principles and processes required for community recovery. What are the particular issues associated with leadership in disaster recovery processes?

References AEMI (Australian Emergency Management Institute). Community Recovery: Handbook 2. Australian Emergency Management Handbook Series. Canberra: Commonwealth of Australia; 2011. Emergency Management Australia. Guide 13 Community Development in Recovery from Disaster. Australian Emergency Management Manual Series. Canberra: Commonwealth of Australia; 2003. Hogg, D, Kingham S, Wilson TM et al. ‘Geographic variation of clinically diagnosed mood and anxiety disorders in Christchurch after 2010/11 earthquakes’ Health & Place. 2014; 30: 270–278. Kenny S. Developing Communities for the Future. 4th ed. South Melbourne: Cengage Learning; 2011. McColl G, Burkle F. ‘From the field, the new normal: Twelve months of resilience and recovery in Christchurch’ Disaster Medicine and Public Health Preparedness. 2012; 6(1): 33–43. Osborne D, Sibley CG. ‘After the disaster: Using the Big-Five to predict changes in mental health among survivors of the 2010 Christchurch earthquake’ Disaster Prevention and Management. 2013; 22(5): 456–466. Taylor J, Wilkinson D, Cheers B. Working with Communities in Health and Human Services. Melbourne: Oxford University Press; 2008. Telford J, Cosgrave J, Houghton R. Joint Evaluation of the International Response to the Indian Ocean Tsunami: Synthesis Report. London: Tsunami Evaluation Coalition (TEC); 2006. The Sphere Project. The Humanitarian Charter and Minimum Standards in Humanitarian Response. 2nd ed. Practical Action Publishing, Schumacher Centre for Technology and Development: Rugby, UK; 2011.

Chapter 19

Psychosocial aspects of disasters Jane Shakespeare-Finch and Paul Scully

Introduction and objectives Disasters can have a significant impact on mental health, which can be aggravated by poor forward planning and inadequate management of the recovery phase (Raphael 1986). People respond to traumatic events in different ways yet psychosocial research in this area has predominantly focused on the detrimental impacts of exposure. For example, a meta-analysis of the health impacts of natural disasters (Ahern et al. 2005) revealed increased levels of anxiety, depression and post-traumatic stress disorder (PTSD), as well as physical symptoms of disease. However, it is a minority of people that will sustain a serious mental illness (Briere and Elliott 2000), and the majority of these will respond, recover and return to pre-event functioning (Bonanno et al. 2011). Traumatic experiences can provide a catalyst for significant positive changes termed ‘post-traumatic growth’ (Calhoun and Tedeschi 2006). It is essential to stress that most people recover from traumatic events in very sound ways psychologically. It is also important to recognise that post-event reactions/behaviours which may be different from the way in which the individual behaves in normal circumstances, are not necessarily a symptom of psychopathology. Rather, responses are likely to be normal reactions to extraordinary events. Significant preparation and appropriate response planning and support should be available to mitigate the potentially negative impacts on the mental health of all members of the affected community, including those directly impacted, emergency service workers, response agency personnel, teachers and volunteers. The aim of this chapter is to outline the potential impacts that disasters can have on mental health and wellbeing. The chapter will also identify ways in which individuals, organisations, healthcare workers and others in positions of responsibility relating to disasters, can aim to prevent and to manage the adverse psychosocial impacts of experiencing trauma, and to promote mental health and wellbeing. On completion of this chapter you should be able to: • • •

Discuss the impact of disasters on mental health and wellbeing. Understand factors that influence mental health and wellbeing in disasters. Identify strategies likely to prevent and manage adverse mental health consequences.

Risks to mental health in disasters Beyond the physical harm that may be inflicted upon victims and survivors of disasters, there is also potential harm to mental health. Stressors may include exposure to the

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evolving hazard and threat of injury or death, to family, friends or pets, loss of property and possessions, and in some instances loss of work and income. An understanding of potential psychological injury following disasters is essential throughout the PPRR cycle. Such injuries are serious and will be made worse if appropriate steps are not taken. While most people do not suffer a diagnosable psychological disorder following a traumatic experience (Bonanno et al. 2011), recovery and return to pre-event mental health functioning can take a long period of time. The impact of disasters on individuals may cause a range of reactions which can A minority of people sustain be described as ‘normal for the circumpsychological injury from exposure to a stances’. These include shock, denial or disaster, but most people are resilient disbelief, as well as irritability, anxiety, or experience post-traumatic growth. mood swings, guilt, shame or self-blame. Such reactions should not be minimised or ignored, but nor should they be immediately characterised as a psychological disorder. Often people affected by disasters have feelings of hopelessness or confusion and can have difficulty concentrating, a tendency to withdraw, a sense of disconnection or a feeling of numbness. In the short term, these may simply be normal reactions to a situation that is far from normal. The stress of disasters may also have impacts on the emotional and behavioural aspects of a person’s life, interrupting and/or changing relationships, and limiting ability to function at work, home or in normal social interactions. Table 19.1 shows a range of potential responses to traumatic experiences that are not, in themselves, psychopathological. Table 19.1 Potential responses to traumatic experiences. Emotional

Cognitive

Physical

Interpersonal

Shock Anger

Fatigue Insomnia

Alienation Social withdrawal

Anxiety, fear Despair

Impaired concentration Impaired decisionmaking Impaired memory Disbelief

Sleep disturbance Hyper-arousal

Emotional numbing

Confusion

Somatic complaints

Terror

Distorted sense of time

Headaches

Relationship conflict Impaired capacity to work Impaired ability to study Increased affiliative behaviours

Survivor guilt

Decreased self-esteem

Irritability Grief or sadness

Self-blame Decreased self-efficacy

Helplessness and loss of control Feelings of insignificance Loss of derived pleasure from regular activities

Intrusive thoughts and memories Worry Dissociation

Gastrointestinal problems Decreased appetite Decreased or increased libido Increased startle response

Source: Adapted from Young et al. (1998).

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For some people these reactions do not easily dissipate, and for a minority, symptoms of distress may increase over time. Left unchecked, a diagnosable disorder such as acute stress disorder (ASD), PTSD or depression may be evident. Such disorders may be diagnosed alone or in combination; for example, anxiety and depression. PTSD According to the Diagnostic and Statistical Manual, 5th edition (American Psychiatric Association 2013), PTSD is a severe and enduring condition that may be diagnosed if symptoms remain and are sufficiently severe for more than 30 days (American Psychiatric Association 2013: p.272). PTSD is specified as acute when the duration of symptoms is less than three months and chronic if the duration of the symptoms is three months or more. Broadly speaking, symptoms of PTSD cluster into three areas: intrusive thoughts and images, avoidance and hyper-arousal. Reacting to trauma is a normal The following symptoms are detailed response to a situation that is far thoroughly in the DSM-5 (APA 2013): from normal. • Intrusive thoughts or re-experiencing the traumatic event is often regarded as the hallmark feature of PTSD. Re-experiencing symptoms may be unwanted images that pop into a person’s head; flashbacks to the traumatic aspects of the experience. People can become upset or distressed when reminded of what happened, and have intense physical reactions like sweating, and a rapid heart rate. Unwanted images and thoughts may be present in dreams or when awake. • Avoidance and numbing symptoms are also common in people suffering from PTSD. Avoidance is characterised by deliberate attempts to keep memories of the traumatic event out of mind; this can result in a person going to extreme lengths to avoid people, places and activities that trigger distressing memories. Numbing symptoms are reflected through a loss of interest in something that formerly brought enjoyment, as well as detachment or estrangement from others and restricted emotional responses (e.g. to experience joy or love). Intentional avoidance is not to be confused with unintentional avoidance. Sometimes, choosing to remove yourself from situations you predict will be distressing is an adaptive strategy for coping (as discussed later in this chapter). • Hyper-arousal symptoms are experienced by the individual as though the ‘fear system’ has been recalibrated to a higher idling level. When people are experiencing increased arousal they may be easily startled, have poor concentration and memory, have increased irritability or anger, and experience sleep difficulties. Essentially, the person is in a state whereby they are constantly alert to signs of danger; they are in a state of high arousal and, therefore, a state of hypervigilance. ASD According to the DSM-5 (APA 2013: p.279), ASD shares the above symptoms of PTSD; however, the duration of the symptoms is shorter (lasting for between three

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days and one month). ASD also has an emphasis on dissociation. Symptoms differ from the reactions to trauma (as detailed in Table 19.1), both in severity and in levels of distress, impacting negatively on the way a person is functioning in occupational or personal contexts. Initially, ASD as a diagnosis was developed in order to identify people who were at a high risk of developing PTSD. However, research demonstrates little evidence to support this proposition (Bryant 2006). Bryant (2006) argues that the majority of people who develop PTSD are not initially diagnosed with ASD. Depression Depression can also be significant after a disaster, especially when the individual has suffered losses. It is worth noting that the incidence of depression following disaster can be very high (17– 45%) (Palinkas et al. 1993). Comorbidity of PTSD and depression is also very common (35–68%) (Blanchard et al. 1998), and acute depression is a strong predictor of severity of subsequent impairment (Blanchard et al. 1998). Yet it should be noted that acute depression can follow a distinct course following a disaster that is independent of PTSD. Although some depression is very likely in the aftermath of a disaster, a picture of severe depression, accompanied by hopelessness, unremitting despair and a loss of belief in any worthwhile future indicates a severe response. In addition, if selfesteem is low, sleep severely impaired, there is a marked weight loss and loss of interest in the world, accompanied by a general slowing down in all activities, then a depressive illness should be suspected and special assistance sought urgently (Raphael 1993). Bereavement reactions and complications Sometimes a disaster will have a double impact on individuals as a result, for example, of the direct impact of the event as well as the death of a loved one. In these circumstances the individual must deal with the personal impact of the event and perhaps loss of property, possession, income and the fear associated with the experience, as well as the pain of bereavement. The memories and post-incident complications will compound this bereavement. Traumatic bereavements include those that encompass the additional element of sudden, perhaps horrific, shocking encounters with death and trauma, with the death of a loved one. Descriptions of traumatic bereavements stand in stark contrast to the experiences of a quiet death in the home, without mutilation, bodily distortion, shock, threat, horror and helplessness. Both bereaved and traumatised people are likely to experience similar symptoms in terms of intrusive recollections, persistent thoughts and images, avoidance reactions and high levels of arousal. However, even though significant overlap may occur, there are substantial differences in these two types of experiences (Raphael and Martinek 1997). The primary message here is that the concepts of ASD and PTSD, and that of traumatic bereavement, are independent entities and care must be taken to ensure that they are dealt with appropriately, supportively, and where necessary clinically.

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Compassion fatigue ‘you can’t wipe away the tears from another person’s face without getting your own hand wet’ (Zulu proverb) Compassion fatigue is a term that denotes the emotional residue or strain of exposure from working with those suffering from the consequences of traumatic events (Figley 1995). In the context of disasters, people at risk of experiencing compassion fatigue include the counsellors who listen to stories of trauma and loss in the aftermath of the crisis, and the emergency service workers who respond to the crisis. Emergency service workers such as paramedics, police and fire crews may be witness to the suffering of others in addition to risking their own lives to respond to victims of disasters. Compassion fatigue can be conceptualised as comprising two factors: secondary traumatic stress (STS) and burnout (Stamm 2010). Secondary traumatic stress has all of the symptoms of PTSD: although in these cases, it is caused by bearing witness to the trauma of others rather than being the direct victim. Burnout, the second concept that comprises compassion fatigue, refers to the emotional exhaustion, depersonalisation, and reduced sense of personal accomplishment that can occur for some people as a result of aspects of their work context. Burnout as a result of trauma exposure shares features with STS, such as feelings of depression, anxiety or helplessness, but onset tends to be gradual rather than sudden (Figley 1995). Burnout results from a cumulative build-up of excessive workplace stress (e. g. exposure to trauma, shift work and time pressure), or could be caused by the emotional demands of working with clients. There is usually an immediate outpouring of concern following any disaster. However, the repetitive nature of disasters and the prolonged time of the recovery phase can lead to compassion fatigue. People who respond to the community in crisis and those who conduct the recovery efforts (e.g. body retrieval teams) are at added risk of compassion fatigue.

Resilience and growth Although many of the above reactions seem negative, it must be emphasised that people also show a number of positive responses in the aftermath of a disaster and other potentially traumatic events. These include resilience and coping, altruism, helping save or comfort others, relief and elation at surviving disaster, and a sense of excitement (Raphael 1993). The struggle that a disaster survivor may experience in ‘coming to terms’ with life following trauma, or a response worker may experience in coming to the aid of victims, can provide a catalyst for positive changes. Such changes include a greater sense of self-worth and personal strength, changes in a person’s philosophy about life, and enhanced relationships with others (Calhoun and Tedeschi 2006). What is important to remember is that people who are resilient and people who experience growth are not immune to the negative impact of disasters. Resilience The term ‘psychological resilience’ is used to describe abilities or protective factors that enable an individual to

Being resilient or experiencing growth does not deny ongoing distress for some people.

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‘bounce back’ from adversity or to maintain a stable equilibrium in situations of adversity or trauma. Although the vast majority of psychological research in the area of disasters and trauma focuses on negative outcomes as discussed above, Bonanno et al. (2007, 2011) have provided convincing evidence that resilience is the most common outcome following such experiences. Despite literature indicating resilience is not equal to the absence of psychopathology, past research has typically assessed resilience by exactly that; the absence of negative mental health outcomes. It is only recently that resilience has begun to be investigated by measuring its presence rather than the absence of pathology such as PTSD and depression (Shakespeare-Finch and Daley, in press). Post-traumatic growth Post-traumatic growth (PTG) is a term coined by Tedeschi and Calhoun (1995) that refers to positive changes a person may perceive to have occurred following the struggle they engage in to come to terms with life following a traumatic experience such as a disaster. PTG represents a movement beyond pre-event levels of adaptation. In other words, unlike resilience which indicates a person returns to their pre-event levels of functioning, PTG represents positive changes such as an increased appreciation of life, a greater sense of personal strength, or improved relationships (Calhoun and Tedeschi 2006). Theoretically PTG rests on the assumption that the disaster or other traumatic experience is severe enough to metaphorically create a psychological earthquake that disrupts a person’s view of the world and themselves within that world. For example, an individual’s way of seeing the world prior to trauma may be that good things happen to good people, that life is mainly predictable. Experiencing a disaster and subsequent losses such as losing a loved one, a home, pets, livestock or possessions, can fundamentally shatter a person’s view of the world and create a sense that the world is not safe, that unpredictable and seemingly unfair things happen to good people. This shattering of previously held views provides an opportunity for a person to re-examine their life. Even people who experience significant distress can also grow & develop from those same distressing experiences.

Preventing and managing mental health risk There are ways in which the risk associated with exposure to disasters can be reduced at both individual and community levels. From an individual perspective, coping resources and strategies are important in minimising psychological injury. At a community level, response to the disaster by relevant authorities can have a significant impact on the likelihood of a community being resilient. Powerful predictors of individual wellbeing include social support; factors that influence the wellbeing of emergency responders such as workplace connectedness and peer support; and variables that influence community mental health such as timely responses to the event itself, insurance claims, and open lines of communication.

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Social support Social support refers to the levels of care, love, comfort, esteem and help received from and given to others. The perception that support is available if required may be as protective as actually receiving that support, but giving support has also been shown to be beneficial to mental health (Shakespeare-Finch and Obst 2011). Social support systems may include family and colleagues as well as religious or spiritual beliefs. For example, religion has been positively linked to cognitive coping processes and to finding meaning in loss (Calhoun and Tedeschi 2006). Although disasters introduce stressors that challenge the wellbeing of individuals and communities, they also provide an environmental context where functional social support may be extensively given and received. Receiving high levels of instrumental and emotional social support during and immediately after a natural disaster may improve perceptions of social wellbeing. Kaniasty (2011) found that the positive experience of social support in the first two months following the 1997 Polish flood led to moderate increases in psychological wellbeing. Receiving adequate social support after a natural disaster provides needed material assistance, but also helps individuals to reframe their social experience, seeing others as dependable and kind (Kaniasty 2011). Social support can play a significant role in recovery following disaster.

Workplace connectedness Workplace connectedness refers to the extent to which an employee feels valued and respected by the organisation they work for, their supervisors and colleagues. Connectivity or a sense of belonging to an organisation has been found to be related to reduced reports of anxiety and depression symptoms (Cockshaw et al. 2012). Within a group of Australian volunteer firefighters Tuckey and Hayward (2011) found that feeling supported and connected to other volunteer firefighters was a protective factor against burnout and post-traumatic stress. Examining post-trauma responses in professional firefighters, Armstrong et al. (2014) found the sense of connection or workplace belongingness was a significant predictor of PTG. In a recent study of mental health in paramedics, connectivity was the strongest predictor of professional quality of life, distress and resilience (Shakespeare-Finch et al. 2014).

Peer support Peer support programs have emerged as standard practice for supporting staff in many high-risk organisations; that is, organisations which routinely expose their personnel to potentially traumatic events (for example, emergency services and the military) (Levenson and Dwyer 2003). With respect to emergency service staff, ShakespeareFinch and Scully (2007) point out that good social support in the work setting can be enhanced by well-trained, skilled and respected Peer Support Officers who are available to assist and support personnel following traumatic incidents in the work context. This concept is related to connectedness but is more specific in its focus and is especially applicable in the aftermath of disasters.

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Community wellbeing AEMI (2011), and other similar organisations around the world, provide guidelines for effective management of the recovery phase of disasters. These principles may be summarised as follows: •

• • •

• •

Effective communication is crucial to help people deal with bad news: no news or lies are much more distressing. A key to reducing anxiety levels is to provide as much information as possible and ensuring communication is truthful, frank and open, even if those responsible may not have all the answers. The provision of practical support builds sense of community and tells people they are not alone. This may be in the form of assistance with clean-up, rebuilding, taking children to school, or cooking a meal. Providing emotional support is important to sustaining people during difficult periods of their lives such as after a disaster. Validating the emotions being experienced may help people to restore a sense of normalcy even when nothing is normal. Providing reassurance that the processes of grief are normal and not evidence of psychopathology may help people to contain the extent of anxiety being experienced. Identifying coping strategies and resources will help people to reduce anxiety and restore functionality. This may include behavioral, emotional and physical strategies. Providing information on, and access to, resources available to help, both physical and emotional, will help reduce anxiety levels.

Conclusion Throughout this chapter two primary and important elements have been identified. Firstly, a small number of individuals who are impacted by a disaster or significant critical event may sustain a diagnosable psychiatric disorder. However, the vast majority will cope and indeed perform well in the face of adversity. Importantly, many within this majority will actually develop an enhanced sense of resilience and coping as a result of their experience with the event, and as a result of the way in which they have helped others, or have been helped by others. In adversity, people adapt in remarkable ways. Full recovery is not always likely to occur immediately, but evidence supports the view that with appropriate support and care, the majority of people do respond well. Given the significant body of available material informing our understanding of mental health, the second element relates to the compelling need for post-disaster mental healthcare and response to be clearly understood and focused. Also that appropriate steps are taken to ensure education and supportive intervention through raising awareness. Proactive mental health education and support strategies to minimise, and where possible to prevent, adverse reactions may be adopted (e.g. in workplaces, community groups and school settings). This is particularly important in disaster management planning contexts and emergency service and response settings.

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Key readings Calhoun LG, Tedeschi RG. ‘The foundations of post-traumatic growth: An expanded framework’. In: Calhoun LG, Tedeschi RG, editors. Handbook of Post-traumatic Growth: Research and practice. New Jersey: Lawrence Erlbaum Associates Publishers; 2006. Kaniasty K. ‘Predicting social psychological wellbeing following trauma: The role of postdisaster social support’ Psychological Trauma: Theory, research, practice, and policy. 2011; 4: 24–33. Shakespeare-Finch J, Scully P. ‘Ways in which paramedics cope with, and respond to, natural large-scale disasters’. In: Gow L, Paton D, editors. The Phoenix Of Natural Disasters: Community resilience. New York: Nova Science; 2007.

Activities • •

Consider a disaster with which you are familiar. What are the factors that may have impacted on the mental health consequences, and how could those consequences be mitigated? If you were asked to set up a mental health support service for a community, what would be its key elements?

References AEMI (Australian Emergency Management Institute). Community Recovery: Handbook 2. Australian Emergency Management Handbook Series. 3rd ed. Canberra: Commonwealth of Australia; 2011. Ahern M, Kovats RS, Wilkinson P et al. ‘Global health impacts of flood; Epidemiological evidence’ Epidemiologic Reviews. 2005; 27: 36–46. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: AMA; 2013. Armstrong D, Shakespeare-Finch J, Shochet I. ‘Predicting post-traumatic growth and posttraumatic stress in fire-fighters’ Australian Journal of Psychology. 2014; 66: 38–46. Blanchard EB, Buckley TC, Hickling EJ et al. ‘Post-traumatic stress disorder and comorbid major depression: Is the correlation an illusion?’ Journal of Anxiety Disorders. 1998; 12(1): 21–37. Bonanno G, Westphal M, Mancini A. ‘Resilience to loss and potential trauma’ Annual Review of Clinical Psychology. 2011; 7(1): 511–535. Bonanno GA, Galea S, Bucciarelli A et al. ‘What predicts psychological resilience after disaster? The role of demographics, resources, and life stress’ Journal of Consulting and Clinical Psychological. 2007; 75(5): 671–682. Briere J, Elliott D. ‘Prevalence, characteristics and long-term sequel of natural disaster exposure in the general population’ Journal of Traumatic Stress. 2000; 13: 661–679. Bryant R. ‘Acute stress disorder’ Psychiatry. 2006; 5: 238–223. Calhoun LG, Tedeschi RG. ‘The foundations of post-traumatic growth: An expanded framework’. In: Calhoun LG, Tedeschi RG, editors. Handbook of Post-traumatic Growth: Research and practice. New Jersey: Lawrence Erlbaum Associates Publishers; 2006. Cockshaw W, Shochet I, Obst P. ‘General belongingness, workplace belongingness, and depressive symptoms’ Journal of Community & Applied Social Psychology. 2012; 23(3): 240–251.

252  J. Shakespeare-Finch & P. Scully Figley CR. ‘Compassion fatigue as secondary traumatic stress disorder: An overview’. In: Figley CR, editor. Compassion Fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. Hoboken: Taylor and Francis; 1995. Kaniasty K. ‘Predicting social psychological wellbeing following trauma: The role of postdisaster social support’ Psychological Trauma: Theory, research, practice, and policy. 2011; 4: 24–33. Levenson R Jr, Dwyer L. ‘Peer support in law enforcement: Past, present, and future’ International Journal of Emergency Mental Health. 2003; 5: 147–152. Palinkas L, Downs M, Patterson J et al. ‘Social, cultural, and psychological impacts of the Exxon Valdez oil spill’ Human Organisation. 1993; 52(1): 1–13. Raphael B. National Health and Medical Research Council. Disaster Management. Canberra: Australian Government Publishing Service; 1993. Raphael B. When Disaster Strikes: How individuals and communities cope with catastrophe. New York: Basic Books; 1986. Raphael B, Martinek N. ‘Assessing traumatic bereavement and post-traumatic stress disorder’. In: Wilson P, Keane TM, editors. Assessing Psychological Trauma and PTSD. New York: The Guilford Press; 1997. Shakespeare-Finch J, Daley E. ‘Workplace belongingness, psychological distress and resilience in emergency service workers’ Psychological Trauma: Research, theory, practice and policy. n.d (In press). Shakespeare-Finch J, Obst PL. ‘Development of the 2-Way Social Support Scale: A measure of giving and receiving, emotional and instrumental support’ Journal of Personality Assessment. 2011; 93(5): 483–490. Shakespeare-Finch J, Scully P. ‘Ways in which paramedics cope with, and respond to, natural large-scale disasters’. In: Gow L, Paton D, editors. The Phoenix Of Natural Disasters: Community resilience. New York: Nova Science; 2007. Shakespeare-Finch J, Wehr T, Kaiplinger I et al. ‘Caring for emergency service personnel: Does what we do work?’ Proceedings of the Australia & New Zealand Disaster & Emergency Conference; May 5–7 2014; Surfers Paradise, Gold Coast, Australia. Stamm BH. The Concise ProQOL Manual. 2nd ed (eBook). Pocatello: ProQOL.org; 2010. www.proqol.org/uploads/ProQOL_Concise_2ndEd_12-2010.pdf (accessed 9 Aug 2015). Tedeschi RG, Calhoun LG. Trauma and Transformation: Growing in the aftermath of suffering. California: SAGE; 1995. Tuckey M, Hayward R. ‘Global and occupation-specific emotional resources as buffers against the emotional demands of fire-fighting’ Applied Psychology. 2011; 60(1): 1–23. Young BH, Ford JD, Ruzek JI et al. Disaster Mental Health Services: A guidebook for clinicians and adminstrators. Michigan: The National Center for Post-Traumatic Stress Disorder; 1998.

Part 7

Unique challenges of particular disasters

Chapter 20

Natural disasters Weiwei Du, Mark Little and Angie Jackson

Introduction and objectives Natural disasters including bushfires, floods, earthquakes, tsunamis and storms are a major adverse event caused by environmental or natural earthly processes. Severity is measured in terms of lives lost, economic losses, and the ability of affected communities to recover. Globally, hundreds of natural disasters occur annually, affecting millions of people. Whether sudden or slow onset, many natural disasters are often predictable. In Chapter 6, disaster risk reduction was discussed as one of the cornerstones of disaster management. This is particularly important for natural disasters. If communities develop in a coastal tropical region prone to cyclones, near rivers that could flood, near forests where bushfires could occur, or in regions prone to earthquakes; improving resilience, governance, planning, mitigation strategies and enhancing disaster preparedness will reduce the impact of a natural disaster on those communities. Throughout this text, emphasis has been placed on an all-hazards approach to disaster management throughout the PPRR cycle. This standardised approach remains critical because while the frequency of events may be statistically predictable, there is no certainty regarding the next event, and the response arrangements that leverage off routine responses need to be standardised (regardless of the hazard) to avoid confusion. However, each event is different and as it unfolds, there are particular issues that must be considered, and subtle changes that need to be made to the response and recovery arrangements to ensure those particular issues are addressed. These actions are dependent on an in-depth understanding of the particular issues of concern. The aim of this chapter is to identify the particular considerations of natural disasters and their overall impact on the health of a population. Arguably, the three most important factors to impact health after natural disasters occur largely due to disruption to water, sanitation and hygiene services. This chapter is not intended to be comprehensive, as the range and scope of events exceeds imagination. However, it is intended to provide observations around the common impacts of common events. On completion of this chapter you should be able to: • • •

Discuss the particular health impacts of common environmental events. Identify the particular issues that must be considered in preparing for, and managing, such events. Demonstrate an understanding of the management strategies required to address those issues.

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Healthcare in natural disasters Planning a response to a disaster must include the pre-disaster background health status of the affected population. This information is important to ensure the response is appropriately targeted to assist not only those directly affected by the disaster, but the overall population. Aside from people directly impacted by the disaster, the health needs of others, especially those with chronic health issues – commonly referred to as non-communicable disease – will need to be addressed. Those with chronic illnesses such as diabetes, cardiovascular, renal or chronic airway disease will require healthcare, because it is common in a disaster for patients to lose medications and be unable to power home oxygen, nebulisers and dialysis. In addition to chronic disease, pregnant women will still deliver babies, children will develop the usual childhood infections, and the daily caseload of myocardial infarctions, strokes and non-disaster related fractures will continue. If health centres are damaged or destroyed, access is limited. This increases the burden on nearby or temporary health services. Even before a natural disaster occurs, health services have a daily elective caseload to manage. Immediately after a disaster the elective demand decreases. It is, however, important to predict and plan for increased demand once the initial emergency surgical caseload has stabilised. A Médecins Sans Frontières surveillance system established after the 2010 Haiti earthquake showed 25% of the 102,054 consultations were for acute respiratory infections. Of note, 50% of consultations for all children less than 5 years old were for acute respiratory infections. The other leading consultations were for acute watery diarrhoea and malaria/fever of unknown origin (Polonsky et al. 2013). Generally, although initial response efforts tend to focus on assisting persons injured as a direct result of the natural disaster, by far the largest demand for health services occurs as a result of day-to-day medical issues. It is incumbent on responders to plan a health response that includes not only those who are directly affected by the disaster, but the entire population.

Case study 20.1: Typhoon Haiyan, November 2013 After Typhoon Haiyan in the Philippines in 2013, the AusMAT field hospital performed 222 procedures in 21 days. Of these, 74 procedures (33%) were performed on 30 patients presenting with chronic foot wounds resulting from type-2 diabetes (Read et al. 2016). Canadian Military level 1 mobile medical teams treated 6,596 patients. Only 3.6% of these presentations had a disaster-related injury or illness, whereas 65.5% had an acute post-disaster medical illness and 30.9% presented for care for a chronic health issue (Savage et al. 2015).

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Predicting health impacts according to types of natural disaster The general health needs of a community affected by a natural disaster are largely predictable (PAHO 2000). Common experiences can be used to plan mitigation strategies to manage the health of affected communities. With all natural disasters, the greatest risk of communicable disease outbreaks is in the setting of overcrowding and catastrophic failure of water and sanitation systems as is seen in mass population displacement and the destruction of public infrastructure. The following discussion will focus on health impacts for common natural disasters. Cyclones and storms Cyclones (including hurricanes and typhoons) are rapidly rotating storm systems with a low-pressure centre and are associated with strong winds, storm surge and heavy rainfall. Cyclones develop, primarily in the tropics, over large bodies of warm water. In the northern hemisphere the wind rotates anticlockwise whilst in the southern hemisphere it rotates clockwise. The major damage occurring from cyclones is: Cyclones, tornados & hurricanes • •

Structural damage due to high winds and storm surge. Flooding.

rarely form within five degrees of the equator.

The damage has the potential to cause significant health impacts due to injuries, loss of basic services such as water, power and sanitation, destruction of health facilities, and exacerbation of underlying endemic/communicable illness such as gastrointestinal illnesses, malaria and pneumonia. Additionally, food resupply may be threatened if transportation routes are destroyed. These issues are exacerbated further if the cyclone hits a large population, especially one where there is limited resilience. A systematic review of the human impact of tropical cyclones from 1980 to 2009 (Doocy et al. 2013b) reveals over 421,000 people died, 290,000 were injured, and 466 million people were affected by cyclones. Mortality was more common in women and extremes of age (children and older adults). The extent of death and injury caused by a cyclone is directly related to the degree of physical protection available to withstand the storm (Schultz et al. 2005), and the resilience of the affected population and community to quickly ‘bounce back’ after the storm. In developing nations, the rate of mortality is highest during the impact phase and is caused by drowning, structural collapse and windborne debris (Schultz et al. 2005). While in developed nations, the highest rate of mortality and morbidity occurs in the post-impact period with most deaths attributed to electrocution and penetrating and blunt force trauma caused by fallen trees and power lines, chainsaws, falls and motor vehicle accidents (CDC 1989, 1996a, 1996b). Minor injuries in the post-impact period include lacerations, blunt trauma, falls, fractures, and puncture wounds, primarily to the lower limbs. The elderly are especially vulnerable during the preimpact phase with the biggest risk of injury occurring during evacuation and sheltering (Schultz et al. 2005).

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Schultz et al. (2005) contend that, postimpact, conditions that increase the chances of infectious diseases occur when: • • •

Public services and health infrastructure have been disrupted. Water and sanitation infrastructure has been damaged. Population displacement and changes in population density have occurred (e.g. crowded evacuation centres and shelters).

Of the 1,080 cyclones recorded during 1980–2009, two thirds of all deaths have occurred in two cyclones: •  TC Gorky, Bangladesh 1991, 138,866 deaths. •  TC Nargis, Myanmar (Burma) 2008, 138,366 deaths. Source: Doocy et al., 2013b

Infectious disease outbreaks have occurred, mainly in developing nations with endemic diseases and poor public health systems. Tsunamis and floods Tsunamis are usually generated by movements in the sea floor creating a surge of water inundating land in coastal areas. A significant earthquake off the coast of Indonesia in 2004 generated a major tsunami. Fourteen countries were affected resulting in an estimated death toll of 250,000 people. Following a magnitude 9 earthquake in 2011, a series of massive tsunamis impacted the coast of Japan resulting in a death toll of 19,000 people and US$300 billion in damages. The waves can travel great distances across oceans. Warning times that are so critical for moving people to higher ground can vary from a few minutes to hours. Large tsunamis can be incredibly destructive to the coastal zone, especially if the shape of the land funnels the water. For example, in Japan in 2011 the tsunami reached 40 metres above sea level after 10 metre high waves struck the coast.

Case study 20.2: Great Eastern Japan earthquake and tsunami, 11 March 2011 Japan has a long history of earthquake and tsunami. With a multi-tier sophisticated earthquake and tsunami defence system and a well-educated population, Japan is well prepared to deal with the threat. In March 2011, warnings were issued for a tremor predicted to be magnitude of 7.2. The earthquake was 100 times more severe measuring magnitude 9. Despite this, defences held and damage was minimal. Further warnings were issued for a tsunami. People were encouraged to get to higher ground or move to designated purpose-built evacuation centres. Japan’s tsunami defences were designed to withstand a mega-thrust event up to 12 metres: however, the 2011 tsunami was 40 metres. Evacuation centres were inundated, the multi-tiered defence system had failed catastrophically, due in part to the way the defences funnelled the flow of water.

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Floods account for 43% of all natural disasters and 55% of the total people affected by natural disasters (CRED 2015). Flood refers to the condition that water overflows the natural or artificial confines of a stream, river, or other body of water, or accumulates by drainage over low-lying areas. The main causes of flood include: • • • •

Precipitation (rain and snow). Rising water levels (sea level rise due to tidal waves, tsunami or global warming). Structural failure (dam and sea defences). Reduced natural draining (reduced absorption or blocked drainage).

The speed of onset of the flood is the main factor for determining the number of floodrelated deaths. This can be associated with the local geography. Flash flood implies sudden onset and may be associated with tsunamis, sudden downpour, or breach of reservoirs; whereas gradual inundation, or riverine flooding, is more predictable and less likely to cause drowning and injury. A specific subset of flooding is blizzards during which the risks associated with immersion are added to by those related to hypothermia, and also the damage to property, transportation, and power and fuel supplies by the physical weight of snow. Drowning is the leading immediate cause of death in floods, with most deaths due to flash flooding rather than the slower riverine flooding. Drowning often occurs because individuals underestimate the power of the current, or depth of the water. In many cases, drowning is associated with people’s choice to enter the water either on foot or by motor vehicle; seriously underestimating the power of the water to dislodge even heavy vehicles. Flood-related injuries may occur as individuals attempt to escape from danger, or from collapsing buildings or other structures. Injuries also occur during clean-up. Orthopaedic injuries and lacerations commonly result from fast-moving water containing debris. Electrical injuries and burns may be caused as floodwaters disrupt power lines, propane and natural gas lines, and chemical storage tanks. Carbon monoxide (CO) poisoning is a common risk during floods, cyclones and other disasters that cause a loss of power supply. CO poisoning and deaths usually result from the use of petrol-powered cleaning equipment or generators being used in closed environments (i.e. indoors, in basements, etc.). Hypothermia with or without submersion is seen in some floods and may occur in any season. Respiratory problems account for a significant proportion of morbidity associated with floods, and mould is a particular hazard for persons with impaired host defences or mould allergies. Communicable diseases including Escherichia coli, Shigella, Salmonella and hepatitis A virus can occur if floodwaters contaminate the local water and food supply and damage the sewerage system. Lack of shelter, overcrowding and poor sanitation also increase the risk of communicable diseases. Stagnant water provides a breeding ground for vectors such as mosquitoes, resulting in diseases including malaria and dengue. Skin contact with floodwaters does not pose a serious health risk other than drowning. Animal displacement commonly occurs during flooding. Displaced domesticated animals, rats, insects, snakes and reptiles often result in an increased incidence of bites. Diseases transmitted by rodents may increase during flooding because of altered patterns of contact. Diseases amongst sick animals may spread to humans.

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Impaired access to health resources and the provision of health services due to flooding can result in health deterioration and increased morbidity. Additionally, patients may lose medication or access to medical devices. Flooding can also cause the loss of medical records, disrupt the provision of health resources, consumables and the infrastructure required to maintain services. Disability from trauma in the long-term is a common cause of morbidity, particularly if exacerbated by complications such as infection. Disability may also be associated with the exacerbation of chronic diseases such as asthma or ear, nose or throat conditions. Mental health problems are common in floods, and may derive from physical health problems or from personal losses, social disruption and economic hardship. The destruction of food supplies potentially results in poor nutrition, and may disrupt livelihoods and affect household incomes and their capacity to purchase food, particularly for those living on low incomes. Earthquakes Earthquakes are due to a sudden release of energy from the earth’s crust resulting in seismic activity. The magnitude of the energy released is measured using seismometers and is often referred to as the Richter magnitude scale. Earthquakes with a magnitude of 3 are rarely felt and those with a magnitude > 7 often result in serious damage. In addition to the ground shaking, earthquakes can cause tsunamis, landslides, fires if gas and power lines are disrupted, soil liquefaction and floods. This may not only lead to significant injuries and deaths, but also result in significant damage to infrastructure. In the 20th century, 1.87 million deaths have occurred due to earthquakes. Deaths The Pacific Rim has experienced 81% are more likely if the earthquake occurs at of the world’s largest earthquakes. night, if it occurs in areas with high population density and if the housing is made Source: Doocy et al., 2013a of adobe, stone or unreinforced masonry (as compared to wooden structures). Earthquakes often cause high mortality and numerous injuries associated with buildings and infrastructure collapse. Both major and minor injuries are to be expected. Major injuries include limb and spinal fractures, dislocations, crush injuries and head injuries. There are significantly more cases of minor injuries and wounds. The 2011 earthquake in Christchurch, New Zealand, caused 6,659 injuries and 182 deaths. Of those injured, the majority had soft tissue injuries, and limb wounds. The Christchurch Hospital was overwhelmed with casualties immediately after the earthquake (Ardagh et al. 2012). Earthquakes occur with little warning: there are often many casualties presenting for treatment with little time to cope with increase in demand for health services. This has the potential to overwhelm health systems. If the earthquake is large, it is also likely that health facilities will be severely damaged and disrupted. There is an increased risk of damage to water and sewerage systems with the consequence being an increased risk of waterborne diseases such as gastroenteritis. Infectious disease outbreaks, such as pneumonia, diarrhoea and measles, can be expected, especially in a populated city with inadequate public health planning and surveillance. Proof of the effectiveness of public health planning and surveillance was

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seen after the 2008 Wenchuan (People’s Republic of China) earthquake. Following the earthquake, over 16,000 healthcare workers were deployed to initiate a rapid vaccination program. This resulted in a large fall in cases of infectious disease in the two years post-earthquake compared to pre-earthquake figures (Zhang et al. 2012). Drought A drought is a period of below-average precipitation in a given region, resulting in prolonged shortages of water supply. Depending on the severity and duration of the dry period, drought can by categorised by: • •

Severity (e.g. abnormal, moderate, severe, extreme or exceptional). The degree of impact (e.g. meteorological, agricultural, hydrological or socioeconomic).

Although drought accounts for around 5% of all disaster occurrences, it affects as many as 25% of disaster-affected populations worldwide. In the period 1994–2013, drought was estimated to affect approximately one billion people (CRED 2015). Droughts can last for several years and some have extensive, long-term economic impacts that result in negative health impacts and displacement of large sections of the affected population. The health effects of drought are numerous and far reaching, but difficult to document because they are both direct and indirect and impact over time. Droughtrelated deaths are extremely difficult to quantify, not only because of poor recordkeeping, but because the start/end date of drought is difficult to define. There is little doubt, however, that drought mortality is high because of increased hunger, poverty, and the perpetuation of under-development. Nutrition-related health effects are one of the most prominent results of droughts, due to agricultural failures, loss of livestock, and shortages of safe drinking water. This includes general malnutrition, micronutrient malnutrition and anti-nutrient consumption. Dry soils and wildfires during a drought can cause dusty and dry air, which can exacerbate asthma, chronic airway disease and cardiac failure. There is also an increased risk of communicable diseases in times of drought. This may include water, air and vector borne diseases. Water-related disease due to contaminated water includes salmonella, E. coli, cholera and algal bloom. Poor air quality can result in different pathogens and a changed profile or even outbreak of infectious disease such as coccidioidomycosis (a type of fungal infection), and bacterial pathogens causing acute respiratory infections. Finally, changing habitats for wildlife and stagnant water reserves may increase the potential for vector borne disease, including malaria, dengue, West Nile virus and St. Louis encephalitis (Yang et al. 2013). Although the physical impacts of drought in terms of health may be significant, the psychological impact can also be significant due to financial hardship. This results in increased rates of stress, depression, anxiety and suicide. The probability of drought-related health impacts varies widely, and largely depends upon drought severity, baseline population vulnerability, existing health and sanitation infrastructure, and available resources (Stanke et al. 2013). Numerous strategies could improve outcomes for vulnerable populations. Sanitation and hygiene education are

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important in times of drought to reduce contamination and disease transmission. Other risk management strategies include better monitoring of the indirect health effects, and drought early warning systems to better prepare people for water shortages. A number of risk reduction strategies could be implemented to decrease the impact of drought including building dams and canals, desalination of seawater, and redirecting rivers. Others improvements such as promoting green buildings, capturing rainwater and water recycling will improve water management. Bushfires Bushfire (wildfire, grassfire or forest fire) is an uncontrolled fire that differs from other fires by its size, speed of propagation and potential to change direction unexpectedly. There is no particular definitional distinction between these terms other than topographical conditions and local traditional terminology. Bushfires are a dangerous problem, particularly in rural areas that border urban settlements. The cause of bushfires varies worldwide. In some countries, lightning is the major source of ignition whereas elsewhere, human activity is the major cause, with the latter including deliberate acts, careless acts (e.g. a discarded cigarette butt) or accidents. In many rural areas, windstorms blowing down power cables can cause bushfires. Other fires occur when campfires or controlled agricultural burns escape. Major bushfires can result in severe loss of life as fast-moving fires isolate and trap people, as well as destroying power lines and other infrastructure. Fires also cause extensive damage to property, vegetation, crops, and domestic and wild animal stocks, thus increasing the financial and psychological burden on affected populations. Bushfires produce copious quantities of smoke that often disperses over long distances depending on climatic conditions, topography and vegetation sources. Exposure to bushfire smoke causes an increased incidence of respiratory and cardiovascular pathology (e.g. shortness of breath, itchy eyes, sore throat, runny nose and coughing), though the adverse effects are not well defined (Chen et al. 2006; De Vos et al. 2009). Bushfires may pose severe occupational health and safety risks such as cardiovascular disease, musculoskeletal injury, and heat and smoke exposure to firefighters working long hours in hot, smoky conditions. Management strategies for bushfire are directed at prevention, early detection and suppression. While each of the strategies is rational in isolation, they may conflict directly with other community interests. Prevention largely focuses on fuel reduction through selective land use, vegetation plantings and controlled burning. Preparedness includes proper building design, clearing fuels, and the construction of fire refuges. Protection is directed towards recommended actions to be taken in the light of an imminent fire and may include the preparation of water storage, firefighting equipment, protective kits, generators for power for electrical pumps, back burning and evacuation. Education and self-reliance are critical to ensure self-protection during bushfires and to enhance complementary action provided by local fire authorities. Response management strategies include controlled back burning, clearing of firebreaks and suppression. The fire suppression functions are largely led by fire services. The recovery phase involves redevelopment of infrastructure and the restoration of community functionality.

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Case study 20.3: Bushfires in Victoria, February 2009 Tibbits et al. (2007) found 78% of bushfire fatalities in Australia occurred outside or in an indefensible space. However, in a bushfire in Victoria, Australia, in 2009, only 22 of the 173 deaths occurred when people were attempting to evacuate. The remaining 151 people died in houses or other buildings close to their home. Seventeen of the deaths were people older than 80 years, with 23 deaths of people under 17 years old. These fires caused a rethink of the concept of defensible space and the need to consider early evacuation for children, the elderly and frail, and pets at times of catastrophic fire conditions (Teague et al. 2009).

Heatwaves The definition of ‘heatwave’ is not clear in the literature mainly because what is a heatwave in one region, may be a normal temperature in another (e.g. 35oC in London compared to northern Australia). It is likely that heatwaves are the most lethal of natural disasters with many thousands of people, mainly elderly or others with co-morbidities, dying each year. In 2006, France recorded 2,065 excess deaths after an 18-day heatwave. Seven years earlier London experienced a 2.6% increase in emergency department presentations and a daily mortality rate increase of 10.8% during a six-day heatwave. Many of the deaths occur in the elderly due to aggravation of chronic respiratory or cardiovascular disease by dehydration (Kovats et al. 2004). At moderate environmental conditions, these vulnerable groups can cope with some physiological changes, but extreme temperatures exceed their limited physiological reserve of diseased organs and as such, they fail. Persons with psychiatric illness are another high-risk group during heatwaves. This is either attributed to an inability to care for themselves, or due to the effects of neuroleptic drugs. Unlike many other natural disasters, heatwaves are often predictable with many governments developing strategies to mitigate the adverse effects. These revolve around early warning systems and public announcements aimed at protecting popIn a heatwave, the elderly are ulation health, especially the vulnerable. arguably the most vulnerable group. Specific advice is usually aimed at reducDuring a heatwave, conduct daily ing dehydration, maintaining a tolerable welfare checks on elderly friends temperature of the environment and & neighbours, especially if they encouraging community support. live alone.

Conclusion All natural disasters are highly likely to result in increased mortality whether at the time of the disaster or in its aftermath. It is important that healthcare personnel work closely with local communities to observe not only local customs, but also to follow

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the correct legal processes; this is especially important when dealing with the deceased. There are unsubstantiated beliefs about the health concerns to the public in areas where there exists large numbers of deceased. Other than a few exceptional circumstances, dead bodies do not present an increased risk for infection. They do, however, present logistical and legal challenges. When responding to a natural disaster it is important to understand not only the epidemiology of the injuries that are associated with specific disasters, but also the pre-disaster health status of the affected population. This includes understanding the endemic disease patterns that Deaths caused by the traumatic already existed in the affected region and forces of natural disasters, as opposed the known chronic health issues. Health to deaths caused by contagious responders should plan to treat the daydisease, do not lead to epidemics of to-day heath needs of the community infectious diseases. that existed before the disaster. Source: de Ville de Goyet, 2000, 2004 Injuries suffered in natural disasters are often predictable and, when these are considered with the pre-disaster health status of the population, a focused and more targeted health response can occur that will avoid waste, but, more importantly, be directed towards benefitting those in greatest need of health services. After natural disasters, an increase in common communicable illnesses, such as diarrhoeal diseases, malaria, respiratory infections and vaccine-preventable diseases, often occurs. Early establishment of surveillance systems that monitor and treat disease outbreak, vaccination programs, and effective public health interventions such as restoration of clean water and sanitation services are likely to have the most impact on overall morbidity and mortality.

Key readings Dancause K, Laplante D, Hart D at al. ‘Prenatal stress due to a natural disaster predicts adiposity in childhood: The Iowa flood study’ Hindawi Publishing Corporation Journal of Obesity. Volume 2015; Article ID 570541: http://dx.doi.org/10.1155/ 2015/570541 (accessed 3 May 2016). Murray V, Aitsi-Selmi A, Blanchard K. ‘The role of public health within the United Nations post 2015 framework for disaster risk reduction’ Int J Disaster Risk Sci. 2015; 6: 28–37. Rydberg H, Marrone G, Stromdahl S et al. ‘A promising tool to assess long term public health effects of natural disasters: Combining routine health survey data and geographic information systems to assess stunting after the 2001 earthquake in Peru’ PLoS ONE. 10(6): e0130889. doi:10.1371/journal.pone.0130889 Stanke C, Kerac M, Prudhomme C et al. ‘Health effects of drought: A systematic review of the evidence’ PLOS Currents. 2013; 5(5): 1–32.

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Activities • •

Identify the natural disasters that affect your community and their risks. How would those risks vary in a less developed nation? How should health services be reconfigured during a natural disaster to ensure the ongoing risks to the community are reduced?

References Ardagh MA, Richardson SL, Robinson V et al. ‘The initial health-system response to the earthquake in Christchurch, New Zealand in February 2011’ Lancet. 2012; 379: 2109–2115. CDC. ‘Deaths associated with Hurricanes Marilyn and Opal – United States’ Morbidity and Mortality Weekly Report. 1996a; 45(2): 32–38. CDC. ‘Surveillance for injuries and illnesses and rapid health-needs assessment following Hurricanes Marilyn and Opal’ Morbidity and Mortality Weekly Report. 1996b; 45(4): 81–85. CDC. ‘Medical Examiner/Coroner reports of deaths associated with Hurricane Hugo – South Carolina’ Morbidity and Mortality Weekly Report. 1989; 38(44): 759–762. Chen L, Verrall K, Tong S. ‘Air particulate pollution due to bushfires and respiratory hospital admissions in Brisbane, Australia’ International Journal of Environmental Health Research. 2006; 16(3): 181–191. CRED (Centre for Research on the Epidemiology of Disaster). The Human Cost of Natural Disasters: A global perspective. Brussels: CRED; 2015. de Ville de Goyet C. ‘Epidemics caused by dead bodies: A disaster myth that does not want to die’ Rev Panam Salud Publica. 2004; 15(5): 297–299. de Ville de Goyet C. ‘Stop propagating disaster myths’ Lancet. 2000; 356(9231): 762–764. De Vos AJBM, Reisen F, Cook A et al. ‘Respiratory irritants in Australian bushfire smoke: Air toxics sampling in a smoke chamber and during prescribed burns’ Archives of Environmental Contamination and Toxicology. 2009; 56(3): 380–388. Doocy S, Daniels A, Packer C et al. ‘The human impact of earthquakes: A historical review of events 1980–2009 and a systematic literature review’ PLOS Currents Disasters. 2013a; April 16: 5: 1–46. Doocy S, Dick A, Daniels A et al. ‘The human impact of tropical cyclones: A historical review of events 1980–2009 and a systematic literature review’ PLOS Currents Disasters. 2013b; April 16: 1–39. Kovats RS, Hajat S, Wilkinson P. ‘Contrasting patterns of mortality and hospital admissions during hot weather and heatwaves in Greater London, UK’ Occupational and Environmental Medicine. 2004; 61: 893–898. PAHO (Pan American Health Organization). Natural Disasters: Protecting the public’s health. Washington, DC: PAHO/WHO; 2000. Polonsky J, Luquero F, Franscois G et al. ‘Public health surveillance after the 2010 Haiti earthquake: The experience of Médecins Sans Frontières’ PLOS Currents Disasters. 2013; 7(5): 1–28. Read DJ, Holian A, Moller CC et al. ‘Surgical workload of a foreign medical team after Typhoon Haiyan: Surgery after Typhoon Haiyan’ ANZ Journal of Surgery. 2016; 86(5): 361–365. Savage E, Christian MD, Smith S et al. ‘The Canadian Armed Forces medical response to Typhoon Haiyan’ Canadian Journal of Surgery. 2015; 58(3 Suppl 3): s146–s152. Schultz JM, Russell J, Espinel Z. ‘Epidemiology of tropical cyclones: The dynamics of disaster, disease and development’ Epidemiologic Reviews. 2005; 27(1): 21–35. Stanke C, Kerac M, Prudhomme C et al. ‘Health effects of drought: A systematic review of the evidence’ PLOS Currents. 2013; 5(5): 1–32.

266  W. Du, M. Little & A. Jackson Teague B, McLeod R, Pascoe S. 2009 Victorian Bushfires Royal Commission – Interim report. Victoria: Parliament of Victoria; 2009. Tibbits A, Handmer J, Haynes K et al. ‘Prepare, stay and defend or leave early: Evidence for the Australian approach’. In: Handmer J, Haynes K (eds) Community Bushfire Safety. Melbourne: CSIRO Publishing; 2007. Yang L-P, Han D-B, Jiang BF. ‘Drought and human health: A review of recent studies’ Journal of Environmental Health. 2013; 30(5): 453–455. Zhang L, Li Y, Liu Y et al. ‘Emergency medical rescue efforts after a major earthquake: Lessons from the 2008 Wenchuan earthquake’ Lancet. 2012; 379: 853–861.

Chapter 21

Manmade disasters Carissa Oh, Stefan Mazur and Peter Logan

Introduction and objectives There has been considerable debate regarding the terminology of natural versus manmade disasters. Natural disasters, for example earthquakes, cyclones and floods, imply occurrences which are unavoidable, but whose effects can be mitigated with preparation and planning. Manmade disasters, often referred to as ‘technological’ disasters, are events caused by system failures, which may include human negligence. Manmade disasters are avoidable and ought to be preventable, i.e. through legislation and regulation. These include transport and industrial accidents, mass gatherings, and terrorist-related events. These manmade events can have devastating effects with loss of life, and damage to property and the environment. The effects can be both immediate and long term. For example, the Exxon Valdez oil spill in 1989 killed thousands of birds, marine life and wildlife. More than two decades on, not all species have recovered and there are still remnants of crude oil on some Alaskan beaches. On completion of this chapter, you should be able to: • • •

Identify the risks posed by manmade disasters. Demonstrate an understanding of the particular clinical and logistic issues associated with different types of manmade events. Discuss the particular management strategies required to prepare for, and respond to, such events.

Industrial disasters Industrial disasters affect industrial sites or production facilities. Incidents include fires, building or infrastructure collapse, and accidental emissions and explosions due to chemical mixtures or gas (with resultant release of toxic substances or radiation). These disasters may be a consequence of system failure, negligence, incompetence, or a deliberate act of sabotage. Irrespective of the cause, the outcome may be significant morbidity and mortality, often accompanied by significant damage to both property and the environment. These disasters may result in economic and social consequences for individuals and the community, in both the short- and long-term. Advances in technology and engineering combined with work health and safety legislation have created safer work environments and reduced risk for communities

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near facilities. Unfortunately in many countries with cheap production costs (including labour), there are often less developed work health and safety systems and lax safety regulations. Following an industrial disaster in these environments, companies may attempt to cover up or dissociate themselves from any legal or ethical responsibility: for example, the 1984 Bhopal gas disaster in India (Broughton 2005). The risk of rapid unregulated industrial growth needs to be balanced against environmental health and public safety, with consideration given to the ability of the local infrastructure to support hazardous industries. Prevention and preparedness All industries should have an incident management plan for dealing with emergencies. This plan needs to address any potential significant incident including those of low probability (McKenna et al. 2007). Arrangements for incident management and response need to include both the site operator and external agencies. This must be determined in advance. If there is a requirement for decontamination (for instance, in a chemical, biological, radiological or nuclear (CBRN) incident), the logistics of how, where and when this will occur, and who is responsible, must be pre-planned. Criteria for the implementation of urgent and longer term actions and for return to normal operations also need to be established before an incident occurs. All organisations are required to keep a safety data sheet (SDS) for chemicals used or stored in the workplace. The SDS is often prepared by the manufacturer and provides information such as physical data, safe handling, potential hazards and emergency procedures. This can be a useful source of information following an incident involving chemicals. The issue of decontamination needs to be considered and should be easily and immediately available for any responding resource. Response and recovery Following an industrial accident, there may be confused accountabilities for incident response. The environmental risks and hazards associated with certain industries may mean that it is unsafe for untrained external rescue personnel to enter such an environment following an incident (for example, in mines or nuclear power plants). It may be the responsibility of the site operator familiar with the environment to manage the hazards and extricate the injured, but joint arrangements are required for command and control. Industrial disasters can have both immediate and long-term consequences. Whilst traumatic injuries occur with fire and explosive incidents, there may also be short- or long-term medical issues due to exposure to hazardous substances. When incidents occur involving chemical and radiation plants resulting in toxic emissions, it is worth remembering that emergency service responders and receiving healthcare facility staff may also be exposed. In some situations, the consequences of an incident may not be fully appreciated initially and may only become apparent after increased deaths among local livestock and wildlife are reported. The effects on humans may not manifest immediately (for example, the 1976 Seveso dioxin release in Italy), and serious medical sequelae (for example, Bhopal in India, 1984, and Chernobyl in Ukraine, 1986) may not become evident until decades later. This may affect not only those in the area

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Case study 21.1: Industrial accident in Seveso, 10 July 1976 In Seveso, Italy, on 10 July 1976, dioxin from a chemical plant released a chemical cloud into the environment causing severe Tetrachlorobenzodioxin (TCDD) exposure to the vast, densely populated region. The health of the exposed population has been extensively studied since the incident: Rehder et al. 1978; Bisanti et al. 1980; Filippini et al. 1981; Tenchini et al. 1983; Ideo et al. 1985; Mocarelli et al. 1986; Mastroiacovo et al. 1988; Barbieri et al. 1988; Bertazzi et al. 2001; and Pesatori et al. 2003. A 25-year follow-up study undertaken by Consonni et al. (2008) confirmed previous findings of increased incidents and mortality from hematopoietic and lymphatic tissue neoplasms, circulatory disease and chronic obstructive pulmonary disease (COPD). There was also increased mortality from cancers of the rectum and lung, and from diabetes mellitus (Consonni et al. 2008).

around the industrial site, but also those remotely exposed to contaminated food and water. The long-term psychological effects on those affected may also be significant. A critical incident may result in closure of the affected industry. This can be a double blow to communities affected by the physical and environmental consequences of the initial disaster but which now have to deal with the economic and social consequences brought about by the closure of a major industry.

Transport disasters Worldwide, population growth coupled with increasing population mobility, primarily due to advances in transport technology and capabilities, have increased the total number of people exposed to risk of a transport-related disaster. Bigger planes, faster trains, busier roads and cheaper cars result in more people (not to mention increased amounts of dangerous freight) mobile at any one time. Partially off-setting this increased load are advances in transport and computer technology, including inbuilt safety systems, that have made most modes of transport, in the developed world at least, intrinsically safer. The end result of this is probably less transport-related mass casualty incidents in total, but when a significant incident does occur, it can be catastrophic in its consequences due to the size and speed of the transport platform involved. In countries where safety regulations are less stringent, overcrowding, particularly on public transport systems, remains a problem. This combined with inadequate safety equipment (such as insufficient life jackets on ferries) and poorly maintained infrastructure (for roads and railways) has contributed to an increase in preventable mortality from major transport accidents. Prevention and preparedness Terrorism-inspired targeting of mass transport services (for example, 1988 Lockerbie disaster in the UK; September 11, 2001, World Trade Centre and Pentagon targets

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in the US; 2004 Madrid train bombings in Spain; and 2005 London underground bombings in the UK) have resulted in increased transport security vigilance, most notably at airports with increased passenger and luggage screening. Although able to be applied in airport terminals, the same systems on rail or bus services would cripple commuter systems worldwide. This leaves them potentially ‘softer targets’. Airports frequently rehearse mass casualty plans and undertake real-time major incident scenarios regularly, as dictated by legislation (Federal Aviation Administration Certification requirements Part 139). This will invariably involve the scenario of a catastrophic aeroplane failure somewhere in the boundaries of the airport and the use of emergency services in a real-time response involving infrastructure damage and simulated casualties. However, this mandated simulated major incident rehearsal is less likely to occur with other passenger transport modalities and dangerous freight transport. Response and recovery Transport disasters are often the result of environmental factors such as inclement weather or rugged terrain. Consequently, the conditions that contribute to the incident will also play a major role in the effectiveness of the response. Poor environmental conditions (e.g. snow, ice, flood or fog) and challenging topography will result in difficult access for emergency services responding to a major transport incident. The 1999 Mont Blanc tunnel fire in France/Italy is a classic example (Fraser-Mitchell and Charters 2005; Duffe and Marec 1999). Similarly, water transportation major incidents will often have significant adverse environmental conditions, which along with the added difficulty of sourcing appropriate rescue resources (e.g. rescuecapable helicopters and boats) make adequate emergency response difficult. Extreme weather conditions, such as storms in the 2015 Yangtze ferry disaster in the People’s Republic of China (over 400 dead) and freezing water in the 1987 Zeebrugge ferry disaster in Belgium (193 dead) (Department of Transport 1988) add significantly to rescue and response difficulties. These conditions undoubtedly contributed to fatality rates. Transport disaster management can also be compromised by conflicts around accountability and responsibility for response to the incident. When is it the responsibility of the transport operator to manage the incident and its consequences as opposed to external designated rescue services? Can business and financial interests create potential for conflict of interest with regards to incident management and communication? Often the size and complexity of the incident (or alternatively, pre-ordained When is it the responsibility of the legislation or government regulation) transport operator to manage the will dictate where responsibilities lie. transport incident & its consequences Nevertheless, the transport operator must versus external designated rescue fit into the command and control strucservices? Can business & financial ture for the incident management of the interests create potential for conflict external lead response agency. This can of interest with regards to incident create problems around potential conflict management & communication? of interest and willingness to submit to an externally dictated hierarchy.

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Mass gatherings Most mass gatherings are planned events (e.g. sporting events, music festivals or protest marches). This allows for a degree of pre-event planning, crucial to facilitating good crowd management, ensuring timely treatment and transport of the ill or injured, and minimising the impact large crowds may have on local facilities. Without this prior preparation and planning, any adverse incident, either for an individual or a crowd, will result in significantly worse outcomes for those affected. Prevention and preparedness ‘To fail to plan is to plan to fail’ – and mass gatherings are no exception. When a large number of people are gathered together, there is always the potential for a catastrophic event. Whilst it may be difficult to predict if, what and when an incident may occur, risk analysis can help emergency services prepare for the more likely scenarios based on pre-event information. Table 21.1 provides an overview of the issues to be considered as part of the risk analysis during the planning phase of a mass gathering event. Whilst each mass gathering may be different in terms of purpose, size and population attending, an emergency management plan may already exist for high-risk venues or for regular recurring events. These plans will need to be reviewed and modified prior to each event. Examples of these include plans for sporting and concert venues and events (ranging from local stadia to the Olympic Games), religious gatherings (e.g. pilgrimage to the Hajj or World Youth Day), and mass community events (such as fun-runs and New Year’s Eve celebrations). Planning for a mass gathering involves an inter-agency response and collaboration with local authorities. Engagement of public health is important when dealing with Table 21.1 Risk analysis considerations for mass gathering planning. Type and purpose of the gathering Location

Population

Local and environmental factors

Other

•  Duration of the gathering and time of day. •  Expected number of people. •  Size and capacity of the venue. •  Purpose built or constructed for event. •  Indoors versus outdoors. •  Seated versus mobile. •  Access (ingress and egress) to the venue. •  Access within the venue. •  Demographics including age, gender and socioeconomic status. •  Health status of the population. •  Predictable medical problems that may occur. •  Motives, mood and behaviour of the crowd. •  Availability/acceptability of alcohol and other recreational or illicit drugs. •  Weather. •  Local infrastructure: transport, health resources and facilities, toilets and washing facilities. •  Endemic diseases. •  Command and control. •  Communications.

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events of a prolonged duration. Crowd members have often travelled from varied locations and consideration needs to be given to food, water and waste management, sanitation facilities, communicable diseases and the potential need for identifying contacts and quarantining patients (Kollek 2014). Response and recovery The response and management of an incident occurring at a mass gathering depends on the nature of the incident and the number of people affected. This may result in the need to evacuate or manage a ‘well crowd’ (e.g. bomb threat, fire or simply post-event), or a need for medical care and possible evacuation of patients (e.g. illness, accident or terrorist-related incident) or a need for quarantining those with communicable disease, especially during prolonged events. The provision of medical services at a mass gathering needs to be tailored to the type and complexity of the event, and the predicted medical problems that may be encountered. This will determine the resources required. Staff may range from first-aid providers and paramedics at mobile or static first-aid posts, to nurses and doctors running a medical centre or field hospital. Currently the average healthcare staffing at Australian events is 0.6 staff per 1,000 people (Arbon 2005). Patient presentations to healthcare services at mass gatherings range from 0.5 to 2 per 1,000 spectators. More than 80% of patient presentations consist of respiratory and heat-related illnesses, minor injuries and minor first-aid problems (e.g. dressing of minor wounds or relief from mild pain) (Arbon 2005). More than 95% of presentations are classified as mild and do not require transport to a hospital (Locoh-Donou et al. 2013). Without prior planning, local health facilities may be burdened by increased presentations, which could effectively be managed onsite, largely by first-aid personnel. All health personnel employed at a mass gathering must be aware of their primary healthcare role, as well as how their role will change should the situation evolve from normal operations to a major incident. A catastrophic event will rapidly overwhelm onsite medical resources, the local health facilities and emergency services. An allhazards approach needs to be adopted for dealing with mass gatherings. Response to such an event may require activation of disaster plans and mobilisation of state or national resources.

Conflict, terrorism and mass shooting While widespread international conflict is becoming less frequent, there is a widely held public perception that terrorism is increasing. Definitions of terrorism vary, but most contain the central theme of the threatened or actual use of violence against civilians in order to achieve a political end. Prevention and preparedness Terrorist acts have traditionally revolved around firearms and improvised explosive devices (IEDs), although there is increasing concern around attempts by some groups to acquire weapons of mass destruction (WMD). Spree killing and lone shooter type events, where disturbed or disgruntled individuals attempt to kill large numbers of

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people, are also well documented. The principal protective strategy for such events remains prevention via: • • • •

Gun control legislation. Control of access to commercial explosives. Control of access to explosive precursors, such as ammonium nitrate fertiliser. Effective and timely use of intelligence by authorities to disrupt plots.

The balance between intrusive surveillance and intelligence gathering by state, and individual liberties is a matter in which each society must find its own way. In addition to targeted assassination attempts against identified individuals, some groups have launched increasingly sophisticated transnational attacks, utilising a high degree of coordination to launch simultaneous bomb and gun attacks at multiple sites in order to overstretch responding agencies and to degrade their command and control (Paris 2015 in France is such an example). The willingness of some attackers to lose their lives whilst causing as many casualties as possible adds to the difficulties of preparation and planning for this circumstance. These attacks have led to a change in strategy amongst law enforcement agencies from a policy of negotiation to a more active, early intervention approach. Response and recovery From a response agency point of view, such situations provide unique challenges: • • • • •

The situation on the ground is highly dynamic. The overall incident may consist of multiple scenes, all of which require health services. Responders may be considered to be high-value targets by perpetrators seeking to maximise shock value. The possible use of chemical and radiological substances adds to the complexities of identification and decontamination. Health infrastructure and personnel may be actively targeted.

Good command, control and coordination procedures are essential. Entry into a dangerous environment is restricted until the lead agency declares the scene safe. Endangering emergency service personnel reduces their ability to do their job: therefore, initial response should be restricted to those best prepared to secure the environment and make it safe.

Mass burns Mass burns events place unique challenges on clinicians and trauma systems and are a classic example of the requirement for a whole-of-system approach. A mass casualty burns event is often the result of fire in a high-density urban dwelling or explosion at a mass gathering, mining site or offshore oil rig. Approximately 10–15% of live casualties from terrorist-related events involving IEDs have severe burn injury. The nature of severe burns-related injuries dictates their management in specialist burns centres, especially if there is accompanying respiratory or ventilatory compromise.

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Following the 2002 Bali (Indonesia) bombing, 62 casualties were admitted to specialist burns centres across Australia. Following this one incident, all adult burns beds in Australia were being occupied. Source: Australian Government, 2011

The relatively low frequency of significant burn injuries in most western societies (about seven per day in Australia: Australian Government 2011) means any individual institution’s capacity to manage large numbers of burns patients is limited. Furthermore, specialist burns centres are generally centrally located tertiary hospitals in major metropolitan centres.

Prevention and preparedness Any detailed mass casualty plan should include specific details relating to the management of casualties with severe burns. The AUSBURNPLAN (Severe Burn Injury Annex to AUSTRAUMAPLAN) suggests that in a scenario with up to 2,000 live casualties, as many as 300 could have severe burn injury (Australian Government 2011). Therefore, any mass casualty medical assistance deployment plan should have the ability to include acute burns management expertise within its ranks if circumstances dictate. Given capacity limitations of individual burns centres, the matching of patient requirements to burns resources will often require patients to be distributed across regional, national or potentially international burns capabilities. This will have significant impact on retrieval resources for those patients requiring critical care and should be considered in any planning undertaken in preparation for a mass burns event. Response and recovery Management of these events must factor in circumstances of the burns injury and available resources. For example, explosion with concomitant blunt or penetrating trauma injuries, chemical burns with need for decontamination, or enclosed space increasing risk of carbon monoxide toxicity or hydrogen cyanide exposure. Whilst classical management of patients with potential airway burns dictates early definitive airway management with intubation and ventilation (Dzulhijjah 2013), this may not be feasible or desirable in a mass burns event with limited availability of transport ventilators and increased demand for ventilation gas (pressurised oxygen cylinders). In these circumstances, delaying or limiting initial fluid resuscitation will delay airway and facial swelling: however, the clinical trade-off is increased incidence of renal failure and/or gut ischaemia. Traditionally, burns fluid resuscitation teaching (modified Parkland Formula) requires a significant amount of fluid resuscitation, particularly in the first eight hours depending on the percentage of body surface area affected (Dzulhijjah 2013). Due to the number of patients, initially, these volumes of fluid will often be unavailable. Receiving centres will find themselves ‘playing catch-up’, depending on transport times required to shift patients from scene to receiving hospitals. Although full thickness burns are often described as painless, associated partial thickness burns will require high doses of analgesia. Any patients who are intubated

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and ventilated will also require high doses of analgesia, as invariably, they have a normal underlying conscious state. Analgesic and fluid requirements should be factored into resource requirements for responding assistance teams. For patients with ventilatory compromise resulting from full thickness chest burns, or compromised limb perfusion due to circumferential burns, medical response teams will need to have the equipment and clinical expertise to undertake escharotomies, particularly if transport time will be prolonged. As age and the percentage of body surface area burn increase, so does mortality, both short and long term. Whilst the expectant category is not used in civilian triage, it is worth considering how patients with severe burns (both nature and extent) will be managed when resources are limited and the number of casualties overwhelming.

Chemical, biological and radiological disasters In many jurisdictions, the term HAZMAT (hazardous material response) refers to incidents involving natural and accidental exposure to potentially harmful substances, whilst the term CBR (chemical, biological, radiological) implies deliberate release of an agent. Deliberate release of agents could be used as a means of achieving political goals. The commonly accepted way to describe this in Australia within both state and federal plans is to classify the event into one of five groups. These are: 1 Chemical. 2 Biological. 3 Radiological. 4 Incendiary. 5 Explosive. The use of CBR agents in warfare is far from a modern development. Table 21.2 provides examples. Community recovery from a CBR event is likely to be prolonged. Public health units are critical to the process, both in assuring human health and in assessing ongoing environmental hazards. Psychosocial morbidity is also likely to be high; therefore mental health clinicians should play an early and central role in the process.

Table 21.2 Examples of CBR (chemical, biological, radiological) agents in warfare. 150 bc 1915 1995 2001 2015

Pausanias describes the use of plant roots to successfully poison the water supply of the besieged city of Kirrha in 590 bc. German army uses chlorine gas released from industrial cylinders against British and Canadian troops at Ypres in Belgium. Aum Shinrikyo releases Sarin gas into the Tokyo subway system, killing 12 and injuring 3,800 people. Anthrax spores sent through the US mail cause 22 infections and 5 deaths. OPCW (Organisation for the Prohibition of Chemical Weapons) confirms the use of mustard agent in the Syrian conflict.

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Chemical weapons The Organisation for the Prohibition of Chemical Weapons (OPCW) classifies chemical weapons as nerve, choking, blister and blood agents. Nerve agents, such as sarin, impair onward transmission of electrical impulses in nerve fibres. They may be absorbed through multiple routes and belong to the same group of compounds as organophosphate insecticides. In high concentrations, they cause rapid onset of convulsions, respiratory muscle paralysis, and death. A characteristic feature of nerve agent poisoning is a dramatic increase in physiological secretions and constriction of the pupils (miosis). Treatment consists of supportive care, together with administration of adequate quantities of atropine, oximes and anticonvulsants. Choking agents, such as chlorine and phosgene, typically function by causing damage to the eyes and respiratory tract, leading to pulmonary oedema and consequent impaired lung function and gas exchange. Extensively used in World War I, treatment consists of supportive care, since no specific antidotes exist. Blister agents, such as sulphur mustard and lewisite, cause cellular damage by altering the chemical composition of cellular DNA, thereby interrupting cellular division. Both dermal and inhalational routes readily absorb the agents and symptoms initially manifest with formation of large dermal blisters, often resembling severe burns. Ocular exposure frequently renders the victim either temporarily or permanently blind with longer term effects including cancer. Treatment consists of supportive care only. Blood agents, such as hydrogen cyanide, function by interfering with the body’s ability to utilise and transfer oxygen. Exposure to these agents, therefore, rapidly results in similar symptoms to suffocation. Various antidotes exist, all functioning by attempting to restore the ability of the red blood cell to utilise and transport oxygen to the tissues. Successful antidotes include intravenous vitamin B12, thiosulphate and cobalt compounds. Prevention and preparedness International attempts to prevent weapons of mass destruction (WMD) proliferation have resulted in work to define, track and reduce international transfer of both chemical weapon precursors and potential dual use chemicals. Limited precedents are available to assess the impact of a deliberate chemical release on a civilian population. The 1995 Sarin attacks in Tokyo, Japan, killed 12 people; however, over 5,000 people presented to hospitals with few, if any, symptoms. This demonstrates the profound psychological impact WMD’s are likely to have on an unprepared population. The following are important considerations in any prior planning for a chemical weapon event: •

Decontamination: Few health facilities are capable of true mass decontamination. This process in Australia is the remit of the Fire and Emergency Service. High utilisation of such assets may be anticipated at the incident scene, leaving few, if any, resources available to assist healthcare facilities where significant numbers of people may also self-evacuate and present spontaneously. This poses significant challenges to local healthcare facilities.

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• •

•

Personal protective equipment (PPE): Large quantities of PPE are rapidly required, as well as personnel who are trained and familiar with its use. Skills maintenance in the use of PPE poses significant challenges. Agent identification: Identification of any CBR agent in sufficient time for it to impact on patient care is challenging. Clinicians may find themselves dealing with large numbers of casualties poisoned with an unknown substance. In the early stages, patients may need to be empirically treated based on their clinical toxidrome. Antidotes: Retention of sufficient specific antidotes for agents such as sarin and cyanide poses significant challenges. Drug doses may far surpass the dosages utilised in routine clinical practice. This, combined with a large number of patients, may overstretch the ‘just-in-time’ supply chain utilised by most jurisdictions. Many antidotes are expensive and have a finite shelf-life, meaning stockpiling agents for low-frequency, high-impact events may not be economically viable. If antidotes are stockpiled, then it is essential that sufficient quantity is available in sufficient time for them to make a difference to the health response. Stockpile location, access and distribution procedures should be streamlined and well established.

Response and recovery CBR incidents are frequently delineated using a hot/warm/cold zone model: • •

Hot zone: The scene of the incident where both victims and the environment may be contaminated with agent. Warm zone: Area to where victims or items from the scene are moved, leaving potentially contaminated people in an uncontaminated environment.

Case study 21.2: Gas use in Dubrovka Theatre, 23 October 2002 On 23 October 2002, at the Dubrovka Theatre in Moscow, 40 Chechen militants took 912 people hostage. The siege ended three days later when Russian security services immobilised the militants and hostages after pumping an unnamed gas into the theatre. Of the hostages, 130 died, purportedly because of the effects of the gas. Following the tragedy, allegations that hostage safety was sacrificed so the government could maintain complete secrecy abound. Public health services were not informed of the siege, or the use of the gas; ambulances could not access the scene until one-and-a-half hours after the start of the operation; and doctors treated patients without knowing what agent was involved because authorities did not acknowledge the use of a gas for a further eight hours. It is now thought the agent was fentanyl, an opioid 80 times more potent than morphine. The real tragedy of this siege is that the drug naloxone could have been used to reverse the effects of opioid overdose and so, potentially, many victims would not have perished had doctors known this much earlier.

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•

Cold zone: Area to where victims are moved after decontamination, leaving decontaminated people in an uncontaminated environment. Realistically, this is the only zone where definitive patient care can occur.

Scene management principles for a CBR incident include: • • •

Placing appropriate cordons at the scene controlling both access and egress to prevent further contamination of persons, equipment and the environment. Removing contaminated victims from the hot zone to a warm zone where decontamination may safely be carried out. Decontamination involving clothing removal and deluging the subject with large quantities of running water:



– walking-wounded patients may self-decontaminate; – nonwalking-wounded patients require assistance from emergency services staff in PPE.

•

On completion of decontamination, patients cross a ‘clean–dirty’ line separating the warm zone from the cold zone:



– everyone and everything crossing from the dirty to the clean side of this line must be decontaminated.

•

Once decontaminated, patients are transported to hospital via the usual mechanism.

Biological weapons Biological agents may consist of bacteria, viruses, fungi or toxins. Table 21.3 outlines the biological weapons listed by the World Health Organization as being of particular concern. Table 21.3 Biological weapons of concern, as identified by the World Health Organization (2002). Toxins

Bacteria and Rickettsiae

Viruses Fungi

Ricin Saxitoxin (paralytic shellfish poisoning) Clostridium botulinum toxin (botulism) Staphylococcal enterotoxin (food poisoning) Aflatoxin Bacillus anthracis (anthrax) Francisella tularensis (tularaemia) Brucella suis (brucellosis) Burkholderia mallei (glanders) Burkholderia pseudomallei (melioidosis) Yersinia pestis (plague) Rickettsia prowazeki (epidemic typhus) Coxiella burnetii (Q fever) Venezuelan equine encephalitis virus Variola major (smallpox) Coccidioides (valley fever)

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Prevention and preparedness Use of toxins and infectious diseases as biological weapons may present in two discrete ways, depending on whether the initial release is overt or covert: 1 Overt release tends to take the form of a traditional ‘white powder’ type incident. 2 Covert release may not initially be identified until patients become symptomatic. Response and recovery Overt release is managed in a similar fashion to a chemical incident. Initial recognition of a covert release, however, may only occur when frontline clinicians identify a pattern of presentations. Recognition may even occur by veterinarians or pathologists. The presence of an asymptomatic incubation period for many diseases, coupled with onward person-to-person transmission in some agents, further complicates assessment. Public health and communicable disease clinicians are central to the response, since rapid identification of the agent, the at-risk population, the route of onward transmission, as well as any residual environmental hazard is essential to the response. Mitigation strategies are likely to be similar to those used in a pandemic. Radiological weapons Deliberate use of radiological sources as weapons is also of concern. This could be covert placement of a radioactive source in a public place, or creation of a radiological IED, the so called ‘dirty-bomb’, in which conventional explosive is used to fragment and widely distribute a radiation source, thus externally contaminating people and the environment. Prevention and preparedness Covert placement of a source is likely to result in patients presenting with a specific constellation of symptoms, and may pose problems similar to a covert biological release. Response and recovery Rapid access to specialised advice is essential with public health units again being at the forefront of the response. Initiation of a radiological IED is likely to have an impact far greater than its actual health effects. Immediate access to specialised advice is essential, but the following general principles are likely to apply: • • •

Cordoning, containment and external decontamination processes similar to a chemical event should be instituted. Specialist advice from Fire and Rescue services and the Bureau of Meteorology will assist in plume modelling and assessing evacuation requirements. Medical management of casualties takes precedence over radiological concerns. Externally contaminated casualties pose minimal risk to carers.

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• • •

Rarely, special arrangements may be required to deal with a penetrating wound from a high-activity foreign body. This requires a joint approach between clinicians and radiation safety advisors. Radiation tends to potentiate the adverse effects of trauma. Reassurance and management of the worried well.

Key readings Department of Health. Australian Clinical Guidelines for Radiological Emergencies. Canberra: Commonwealth of Australia; 2012. Heponstall J, Gent N. CBRN Incidents: Clinical management & health protection. London: Health Protection Agency; 2008. World Health Organization, Risks Including Drug Resistance Team. Preparedness for the Deliberate Use of Biological Agents: A rational approach to the unthinkable. Geneva: WHO; 2002. World Health Organization. Communicable Disease Alert and Response for Mass Gatherings: Key considerations. Geneva: WHO; 2008. World Health Organization. Initial Clinical Management of Patients Exposed to Chemical Weapons. Geneva: WHO; 2014.

Activities • •

How would the presence of physical danger from terrorist threat alter the health response to a scene? How would you ensure your health service is prepared to receive patients from a chemical spill?

References Arbon P. ‘Planning medical coverage for mass gatherings in Australia: What we currently know’ Journal of Emergency Nursing. 2005; 31: 346–350. Australian Government, Department of Health. AUSTRAUMAPLAN: Final November 2011. Canberra: Commonwealth of Australia; 2011. Barbieri S, Pirovano C, Scarlato G et al. ‘Long-term effects of 2,3,7,8 tetrachlorodibenzo-pdioxin on the peripheral nervous system: Clinical and neurophysiological controlled study on subjects with chloracne from the Seveso area’ Neuroepidemiology. 1988; 7(1): 29–37. Bertazzi AP, Consonni D, Bachetti S et al. ‘Health effects of dioxin exposure: A 20-year mortality study’ American Journal of Epidemiology. 2001; 153(11): 1031–1044. Bisanti L, Bonetti F, Caramaschi F et al. ‘Experience from the accident Seveso’ Acta Morphol Acad Sci Hung. 1980; 28(1–2): 139–157. Broughton E. ‘The Bhopal disaster and its aftermath: A review’ Environmental Health: A Global Access Science Source. 2005; 4(1):1–6. Consonni D, Peastoril A, Zocchetti C et al. ‘Mortality in a population exposed to dioxin after the Seveso, Italy, accident in 1976: 25 years of follow-up’ American Journal of Epidemiology. 2008; 167(7): 847–858. Department of Transport. The Merchant Shipping Act 1894 mv Herald of Free Enterprise: Report of Court No. 8074: Formal Investigation. London: HMSO; 1988. Duffe P, Marec M. Task Force for Technical Investigation of the 24th March 1999 Fire in the Mont Blanc Vehicular Tunnel. Report of June 1999. www.miliarium.com/Monografias/ Tuneles/Mont_Blanc.htm (accessed 18 May 2016).

Manmade disasters  281 Dzulhijjah ZA. Emergency Management of Severe Burns: Course manual. 17th ed. Albany Creek: Australia and New Zealand Burn Association Ltd 1996; 2013. Filippini G, Bordo P, Crenna P et al. ‘Relationship between clinical and electrophysiological findings and indicators of heavy exposure to 2,3,7,8-tetrachlorodibenzo-p-dioxin’ Scandinavian Journal of Work Environment & Health. 1981; (7): 257–262. Fraser-Mitchell J, Charters D. ‘Human behaviour in tunnel fire incidents’ Fire Safety Science. 2005; 8: 543–554. Ideo G, Bellati G, Bellobuono A et al. ‘Urinary D-glucaric acid excretion in the Seveso area, polluted by tetrachlorodibenzo-pdioxin (TCDD): Five years of experience’ Environmental Health Perspectives. 1985; 60: 15–57. Kollek D. An Introduction to Mass Gatherings. Canada: Centre for Excellence in Emergency Preparedness; 2014. Locoh-Donou S, Guofen Y, Welcher M et al. ‘Mass gathering medicine: A descriptive analysis of a range of mass gathering event types’ American Journal of Emergency Medicine. 2013; 31: 843–846. Mastroiacovo PP, Spagnolo A, Marni E et al. ‘Birth defects in the Seveso area after TCDD contamination’ JAMA. 1988; 259(11): 1668–72. McKenna T, Buglova E, Kutkov V. ‘Lessons learned from Chernobyl and other emergencies: Establishing international requirements and guidance’ Health Physics. 2007; 93(5): 527–537. Mocarelli P, Marocchi A, Brambilla P et al. ‘Clinical laboratory manifestations of exposure to dioxin in children. A six year study of the effects of an environmental disaster near Seveso, Italy’ JAMA. 1986; 256 (19): 2687–2695. Pesatori AC, Consonni D, Bachetti S et al. ‘Short- and long-term morbidity and mortality in the population exposed to dioxin after the “Seveso Accident”’ Industrial Health. 2003; 41(3): 127–138. Rehder H, Sanchioni L, Cefis F et al. ‘Pathological and embryological studies on abortion cases related to the Seveso accident’ (In German) Schweiz Med Wochenschr. 1978; 108(42): 1617–1625. Tenchini ML, Crimaudo C, Pacchetti G et al. ‘A comparative cytogenetic study on cases of induced abortions in TCDD exposed and nonexposed women’ Environmental Mutagenesis. 1983; 5(1): 73–85. World Health Organization (WHO). Preparedness for the Deliberate Use of Biological Agents. A rational approach to the unthinkable. Geneva: WHO; 2002. www.who.int/csr/resources/ publications/deliberate/WHO_CDS_CSR_EPH_2002_16_EN/en/ (accessed 18 May 2016).

Chapter 22

Complex events Penny Burns, Brett Sutton and Peter A. Leggat

Introduction and objectives Arguably, all disasters are complex events, as they constitute a complex interaction between the society and the hazard that creates a risk to that society. Some events, however, are worthy of special consideration due to their multifaceted or interdependent elements. These events are presented here to highlight and explore their complexity in more detail. The aim of this chapter is to address those events in which there is a complex interplay of causative factors and impacts. On completion of this chapter you should be able to: • • •

Describe the particular characteristics of pandemics, and complex humanitarian emergencies. Demonstrate an extensive understanding of the complex interaction of risks that characterise major events. Identify the particular management strategies required to ensure these events are effectively managed throughout the PPRR cycle.

Complex humanitarian emergencies (CHE) CHE describe situations where there is a complex interaction of displaced communities with unstable security, lack of food, and failed infrastructure, in particular the collapse of basic health services. Large numbers of people are affected by civil conflict, displacement, disease and hunger. The most effective strategies to reduce mortality and morbidity are those aimed at the provision of adequate and appropriate food, clean water, sanitation, primary healthcare, infectious disease control, and protecting affected populations from violence and human rights violations. Klugam (1999) maintains CHE are human-induced. Natural disasters are excluded unless they trigger a CHE; for example, conflict already exists. They are multidimensional, involving war or widespread conflict as well as hunger, disease, forced displacement and the loss of normal infrastructure and services, particularly basic health services. They are essentially political and politicised. Military and other actors may seek to divert food and other resources to further military and political aims, including the coercion of communities, aid agencies or the United Nations.

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The key challenge is how to provide humanitarian assistance in an environment of genuine danger. The Sphere Project is a voluntary initiative bringing together a wide range of humanitarian agencies around a common aim – to improve the quality of humanitarian assistance and the accountability of humanitarian actors to their constituents, donors and affected populations (The Sphere Project 2011). Sphere describes its vision thus: Sphere envisions a world in which all people affected by disaster or conflict are able to re-establish their lives and recover their livelihoods in ways that respect and promote their dignity. (The Sphere Project 2011: p. 4) The Sphere handbook: Humanitarian Charter and Minimum Standards in Humanitarian Response (The Sphere Project 2011) is among the most internationally recognised and endorsed minimum standards for humanitarian settings. The Humanitarian Charter, regarded as the cornerstone of the Sphere handbook, provides the ethical and legal foundations for humanitarian action. It details the shared conviction of humanitarian agencies that all people affected by disaster or conflicts have a right to receive protection and assistance to ensure the basic conditions for life with dignity. The role of humanitarian agencies is affirmed, and common principles, rights and duties are elucidated. Finally, it expresses a commitment to these principles and to the core and minimum standards as detailed in the handbook. Sphere’s core standards cover six main thematic areas, each with key actions, indicators and guidance notes. These six areas are: 1 People-centred humanitarian response. 2 Coordination and collaboration. 3 Assessment. 4 Design and response. 5 Performance, transparency and learning. 6 Aid worker performance. In addition to the core standards, the handbook’s chapter on protection principles outlines how humanitarian agencies can help protect those faced with the threat of violence or coercion. Finally, the minimum standards provide sector-specific standards in: • • • •

Water supply, sanitation and hygiene promotion. Food security and nutrition. Shelter, settlement and non-food items. Health action.

To understand CHE, it is important to be intimately familiar with the Sphere handbook and standards. Additionally,

Websites to assist in developing a broader understanding of CHE: •  The Sphere Project  www.sphereproject.org •  OCHA  www.unocha.org •  Reliefweb  www.reliefweb.int

284  P. Burns, B. Sutton & P.A. Leggat

maintaining familiarity with news and information on humanitarian issues and disasters will also assist in understanding CHE.

Epidemics and pandemics Ingenuity, knowledge, and organization alter but cannot cancel humanity’s vulnerability to invasion by parasitic forms of life. Infectious disease which antedated the emergence of humankind will last as long as humanity itself, and will surely remain, as it has been hitherto, one of the fundamental parameters and determinants of human history. (McNeill 1976: p. 291) Micro-organisms including worms and insects, protozoa, viruses, bacteria, fungi and prions cause infectious diseases (Guerrant et al. 2011). Transmission can be from animals to humans, and from human to human, and cause an outbreak of disease in the community. This is known as an ‘epidemic’, defined as an excess of cases in the community above that normally expected and may be due to the emergence of a new infectious disease. When they occur globally across multiple international boundaries, they are called ‘pandemics’ (Last 2001). The term ‘pandemic’ comes from the Greek; pan meaning ‘all’ and demos meaning ‘people’. These terms are meant to distinguish outbreaks of disease from endemic disease occurring at constant or relatively stable levels within any community. Morbidity and mortality from infectious disease in developed countries has declined. Vaccination currently prevents many illnesses, and antibiotics can control certain acquired infections in individual patients. However, the threat of a new emerging infectious disease or a change in an existing organism is a very real possibility, having the capacity to result in major outbreaks. Resurgence of infectious disease presents an ever-present challenge to community health. Perhaps the most cited pandemic, known as the Spanish Flu, occurred in 1918, at the end of World War I. This highly virulent and highly transmissible form of influenza emerged first in military camps in Europe, but the disease subsequently spread to every continent and all countries. Health standards and the capacity to treat people have changed considerably since 1918. Simultaneously, globally, societies are more integrated and interdependent. This is characterised by rapid transport, global trade and instantaneous communications. The net effect of these differences makes it difficult to predict the full potential impact of a modern pandemic. The phases of a pandemic The World Health Organization (WHO) describes pandemics in six phases with Phases 1–3 correlating with preparedness and Phases 4–6 signalling the need for response and mitigation (WHO 2009): • •

Phase 1: disease present in animals but no evidence of spread to humans. Phase 2: evidence of a circulating animal disease known to have caused disease in humans, but no current evidence of human disease.

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• • • •

Phase 3: small number of human cases but no person-to-person spread except in rare circumstances of very close contact. There is no sustained community outbreak. Phase 4: evidence of person-to-person spread in very small clusters involving common exposure or intimate contact. There are sustained community outbreaks. Phase 5: large clusters of cases arising from person-to-person contact, with sustained community outbreaks in two or more countries in one WHO region. Phase 6: increased and sustained person-to-person spread with widespread distribution of the disease across at least two WHO regions.

The rate of spread depends on the transmissibility of the organism; the impact depends on the case severity of the disease. The WHO reviewed its approach to pandemics following the experience learned from the 2009 H1N1 (Swine flu) pandemic. As seen in Figure 22.1, it now links the phases to the all-hazards principles of emergency risk management across the PPRR disaster framework (WHO 2013). Different diseases may be present in different phases at any particular time. To summarise the phases: • • •

Interpandemic phase: period when there is no active epidemic of influenza in humans. Pandemic alert phase: period where there is evidence of influenza due to a new influenza strain in humans, but there is no major outbreak of the disease in humans. Pandemic phase: period when there is evidence of sustained person-to-person spread across WHO regions.

This continuum of pandemic is based on virological, epidemiological and clinical information, and emphasises risk assessment. Response to a pandemic is global; however, at any one time, different countries, and different regions within countries, are likely to be in different phases. Although designed specifically for the WHO, the pandemic influenza risk management description may be applied generically to any epidemic or pandemic.

Pandemic Dhase A lert phase

Transition phase

Interpandemic phase

Interpandemic phase RISK A S S E S S M E N T

Preparedness

Response

Recovery

Preparedness

This continuum is according to a ‘global average’ of cases, over time, based on continued risk assessment and consistent with the broader emergency risk management continuum.

Figure 22.1 World Health Organization pandemic phases (based on WHO 2013).

286  P. Burns, B. Sutton & P.A. Leggat Table 22.1 National pandemic preparedness planning in Australia. Stage

Activities

Preparedness Response: Standby

Plan, practise and ensure resources are available. Ongoing surveillance. Monitor the emergence of the disease locally with readiness to respond immediately. Response stage when not much is known about the disease and information is still being gathered. Response stage when enough is known about the disease to respond more specifically. Move back to business as usual and revise plans for future pandemics.

Response: Action – Initial Response: Action – Targeted Response: Stand down

Source: Department of Health and Ageing (2014).

Variability of response stages between nations While governments may be guided by the WHO pandemic advice, they encourage countries to have their own locally relevant response. The Australian stages of pandemic response are closely aligned with the PPRR cycle of disaster management, as shown in Table 22.1. Disease factors in epidemics The WHO technical set of requirements in a virus for pandemic potential include the ability to: • • •

Infect humans. Cause disease in humans. Spread readily between humans.

Phenomenon unique to the 1918–1919 influenza pandemic: •  Death rates amongst those aged 15–34 years was >20 times higher than in previous years. •  Nearly half of all influenza deaths were young adults aged 20–40 years. •  The absolute risk of influenza death was higher in 99% of all excess influenzarelated deaths in 1918–1919). Sources: Grove and Hetzel, 1968; Taubenberger and Morens, 2006

The word virus derives from Latin meaning ‘poison’ (Barnhart 2002). Human influenza causes annual winter epidemics and is considered the most significant global pandemic threat. The variability of the influenza virus results in ineffective natural or acquired immunity. The virus continues to mutate, meaning immunity to previous strains does not prevent infection from new variations of the virus. Influenza is a highly infectious disease with the potential to cause significant morbidity and mortality usually amongst the very young, elderly or immunosuppressed people, with a comparatively low rate of death for the middle age group (Taubenberger and Morens 2006).

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High

H IN I ‘Spanish flu’ 1918-19 *H 5 N I ‘A vian flu’ 1997-ongoing

Moderate

lead

‘A sia n flu’

1957:

lead

H3N2 H o n g K o n g flu’ 1968-69

‘Sw ine flu’

CTmraTiM

Low Low

Moderate

High

Transm issibility *H 5 N I 1997-ongoing is not a true pandemic but has been included for demonstration purposes.

Figure 22.2 Clinical severity and transmissibility of influenza pandemics (based on Department of Health and Ageing 2014).

However, the characteristics of those most vulnerable can vary between strains. Two important characteristics define the effect of each influenza strain on the community. They are the severity of the disease, including how many people get sick or die from the disease, and the transmissibility of the disease, meaning how quickly it spreads. Figure 22.2 shows the difference in severity and transmissibility of previous pandemics, clearly demonstrating the deadly combination of high levels of both characteristics present in the Spanish Flu strain of H1N1. The continuing evolution of new human influenza strains with a mixture of elements of animal influenza virus can also have a profound effect on the impact of influenza pandemics. For example, Swine flu is a respiratory disease of pigs caused by H1N1 viral influenza. Initially only causing isolated outbreaks, in 2009/10 it caused a major pandemic. At the time of writing, H1N1 has become one of the seasonal winter influenzas. H1N1 influenza infections have no clearly distinguishable features from other human influenza. The majority of cases are likely to have been overlooked. The most publicised outbreak occurred in 1976 in New Jersey, USA, when up to 230 soldiers were infected. The 2009 Swine flu outbreak began in Mexico with a local increase in flu-like illness. Its highly transmissible qualities resulted in rapid spread around the world. Figure 22.2 shows H1N1 has a moderately high transmissibility but low clinical severity, meaning it was a mild pandemic. H1N1 spread rapidly and globally without high mortality figures. The official WHO laboratory confirmed cases were less than 18,500 deaths, but later international studies suggest that it was at least ten times this amount (Simonsen et al. 2013a). This does not include the known effect of influenza on mortality from other pre-existing chronic conditions such as heart or lung disease. New demands are emerging with many existing infectious diseases. The emergence of resistant organisms is challenging capacity to prevent or treat infection at the individual or community level. Multiple drug-resistant tuberculosis, now common in

288  P. Burns, B. Sutton & P.A. Leggat

Papua New Guinea and the Torres Strait Islands, is continuing to spread. Vancomycin and Methacillin resistant Staphylococcus aureus is a significant concern to hospitals globally as it exposes people to infection with an agent that is largely untreatable. Resistant Staphylococcus strains are a particular concern in health facilities due to the presence of immuno-compromised vulnerable people. Emerging infectious diseases are those where the incidence in humans has recently increased. They may be due to a new agent, an existing disease that has gone undetected, or an environmental change that allows an ‘epidemiological bridge’ (Lederberg 1993). New human illness-causing organisms such as HIV, Ebola virus, Middle East Respiratory Syndrome Coronavirus (MERS-CoV), H5N1 and H7N9 influenza, and Hendra and Nipah viruses are all now recognised. These novel viruses are emerging as a significant threat to population health because of close human habitation and contact with animals, population mobility, and variable effectiveness of treatment or prevention. Speed and scale of global transportation is facilitating the rapid spread of some diseases. Avian flu (H5N1) is an example of an animal disease with the capacity to cause human disease. The current H5N1 virus has been shown to be highly lethal to chickens, but causes low pathogenic or non-pathogenic disease in other migratory birds. This helped the disease spread around the world. Humans in close contact with infected birds can be infected. There is the capacity for human-to-human spread, but only from very close contact with infected people. The principal risk of this disease is that it could modify or mutate into an easily transmissible human disease and cause a widespread pandemic. SARS is caused by an animal (coronavirus) virus which leads to highly contagious and highly fatal disease. Originating in Guangdong province, China, SARS probably circulated among wild mammals in contact with humans in marketplaces. SARS came to international attention when a doctor from Guangdong province who had treated several cases visited Hong Kong before becoming unwell. He presented to a local emergency department for treatment. SARS spread to five continents and caused over 800 deaths with the majority of cases traced back to this doctor. The outbreak had a huge economic and social impact before public health measures eventually contained the disease. The experience with SARS has enhanced international understanding of the risks of epidemics and has considerably enhanced planning and preparedness (Wong and Yuen 2005). Nevertheless, the emergence and continued presence of a similarly deadly coronavirus, MERS-CoV, highlights the ongoing challenge of such zoonoses. The impact of new pandemics New and emerging pandemics will have not only a significant effect on the health of communities, but also significant economic, social and environmental effects. The outbreak of SARS was estimated by the Asian Development Bank to have cost between US$10 billion and US$30 billion (Robertson 2003). Many tourist and transport ventures failed due to the sudden reduction in travel and this has long-term consequences on those who owned, or worked for, those organisations. Widespread pandemics have significant social impact. Authorities may restrict travel, and people may restrict their own movement and be reluctant to move from the safety

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of their own homes. During the 2009 H1N1 pandemic about half of people CDC estimated the healthcare costs indicated some level of concern regarding of a significant pandemic in the US travel. About one-third indicated that would be between $71.3 billion & they would cancel their travel if they had $166.5 billion. Additional costs in a cough or fever that lasted more than terms of economic consequences, one day (Leggat et al. 2010). People tend failed ventures, lost productivity, to avoid public locations including & support for the bereaved are workplaces, leading to further economic unmeasurable. impact on individuals and the community. Source: Meltzer et al., 1999 Competition for scarce resources may exist. Loss of family and friends may have a long-term personal impact on communities and on future productive capacity. Interestingly, 95% of people reported that they would comply with physicians’ advice to stay at home for seven days if they were diagnosed with pandemic H1N1 2009 or H5N1, compared with 71% compliance in the setting of seasonal influenza (Brown et al. 2010). The characteristics of the SARS outbreak made those affected particularly at risk of adverse psychosocial effects. The SARS outbreak in Hong Kong originated in some residential housing blocks in Amoy Gardens. Residents in those buildings reported distress from the stigma and marginalisation during the outbreak (Lee et al. 2005). Psychosocial impacts are of particular significance to health services. In epidemics and pandemics, the infectious agent poses a real risk to health professionals who may be reluctant to expose themselves and their families to the risks associated with caring for epidemic victims. During the SARS outbreak in Hong Kong, nearly a quarter of cases were healthcare workers, and in Canada, 65% of the 141 probable cases were healthcare workers (Emanuel 2003). During an epidemic, the risk of working with a number of highly infective patients in hospitals and other health facilities is likely to increase the risk of exposure to infection and reduce the willingness of staff to work. Epidemics, particularly those derived from animal illnesses, may result in significant changes to the environment. The presence of certain animal species may be at risk either from the virus, or from attempts to control spread by extermination of the animal sources or carriers. There was much controversy over Egypt’s decision in 2009 to undertake a mass culling of pigs to prevent Swine flu. The extent and nature of the impact of any epidemic will depend on the characteristics of the agent, the characteristics of the community, and the effectiveness of control strategies. The interplay of these factors will directly affect the speed of the onset of the epidemic, the number of people infected, and the number who suffer significant adverse health outcomes, including death. Factors affecting the spread of an epidemic include: •

The nature of the organism which determines the nature of the disease, its pathological impact (severity), and its capacity to efficiently spread. Upper respiratory infections are highly contagious as they are often associated with symptoms such as sneezing or coughing, which are efficient dispersers of virusladen water droplets. Conversely, diseases associated with blood-borne infections

290  P. Burns, B. Sutton & P.A. Leggat

• •

(e.g. HIV) are inefficient spreaders of the disease as they rely on exchange of bodily fluids. The characteristics of the population, such as level of immunity, and the community environment, such as population density. The extent and effectiveness of routine infection control procedures and public health preparedness within the community. Dr Joanne Liu, International President of Médecins Sans Frontières, said of the spread of Ebola in 2013: We don’t have all of the information yet, but one reason is that past epidemics occurred in rural, isolated areas, where people were not very mobile. The chain of transmission would stop after a few hundred people were infected and the disease would essentially die out on itself. (Francoeur 2014)   The epicentre for the 2013 Ebola outbreak was in Guéckédou, Guinea, close to the borders of both Sierra Leone and Liberia. People who live in this area are quite mobile and cross the borders regularly, so the disease was able to move very quickly into other urban areas such as Monrovia, the capital of Liberia (Francoeur 2014).

•

The effectiveness of public health and community intervention strategies. Early recognition of the disease, dependent on effective surveillance, will enable a rapid response whereby limiting the disease impact. The extent of containment, and the presence of effective treatment or prevention measures such as vaccines, isolation and quarantine, will also determine the extent and impact of the epidemic. Note that vaccination for the pandemic influenza virus will not be available early in the pandemic. At the very least, vaccines will require several months to develop and produce.

The average number of people who an infected patient may infect is defined as the ‘R factor’ of the epidemic. If the R factor exceeds one, then the epidemic will continue to expand. If the R factor is less than one, then the epidemic will decline. The pathogenicity of the agent paradoxically may limit its ability to spread rapidly. A disease which kills rapidly may be more likely to limit the mobility of infected people, and their ability to make contact with vulnerable individuals or populations. Equally, the fear of Ebola and the limited treatment options in hospitals led to many more exposed individuals as patients avoided or fled hospitals, seeking care from traditional or religious healers. Managing epidemics or pandemics The key objective in managing an epidemic is to minimise transmission, morbidity and mortality. There is a community and professional expectation that health services will do everything possible to minimise the likely emergence and impact of any current or potential epidemic. The key challenge for these services is to ensure an organised and comprehensive approach to prevention and management with clear consistent communication of information and coordination of services and resources.

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Pandemics not only have a health impact, they also have a whole of society impact. A major pandemic will be a disaster and managed in accordance with both national and international disaster response arrangements. Health services will play a lead role, particularly in the provision of advice on system strategy and in the management of the patients. A major outbreak will have a massive impact outside of the health environment and, therefore, national and jurisdictional disaster management arrangements will be involved in the preparation and management of the response. The experience of SARS and novel influenza types has generated growing international concern regarding the risk of pandemics. The more recent threats posed by Ebola and MERS-CoV has, in some respects, been an even greater source of concern. Developed by the WHO, a suite of international standards complement the latest update of the International Health Regulations (IHR) (WHO 2005a). These legally binding agreements by member states agree to work cooperatively on the management of new outbreaks at the source, not just at national borders. The WHO has also developed a strategic response plan for the West African Ebola epidemic and, given the criticisms of the global response to Ebola, is reappraising a model for rapid responses to significant infectious diseases of pandemic potential (WHO 2015). Most countries have developed pandemic preparedness plans, which are regularly updated and practised. Epidemics do not respect international borders. Therefore, international cooperation is essential in managing the consequences and limiting the impact. International cooperation is directed towards protecting the interests of reporting countries so they may have the confidence to report new epidemics. Poorer countries are most susceptible to disease outbreaks; but they have fewer resources and less capacity to sustain the economic and social impact. Management strategies Defining an epidemic as a pandemic relates to the spread of the disease rather than the severity or impact on the community. One of the lessons identified from the 2009 influenza pandemic, which had a lower fatality rate than usual seasonal influenza, was that not all pandemics are the same. The response needs to be tailored to the characteristics of the particular causative organism. Protection of the community against potential epidemics relies on both individual and population strategies. At the individual level, strategies aim to prevent infection and to break the chain of transmission. This is achieved by ensuring maximum personal protection through immunisation, use of physical protective devices such as mosquito nets or condoms, the use of prophylactic drugs (e.g. anti-malarial), by applying universal personal infection control and personal hygiene measures, and with appropriate management of individual infection. At the population level, strategies aimed at reducing the spread of disease include monitoring, surveillance, and early recognition and intervention. Monitoring the presence of risk factors including vectors and the incidence of infections through reporting of disease will support early recognition and intervention. Maintenance of laboratory capacity will ensure accuracy of diagnosis to aid both recognition and management. Rapid case investigation and response will minimise the potential spread of individual cases. All countries have a responsibility under the IHR to maintain a

292  P. Burns, B. Sutton & P.A. Leggat

system of disease surveillance, monitoring, and reporting to international authorities regarding the outbreak of infectious diseases (WHO 2005b). Systems of surveillance are active during interpandemic phases as part of normal operations in many countries. Frontline community health providers including general practitioners (GPs) (or family physicians), pharmacists and emergency departments carry out surveillance. These groups manage much of the usual seasonal influenza as normal operations. Early identification and containment of new infectious organisms is crucial in reducing spread of infectious agents, understanding the characteristics of the disease, and developing vaccinations. Strategies for managing the surge in numbers during usual winter flu season can be increased for pandemics. Functional surge management often involves reduction in unnecessary services, such as postponement of non-urgent surgery or patient consultations. Consideration of creative management options is also part of preparedness planning in most countries. During a pandemic both GPs and emergency departments must manage their usual daily caseload in addition to influenza-like illness (ILI). Victoria, Australia, was one of the first southern hemisphere jurisdictions to experience the 2009 influenza pandemic. One strategy used to expand the workforce was community-based influenza clinics. Established to decrease the load on other health services, they operated for about six weeks (Lum et al. 2009). Such cohorting of patients can decrease the amount of personal protective equipment (PPE) required and reduce the likelihood of depleting supplies before the pandemic has finished. Some countries have the capacity to stockpile stores including antiviral agents, PPE, vaccines and equipment required during an epidemic. They include physical stockpiles, such as those stored in warehouses, or imbedded stockpiles that at any time are in the manufacture, distribution, supply and storage pathways. In the event of an outbreak, it may be important to identify the latter and secure this stockpile for priority usage.

Case study 22.1: Norway strategy for 2009 influenza pandemic In 2009, health authorities in Norway introduced a system of seven days’ sick leave without a certificate for those with influenza-like illness (ILI), and the release of over-the-counter antiviral medication at pharmacies to assist with the high-level of expected demand on health services (Simonsen et al. 2013b). Despite these measures, GPs saw a 3.3 fold increase in ILI consultations compared with the previous year (Simonsen et al. 2013b). This surge was manageable within this group as part of business as usual during the annual flu season. The GP consultations were only 14% of the estimated 900,000 infected individuals. For young people, and those with milder illness, management was by telephone consultation, and this accounted for 75% of all influenza encounters (Press et al. 2010). Other management strategies included innovative ways to expand the workforce, such as increased flexibility in working from home and use of retired health professionals.

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In the event of a significant outbreak, effective management will depend on strategies which seek to localise the disease and to protect those at higher risk of complications and fatality. Human resources, particularly health professionals, may also be affected, and there may be a lack of willingness to work in an at-risk environment. Adequate provision of PPE will be crucial in supporting health professionals to continue working during pandemics. Locally relevant innovation will be needed in healthcare services to reduce the spread of disease. The Royal Australian College of General Practitioners (RACGP n.d.) advises potential options in general practice (family medicine clinics) and community health clinics, including: • • • • •

Increasing infection control precautions. Changing patient management systems through increased online consultations and prescriptions of medication. Reducing non-urgent consultations; and redesigning the flow of patients through the clinic to reduce cross-infection. Moving reception to the front of the building; and seeing patients in their cars. Cohorting patients to reduce the amount of PPE needed.

Potential options in emergency departments include: early establishment of flu clinics or patient cohorting by identifying and isolating areas of the premises as flu treatment areas; redeployment of at-risk staff to other areas; extending the scope of practice of staff; advanced triage; and appropriate signage/staffing at the entrance to redirect patient flow as necessary (ACEM 2014). A crucial issue in any disaster, including pandemics, is communication; clear, consistent, accurate up-to-date information that is reliable and regularly distributed across all responders and affected communities. This is true for those in authority who are making decisions on population management; for health-professionals who need to be clear about their role, and how those infected with the disease are to be managed; and for concerned members of the community who wish to remain safe and healthy. Increased education on disease transmission and how to reduce the spread of infection along with use of infection prevention and control measures is important for both the public and health professionals. The media also has a clear role in this area. Regular, clear and consistent communication is likely to decrease the potential psychosocial impact. Following any major event, normal health consequences continue. People still have heart attacks and give birth. Such business as usual needs to be considered in planning. In pandemics with higher fatality rates, dealing with grief and bereavement for families and communities will be an ongoing issue. Health systems must recover as well. Learning from any event is an important part of system development. Reporting the outcomes, and identification of issues to be incorporated into future planning and preparedness helps the system recover. Facilities, personnel and other resources must be restored. In particular, those involved in the care of others should be cared for in turn and assisted as appropriate in recovery from the challenges and losses that have been faced.

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Key readings Centers for Disease Control and Prevention. Home. 2010. www.cdc.gov/h1n1flu/ (accessed 5 Dec 2015). Centers for Disease Control and Prevention. Information on Swine Influenza/Variant Influenza Viruses. 2014. www.cdc.gov/flu/swineflu/ (accessed 10 Dec 2015). Davies E. ‘The influenza epidemic and how we tried to control it’ Public Health Nurse. 1919; 11(1): 45–49. Department of Health, Australian Government. Pandemic Influenza. 2014. www. health.gov.au/internet/main/publishing.nsf/Content/ohp-pandemic-influenza.htm (accessed 5 May 2015). Doty P. ‘A retrospect of the influenza epidemic’ Public Health Nurse. 1919; 11(12): 949–957. Refworld. Home. 2015. www.refworld.org/cgi-bin/texis/vtx/rwmain (accessed 5 Dec 2015). The Royal Australian College of General Practitioners. Public Health and Natural Disasters: Pandemic flu kit. n.d. www.racgp.org.au/your-practice/business/tools/ disaster/pandemics/ (accessed 5 Dec 2015). Westphal M. ‘Influenza vignettes’ Public Health Nurse. 1919; 11(2): 129–133. World Health Organization. Emergencies Preparedness, Response: Swine influenza – update 3. 2009. www.who.int/csr/don/2009_04_27/en/ (accessed 5 May 2015).

Activities •

Read this commentary on Australia’s responses to the Swine flu pandemic in 2009: Hamilton A, Crocket R, Skippen B. ‘Australia’s response to swine flu in 2009 – has it been appropriate?’ Journal of Rural and Tropical Public Health. 2009; (9): 14–18.



– Identify the key issues of significance and consider how you would improve your own community’s response. – List five key lessons for pandemic preparedness.

• •

What strategies would you take to ensure a health service was able to continue to operate during a pandemic? What are some key humanitarian core standards and health standards to consider in a complex humanitarian emergency, such as the civil war in Syria?

References ACEM (Australasian College For Emergency Medicine). Management of Severe Influenza, Pandemic Influenza and Emerging Respiratory Illnesses in Australasian Emergency Departments [Pamphlet]. Melbourne: ACEM; 2014. Barnhart R. Chambers Dictionary of Etymology. Edinburgh: Chambers; 2002. Brown LH, Aitken P, Leggat PA et al. ‘Self-reported anticipated compliance with physician advice to stay home during pandemic (H1N1) 2009: Results from the 2009 Queensland Social Survey’ BMC Public Health. 2010; 10: 1–5. Department of Health and Ageing. Australian Health Management Plan for Pandemic Influenza. Canberra: Commonwealth of Australia; 2014.

Complex events  295 Emanuel EJ. ‘The lessons of SARS’ Annals of Internal Medicine. 2003; 139(7): 589–591. Francoeur G. ‘On the frontlines in the Ebola crisis’ McGill News Alumni Magazine. Oct 2014. http://publications.mcgill.ca/mcgillnews/2014/10/07/on-the-frontlines-in-the-ebola-crisis/ (accessed 18 May 2016). Grove RD, Hetzel AM. Vital Statistics Rates in the United States: 1940–1960. Washington, D. C.: US Government Printing Office; 1968. Guerrant RL, Walker DH, Weller P. Tropical Infectious Diseases: Principles, pathogens and practice. 3rd ed. London: Elsevier; 2011. Klugam J. Social and Economic Policies to Prevent Complex Humanitarian Emergencies: Lessons from experience. Helsinki: The United Nations University for Development Economics Research (UNU/WIDER); 1999. Last J. A Dictionary of Epidemiology. 4th ed. Oxford: Oxford University Press; 2001. Lederberg J. ‘Emerging infections: Microbial threats to health’ Trends in Microbology. 1993; 1(2): 43–44. Lee S, Chan LY, Chau AM et al. ‘The experience of SARS-related stigma at Amoy Gardens’ Social Science & Medicine. 2005; 61(9): 2038–2046. Leggat PA, Brown LH, Speare R. ‘Level of concern and precaution taking among Australians regarding travel during pandemic (H1N1) 2009: Results from the 2009 Queensland Social Survey’ Journal of Travel Medicine. 2010; 5: 291–295. Lum ME, McMillan AJ, Brook CW et al. ‘Impact of pandemic (H1N1) 2009 influenza on critical care capacity in Victoria’ Medical Journal of Australia. 2009; 191(9): 502–506. McNeil WH. Plagues and Peoples. New York: Anchor Books; 1976. Meltzer MI, Cox NJ, Fukuda K. ‘The economic impact of pandemic influenza in the United States: Priorities for intervention’ Emerging Infectious Diseases Journal. 1999; 5(5): 659–710. Press K, Hansen E, Hunskar S. Pandemic Influenza During the Season 2009; Encounters to the out-of-hours services in Norway. Bergen: National Centre for Emergency Primary Healthcare, Uni Health; 2010. RACGP (The Royal Australian College of General Practitioners). Public Health and Natural Disasters: Pandemic flu kit. n.d. www.racgp.org.au/your-practice/business/tools/disaster/ pandemics/ (accessed 11 Dec 2015). Robertson J. Research Note: The economic costs of infectious diseases. Canberra: Commonwealth of Australia; 2003. Simonsen K, Steinar H, Sandvik H et al. ‘Capacity and adaptations of general practice during an influenza pandemic’ PLOS ONE. 2013b; 8(7): 1–5. Simonsen L, Spreeuwenberg P, Lustig R et al. ‘Global mortality estimates for the 2009 influenza pandemic from the GLaMOR project: A modelling study’ PLOS Currents Disasters. 2013a; 10(11): 1–16. Taubenberger JK, Morens DM. ‘1918 influenza: The mother of all pandemics’ Emergent Infections Diseases. 2006; 12(1): 1–20. The Sphere Project. The Humanitarian Charter and Minimum Standards in Humanitarian Response. 2nd ed. Rugby, UK: Practical Action Publishing, Schumacher Centre for Technology and Development; 2011. www.sphereproject.org/ (accessed 9 Dec 2015). WHO (World Health Organization). Strengthening Health Security by Implementing the International Health Regulations. 2005a. www.who.int/ihr/en/ (accessed 16 Aug 2015). WHO (World Health Organization). Combating Emerging Infectious Diseases in the SouthEast Asia Region. New Delhi: World Health Organization, Regional Office for South-East Asia; 2005b. WHO (World Health Organization). Emergencies Preparedness, Response: Current WHO phase of pandemic alert for pandemic (H1N1) 2009. 2009. www.who.int/csr/disease/swineflu/phase/ en/ (accessed 12 Dec 2015).

296  P. Burns, B. Sutton & P.A. Leggat WHO (World Health Organization). Pandemic Influenza Risk Management: WHO interim guidance. Geneva: WHO; 2013. WHO (World Health Organization). WHO Strategic Response Plan: West Africa Ebola outbreak. Geneva: WHO; 2015. Wong S, Yuen K. ‘The severe acute respiratory syndrome (SARS)’ Journal of NeuroVirology. 2005; 11: 455–468.

Part 8

Strategic considerations

Chapter 23

Leadership Dudley McArdle, Peter Channells and Bob Jensen

Introduction and objectives Disaster health leadership is not just about the response during an event, although it is this aspect that receives most attention and is subject to closest scrutiny after a disaster. Rather, leadership in disaster management spans the full spectrum of the PPRR cycle. In other words, it is about leadership before, during and after an event. Leadership across all phases is equally important. However, the required leadership qualities will vary, largely depending on the degree of urgency and/or strategic vision required in each phase. For example, a leader in the response phase will need to be able to manage a high degree of urgency. A leader in the other phases usually has less urgency, but needs to take a strategic view, knowing that their actions could significantly impact the success or failure of a response. While appointed persons (particularly those in government roles) may have a leadership role across several phases, they may not necessarily be the best person for the job at all stages of the event. Consideration should always be given to ensuring that the best person for the job is leading that particular phase. In an emergency management context, leadership also operates at all levels, from the team to the incident controller, the department head and the Minister. Each level of this continuum has a distinct role and responsibility but the fundamental elements are the same. In general, team leaders must have a tactical focus as well as a strategic focus on such factors as training, resources, mitigation measures, planning and alliance building. Conversely, incident controllers, department heads and Ministers often have a strategic focus with no tactical role, but they still need to understand the tactical level. The key to success is obviously a strong network of relationships between leaders at all levels based on trust and common goals. Are leaders born or made? In our view it is a combination. All great leaders need and have excellent interpersonal skills. This is related to innate personal qualities such as values, personality and presentation – the result of the nature of the person along with growth and experience. However, good leaders need to hone their skills; increase their understanding of the subject area in which they are working; increase their knowledge of the contemporary environmental conditions in which they work; and know and understand their stakeholders, especially their needs and priorities.

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This chapter tries to contextualise leadership in disaster management rather than discuss in detail the characteristics of leadership on which countless volumes have been written. At the end of this chapter you should be able to: • • •

Demonstrate a comprehensive understanding of the qualities of effective leadership styles during all phases of disaster management, and the steps organisations need to take to plan future leaders. Discuss why leadership during a disaster is different. Identify the difference between crisis and crisis response vs. consequence management.

The leader There are a multitude of books and articles written about leadership and many hundreds of leadership development programs. Prospective leaders can find many sources for learning the basics of leadership, studying such concepts as the various ‘leadership styles’ (e.g. directive, visionary, affiliative, participative, pacesetting and coaching). Some sources for those who wish to pursue these concepts are listed in the key readings section at the end of this chapter. Leadership qualities that are especially applicable during emergency events include: • • • • • •

Taking responsibility in both good and bad times for those they are leading. Making the hard decisions, whether determining who gets what resources or deciding a behavioural matter within the team. Demonstrating self-reflection and self-awareness to understand strengths and weaknesses. Measuring and building emotional intelligence competencies including selfawareness, social awareness, self-management and relationship management. Ensuring connectedness with the teams, and fully understanding their skills and needs. Working with the political system.

Petrie (2014) suggests that as leaders progress through their leadership development, they should: • • • •

Focus more on their leadership development process and less on actual leadership content. Make their leadership development and their work inseparable. Create strong development networks. Make their leadership development a process not an event.

In ensuring that they are well prepared for their role, leaders need to continuously cultivate their personal readiness by: • • •

Analysing learnings from previous events. Undertaking broad research and reading (‘Leaders are Readers’). Recognising their own vulnerabilities, as well as vulnerabilities in their teams.

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Identifying their own skillsets. Rehearsing – practise, practise, practise.

Why is leadership in emergency and disaster management different? Emergencies and disasters are not a theoretical construct. They are real events typified by uncertainty, relatively short periods of extreme intensity, long periods of recovery, are not able to be prevented and are highly public. Furthermore, there are often long periods with no disaster. It therefore follows that leaders in this environment require additional skills. Table 23.1 compares the leadership of former QLD Premier Anna Bligh during the 2010–2011 floods and cyclone, and former CEO of BP Tony Hayward following the 2010 Deepwater Horizon oil spill in the Gulf of Mexico. These two leaders showed two very different leadership styles during a disaster. The media headlines for Premier Bligh were complimentary throughout and she was publicly praised for her leadership, presenting facts with genuine care, and her determination. Throughout the extended flood period, Premier Bligh consistently demonstrated a unity with those impacted by the floods. See also: Anna Bligh’s emotional press conference at: Channel Ten. We Will Rebuild. 2011. www.youtube.com/watch?v=nfPXmEtyKrA (accessed 6 May 2016). In contrast, Tony Hayward, CEO of BP, in response to the Deepwater Horizon oil spill, was perceived to be consistently off the mark, failed to demonstrate ownership of the problem, and appeared to have no concept of the scale of the disaster or the impact it had on the environment and communities affected. Combining these two examples, there are a few simple rules to consider for effective disaster management leadership: • •

Publicly recognise, and if necessary, own the problem early. Act fast: there is ample time for analysis (see, for example, the 2009 Black Saturday fires in Victoria, Australia, and the Royal Commission that followed).

Table 23.1 Comparison of two leadership styles: Anna Bligh and Tony Hayward. Anna Bligh, former Premier of Queensland, Australia, during the 2010–2011 floods and cyclone.

Tony Hayward, former chief executive of BP following the 2010 Deepwater Horizon oil spill in the Gulf of Mexico.

•  Was in control. •  Took ownership. •  Knew the name of each town already impacted by the flood and which towns were under threat. •  Could talk accurately about river heights, and the response and recovery arrangements. A key factor was that she did not try to hide the fact that people were likely to die and the community should prepare for that possibility. ‘It might be breaking our hearts . . . but it will not break our will.’

‘What the hell did we do to deserve this?’ (29 April) ‘I want my life back.’ (31 May) ‘I think the environmental impact of this disaster is likely to be very, very modest.’ ‘I don’t feel my job is on the line.’ (31 May)

Sources: Davies (2011) and Owen (2011).

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• • •

Show empathy with those impacted by the disaster and do not be afraid to express genuine emotion. Know the facts and voice them. Communicate often.

With the wealth of data from the many disasters faced across the world, there really is no excuse for getting disaster management leadership (and these few simple rules) wrong. Until relatively recently, management of emergencies was not a mainstream consideration of most departments and organisations. Instead, they were dealt with by emergency service agencies; and considered almost a ‘black art’. The change is generally agreed to have occurred following the 9/11 attacks on the World Trade Centre in 2001 and the Bali bombings in 2002, followed by the 2003 Canberra fires, 2004 Indian Ocean tsunami, 2005 Hurricane Katrina, 2006 Cyclone Larry and 2011 Japanese earthquake and tsunami. Awareness of these natural disasters coincided with increased terrorism risk and has meant that emergency management is now everybody’s business. Leaders in emergency management are now under more intense public scrutiny, especially with social media leaving the impression that we do not have disasters but political events. From the community perspective, greater connectivity, increased interdependencies, just-in-time supply chains, and increased urbanisation have led to greater community vulnerability so that previously ‘normal’ disasters have much greater impact. Climate change and geopolitical events have created disasters not previously encountered. For example, in the last 15 years: Australia received disaster-affected evacuees; evacuated Australians from various countries; responded to terrorism events and threats; responded to huge fires and floods; and provided major assistance in other countries’ disasters. Against this backdrop, more than ever before, today’s environment has created more complexity and placed greater responsibility on the shoulders of emergency management leaders. Disaster managers no longer have to solely focus on the incident, they need to deal with an equally large, demanding and complex situation created from the constant need for senior briefings and community expectations and reassurance. Some of the compounding factors that require clear, strong leadership include: • • • • • • •

Changing demographics: including urbanisation, the aging population and ‘sea/ tree changers’ (i.e. moving from city living to a more rural setting). Climate change. International and domestic political interest: meaning a very high degree of political interest. Politicians want to be more involved and therefore place more demands on managers. Instant media and social commentary: particularly as a consequence of immediate access to information, but not necessarily facts. Community and political expectations: expectations of more data, more quickly, and greater performance expectations of managers. Enhanced emergency management: many more agencies/stakeholders have a role in emergency management than ever before. Standards: emergency management has been slow to embrace professionalism.

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Non-routine events: campaign events such as fires burning for months; slow-onset events (e.g. a nine year drought); terrorist attacks; and industrial mishaps all require much more sophisticated responses than the ‘standard’ floods and fires. High likelihood of post-incident commissions or inquiries: unfortunately, postevent inquiries/reviews, while important to enable lessons to be learnt, frequently result in finger pointing and blame allocation (which is often triggered by the media).

Disaster leadership – What does it look like? Hudson is a global recruitment and talent management leader. Surveys of over 100 human resource business leaders in Australia and New Zealand conducted by Hudson in 2015 and 2016 show that leadership development was their highest priority in both years. These surveys also showed that only 54% of organisations actually had their own clearly articulated leadership strategy. Leadership is not an exact science but any organisation can improve the quality of their leadership. Hudson (2015) describes four key factors in building leadership in an organisation: 1 Define what good leadership looks like in your organisation (capability) that can be used to guide recruitment and development. 2 Plan for the future; update annually. 3 Identify the people you need, then develop assessment methodologies to understand their development needs and to evaluate potential leaders. 4 Develop the capability of your leaders.

Crisis vs. consequence leadership The single most important consideration of any leader with responsibilities in an emergency situation is the recognition that they have two responsibilities. Firstly, they must address the crisis itself – prevent it, bring it to an end, mitigate it, ‘douse the fire’. Secondly, they must address the consequences of the event. As previously discussed throughout this text, communities represent societies with a multitude of interrelated systems and any crisis that disrupts one or more of those systems causes disruption to the smooth operation of our communities. Crisis leaders, then, must address not only the crisis itself, but, perhaps more importantly, the consequences to the community of the event. After all, if an event presents no consequences to the community it is not a crisis! (For example, when Lake Eyre in South Australia floods, it causes no harm to the community and is actually a tourist attraction!)

Crisis (response) leadership There are a number of principles that must guide a crisis leader to inform his/her actions and priorities: • •

Primacy of life: the first priority in crisis decision-making is to protect the life of employees, community members and emergency workers. Community protection: the protection of communities and their assets and infrastructure is an important part of crisis management.

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• •

•

Multi-agency/all hazards: dealing with emergencies requires engagement with and input from all agencies, government departments, the community and the private sector. Community engagement: the community is best informed and positioned to identify how and what is required to restore them to the new normal before, during and after an emergency. The preparedness and resilience of a particular community will inform this. Accountability and constant improvement: all actions and decisions will be reviewed after the crisis so it is critical to record them to understand both how that crisis was managed and also to inform management of future crises.

In any emergency, the government’s priority is to restore public faith in the government and the future. Emergency management leaders must recognise that they are government appointees/ representatives in the eyes of community members, no matter what brand of uniSource: Boin et al., 2005 form or suit they wear. The community and their political masters expect leaders to be able to clearly articulate what is going on (and why), what it means, what is being done about it and what is expected of others. To do this the leader needs to create confidence and purpose by moving from ‘normal operations’ to the unknown; making sense of the event, establishing a coalition of agencies/services, knowing and understanding the community’s priorities, risks and information needs, and managing the now while anticipating the next. Leaders also need to define the strategy to resolve the issues, and to communicate with their team, the media, the community, their political masters and other agencies. Finally they need to predict and address the consequences of the event. Table 23.2 outlines what a crisis leader must establish. In establishing and maintaining an effective control centre for the disaster/emergency, the leader needs to give attention to a number of issues driving the workforce, including standards, commitment, flexibility, clarity of purpose, rewards and responsibility (Hay/McBer 1995). The critical phase of a major incident can be very short. Within four days of the 2002 Bali bombings, all Australians were repatriated and admitted to hospitals across Australia. Yet elements of the recovery phase still continue today. In contrast, a disaster can continue for a lengthy time, and this can sometimes be referred to as a ‘campaign event’. Examples include severe bushfire seasons and the initial ‘white powder’ incidents. However, when a disaster starts it may not always be obvious whether it will be short lived or will continue. Leaders need to consider this aspect very early, plan accordingly and reflect this in their public messaging. Table 23.3 provides an example of a leader’s decision-making process following a bushfire. Leaders must ensure that they are effectively communicating with all the key stakeholders involved in a crisis. They should have a crisis communication plan in place and the leader’s team needs to include the key communications officers from the organisation. The plan should not be media-centric, but should use all available channels to ‘In a crisis, leaders are expected to reduce uncertainty & provide an authoritative account of what is going on, why it is happening, & what needs to be done.’

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reach the key stakeholders, including the community. Communication should be twoway and should be based on sound risk communication principles. Special attention to the families of any victims involved in an event must also be planned. Table 23.2 A disaster management strategy for a crisis leader. Sense-making:

Decision-making:

Meaning-making:

Terminating:

Learning:

Appraise the threat. Define the nature of the threat. What is the crisis about? How threatening is it? How will it develop? What to do about it. Choices and options. Interagency collaboration. Effective implementation. Communicating. Present a compelling story. Draw a coherent picture. Frame the crisis. Interpretation. Shifting to routine. Downsizing. Rendering account of what has happened. Gaining acceptance of the account. Governance re-established. Accountability. Review governance. Update policy. Reinforce systems. Training and rehearsal.

Table 23.3 Example of a leader’s decision-making process after a bushfire. Risk/issue: Consequence: Action:

Responsible: Communication:

40 homes have been destroyed by a fire. Individuals/families are without accommodation and personal items. 1 Local Government Authority (LGA) to establish a relief centre for immediate needs (within 1 hour). 2 Department of Human Services (DHS) to plan temporary accommodation options (within 24 hours). 3 Outreach and case management options to be explored (within 48 hours). Municipal and Regional Recovery Manager. Public information mediums to advise that Bluerock Relief Centre is operating 24 hours.

Consequence leadership Consequence management is a broad term encompassing measures to protect the community’s health and safety, restore essential services, and to provide relief to

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governments, businesses and community members affected by an event. By definition it requires a multi-function, all-agency response coordinated by the crisis leader. Consequence management occurs before a crisis through prevention, preparedness and mitigation, and after the crisis during the recovery phase. These roles are perhaps the most difficult and the most time consuming for emergency management leaders. During the ‘prevent and prepare’ (before) phase, leaders need to be able to maintain the involvement of key stakeholders. This can be particularly difficult during periods of less frequent incidents when budget priorities change. Leaders need to focus on building relationships, particularly with their communities, and recognising (and sometimes creating) opportunities to better position their teams, often over a lengthy time period. In a crisis, trust is essential for the time-limited decisions that need to be made. This is true within an organisation and even more critical in a multi-agency environment where different priorities exist and where familiarity is more difficult. Relationships cannot be developed in the heat of an incident. Building these relationships and maintaining them is yet another critical role for emergency management leaders in the before phases. Emergency managers are increasingly aware that following any incident, questions will be asked about what could or should have been done to prevent or at least mitigate the consequences and the speed of recovery from the incident in question. These are reasonable questions and leaders are advised to address them early.

Recovery leadership The recovery phase of a crisis often very quickly disappears from the public arena. Leaders need to be patient! It took This can lead to a diminution of resources Australian medical laboratories available for the recovery of communities two years to gain access to the affected by a disaster. It may occur because Laboratory Response Network run another crisis has occurred or another by the CDC. Access now provides priority has become more important – or Australia with a very effective sometimes disaster-fatigue means people resource in cases of zoonotic ‘move on’. However, for the community & other diseases & viruses. impacted by the crisis, their support remains the most important issue. A key element for a recovery leader is the ability to ensure recovery aspects are included as the response is first unfolding. As recovery proceeds, the clarity of outcome diminishes and complications begin to creep in compared to the very sharp focus on outcomes that are relatively easy to measure in a response phase. For example, if a building collapses from an earthquake, the immediate focus is clear – rescue survivors with little regard to cost. As time progresses those affected (physically and psychologically) need to be cared for. Unfortunately, issues of priority and cost begin to be considered. The community sometimes compares treatment of those survivors to those from other disasters where perhaps different priorities and strategies were applied. Differences are critically and publicly discussed. Recovery leaders need to bear this in mind as they coordinate recovery strategies.

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Recovery leaders must ensure that what they learn is used to inform not only future recovery operations, but also the prevent, prepare and respond aspects of future events. Comprehensive record keeping and post-event debriefs are essential. Recovery leaders need to be able to establish and maintain engagement ‘An organisation cannot afford to stay over an extended time frame, sometimes in crisis mode forever. A sense of for many years, and even decades. This, normalcy has to return.’ by necessity, will include establishing effective and efficient systems that are Source: Boin et al., 2005 independent of any particular individual. Processes and services must be ‘mainstreamed’ – they must become business as usual for the appropriate agencies or departments.

Whole-of-community approach It is fitting that the final part of this chapter views emergency management leadership from the end-user perspective: the community. Leaders must see the community as partners in dealing with disasters, although the direct role of the community (largely untrained and ill-equipped) is more in preparedness and recovery rather than in response. Communities need to be engaged so that they understand their risk exposure; ‘Whether an organisation survives a understand what measures they can crisis with its reputation, operations take to better prepare; and understand & financial position intact is the recovery process. For example, determined less by the severity communities in Japan know the risk of the crisis, than by the timeliness of earthquake, while communities in & effectiveness of the response.’ California, USA, understand the fire risk. Source: Garcia, 2006 As a generalisation, those communities in natural disaster-prone areas understand their risk, although this changes when urban dwellers shift to rural areas. In this situation, leaders need to target messages for specific communities, rather than simply relying on a broadcast approach. The principles that underpin whole-of-community leadership in disasters and which should be applied include: • • • • • •

People understand the risks that may affect them and others in their community. People have taken steps to anticipate disasters and protect themselves, their assets and their livelihoods. People work together with local leaders using their knowledge and resources to prepare for and deal with disasters. People work in partnership with emergency services, their local authorities and other relevant organisations before, during and after emergencies. Businesses and other service providers undertake wide-reaching business continuity planning that links with their security and emergency management arrangements. Public and private partnerships are important to better serve the community, and are particularly valuable with vulnerable community members.

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Conclusion Emergency management leaders have a very complex role under microscopic, universal scrutiny. The rewards for a job well done, if recognised, are great; but they can be sure that perceived mistakes will attract opprobrium. Only by preparing themselves, their teams and their communities; by learning the lessons from previous events; and by adopting a sound, logical approach, underpinned by well-established networks and evidence-based decisions, can they be sure that they have provided the best service to the communities who rely on their expertise. The most underdeveloped aspect of crisis management is the final task – political and organisational lesson-drawing. (Boin et al. 2005)

Key readings Cantwell J. Leadership in Action: Lessons for the real world from a real leader. Melbourne: Melbourne University Press; 2015. Lichtenstein B, Uhl-Bien M, Marion R et al. ‘Complexity leadership theory: An interactive perspective on leading in complex adaptive systems’ Emergence: Complexity and organization. 2006; 8(4): 2–12. Prewitt J, Weil R, McClure A. ‘Crisis leadership: An organizational opportunity’ Australian Journal of Business and Management Research. 2011; 1(6): 60–74. Probert J, Turnbull JK. ‘Leadership development: Crisis, opportunities and the leadership concept’ Leadership. 2011; 7(2): 137–150.

Activities • •

Consider the various phases of disaster management across the PPRR cycle and produce a small table which captures the different leadership traits you think may be appropriate to each stage. How would you evaluate the effectiveness of leadership in crisis management?

References Boin A, ‘t Hart P, Stern E et al. The Politics of Crisis Management: Public leadership under pressure. New York: Cambridge; 2005. Channel Ten. We Will Rebuild. 2011. www.youtube.com/watch?v=nfPXmEtyKrA (accessed 10 Dec 2015). Davies A. ‘Captain Bligh steers the ship in face of adversity’ The Sydney Morning Herald. 13 Jan 2011. www.smh.com.au/federal-politics/political-opinion/captain-bligh-steers-theship-in-face-of-adversity-20110112-19ob0.html#ixzz3sjRKOYPH (accessed 10 Dec 2015). Garcia HF. ‘Effective leadership response to crisis’ Strategy & Leadership. 2006; 34(1): 4–10. Hay/McBer. The Organizational Climate Dimensions. Boston, Mass: McBer and Company; 1995. Hudson. Hudson 2015 Leadership Survey Results: HR leaders reveal top people priorities for 2016. 2015. http://au.hudson.com/talent-management/hudson-2015-leadership-surveyresults (accessed 12 Feb 2016).

Leadership  309 Owen J. ‘BP oil spill crisis management: How not to do it’ CBS News. 11 Jun 2011. www. cbsnews.com/news/bp-oil-spill-crisis-management-how-not-to-do-it/ (accessed 10 Dec 2015). Petrie N. Vertical Leadership Development – Part 1: Developing Leaders for a Complex World (Pamphlet). Colorado: Center for Creative Leadership; 2014. http://insights.ccl.org/ wp-content/uploads/2015/04/VerticalLeadersPart1.pdf (accessed 18 May 2016).

Chapter 24

Evaluation and learning Gerry FitzGerald and Marie Fredriksen

Introduction and objectives Evaluation is a critical part of all we do. Literally, evaluation means assigning value and this follows a process of critical and comparative analysis in which the effectiveness of what we do is compared with ‘best practice’ or prior knowledge and experience. Therefore before, during and after a disaster there is a need to evaluate what happened, to address why things happened as they did and to identify what could be done in the future to minimise adverse impacts. The impacts may be evaluated within the framework of their effects on the community, health services, society and the economy. The key challenge for evaluation is identifying useful frameworks that will allow the identification of what should be evaluated, how it should be evaluated and what the benchmarks or best practices are. This is then compared against the performance, i.e. what actually happened. The infrequency of disasters means that personal, or even corporate knowledge is minimal, so the learning from each event must be communicated so others can benefit. Reporting is an important part of the communication flow. Reporting helps community reassurance and identifies additional assistance required. Unfortunately, the processes of evaluation and reporting face the very real danger of becoming adversarial; seeking to assign blame rather than identify lessons to be learnt. Individuals or society in general may seek to absolve itself of any collective responsibility for failure to prepare and plan by simply blaming someone else. Therefore the strategic lessons are often not learnt or certainly not applied, and the passage of time dims memories. The aim of this chapter is to outline processes and mechanisms for evaluation and how the outcomes of that evaluation may inform future development, public policy and organisational performance. On completion of this chapter you should be able to: • • • •

Identify standards against which disaster management may be assessed. Discuss the principles and processes of evaluation. Explain how the lessons learned from disasters may be used to inform future development of disaster management in organisations and communities. Outline the principles and practices of reporting.

Evaluation concepts, principles and standards The process of evaluation seeks to make sense of what has occurred and to ascribe meaning that can inform future directions in regard to policy, preparedness, response

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and recovery from disasters. Evaluation should occur throughout the entire cycle of disaster management and around a structure of assessing inputs, processes, outputs and outcomes. Leaders in disaster management at strategic levels, including political office-holders, agency leaders and other senior executives, need to ensure that the lessons that should be learnt from each event are identified and used to transform future preparedness and responses. At the tactical/operational level, including incident commanders and operations managers, there is a need to identify and imbue meaning into the events and impacts of what has happened. A review of major disasters in Australia conducted by the Monash Injury Research Institute identified six major strategic research and evaluation issues (Goode et al. 2011): 1 State emergency management arrangements. 2 Understanding, awareness and assessment of risk. 3 Critical infrastructure. 4 Community communications and empowerment. 5 Research. 6 Defining disaster resilience for the community. In 2003, the World Association for Disaster and Emergency Medicine published Guidelines for Evaluation and Research in the Utstein Style (Sundnes and Birnbaum 2003). This was an attempt to standardise the conceptual framework, terminology and approaches. This framework has recently been reviewed in a series of articles published in the journal Prehospital and Disaster Medicine. In introducing those articles, Birnbaum et al. (2014) identified two broad research approaches, epidemiological and interventional, that are transcended by five frameworks: 1 Conceptual framework recognises the casual linkage between hazards, events, impacts and consequences. 2 Longitudinal framework describes the chronological continuum throughout the pre-event, event and post-event. 3 Transactional societal framework recognises the complexity of interactions between 13 societal systems that underpin the risk and consequences of disasters, and which interact with each other through a 14th system of coordination and control. 4 Relief/recovery framework provides the basis for understanding the effectiveness of interventions during the response phase. 5 Risk-reduction framework details the effectiveness of risk reduction strategies. There are some generally accepted principles underpinning evaluation, including: • • •

Useful: that the evaluation is useful to the stakeholders. Practical: that the evaluation is able to be done effectively without disrupting the normal functions of the community and its recovery, and is cost effective. Evaluation may need to include both qualitative and quantitative approaches. Ethical: that the evaluation respects people’s rights but also maintains perspective.

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• •

Accurate: that the evaluation is conducted objectively and is reliable. Engaged: that the evaluation involves the perspectives of those affected and in turn reports outcomes to them.

A submission to the 2010 Bushfire Cooperative Research Centre in Victoria, Australia (‘t Hart 2010), identified six common errors encountered in evaluation that should inform preparedness and response management: 1 The planning syndrome: The tendency to focus on the plan as the outcome and to be restrained by its limitations when the unstructured and unpredictable nature of disasters may result in pervasive surprise, uncertainty and overwhelming scale. 2 The obsession with full information: Full information will never be available, at least initially, if at all. The search for full information can paralyse decisionmaking and assessment. 3 Communication breakdowns: Evaluations always focus on communication breakdowns. The nature of crises is such that communication is difficult, restrained not only by incomplete information, but also by the intensive nature of the environment. 4 Total reliance on command and control: Modern complex societies, particularly in Western democracies, have challenged traditional views of command and control. Emergent behaviours and emergent leadership facilitated by access to social media may undermine traditional approaches, leading to breakdowns in organisation which may appear chaotic. 5 Underestimating that the medium is the message: During disasters, the relationship between disaster manager and the media is often fraught, if not adversarial. Managers often see the media as a managerial challenge rather than an ally, particularly when the media takes up its social responsibility role and is critical of management. The internet and social media have fundamentally altered the media’s role, and the ability of anyone to control it. 6 Underestimating the crisis after the emergency: The post-response phase is the most complex and challenging period as the public’s attention wanes but the managerial challenges expand. Other players including lawyers, insurers, politicians and academic commentators will buy into the critical analysis, often with incomplete information, or in Kennedy’s words with ‘the comfort of opinions without the discomfort of thought’ (1962). The management challenge is to understand these issues and to develop means of dealing with them. Disasters that can be prevented, or at least mitigated, are inevitably followed by recriminations and cries of ‘how could this have happened? It must never happen again’. Comprehensive evaluation following disaster is a powerful tool to identify gaps in systems and structures and plan future training needs. However, recurring themes following disasters continue to be identified leaving the question; do we ever learn? Analysis of 12 major Australian bushfire reports and inquiries dating back to 1939 (Ellis et al. 2004), the 2009 Black Saturday bushfires in Victoria (Teague et al. 2009) and the technological disasters of space shuttles 1986 Challenger (Rogers Commission Report 1986) and 2003 Columbia (CAIB Report 2003) all identified the

Evaluation & learning  313 Table 24.1 Recurring themes in Australian bushfires and NASA space shuttle accidents. Major Australian bushfires 1939–2009

Challenger and Columbia space shuttle accidents

Deficiencies in prevention activities and risk reduction, resources and activity, education and awareness, clearing of fuel around buildings, track access and fuel reduction, including: •  Recognition of the value of volunteers and their contribution to the community. •  Complacency before every fire. •  Inadequate resources. •  Communication and telecommunication infrastructure failures. •  Failure to utilise local knowledge. •  Lack of understanding of the roles and responsibilities of local government.

•  Failure of NASA’s safety system. •  Organisational problems. •  Fundamental problem within the culture of NASA. •  A deeply flawed risk philosophy preventing investigation of anomalies during previous shuttle flights. •  Adopting the position that because nothing happened during previous missions and the same risk still existed, prevented NASA from sufficiently rectifying risks or delaying missions.

same causal factors in each event. Evaluation following a disaster is of little purpose if the same mistakes are repeated over and over again. Table 24.1 shows the recurring themes of these disasters. The literature provides countless case studies and analyses of disasters and best practice for responding to and recovering from their impact: Boin and ‘t Hart (2010); Boin et al. (2005, 2008, 2010); Deverell (2010); Flin et al. (2008); Rodriguez et al. (2006); ’t Hart et al. (2005); Flin and Arbuthnot (2002); Hilliard (2000); Birkland (1997); Stern (1997); and Flin (1996). Drawing upon this literature, the authors offer a procedure for evaluating the response and recovery operations following a disaster. These steps allow all actors involved to identify gaps in the PPRR cycle and provide opportunities to improve structures and systems, and community resilience. The steps are as follows: 1 Sense-making: How well did communication flow within and between systems and organisations involved? Did this hinder warning messages and the ability to provide an appropriately resourced response? Did organisations work in collaboration with each other? Were there any conflicts? How were conflicts resolved? 2 Meaning-making: Were reports and public accounts of what was happening, why it was happening, and what was being done to rectify or mitigate the situation, appropriate? How were the media (including social media) used? Did this hinder or assist the response? 3 Decision-making: Were strategic policy judgements appropriate? Were there any gaps in policy that impeded decision-making? Did the response and recovery have an agreed authoritative decision-making and conflict-resolution structure? –  Diagnosing and deciding: At strategic, tactical and operational levels, was there an understanding of the nature and extent of the situation? Were responses sensible, feasible and continually updated as the situation evolved and new information became known? –  Informing and empowering: Was the dissemination and flow of information – up, down and out of the crisis response structure and to the community –

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accurate, timely and actionable? Did the information allow informed crisis response decisions to be made? 4 Coordinating: Was communication and collaboration at a strategic level appropriate? Did each agency work effectively together at all levels? Was this sustained throughout the response and recovery? Was this reflected within and across public, private and community sectors? –  Mobilising and organising: Were the necessary resources to meet demand available? Were resources deployed appropriately in a timely manner? –  Containing and mitigating: Were available resources used in the most effective and efficient way to minimise loss of life and damage to property? 5 Consolidating: Was there any loss of attention and/or momentum during the transition from response to recovery and business as usual? Were immediate, shortterm, mid-term and long-term services delivered appropriately and to all those who were eligible? 6 Account-giving: Were the media managed appropriately? Were legislative processes adhered to? Were responsibilities clarified and accepted? 7 Learning: Were there opportunities for agencies and the community to participate in critical, non-defensive briefings during, and debriefings following, the response and recovery phases? Were responders provided a safe forum to reflect on the response/recovery without recrimination? What are the lessons to be learnt from this disaster? What needs to be done to prevent the same errors and omissions from being repeated in the future? 8 Remembering: Were lessons identified from previous disasters learned or were the same errors and omissions repeated?

Locating the data The process of evaluation necessarily involves the collection of data that may inform not only reporting of what occurred but also may enable evaluation of the effectiveness of the preparation for management of the event. The challenge is to obtain this data while not permitting the process of data collection to become an impediment to providing critical relief. The scope of required data must necessarily focus on the key components for any evaluation, including: • • • • • • •

The nature and extent of the impact. The activities that occurred in responding. The opinions of those involved and of experts. Objective measures of outcomes and comparison with benchmarks if available. Recording of any adverse incidents and experiences during the event. Resources, equipment and facilities used; their quantum and suitability. The people involved in the management of the event.

The challenge of collecting data contiguous with management of the event requires creative solutions. Accurate data is critical even though at times it is almost impossible to obtain. Not only does it determine the activities required but it also provides

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community assurance that the response is being well managed and coordinated. For example, imagine reporting on the initial phases of a tsunami. The number of people affected is unknown and widespread damage makes physical on-scene counting impossible, yet the level of response required, and the resources needed for providing medical care, are dependent on the numbers affected. Additionally, families will be seeking reassurance and/or information. Previous chapters have noted health services are more immediately interested in the injured rather than the deceased. Assessing the number and severity of those injured requires systems of retrieval, triage and clinical assessment. Some attempt at counting the number of patients and the nature and extent of their injuries is critical information required to inform response arrangements. Dealing with the inevitable uncertainty around these numbers proves particularly challenging for community leaders. Processes need to be put in place to account for those injured and to record their essential information. Preparedness arrangements should be in place to provide simple workarounds where normal systems may be destroyed or overwhelmed. Consider the collection of data on the number injured. Police may identify those affected, field retrieval teams may be able to identify the number of people they attend, and hospitals record those who they treat. But consider the difficulties with each of these sets of numbers. Whilst the number of people on a crashed aircraft is immediately known, the number of people in a village on a particular night a tsunami impacts may never be known. Some of the injured will self-evacuate but not all will seek medical care. How can the final death count toll ever be recorded when some bodies may never be recovered? The leadership challenge is to deal with uncertainty and to communicate with honesty and trust when the information is simply not there. Inaccurate or inconsistent data will cause confusion and loss of community confidence. It is critical that data be reported as accurately as possible within the limits of what is known. Data should never be made up! It is safer to say we don’t know. The collection of data needs to be planned ensuring that this process, wherever possible, is a by-product of response arrangements. Everything should be retained and simple collection systems put in place wherever possible. It is easier to keep everything rather than try to think through what may be useful in the subsequent evaluation. Assign individuals to record and collate information, using a single source of data wherever possible. Variable data causes confusion and a loss of community and political confidence. Inefficient systems of data collection will impose on the effectiveness of operational responses, leading to irritation for responders and victims alike. Systems also need to be put in place to collect information which may be of assistance to those tasked with conducting formal and legal enquiries.

Capturing the lessons to be learnt from an incident Disasters are high-impact, low-frequency events. Therefore it is unlikely that individuals or organisations will learn from their own experiences, but rather they rely on the experiences of others. It is inevitable that as a society we will reflect on major events seeking to understand what happened, how prepared we were, how we managed it and how we recovered. Thus consideration must be given as to how those

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experiences can be captured and communicated. The process of incident evaluation and reporting of those findings enables others to use those lessons to inform their preparedness. It is therefore critical. Incident evaluation is also of particular importance because of the level of scrutiny applied either through media attention, or more formally through subsequent official enquiries. Identifying and recording lessons requires organised and structured approaches to which debriefing is an important aspect. An opportunity to identify issues and lessons to be learnt, and to allow some degree of mutual support, debriefing has traditionally been of two broad types: We talk about the lessons being ‘learnt’ for each disaster. This should also be extended to lessons being learnt for each disaster, by each agency.

1 Personal debriefing enables individuals to express their personal reactions and stressors (although heavily structured personal debriefing has been shown to aggravate and not assist mental health amongst responders). 2 Organisational debriefing focuses more on the systems and structures and the lessons to be learnt. If poorly managed, any debriefing has the capacity to have an adverse impact on the health and wellbeing of participants. They should be professionally facilitated and conducted in an objective manner. Participation must be voluntary and offered to multi-agencies. There can be no judgement or assignment of blame. In terms of the design, conduct, and assessment and reporting of disaster responses, there is not currently a standard protocol used by disaster workers. Although templates for the collection of such have been devised (Gunn and Masellis 1996), they are not always used in disaster response. The use of such tools requires significant planning and education for those who are likely to be involved. Without prior preparation, it is unlikely that valuable incident response evaluations can be instigated after the event. Though many post-event evaluations have occurred in the past, these may have provided a less-than-complete understanding of the strengths and weaknesses of the response to an event. Performing response evaluations has the benefit of avoiding the continuation of disaster myths. The propagation of these myths has led to numerous inappropriate responses endangering life and property in past events (de Ville 2000). Evaluation is useful to assess the performance and value of community programs. It acts as a learning tool, and Post-disaster evaluation is of little gives credibility to and validates previous purpose if the previously identified work. The evaluation should address lessons have not been learnt & the contextual issues, desired outcomes, same errors & omissions are strategies, performance indicators, data repeated. sources, findings and actual outcomes, and recommendations.

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Reporting Those tasked with responsibilities for managing disasters throughout the PPRR cycle, also have both personal and professional responsibilities to report on what has occurred. That responsibility derives from our position as officials, to aid in informing any subsequent enquiry, to meet professional accountabilities, to help with incident management, and to inform future planning and preparedness. Reports will rely on the availability of reliable information. Data collection is often considered an irritable by-product of operational management, so systems will be required that ensure reliable data collection whilst also being least invasive on the time and focus of those responsible for managing the response. Determining lessons learned is difficult and requires some level of analysis including feedback from those affected, responders, and stakeholders captured as part of the debriefing process. Objective outcome measures may be useful but are often difficult to identify beyond the overt of mortality, admissions and procedures performed. Any report should meet relatively simple criteria: • • • •

Objectivity of analysis and comment. Analytical to examine reasons why things occurred as they did and to identify remedial action if necessary. Respectful towards the privacy of individuals and of the performance of other responders. Relevant to the context and purpose.

We don’t respond alone so we shouldn’t prepare alone . . . Or learn alone.

The format for any report is often determined within a particular jurisdiction. However, in broad principle the report should have a simple structure to include what happened, what impact it had, how it was managed, what was learned from it, and what remedial recommendations should be made.

Managing the review Any event may result in a formal review. Most organisations will seek to identify the impact the event had on them and the effectiveness of the actions taken so that lessons identified may inform future planning and preparedness. It is important for organisations to do these reviews, but in doing so to ensure that they are effectively managed. Poorly managed reviews may fail to identify objectively the key findings, or they may become distracted by internal political matters. Equally a poorly managed review may be destructive to individuals within the organisation or to the organisation as a whole, resulting in secondary damage. Additionally communities of any size may seek to conduct a community-wide review. The terms of reference of that review may be narrow (i.e. focussed on particular elements) or broadly based. In theory such reviews should be focussed on identifying the lessons to be learnt, but unfortunately they are often captured by sectional interests pushing political agendas. These may include identification of fault to use for political purposes or as grounds for compensation.

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There is also considerable experience with formal community-wide reviews that have widespread compulsive powers to attend and give evidence, with penalties imposed for failure to cooperate or the provision of false information. Such reviews are of considerable public interest and draw daily media attention. Yet they necessitate defensive action by those whose actions are likely to be the focus of the review, and thus they become a highly formalised legal process.

Key readings Department of Homeland Security. Chapter Five ‘Lessons learned’. In: The Federal Response to Hurricane Katrina. Washington: United States Government; 2006. Hu Q, Connolly Knox C, Kapucu N. ‘What have we learned since September 11, 2001? A network study of the Boston marathon bombings response’ Public Administration Review. 2014; 74(6): 698–712. Lange A, Hernates J, Mari Sarriegi J. ‘Analysis of disaster impacts and the relevant role of critical infrastructures for crisis management improvement’ International Journal of Disaster Resilience in the Built Environment. 2015; 6(4): 424–437. Voss M, Wagner K. ‘Learning from (small) disasters’ Natural Hazards. 2010; 55: 657–669.

Activity Imagine you have been asked to prepare terms of reference for an enquiry into a major flood. • •

Draft brief terms of reference. Identify the data required for the enquiry.

References Birkland T. After Disaster: Agenda-setting, public policy, and focusing events. Washington: Georgetown University Press; 1997. Birnbaum ML, Daily EK, O’Rourkea AP et al. ‘Disaster Research/Evaluation Frameworks, Part 1: An overview’ Prehospital and Disaster Medicine. 2014; 14: 1–12. Boin A, ‘t Hart P. ‘Organising for effective emergency management: Lessons from research’ The Australian Journal of Public Administration. 2010; 69(4): 357–371. Boin A, ’t Hart P, Stern E et al. The Politics of Crisis Management: Public leadership under pressure. Cambridge: Cambridge University Press; 2005. Boin A, McConnell A, ‘t Hart P. Governing After Crisis: The politics of investigation, accountability and learning. Cambridge: Cambridge University Press; 2008. Boin A, McConnell A, ‘t Hart P. ‘Crisis leadership’. In: Couto RA, editor. Political and Civic Leadership: A Sage reference handbook. London: Sage; 2010. CAIB Report. The Columbia Accident Investigation Board Report. Washington, D.C. 2003. https://www.nasa.gov/columbia/caib/html/start.html (accessed 18 May 2016). de Ville de GC. ‘Stop propagating disaster myths’ Lancet. 2000; 356 (9231): 762–764. Deverell E. Crisis-Induced Learning in Public Sector Organizations. Stockholm: Elanders Sverige; 2010. Ellis S, Kanowski P, Whelan R. National Inquiry on Bushfire Mitigation and Management. Canberra: Commonwealth of Australia; 2004.

Evaluation & learning  319 Flin RH. Sitting in the Hot Seat: Leaders and teams for critical incidents. Chichester: Wiley; 1996. Flin R, Arbuthnot K. Incident Command: Tales from the hot seat. Aldershot: Ashgate; 2002. Flin R, O’Connor P, Crichton M. Safety at the Sharp End: A guide to non-technical skills. Aldershot: Ashgate; 2008. Goode N, Spencer C, Archer F et al. Review of Recent Australian Disaster Inquiries. Melbourne: Monash Injury Research Institute; 2011. Gunn S, Masellis M. ‘Evaluation of the disaster medical response: A proposal for a research template’ Annals of Burns and Fire Disasters. 1996; IX (4): 1–4. Hilliard M. Public Crisis Management: How and why organizations work together to solve society’s most threatening problems. Lincoln: Writer’s Club Press; 2000. Kennedy John F. Commencement address at Yale University. 11 June 1962. Rodriguez H, Quarantelli EL, Dynes RR. Handbook of Disaster Research. New York: Springer; 2006. Rogers Commission Report. Report to the Presidential Commission on the Space Shuttle Challenger Accident. Washington, D.C. 1986. http://history.nasa.gov/rogersrep/genindex.htm (accessed 18 May 2016). Stern EK. ‘Crisis and learning: A balance sheet’ Journal of Contingencies and Crisis Management. 1997; 5(2): 69–86. Sundnes KO, Birnbaum ML. ‘Health disaster management: Guidelines for evaluation and research in the Utstein Style’ Prehospital and Disaster Medicine. 2003; 7(3): s1–s14. Teague B, McLeod R, Pascoe, S. 2009 Victorian Bushfires Royal Commission: Interim report. Victoria: Government Printer for the State of Victoria; 2009. ‘t Hart P. Organising for Effective Emergency Management: Submission to the Royal Commission on the Victorian Bushfires. 2010 (updated 2015). www.amsa.gov.au/forms-and-publications/ environment/publications/NP-Reports/documents/Paul%20t’Hart%20Organisaing%20 for%20Effective%20Emergency%20Management.pdf (accessed 3 Feb 2016). ‘t Hart P, Ullberg S, Kofman-Bos C. ‘The long shadow of disaster: Memory and politics in Holland and Sweden’ International Journal of Mass Emergencies and Disasters. 2005; 23(1): 5–26.

Chapter 25

Education, training and research Amy Hughes, Vivienne Tippett, Nieves Amat Camacho and Peter Horrocks

Introduction and objectives To avoid the difficulties in separating education and training, this text will refer to the terms as one. Nevertheless, it must be recognised that education is traditionally considered to develop knowledge and understanding while training develops skills. Previous chapters have emphasised the critical importance of capability development through training and education, and the need for policy and practice to be based on the best available evidence. However, the system-wide challenge lies in how to take an organised and disciplined approach to the composition of best evidence and translate this into practice through policy, education and training. It is vital to establish a resilient, integrated and standardised approach to education and research as a foundation from which to develop training needs. Traditionally there has been little consistency in education and training for disaster management. Additionally, disaggregation of policy responsibility and leadership at government levels in many countries makes it increasingly difficult to identify and accept a standardised approach. There is considerable value in standardising core aspects of training and education while ensuring flexibility in delivery to enable adaptation to different contexts. This balance between standardisation and flexibility is the key to a resilient training and education framework. This chapter examines current disaster education, training and research strategies and aims to identify the key challenges involved in crafting an effective and organised approach to future development. On completion of this chapter you should be able to: • • • •

Understand the core elements of an effective disaster management training, education and professional development program. Design and organise delivery of training and education programs including desktop and field exercises. Explain the use of evidence-based research to improve health disaster management policy and strategies to strengthen actions at all levels. Direct and design an appropriate and progressive research agenda in disaster management.

Education and training frameworks There are innumerable training and education programs in disaster management provided by a broad range of organisations including government bodies, service

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providers, universities and other education colleges, non-governmental organisations (NGOs), commercial entities and individuals. There are also a number of approaches to the delivery of training and education, including e-learning (online), simulation and table-top exercises, workshops, and didactic lectures. This diversity provides variety for those seeking training and education opportunities, but conversely, such diversity weakens the strength of capability development, inevitably leads to duplication and wasted effort, and reduces the prospects for interoperability and standardised approaches. The current education provision can be classified into the following categories: •

• •

Credentialed courses that result in attainment of a qualification through achievement of learning objectives or the demonstration of competence. Such programs may be found across the full spectrum of education offerings from basic certificates through to university doctorates. These programs may be either inherently theoretical or a mixture of theory and practical application. Non-credentialed short programs that focus on the development of specific skills or competencies and assist with broadening understanding. Continuing professional development programs which aim to update and extend an individual’s capability.

Following the 2010 Haiti earthquake, there was a clear recognition by many of those involved in the response of the need for a global consensus on international standards for education and training of personnel, particularly international healthcare workers involved in disaster response. Equally recognised was the need for improved coordination amongst international organisations, increased support for host countries in the aftermath of a disaster, improved governance and accountability from international responders, and the need for a global registration system for deploying organisations. The challenge to date has been to achieve consistency in education outcomes, and to provide mechanisms so participants can follow a structured hierarchical approach to training and education. In 2010, an Australian national network of disaster health educators recommended a structured approach to disaster health education and training (FitzGerald et al. 2010). This framework proposes seven levels of education and awareness, as outlined in Table 25.1. However, it may be considered that this approach of standardising programs is input (course) focused while a more appropriate approach would be competency focused. Two reviews of expected competencies (Daily et al. 2010; Gallardo et al. 2015) have sought to create competency outcomes as the foundation for standardisation of education and training frameworks. Limitations include difficulties for their translation and applicability into practice, and cohesion into one standardised framework. Looking from a more operational perspective, current emphasis has been placed on ensuring training platforms are: • • • •

Inclusive of both generic and context-specific knowledge. Academically and operationally focused and multidisciplinary. Focused on improving the knowledge and understanding of the needs of the affected country and level of support required from the international community. Adapted as appropriate for domestic and international response.

322  A. Hughes, V. Tippett, N. Amat Camacho & P. Horrocks Table 25.1 A framework for disaster health education and awareness. Level

Strategy

1

General public awareness of threat, impact and broad principles of disaster management and community resilience. Introduction to principles of disaster management arrangements and practice designed to provide health workers with a common understanding. Intended to create awareness amongst health workers likely to be involved in major incident responses. Includes the principles and practice of disaster response and the roles and responsibilities of key individuals and organisations. Targets leadership with key roles in preparedness or response. Addresses detailed PPRR (prevention, preparedness, response, recovery) arrangements and the skills required to manage those arrangements. Targets individuals responsible for leading development of preparedness and response arrangements. Provides an in-depth understanding of the principles and practice of disaster health management. Aimed at the future educators and system designers. Intended to provide candidates with an extensive understanding of both the principles and practice of disaster health management and in-depth awareness of specific components. Individuals who are leading the innovation and creative edge.

2 3 4 5 6 7

Source: FitzGerald et al. (2010).

Two specific considerations should be taken into account regarding training for those participating actively in disaster response teams and coordination: 1 Broadening of knowledge for all team members on general disaster and humanitarian principles and practice: security, logistics, water/sanitation, relevant general health epidemiology, culture and communities. 2 Development of technical skills specific to the deploying context for the individual roles within the team (doctor, nurse, team leader, data manager or logistician). Training for response teams & disaster coordination should include: •  Develop knowledge of all team members on general disaster & humanitarian principles & practice. •  Develop technical skills specific to deployment context for individual roles. • •

In view of such variability amongst the different approaches to education and training and the current lack of set standards, leaders in organisations are faced with the difficulty of developing an education and training program relevant to their particular context. Without limiting in any way the need for flexibility and country-specificity programs, a comprehensive health program may include:

Core principles of disaster health management and the organisational and governance arrangements required for planning, preparedness and response. Mass casualty management that is context and resource appropriate. For example, a mass casualty incident in a country with a developed healthcare system and

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•

• • •

extensive pre-hospital medical services will be approached very differently to a similar incident in a country with a less developed healthcare system and resource infrastructure. International mutual-aid, including the role of national and international organisations/teams, familiarisation with national health guidelines and clinical practice, public health, population health, and resource and culturally based decision-making. Health and trauma needs following disasters, including for chronic health, noncommunicable disease and mental health. Public health protections following disasters, including sanitation, food and water safety and environmental health. Health logistics and the supply of consumables and services.

In addition to any tiered approach to the underpinning principles and practice, there is also a need for task-specific training relating to a particular role. For example, international response teams will need to be trained to an appropriate level for their roles in the principles and practice of disaster management. This may then need to be complemented by specific training in the role and its responsibilities and by contextspecific briefing relating to the particular deployment. Special programs may also be required, for example: • • • • • • •

Major incident management systems. Urban search and rescue. Mass casualty management in the clinical management of victims of major incidents. Chemical, biological and radiological (CBR) program designed to complement programs offered by emergency services but with a particular emphasis on the health impact of CBR. International assistance program targeting health teams that offer international assistance. This program would include aspects of public and refugee health. Pandemic preparedness program for public health workers. This would incorporate the short course disaster management program with a particular emphasis on pandemic preparedness and management. Mental healthcare and disasters program consistent with a national framework of disaster education.

Additionally, the scope and level of training and education programs needs to focus on the role of the individual and his/her functions within the health system. Consideration may be required for specific roles such as: • • •

Team leader development; detailed knowledge of the principles, governance and organisational arrangements, awareness of key issues, and skill development in crisis leadership, language and coordination skills. Those involved in monitoring and evaluation; debriefing procedures, and data information and protection procedures. Those involved in building resilience; planning and preparation.

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All education and training within disaster and emergency management should have a three-tiered approach, where each tier is of equal importance: 1 Training relevant to the individual (e.g. specific healthcare training). 2 Training relevant to the team and adapted to the context (e.g. team-focused operational simulation training). 3 Training relevant to the organisation (e.g. training on specific security procedures or integration in the humanitarian system). Finally, it is worth reviewing the myths outlined by Burstein (2006) regarding disaster education: •

• • • •

In a three-tiered approach, training must be relevant to:

•  The individual. People need to know special things in •  The team & adapted to the context. disasters. Disaster responses should •  The organisation. be based on normal, but context- and resource-appropriate, practice. We are smart; hearing it once is enough. One-off courses provide only a temporary boost to knowledge and performance: this type of work needs to be continually professionalised. A drill now and then is enough. Drills need to be applied to various contexts and continually repeated to refresh and maintain awareness. The government will take care of it. The government is a key player and must be supported by the international community; but mostly, it is the local community who will respond. It is impossible to be prepared. Putting aside the digital nature of this myth (it is never all or nothing); people, organisations and communities can be prepared.

Exercises and simulations One of the most effective means of testing an organisation’s preparedness and response capability is through context-specific exercises. Most organisations are familiar with fire drills and evacuations, but few conduct regular disaster management exercises. In particular, health organisations find it difficult to suspend normal emergency activities to test their capabilities for non-routine events. In emergency management, exercises are important to ensure personnel are exposed to a simulated situation to develop their experience. Simulation exercises are also important to ensure policies, plans and procedures are tested and evaluated in as ‘near to real’ environment as possible. Creative and innovative ways may be necessary to find opportunities to test preparedness and response capabilities. Some may find opportunistic events that require large-scale activities to test their capability. For example, moving into a new facility may be used to test evacuation capabilities and a mass crowd event may be an opportunity to test preparedness and planning. Exercises may be desktop or live and those involved may be players, controllers and the observers: •

Desktop or table-top exercises are indoor facilitated discussions with no operational response. They may take the form of discussion exercises designed to

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•

tease out the elements of a problem or functional exercises replicating the real world environment without its physical or visual clues. Live exercises are usually simulations to test parts of the plan against a scenario. They are often conducted outdoors and require an operational response.

Exercise papers will include scenarios, narratives and serials.

Case study 25.1: Exercise NUGENTS, 2012 Exercise NUGENTS was developed following the 2010/2011 flood events in Queensland, Australia. A large-scale live exercise, NUGENTS was conducted over three days from 30 November 2012. NUGENTS was designed to enhance the readiness of disaster management groups by practicing disaster management arrangements in the context of an extreme weather event. Developed to incorporate the key elements of disaster preparedness and response, NUGENTS enabled participants to build and validate disaster management capability by providing participants with: Opportunity to: •

Trigger the activation of disaster management arrangements.

Practice in: • • •

Procedures to initiate different warning mechanisms, including those that do not rely on electricity and the SMS alert approval process. Safety messaging and media interviews. Handover briefs, shift change and 2nd roster.

Exercise in: • • • • • •

Disaster management group relationships and engagement at local and district level. Support between councils. Disaster coordination centre capacity to deal with high volume calls. Evacuation plans and sub-plans, including those involving facilities in which residents require assistance to evacuate, and plans for evacuation centres. Re-supply arrangements and other specific arrangements for communities isolated by disaster. Evaluation of the effectiveness of software in facilitating the communication flow between disaster management groups.

Prior to the live exercise, a planning meeting where participants were encouraged to identify areas within their jurisdiction to be exercised was held. Flexibility was built into NUGENTS design to allow participants to exercise as fully as resources permitted while continuing business as usual.

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An overview of the exercise was presented at a pre-exercise briefing and discussion exercise. Attendees were presented with two severe weather events similar to the scenarios used in the NUGENTS exercise. Participants worked through the scenarios in their respective disaster management groups to formulate strategies to manage the situation. Feedback from participants was that this was a worthwhile desktop exercise identifying a number of issues. Answers provided were used as a basis for NUGENTS serials: 670 serials were written for the exercise. Serials were aligned with participants’ identified objectives and the call centre component of the exercise. These included vulnerable clients, assisted evacuation, call centre capacity, isolated communities, re-supply, council-2-council and community inventory. Lessons identified provided invaluable information for future education and training and provided participants with the opportunity to revise/refine their disaster management arrangements and plans; particularly in relation to improving coordination, clarifying roles and responsibilities and fostering cooperation among agencies.

Live exercises are difficult to organise and consume resources. They may be difficult to justify on economic or clinical grounds as they distract resources from normal operations. The value of live exercises is that they are high-profile events that genuinely test responses in a real-time environment. Table-top exercises typically involve a small number of people and concentrate on a specific aspect of the plan. They can easily accommodate complete teams or a single representative from each of several teams. Typically, participants work through a simple scenario then discuss specific aspects of the plan. An intermediate style of exercise may be conducted within a ‘virtual world’, bringing together several departments, teams or disciplines. A complex exercise aims to have as few boundaries as possible. It incorporates all the aspects of a medium exercise. The exercise remains within a virtual world, but maximum realism is essential. This might include no-notice activation, actual evacuation and actual invocation of a disaster recovery site. Thunderbolts are no-notice, internally run exercises that focus on specific portions of an organisation or a specific process. They are usually of short duration and are a key tool for a leader to test his/her team. Training for leaders and those they lead includes: • • •

Preparation including media training, risk communication training and best practices for dealing with hostile audiences. Learning from past events and analysing how other organisations handled a crisis to help leaders look at their own organisation’s level of preparedness. Knowledge of individual crisis response roles and associated specific training. Exercises can identify which team members and parts of an organisation need further training and/or capability building.

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IDENTIFY THE NEED EVALUATE THE EXERCISE

PLAN THE EXERCISE

FIVE PHASES OF DISASTER EXERCISE MANAGEMENT DEBRIEF THE EXERCISE

CO NDUCT THE EXERCISE

Figure 25.1 Exercise management cycle for a disaster.

The disaster exercise management cycle includes five phases, as shown in Figure 25.1: 1 Identify the need: All exercises begin with a specific need to test, evaluate and validate plans, assess performance, practice or train, and identify issues. It is important that the exercise has a clearly defined purpose. The identified need should be analysed to determine the aim and objectives for the proposed exercise. 2 Plan the exercise: All exercises need to be planned in detail and in as close to a realistic context as possible. The plan needs to be documented so that each of the key controllers is aware of their role. The information available to participants needs to be provided in as close to real time as feasible. 3 Conduct the exercise: Conducting the exercise involves pre-exercise activities such as briefing, starting, managing and finishing the exercise and debriefings. 4 Debrief the exercise: Debrief is the process of critically analysing the conduct of the exercise. 5 Evaluate the exercise: Evaluation should include the design and conduct stages of the exercise as well as the participants’ response to the developing scenario. Evaluation may take the form of an ‘after-action review’ and should include an evaluation of any recommendations for subsequent action. Information on the exercise is usually provided within a paper to the participants. It details the scenario, as well as providing a narrative of the event and individual items of input (e.g. phone or fax messages or a visit).

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Finally, all exercises need to incorporate an evaluation program that identifies the elements to be evaluated, the criteria to be used in the evaluation and the standards expected.

Research approaches and fields of endeavour Effective research in any discipline is dependent on a comprehensive understanding of the available literature and the calibre of that evidence. New research efforts need to be focused on addressing current gaps in the field, but should build on previous research. Practitioners interested in contributing to this field of endeavour will need to be skilled in conducting literature searches and the evaluation of evidence as well as a broad spectrum of research methodologies. Disaster literature has developed considerably over the past several decades. This body of work has discredited disaster myths; described the actual responses of people and various groups; discussed the challenges of multi-agency coordination; and examined issues in disaster preparedness, response and management. There is now an understanding that during disasters, whether they are natural hazards or manmade events, individuals and communities often respond in different ways than anticipated (Misanya and Oyhus 2014). New research has begun to explore in more depth the processes associated with the choices humans make under the duress of disasters. This may identify opportunities to provide improved decision-making support. Understanding human behaviour in these circumstances also assists agencies in coordinating responses more effectively (Drabek and McEntire 2003). Contemporary advances in technology and communications open extensive opportunities for new interdisciplinary and industry partnerships to address the challenges associated with community and organisational preparation, response and recovery. How might we structure a research program? While there is undoubtedly a place for spontaneous and opportunistic research endeavour, a reliable body of evidence is generated by sustained and targeted effort. Achieving this requires adherence to some form of theoretical framework against which we can scaffold and prioritise the activity. It is generally well recognised that there are a number of structural social changes unique to disasters (Kreps and Drabek 1996). New behaviours, social relationships and community organisations will often appear after a disaster. These new relationships are also sometimes characterised by an extension of roles and responsibilities of professionals. This ‘emergent phenomenon’ has been the subject of a considerable body of work over the last 15 or so years. They are most likely to occur where demands are not met by the organisations in place; when traditional structures and tasks are inappropriate, or the community decides it is necessary to move forward (Drabek and McEntire 2003). An emergent group has more recently been defined comprising citizens working together towards common goals relating to a disaster, but whose organisation has not become institutionalised as yet. These citizens can include a mix of public and private sectors as long as the collective develops new relations and tasks before, during or after the disaster (Drabek and McEntire 2003; Hughey and Bell 2012).

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Other examples of emergent phenomena include the new categorisation of emergent groups, for example those with latent knowledge. These would be fully emergent groups with no previous knowledge of each other performing non-regular tasks, but sharing the common characteristic of being trained in emergency responses. This is an expanding group as their tasks are not defined and their knowledge has not been used before. According to Drabek and McEntire (2003), these recent conceptualisations are primitive and need refinement of the theory and empirical support. Additionally, there is a small area of research examining the impact of culture, religion, gender and race/ ethnicity on emergent phenomena. For example, cultural attitudes and beliefs about self-reliance and expectations of government response agencies may limit self-initiated responses. Some physical and psychological phenomena associated with disasters only appear sometime after the event (North and Pfefferbaum 2013). Progressing this body of work will necessarily require longitudinal mixed methods approaches. Organisation and role are important parts of sociological theory but, to date, research has not successfully related these components to structure. Social action and social order describe the process by which an individual commits to a course of action and how social units influence the involved thoughts and behaviours. In order to attempt to relate these concepts to disaster management, organisation and emergency roles, there needs to be a conceptualisation of social structure showing the variables. This structure is based on the following elements, each of which gives rise to important areas of research endeavour: • • • •

Domains: boundaries distinguishing a group from others. Tasks: including division of labour giving focus and direction. Resources: capacities and technologies of individuals and collectives. Activities: combines actions of individuals and social units.

An alternative way to structure a comprehensive research agenda is to consider the widely accepted phases of a disaster characterised by the PPRR model (Kelly 1999). Although this model has been criticised by some for its assumption of a linear relationship between the stages of an incident (Crondstedt 2002), it nevertheless provides a reasonable theoretical platform on which to structure a disaster research program. Regardless of the theoretical framework applied to the research, it is critical in any research endeavour to: • • •

Relating concepts to disaster management, organisation & emergency roles requires conceptualisation of social structure based on: •  Domains. •  Tasks. •  Resources. •  Activities.

Identify and define the problem. Build a set of coherent and evidence-based set of assumptions to test/explore. Select a methodology appropriate to the nature of the question.

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Potential research targets With the increase in major disaster incidents globally, both natural and For any research endeavour, it is manmade, there is increasing research critical to: attention on the challenges associated •  Identify & define the problem. with large-scale collaborative inter•  Build a set of coherent & evidencenational responses, for example the 2004 based assumptions to test/explore. Asian tsunami. There is, however, a great •  Select a methodology appropriate deal more work that could be done in this to the nature of the question. area. The scope of the research opportunity in examining the effectiveness and efficiency of response to these events is broad. Logistics and supply chains; inter-agency operations; communications; community re-location and re-establishment; and policy and procedures are all areas which warrant exploration (de la Torre et al. 2012). In attempting to conduct this work, researchers face a number of definitional challenges which can constitute impediments to systematic analyses of this body of work. In a rigorous analysis of disaster management research, Galindo and Batta (2013) draw attention to the current lack of research in several areas. These topics include definitions of organisational networks which facilitate coordination and communication; exploration of opportunities for the development of new technologies to assist disaster preparedness and response; business continuity; infrastructure design; modelling of service allocation to disaster victims; post-disaster housing; re-establishment of community post-event; and the specific challenges facing communities in the developing world. These authors also valuably identify flaws in many of the assumptions that researchers have brought to attempts to contribute to the development of operational management and community response to disasters.

Key readings Cranmer HH and Biddinger PD. ‘Typhoon Haiyan and the professionalization of disaster response’ N Engl J Med [Internet]. 2014; 370(13): 1185–1187. www.nejm. org/doi/full/10.1056/NEJMp1401820 (accessed 9 May 2016). Van Hoving DJ, Wallis L, Docrat F et al. ‘Haiti disaster tourism—a medical shame’ Prehosp Disaster Med. 2010; 25(3): 201–202. WADEM (World Association for Disaster and Emergency Medicine). ‘Guidelines for evaluation and research’. https://wadem.org/publications/guidelines-evaluationresearch/ (accessed 9 May 2016).

Activities • • •

What is the benefit of developing an education and training framework for disaster health? Should a research agenda be developed for disaster health or should it be left to individual researchers to set their own agenda? Review and discuss the flaws in some of the assumptions that research has made about operations during disaster events, as identified by Galindo and Batta (2013).

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References Burstein J. ‘The myths of disaster education’ Annals of Emergency Medicine. 2006; 47(1): 50–52. Crondstedt M. ‘Prevention, preparedness, response, recovery: An outdated concept?’ The Australian Journal of Emergency Management. 2002; 17(2): 10–13. Daily E, Padjen P, Birnbaum ML. ‘A review of competencies developed for disaster healthcare providers: Limitations of current processes and applicability’ Prehosp Disaster Med. 2010; 25(5): 387–395. de la Torre LE, Dolinskaya IS, Smilowitz KR. ‘Disaster relief routing: Integrating research and practice’ Socio-Economic Planning Sciences. 2012; 46: 88–97. Drabek TE, McEntire DA. ‘Emergent phenomena and the sociology of a disaster: Lessons, trends and opportunities from the research literature’ Disaster Prevention and Management. 2003; 12(2): 97–112. FitzGerald GJ, Aitken P, Arbon P et al. ‘A national framework for disaster health education in Australia’ Prehospital and Disaster Medicine. 2010; 25(1): 4–11. Galindo G, Batta R. ‘Review of recent developments in OR/MS research in disaster operations management’ European Journal of Operational Research. 2013; 230: 201–211. Gallardo AR, Djalali A, Foletti M et al. ‘Core competencies in disaster management and humanitarian assistance: A systematic review’ Disaster Med Public Health Prep [Internet]. 2015; 1–10. www.journals.cambridge.org/abstract_S193578931500024 (accessed 9 May 2016). Hughey EP, Bell HM. ‘A model of community response: Institutional structures and disaster management’ Risk, Hazards & Crisis in Public Policy. 2012; 3(2): 1–17. Kelly C. ‘Simplifying disasters: Developing a model for complex non-linear events’ The Australian Journal of Emergency Management. 1999; 14(1): 25–27. Kreps G, Drabek T. ‘Disasters are non-routine social problems’ International Journal of Mass Emergencies and Disasters. 1996; 14(2): 129–153. Misanya D, Oyhus AO. ‘How communities’ perceptions of disasters influence disaster response: Managing landslides on Mount Elgon, Uganda’ Disasters. 2014; 39(2): 389–405. North CS, Pfefferbaum B. ‘Mental health response to community disasters: A systematic review’ JAMA. 2013; 310(5): 507–518.

Chapter 26

Future challenges Gerry FitzGerald, Mike Tarrant, Peter Aitken and Kara Burns

Introduction and objectives While it is difficult to predict the future of disaster health management, we can at least reflect on the challenges and opportunities faced by disaster managers and communities affected by disasters. Modern societies are incredibly complex and dependent on interconnected socio-technological systems which create tremendous opportunity by creating improved services and products, while at the same time potentially increasing vulnerability. The same is true for disaster management. Leaders and managers face diverse challenges characterised by an increasingly complex environment making performance and accountability more difficult. However, it does provide remarkable opportunities to achieve better outcomes in a climate of minimal tolerance for failure. This chapter seeks to explore some of the high-level challenges confronting disaster health managers. Not to provide solutions or to be exhaustive, but rather to use these concepts, principles and practices outlined throughout this text to help practitioners reflect on their practice and explore the complexity that characterises effective disaster health management. On completion of this chapter you should be able to: • •

Demonstrate an understanding of the key strategic issues confronting disaster health management and the ways in which those issues may impact on the health and wellbeing of the community. Identify new challenges and discuss mechanisms for thinking through those issues and undertaking the research and analysis required to better understand and resolve them.

Development and disaster management There is a direct (two-way) association between disasters and development. In general, the poorest communities are most disproportionally affected by disasters and these poorer countries cannot absorb repeated disaster costs and maintain development goals. For example, in the wake of Hurricane Mitch in 1998, Honduras’ President, Carlos Roberto Flores, said damages totalling US$6 billion (more than the national GDP) had destroyed 50 years of progress and set development back by 20 years (Lichtenstein 2001). Following the Indus River floods in Pakistan, the provincial Punjabi authority allocated most of the development budget to disaster response with

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little likelihood of replenishment. The earthquake in Haiti completely devastated one of the world’s poorest countries. Essentially, investments made by poorer countries to achieve their development goals are nullified by these losses. Cities with fast-growing populations in hazard-prone areas will incur larger costs to pay for the damage and losses that will occur with increasing frequency. Indeed, the costs of disasters are challenging the very basis of investments in development; but the impact is not restricted to poorer nations. The Great Eastern Japan earthquake in March 2011 caused at least US$300 billion in damage; floods in Australia in 2010 cost US$10 billion; while an earthquake in the same year in New Zealand cost upward of US$5.5 billion. From 1989 to 2010, 19 countries reported the destruction of 63,667 schools and 4,873 health facilities, and damage to 73,000 kilometres of roads, 3,605 municipal water systems, 4,400 sewer systems and 6,980 power installations. Consider the knock-on effects of this damage to infrastructure through lost educational opportunities, risks to public health, economic consequences of transportation failures (for example, damage to transported goods such as food perishing on trucks cut-off due to flood waters), and the loss of employment and production in industries which may not even be in the impacted area. Given these facts it is surprising very few countries have public investment policies that include effective risk management approaches. Moreover, the international community has yet to fully recognise that if global, sustained and equitable development is to be achieved, then disaster reduction, climate change adaptation and poverty eradication must shape future development plans for energy, water or other strategies for the public good. The Global Assessment Report on Disaster Risk Reduction: Revealing Risk, Redefining Development (United Nations 2011) and the Sendai Framework for Disaster Risk Reduction (United Nations 2015) both highlighted the absence of risk-sensitive development strategies. The goal therefore is to protect development investments and lives. An important opportunity is to improve the relationship between business and corporate community and government, to effectively manage disaster risk through more effective approaches, and thus to reduce risk. Enterprises that understand risk recognise the need to protect supply lines as well as to ensure healthy workforces and customers who will continue to consume. This requires protection of physical assets, infrastructure and the health, as well as welfare, of people. Disasters have a significant impact on development, and emergency risk management is becoming a core concept for community and organisational sustainability including for health. Effectively managing risk builds long-term sustainability and therefore development. Chapter 2 outlined the impact that disasters have on economic development of nations. Disasters tend to impact most on less developed nations contributing further to their slow development. Moreover, poorer nations have less capacity to respond and render aid and are subject to the benevolence of richer nations which often comes with inappropriate aid. Economic development in turn has a direct relationship with disaster impacts. More wealthy communities are able to build more resilient infrastructure and to have available the resources for response and recovery. They have the capacity and funding to adapt; developing alternative industries that can replace those destroyed. They have the capacity to minimise the economic impact on individuals and communities.

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The United Nations developed an international agreement to guide disaster management for the next 15 years. The Sendai Framework (United Nations 2015) identified four priorities: 1 2 3 4

Understanding disaster risk. Strengthening disaster risk governance to manage disaster risk. Investing in disaster risk reduction for resilience. Enhancing disaster preparedness for effective response, and to ‘build back better’ in recovery, rehabilitation and reconstruction.

Risk assessment and early warning systems should be in place; education and information should build a culture of health, safety and resilience at all levels; strategies should aim to reduce underlying risk factors to health and health systems; and emergency preparedness arrangements should be in place for effective health response and recovery at all levels. The challenge for health systems is to broaden the focus away from relying on response to a more encompassing and inclusive approach that includes reduction of risk, protection of health facilities, and collaboration across sectors to meet community needs. This text has also identified the importance of effective recovery and adaptation on the impacts of disaster, particularly in the longer term. Moderating those impacts can be a major contributor to economic development. However, economic development is not without risk. There are inevitably winners and losers, and individuals, communities and organisations will fight to preserve their interest against often the greater good of a broader community. Farmers will fight to retain their lands which may be required for the construction of flood mitigation works; and developers will fight for maximum return from cheap but floodable land.

Governance Governance is becoming increasingly complex as the demand for performance and accountabilities increases. The CEO of any organisation is accountable to the owners, the staff, the customers, and to a range of legislative and regulatory bodies and instruments. Larger companies may be able to afford people to ensure those accountabilities are met but in theory those same accountabilities apply to the solo operator of the coffee cart outside your building. Disaster management preparedness is another of those accountabilities and if simply added to other responsibilities may become an additional burden that threatens business viability rather than enhancing resilience. At the level of government, there are fundamental changes occurring in the role, which are disengaging from service delivery and thus government no longer has direct control over many of the community organisations traditionally considered to be part of government. This has been driven by demands for greater efficiency and cost savings but it results in government being less able to directly meet community expectations, instead relying on contracts with other organisations. This makes disaster management more difficult and vulnerable to the failure of subsidiary organisations. The growing complexity of modern organisational processes and structures has the net effect of limiting not only management’s ability to understand the interconnections, but also to manage those interconnections in the event of any failures of components.

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For example, imagine a hospital with responsibility to manage those injured in an earthquake when the power supplied by independent companies has failed, the drug and other consumable supply companies are unable to deliver due to destruction of the roads, and the company that provides meals has been damaged and is unable to operate. How do leaders and managers meet their objectives by finding workaround solutions and restructuring their systems and processes to fit the situation? A paper prepared for the Bushfire Cooperative Research Centre in Australia (Owen et al. 2014) identified seven key challenges facing emergency managers. Although generic in their application, these challenges are equally applicable to health disaster managers: 1 2 3 4 5 6 7

Increased uncertainty, complexity and convergence. The disconnect between disaster risk reduction and public policy. The expectations and resilience of the community. Social media, networking and emergent behaviours. The political–operational nexus. Evaluating emergency management responses. Development and capability.

Social change Changes in social structures and values may also impact on disaster management: •

•

•

•

Demographic changes, particularly population ageing, are reducing the relative workforce that is available to respond to disasters. Equally, increasing workforce participation has resulted in fewer people being available to support volunteer agencies. Changes in society attitudes have reduced the volunteer workforce. It has not necessarily reduced the sense of compassion and preparedness to help, but it has tended to reduce individual preparedness and ability to commit in a structured way. For example, consider the situation of volunteer organisations such as the state emergency services in Australia. These bodies rely on community volunteers to provide a range of community response activities. At the same time, increasing accountabilities are requiring those who do participate to undertake more training and accreditation to meet health and safety standards. With increasing commitment comes decreased availability. Increased safety and efficiency has had an impact of reducing people’s tolerance for loss. People are reliant on the complex societal systems that characterise modern society. If the power goes down, technology fails, and individuals are less able to find innovative alternatives or workarounds. There is an increasing distrust of authorities making it more challenging to communicate more clearly. The complexity of modern communities is such that there is a decline in the sense of community. Communities in rural areas tend still to be defined geographically (e.g. the Mt Isa community). On the other hand, communities in the city are defined more by commonality of interest which can shift by time of day. For example, you may belong to the workplace community during working hours, the school community at pick-up time and the soccer

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• •

community at weekends; however, you identify mainly with your online special interest community. The 24 hour news cycle makes it difficult to manage disasters. Modern disasters will be played out in real time on television. Thus authorities are required to provide information that they may not have. Increased education standards are improving people’s disaster awareness and literacy; but conversely, it tends to make people more challenging of issues.

There is a changing perspective within society: increasing accountability alongside reduced tolerance of adversity. This apparent lack of tolerance of adversity may also result in unreasonable expectations. Disasters which used to be seen as an ‘act of God’ are now seen as someone’s fault. This changing conceptualisation is placing increased burden on those responsible for disasters management.

Technological changes Technological changes are having a major impact on modern disaster management. There have been vast technological advances in the past 100 years, which directly affect risk as well as disaster management capability. The rate of technological change is only going to increase and this provides remarkable possibilities to enhance disaster management. The consumer world is driving innovation with many services including internet, social media, gaming, music and work emails now available in mobile form. Future PMR (private, mobile and radio) services may access a core network through mobile devices resulting in a more distributive system. The newly developed app GIVIT has great potential for helping people and organisations access resources in disasters (www.givit.org.au/). Social media platforms also allow people to identify as members of communities beyond the traditional socio-cultural and geographic boundaries. Within the disaster management sphere, ‘digital humanitarians’ are an example of this phenomenon (Meier 2015). The movement mobilises individuals outside disaster-affected areas to provide assistance to the affected zones through the analysis of ‘big crisis data’. Practically, this can mean thousands of people who will never meet simultaneously analysing images taken by an unmanned aerial vehicle (UAV) of a disaster zone in order to aid relief strategy and rebuilding efforts. In addition, ‘service-oriented architecture’ characterises systems development and integration of systems based on functional interoperability. Therefore different applications will be able to exchange data with one another. With all these new developments and technologies it becomes clear that in the future, the provision of commercial offset strategies will be a key aspect of investment decisions. Where these are targeted to result in improvements in disaster response, the impact may be far-reaching and more effective than developments funded by government or nongovernmental organisations (NGOs). Information technology and social media are becoming the new norm. While they provide individuals with immediate access to a vast array of information, they also make it increasingly difficult to disentangle accurate information from the enormous amount of inaccurate, incomplete or incorrect information. This makes it more challenging for authorities to communicate clearly and consistently.

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While ‘big data’ is valuable, the sheer volume, the people power, and the computing power required to perform analysis currently limits its usefulness. As computer processors, modelling, machine learning and the data mining behind predictive analytics improve, the amount of information will become more manageable. The challenge will then be to integrate this with existing information. Importantly, movements like this are not usually led by disaster responders but by technology innovators who see a practical application for new technology. The future challenge for disaster managers is to identify these early adopters and harmonise their efforts alongside traditional information pathways.

Changing political climate The combination of societal and technological changes is fundamentally changing the political process. Increasingly there is political volatility. Governments sense their vulnerability to the lethal impact of social media and are becoming increasingly risk averse. Individuals are able to better manipulate the political process through social media than they ever could through traditional political organisations or through print or even electronic media which was controlled by particular sectional interests. While enriching the democratic process, it also has a restraining effect on major disaster mitigation investments. People are able to organise resistance to the construction of dams or to fuel reduction strategies in bushfire-prone areas. This has the effect of weakening decision-making processes which are vital not only to the prevention and preparedness elements of disaster management, but also to recovery.

Intelligence and security Much modern disaster management has been focussed on the challenge of terrorism. It is worth remembering an historical perspective; we probably live in one of the safest times in human history. Consider 100 years ago when the world was involved in World War I and millions died in both direct conflict and from associated illness. Immediately after the war, an estimated 50 million people died around the word from Spanish flu.

Climate change Climate change poses a very serious risk to human wellbeing. Changing global temperatures will impact on sea levels and on the frequency and severity of climatic events such as storms and heatwaves. Similarly, changing temperature alters the patterns of disease vectors, altering patterns of pandemics to effect areas not previously at risk. Climate change begets natural hazards – risk reduction lessens disaster impacts. The latter is a development imperative that will help to anticipate events well in advance, reduce the suffering of millions, and help avert catastrophes that warrant massive humanitarian responses. However, political and economic considerations appear to have prevailed in the minds of many, thus limiting the ability of the global community to reach collective prevention and mitigation agreements. Therefore adaptation strategies remain the only feasible actions.

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Operational policy issues There are many challenges to strategic leadership in the field of disaster management. Most of these have been explored during the detailed considerations throughout this text. However, it is worth mentioning others that need further exploration: • •

•

•

•

•

•

Public expectations: Growing expectations of the community are imposing higher levels of accountability. Health and safety: There is growing interest in the health and safety of rescue workers. At one extreme is a view that rescue is important and, by its nature, heroic and risky. Conversely, some believe rescue and recovery is done without risk. The need for proportionate and considered activities balancing the potential benefit against the potential risk is a more sensible approach. There is little known about the risks to health and safety of emergency workers. There has in the past been considerable attention paid to mental health of workers and less to their physical health. Additionally there has been considerable attention paid to the risks of rescue and recovery but little to the other risks, particularly those associated with subsequent enquiries. Conflicting priorities: Almost all managers and leaders face the daily challenge of managing conflicting priorities including risk management. Expending resources on something that may not happen is often a challenge when compared against expenditure of resources on things that can generate income or reduce daily costs. Policymaking is challenging: Many in disaster management bemoan the transitory nature of public interest. The ‘salience’ of the issue describes its importance in the public mind, and salience varies in a cyclical manner through observable phases (Downs 1972): – Pre-problem awareness. – Alarm discovery and euphoric enthusiasm. – Realising the cost. – Gradual decline in interest. Financial and economic considerations: There is also considerable interest in the issues of disaster insurance and compensation. Disasters are known to have considerable economic impact that can be reduced by effective disaster management. Each jurisdiction has compensation arrangements in place, but the fairness and adequacy of those arrangements has both social and financial consequences to the public and to the community. Financing mitigation: Most countries struggle with the prioritisation between disaster response and recovery funding and funding of mitigation which may have greater economic return. The public will often contribute generously either directly or through government choice to help those affected by disaster recovery but is less generous in terms of funding the costs of mitigation works which may prevent that impact in the first place. Additionally, in most jurisdictions, complex bureaucratic, social and political impediments exist to taking whole-of-government approaches to mitigation. Forging strategic partnerships and communication with stakeholders: Disaster management is a team effort but one inhabited often by passion and egos. The role

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•

•

of the leader is to help provide direction and to consolidate the teamwork necessary to ensure coordinated and integrated responses. Forging a strategic partnership requires strength of leadership to overcome the vested interests involved and the passions of various organisational players. Fragmented government responsibility and who has jurisdiction: In most jurisdictions there is fragmented responsibility; between various levels of government, between government and NGOs, and between public and private sectors. Dispersed technical expertise: The technical expertise required for disaster management is often dispersed through an array of government and NGOs. As disasters are low probability events, it is never possible to retain that expertise solely for disasters and so there is a challenge to marshal that expertise when needed. There is also a challenge to ensure that expertise is appropriate and genuine, and not opportunistic. At the time of a disaster there is a tendency for an epidemic of experts; many of whom have at best transitory interest in the complexity of disasters and are informed by the wisdom of hindsight. These have been referred to in the USA as ‘9/12ers’ referring to the opinionated experts that arrived after the event but were not present on the day.

The unknown Disaster management depends on predicting risks and planning mitigation strategies. Yet history has shown us that some things are not always predictable and are the ‘unknown unknowns’ as Rumsfeld described them, or ‘black swan events’ in risk terminology. While efforts can be made to identify these through scenario or what if-based approaches, the likelihood of success is low due to the very nature of these events. Instead, the challenge is to ensure the development of a flexible, scalable, integrated system with appropriate governance and an appropriately prepared workforce that can manage these events.

Conclusion The challenges for disaster management reflect the broader societal, political and economic challenges facing modern society. It is not possible for any text to identify solutions or even to unpick a detailed understanding of complex issues that continue to evolve. Therefore this chapter highlighted some of the issues and demonstrated the complexity of conceptualisation of those issues as an aid to better understanding the process by which they may be analysed, evaluated and, if possible, resolved.

Key readings Clay E, Benson C. Aftershocks: Natural disaster risk and economic development policy. ODI Briefing Papers. Nov 2005. www.odi.org.uk/resources/download/1946. pdf (accessed 10 Sept 2012). Skertich R, Johnson D, Comfort, L. A Bad Time for Disaster: Economic stress and disaster resilience. Disaster Management Strategic Policy Framework. 2012: State Disaster Management Group, Queensland Government.

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Activities • • • •

Discuss economic influences on vulnerability to disasters. Analyse the future economic and financial management of disasters. What do you see are the major future challenges for disaster health management? What do you think might be the black swan events that we might face in the future?

References Downs A. ‘Up and down with ecology – The “issue-attention cycle”’ Public Interest. 1972; 28: 38–50. Lichtenstein J. After Hurricane Mitch: United States Agency for International Development, Reconstruction, and the Stockholm principles. Briefing Paper 01: Issue 01. Washington, D.C.: Oxfam America; 2001. Meier P. Digital Humanitarians: How big data is changing the face of humanitarian response. Florida: CRC Press; 2015. Owen C, Bhandari R, Brooks B et al. Organising for Effective Incident Management: Final report for the Effective Incident Management Organising Project. Melbourne: Bushfire Cooperative Research Centre; 2014. United Nations. Sendai Framework for Disaster Risk Reduction 2015–2030. Geneva: UN; 2015. United Nations. Global Assessment Report on Disaster Risk Reduction: Revealing Risk, Redefining Development. UK: International Strategy for Disaster Reduction; 2011.

Index

access to health services 30, 142, 260 access to necessities 39–40 access to resources model 153 accountability 217–18, 234 act of God 27, 37, 366 acute health systems 125–7 acute stress disorder (ASD) 245–6 adaptive capacities 8, 148, 170, 234 agencies 215–16, 217–18 agencies-community partnerships 110–11 ‘agony of the moment’ judgement 63 AIDS 11 airports 186, 213, 216 alert phase 137 all-of-health system approaches 124 Al-Madhari, A. F. 4 ambulance services 199 Ambulance Volante 37 American Medical Association (AMA) 65–6 American Psychiatric Association (APA) 245 analyses and assessments 173, 188 animals 259, 288, 289 Armstrong, D. 249 asbestos-containing material (ACM) 33 Asian Development Bank 288 Asian flu (H2N2 1957–58) 287 Asian tsunami (2004) 240 assistance 209–13, 215 Australasian Inter-Service Incident Management System (AIIMS) 55, 195 Australia: bushfires 312–13; disaster health arrangements 53–4; disaster health education 321–2; health incident management 55; legal arrangements 61; pandemic preparedness 286 Australian Emergency Management Institute (AEMI) 229, 232–333, 250 Australian Health Protection Principal Committee (AHPPC) 54 Australian Institute of Health and Welfare (AIHW) 10

Australian–New Zealand Emergency Management Committee (ANZEMC) 54 Avian flu (H5N1 1997-ongoing) 287, 288 Bakke, H. K. 198, 199 Bali bombings (2002) 304 Bangladesh 258 Barker, G. 4 Batta, R. 330 behaviour 328 bereavement 246 Bhopal disaster (India 1984) 26, 268 biological disasters 13 biological weapons 278–9 biophysical vulnerability 153 Birnbaum, M. I. 9, 311 black swan events 339 Bligh, Anna 301 blister agents 276 blood agents 276 Boin, A. 18, 304, 307, 308 Bonanno, G. 248 ‘bounce back’ 107, 170, 247–8 see also resilience Boustany Jr., Charles W. 56 BP 301 Bradford Disaster Scale 14 Bradt, D. A. 9 Braithwaite, J. 132 Bruneau, M. 170 Burkle, F. M. 210 burnout 247 Burstein, J. 324 Bushfire Cooperative Research Centre (Australia) 312, 335 bushfires 194, 262–3, 305, 312 business as usual (BAU) 40, 293 business continuity 82–3, 86, 90, 173 Business Continuity Management ISO 22301 (BCM) 81–90 Business Continuity Plan (BCP) 81–90

342  Index Business Continuity (Standard AS/NZS 5050: 2010) 73–4 business impact analysis (BIA) 86–7 Calhoun, L. G. 248 campaign events 304 Canada 61, 176, 177 Canadian Medical Association (CMA) 66 capability 174, 202 capacity 111, 202, 235 carbon monoxide (CO) poisoning 259 cash assistance 210 Centre for Disease Control (CDC, US) 96, 173, 177 Centre for Research into the Epidemiology of Disasters (CRED) 4, 11–15, 21, 23, 52 Chapman, D. 4 Cheers, B. 108–9 chemical accidents 31 chemical, biological, radiological (CBR) 275–80 chemical weapons 276–8 Chernobyl (Ukraine 1986) 268 childcare plans 138–9 choking agents 276 cholera epidemics: Haiti (2010–15) 28; Zaire (1994) 214 Christchurch earthquakes (New Zealand 2010–11) 216, 232, 260, 333 chronic health conditions 30, 256 civil defence organisations 38 civil disruption 32 Clay-Williams, R. 132 climate change 337 climatological disasters 12, 22 clinical care 201–2 see also healthcare workers clinical governance 140 codes of conduct 60, 217–18 cold zones (CBR) 278 collaboration 41, 111, 201 Comfort, L. K. 206 command and control 194, 200–1, 312 commercial pressures 151 common law 63 Commonwealth Disaster Plan (COMDISPLAN, Australia) 53–4 communicable diseases 173, 259 communication 92–100; barriers/ breakdowns 107, 312; EHS 125–6; infrastructure 171; leadership 304–5, 315, 338–9; pandemics 293; processes and planning 97–8; response management 201; risk management 78–9; staff engagement 142–3; stakeholders 93–7 see also media

communities: basic support 168; communication stakeholders 96–7; decision-making 105; definition 104–5; disaster management 45; distrust of authorities 335–6; impact of disasters 32–3, 106; leadership 307; primary care services 141, 292; recovery outcomes 238–9; response management 200; risk reduction 152; social cohesion 185 community engagement 93, 104–13 community recovery 229–41, 250 Community Recovery (AEMI 2011) 232–3 community resilience 39, 113, 170, 230 compassion fatigue 247 compensation 338 compensatory disaster risk management 44 competency development 86, 321 complex adaptive systems (CAS) 132–3 complex humanitarian emergencies (CHE) 282–4 comprehensive disaster management 41–3 comprehensive health programs 322–3 computer viruses 171 consequence leadership 303, 305–6 Consonni, D. 269 consulting 78–9, 111, 157 consumables 175 contact tracing 176–7 containment 202–3 contaminated water 259, 261 continuity 203 Convention on the Rights of Persons with Disabilities (UN 2006) 60 Coordinated Incident Management System (CIMS, NZ) 55, 195 coordination: disaster management 41, 44; EHS 125–6; evaluation steps 314; healthcare systems 90; international assistance 59, 214–15, 216; recovery processes 234, 235; response management 201; scalable system 55 coordination centres 204 Coppola, D. 186, 216 Core Humanitarian Standard (CHS) 217 co-responders see volunteers corrective disaster risk management 44 Council of Australian Governments (COAG) 54 Cox, R. 110 credentialed courses 321 crisis communication plan 304–5 crisis leadership 303–5 crisis literature 93, 328 crisis management 168 crisis standard of care 141 critical decisions making 194

Index  343 Critical Infrastructure Advisory Council (CIAC) 171 critical infrastructure (CI) 17, 130, 170–3 critical objectives 41 crowd-sourced information 190 cultural considerations 107 Cutter, S. L. 153 cyclones 257–8 Cyclone Gorky (Bangladesh 1991) 258 Cyclone Ingrid (Australia 2005) 6 Cyclone Nargis (Burma 2008) 108, 258 Cyclone Yasi (Australia 2011) 33, 109 data collection 188, 191, 203, 314–15 Day, S. 148 debriefings 316 deceased plans 138 see also mortality decision-making 194, 313–14 decontamination 276 Deepwater Horizon oil spill (2010) 301 defences 148 depression 246 describing risk 77 desktop exercises 89, 324–5, 326 development 231, 234, 332–3 de Ville de Goyet, C. 188, 219, 264 Diagnostic and Statistical Manual 5th edition (APA) 245 digital media platforms 95, 96 direct action 151 Directorate-General for Humanitarian Aid (EU) 51 dirty-bombs 279 disabled people 60 disaster health 9–11 disaster health education 321, 322 disaster health managers 134 disaster impacts 27–33, 39, 174, 333 disaster influences 27 disaster literature 93, 328 disaster management: cycle 42, 168, 169, 173–4; definition 9; leadership 301–2, 304–5; plans 136–9; prevention and mitigation 150; principles 41–5; and risk management 72–3; silent disasters 11; systems 49–50; understanding 39–41 disaster management committees 50 disaster management plans see plans disaster medical assistance team (DMAT) 126 disaster planning see planning disaster recovery see recovery disaster-related risk 71–2 disaster risk management 44 see also risk management

disasters: categories 11–15; costs 333; defining 3–7; and emergencies 14; rates of reporting 24–5 disaster supplies kit 175 disaster tourism 214 disease transmission 259, 288–9 dispersal 200 displaced communities 107–8 disruptive events 82 ‘divert, decant, absorb and expand’ (EMS) 134–5 DNA sampling 138 domestic laws 61–3 donations 52, 239 Drabek, T. E. 329 droughts 261–2 drowning 259 Dubrovka Theatre immobilising gas (Moscow 2002) 277 duty of care 64 duty to treat 65–6 Earthquake Impact Scale 14 earthquakes 260–1 Ebola outbreaks: Africa (2014–15) 60, 97, 137, 221–2, 290, 291; US (2014) 96 economic costs 30–2, 332–3 economic vulnerability 25, 153 education 111, 320–4, 336 effective communication 93, 250 see also communication effective management 40, 293 effective recovery 234–5, 334 see also recovery Eisenhower, Dwight D. 159 elderly people 141, 263 electrical injuries 259 eleven ‘C’s’ incident management 193–4, 200–3 EM-DAT database (CRED) 21, 23 emergency departments 10, 293 emergency healthcare systems (EHS) 125 see also healthcare emergency management: challenges 335–6; cycles 231; definition 8–9; laws 63; leadership 301–3; legal approaches 63 Emergency Management Australia (EMA) 38, 236 emergency medical systems (EMS) 134–6 emergency medical teams (EMTs) 213, 218–22 emergency service workers 64–5, 247, 249 emergent groups 328–9 emergent phenomena 328–9 emerging infectious diseases 284, 288 emerging pandemics 288–90

344  Index emotional support 250 see also psychosocial resilience environmental impacts 33 epidemics 284, 286–93 see also pandemics equipment 174–5, 187 ethical issues 63–6, 176 European Community Humanitarian Office (ECHO) 51 European Union (EU) 51 evacuation facilities 141 evaluation reports 190–1, 240 evaluations 310–18; common errors 312; community engagement 112; exercises 165, 327–8; IMS 194; incidents 183–4; performance 316; recovery programs 239–41; strategies 148 evaluators 190 executive sponsorship 84–5 exercise management cycle 327 Exercise NUGENTS (2012) 325–6 exercises 89, 164–5, 324–8 experience 205 external assistance 209–23 extra-terrestrial disasters 13 Eyjafjallajökull volcano eruption (Iceland 2010) 87 facilities 89, 187, 203 families 138, 140 Fearnley, C. 148 Federal Emergency Management Agency (FEMA, US) 15, 38 final reports 190–1 financial incentives 150 ‘first do no harm’ dictum 132 flexibility 41, 72, 234 floods 22, 32, 105, 152, 258–60 Flores, Carlos Roberto 332 FluTracking.net 173 FluView (CDC) 173 Foot and Mouth disease 17 foreign affairs departments 216, 221 foreign field hospitals (FFH) 213, 218, 219 foreign medical teams (FMTs) 213, 218 forward aid 200 Francoeur, G. 290 Frisch, T. 214 Fritz, C. 3 full recovery tests 89 futile care 139 Galindo, G. 330 Garcia, H. F. 307 generational knowledge 107 geophysical disasters 12, 22 GIVIT app 336

Global Assessment Report on Disaster Risk Reduction (UN) 333 Global EMT meeting (2015) 221 Global Facility for Disaster Reduction and Recovery (GFDRR) 52 global financial crisis (2008) 15, 17, 25 Global Health Emergency Workforce 222 Global Registry for FMTs 219 global warming 25 Golding, D. 70 good governance 40 Good Humanitarian Donorship 218 ‘Good Samaritan’ laws 63 governance 53, 109–10, 158, 334–5 government failure 339 governments 149, 150, 171, 337, 339 Great Eastern Japan earthquake and tsunami (2011) 10–11, 15, 16, 153, 258, 333 greater good concept 153–4 Grove, R. D. 286 Guéckédou, Guinea, 290 Guidelines for Evaluation and Research in the Utstein Style (Sundnes and Birnbaum) 311 Gujarat earthquake 214 H1N1 influenza viruses 287 H5N1 influenza viruses 287 Haddon’s Matrix 148–9 Haiti: cholera epidemic (2010–15) 28; earthquake (2010) 186, 218, 219, 333 Halifax ship explosion (Nova Scotia 1917) 3 Hamlen, M. 110 Hardy, K. 206 ‘Hawaii medical professionals assessment’ (Lanzilotti) 64 Hayward, R. 249 Hayward, Tony (Anthony Bryon) 301 hazards: analyses 71; definition 8; identification 75–6, 160; industrial disasters 268; and sources of risk 77 hazard-specific severity scales 14 HAZMAT (hazardous material response) 200, 275 healthcare: business continuity 83; complex adaptive system (CAS) 132–3; costs 289; impact of disasters 139–43, 199–200; natural disasters 256; structure of organisation 83–4 healthcare workers: availability 64–5, 131, 139–40; communicating with 142; duty of care 64; emergency care 126; EMS response 135; risks of injuries 65–6, 130; training 125 see also key personnel health Disaster Risk Management (DRM) 74, 119–24

Index  345 health impacts 28–30, 108, 257–64 health needs and resources 5–7, 260 health protection 142 health systems 119–27; defining 119–20, 120; disaster health 9; disaster management 136–9; financial viability 131; impact of disasters 129–31, 202; infrastructure 30; resilience 131–3 heat-related illnesses 272 heatwaves 263 Hetzel, A. M. 286 ‘hierarchical escalation’ systems 55 historical knowledge 151 HIV 11, 65, 177 Hobart (Tasmania) 154 Hollnagel, E. 133 Honduras 332 Hong Kong flu (H3N2 1968–69) 287 Hong Kong SARS epidemic 130, 176, 289 hospitals 10, 83, 122, 162 host governments 221–2 hot zones (CBR) 277 House, A. 204 Huber, S. J. 65 Hudson Global, Inc. 303 human behavioural modification 149 Humanitarian Accountability Partnership (HAP) 217 humanitarian assistance 283 humanitarian charter 168–9 Humanitarian Charter and Minimum Standards in Humanitarian Response (Sphere Project) 283–4 human resources 187, 293 human rights 58–9, 60, 178, 209–10 Hurricane Katrina (2005) 31, 56, 130 Hurricane Mitch (1998) 332 hydrological disasters 12 hygiene education 261–2 Hyogo Declaration (2005) 51 Hyogo Framework for Action 51, 120–1 Iceland 87 impact assessments 190 incident evaluation 183–4, 188–90, 316 incident management 83, 193–207 incident management systems (IMS) 193–200, 205–7 incident management team (IMT) 88 incident responses 173 indirect health effects 262 indirect prevention strategies 151 individual decision-making 105 individual vulnerability 152 Indonesia tsunamis (2004) 258

Indus River floods 332–3 industrial disasters 267–9 infection rates (R factor) 290 infectious diseases 60–1, 258, 260–1, 284, 290 influential leaders 186 see also leadership influenza: clinical severity 287; epidemics 17; monitoring 173; pandemic (1918–1919) 284, 286; pandemic (2009) 285, 287, 289, 292; vaccine shortfall (2004) 176 influenza-like illness (ILI) 126, 292 information and awareness programs 151 information reliability 206–7 information sources 96, 187 infrastructure 38, 172, 333 Infrastructure Assurance Advisory Group (IAAG) 171 initial assessments 183–4, 189–90, 215 injuries: bushfires 262; cyclones 257; droughts 260–1; earthquakes 259; floods 258; healthcare workers 65–6, 130; heatwaves 263; natural disasters 212 innovation 336–7 input focussed courses 321 instructing information 98 integrated disaster management 43 integrated services 234 intelligence 195, 337 inter-agency cooperation 205 Interagency Emergency Health Kit (IEHK) 210 Inter-Agency Standing Committee (IASC) 51, 60 internalising information 98 international agencies 217–18 international arrangements 51–3, 59–60 International Association of Emergency Managers (IAEM) 52 International Atomic Energy Agency (IAEA) 14 international classification and standards 218–20 International Committee of the Red Cross (ICRC) 5, 52, 59, 60, 216 international coordination 214–15 International Covenant on Civil and Political Rights (ICCPR) 59 International Covenant on Economic, Social and Cultural Rights (ICESCR) 59 International Emergency Management Society (TIEMS) 52 International Federation of Emergency Medicine (IFEM) 125 International Health Regulations (IHR) 60–1, 121, 291 international interest 185

346  Index International Journal of Mass Emergencies and Disasters 4 International Sociological Association 4 international support strategies 52–3 interpandemic phases 285, 292 investigations, IMS 195 Iran earthquake (2003) 218 iron lungs 17 isolation 177–8 Israeli 64 Japan earthquake and tsunami (2011) 10–11, 15, 16, 153, 258, 333 Jensen, J. 205 job descriptions 85 Johnson, A. L. 112 Joint Emergency Services Interoperability Programme (JESIP, UK) 195 judge-made laws 63 Jung, K. 205 ‘just-in-time’ supply chains 130, 175 Kaniasty, K. 249 Keller, A. Z. 4 Kennedy, John F. 312 key personnel 174, 203 see also healthcare workers Klugam, J. 282 Krimsky, S 70 Kuziemsky, C. 105 land-use planning 154 Lanzilotti, S 64 Larrey, Dominique-Jean, Baron 37 leadership: commitment 84–5; communication 304–5; community engagement 109–10; community recovery 236–7, 307; in crises 303–5; data collection 315; decision-making process 305; disaster management 301–5; qualities 300, 300–1; recovery 306–7; staff engagement 142; training 326 leaning forward 137 learning lesions 315–16 legal frameworks 58–63, 178 legislation 150, 184 Leishman v Thomas (Australia 1958) 63 Liberia 290 Liu, Joanne 290 live exercises 325–6 local capabilities 187 local recovery programs 234 local resources 187, 216 logistics 195, 211, 213 London 126

long-term medical issues 268 long-term sustainability 333 Luckerson, V. 96 MacQueen, K. M. 104 major disruptive events 82 management approaches 234 management levels 40 manmade disasters 25, 267–80 Marsh, G. 106 mass burns 273–5 mass casualties 9 mass casualty first-aid kits 126 mass casualty plans (MCP) 138 mass gatherings 9, 271–2 mass population movements 107 mass shootings 272–3 mass transport 24 Mathewson, J. H. 3 Matrix (Haddon) 148–9 Mayer, R. C. 92 McEntire, D. A. 329 McNeill, W. H. 284 media: access 198; communication stakeholders 94–5; disaster management 312; healthcare issues 139; meaningmaking 313; pandemics 293; twenty four 24 hour news cycle 336 see also communication media convergence theory 96, 99 medical management structure 38 medical teams see emergency medical teams (EMTs) medical vulnerability 153 Médicins Sans Frontières (MSF) 52, 256 Meltzer, M. I. 289 mental health 29, 232, 243–50 Mercy Ships 52 Merson, M. H. 124 message design 99 see also communication meteorological disasters 12 migratory birds 288 military conflicts 25, 38, 272–3 Ministries of Health 221–2 mitigation 147–54, 173, 338 modifying risk 78 Monash Injury Research Institute 311 Mont Blanc tunnel fire (1999) 270 morbidity 28, 29, 284 Morens, D. M. 286 mortality: cyclones 257, 258; droughts 261; earthquakes 260; flooding 259; heatwaves 263; infectious disease 284; natural disasters 21–3; rates 28, 29 multi-agency incident management 204–6 Myanmar (Burma) 108, 258

Index  347 NASA 313 national agencies 215 national disaster authorities 216 national disaster management 53–5 National Disaster Management Agency (NDMA) 122 National Emergency Risk Assessment Guidelines (EMA 2015) 73 national health disaster plans 162, 163 see also plans national health legislation 122 National Incident Management System (NIMS, US) 195 national jurisdiction 162, 339 national sovereignty 58 natural disasters 255–64; deaths and injuries 23, 212; EM-DAT database (CRED) 21–3; healthcare 256; manmade catastrophes 25; predicting injuries 257–63; ten worst disasters 22 Natural Disasters Organisation, Australia (NDO) 38 needs-based support 210, 213, 221, 222 Nepal earthquake (2015) 213, 220 nerve agents 276 Netherlands 105 New Orleans (US) 56 news consumption 96 New Zealand 216, 232, 260, 333 NIMBY (‘not in my back yard’) 152 9/11 terrorist attacks 64–5 ‘no-fly’ zones 216 non-communicable diseases 256 non-conventional missile attacks 64 non-credentialed short programs 321 non-governmental organisations (NGOs) 51–2, 59 non-natural events 18 Norris, F. H. 170 Norway: influenza pandemic (2009) 292; terrorist bombings (2011) 194 novel viruses 288 nuclear accident IAEA scale 14 nutrition-related health effects 261 obesity 11 objectivist approach to risk 71 occupational health and safety risks 262 OCHA (the Office for the Coordination of Humanitarian Affairs 214 Office for Disaster Risk Reduction (UN) 51 onsite operations coordination centres (OSOCC) 215 operational evaluation 187–9 operational policies 338–9 operations 195

opinionated experts 339 opportunities 157–8 organic model of healthcare 132 organisational debriefings 316 organisational environments 184–5 organisational management 40 organisational resilience 150 organisational systems and structures 49–51 Organisation for the Prohibition of Chemical Weapons (OPCW) 276 orthopaedic injuries 259 outcomes 170 out-of-hospital CPR 198 Pacific rim earthquakes 260 Pakistan 332–3 Pan American Health Organization (PAHO) 218 pandemics 176, 202–3, 211, 284–93 see also epidemics Papua New Guinea 287–8 patient load 130 peer support 249 Penrose, J. M. 98 People In Aid 217 performance evaluations 89–90 personal debriefings 316 personal protective equipment (PPE) 277 Petrie, N. 300 pets 140 Philippines 220, 221, 256 physical barriers 148 physical vulnerability 152 plane crashes 18 planning 156–65; context based 158, 184; defining 156–7; disaster management 17; frameworks 161–2; IMS 195; principles 157–8; processes 158–61 planning syndrome 312 plans: application and validation 164–5; content 162–4; health systems 136–9; hierarchy 161–2; as roadmaps 40; structure 162–4; vertical and horizontal integration 163 Poland flood (1997) 249 policy environment 150, 184–8 polio epidemics (1938 and 1953) 17 political environments 185–6, 337 political pressures 151 poor countries 27, 332–3 Poortinga, W. 109 population density 24 post-traumatic growth (PTG) 248, 249 post-traumatic stress disorder (PTSD) 245, 247 practical support 250

348  Index predicting disaster impacts 168 predicting injuries 257–63 pregnant women 256 Prehospital and Disaster Medicine (PreventionWeb/UNISDR) 7, 311 pre-hospital providers 125, 126 preparation 42 preparedness 167–78; activities 42–3; biological weapons 279; bushfires 262; chemical weapons 276–7; conflict, terrorism and mass shooting 272–3; consequence leadership 306; ‘getting ready’ 168; governance 334; industrial disasters 268; mass burns 274; mass gatherings 271–2; multiple bridging strategies 205; pandemics 286; radiological weapons 279; and recovery 230; stockpiles 175; surveillance 173–4; transport disasters 269–70 preparing people 174 preservation of health and wellbeing 9 pressure and release model of vulnerability 153 prevention 42, 59, 147–54 prevention, preparedness, response, recovery (PPRR) 41–2, 50–1, 105, 110, 167–8, 232 PreventionWeb 7 primary care 125 primum non nocere dictum 132 Prince, Samuel Henry 3 principles of maximum benefit 202 privacy 177 private, mobile and radio services (PMR) 336 private sector organisations 55, 171 process-related resilience 170 professional responsibilities 64 progress reports 190–1, 194 Proposed Updated Terminology on Disaster Risk Reduction (PreventionWeb/UNISDR) 7 protection 9, 60 psychological impacts 244, 261 psychological resilience 247–8, 249 see also resilience psychosocial effects 238, 289 public consultations 111 public expectations 25–7, 338 public health: planning and surveillance 142, 261; preparedness 175–8, 290; systems 124; tweets 99 Public Health journal 188 public information 195 public investment policies 333 Pyne Gould building (NZ) 18 qualitative evaluation measures 239–40 quality management 217–18

quantitative evaluation measures 239 Quarantelli, Henry 4 quarantine 173, 177–8 Queensland Ambulance Service (QAS) 99 Queensland floods and cyclone (Australia 2010–2011) 301 radiological weapons 279–80 Rancho Los Amigos Hospital (California) 17 rapidity 170 rationing 141 recovery 229–41; biological weapons 279; chemical weapons 277–8; CI protection 173; conflict, terrorism and mass shooting 273; development process 229; disaster management 50, 138; evaluating programs 239–41; industrial disasters 268–9; leadership 306–7; mass burns 274–5; mass gatherings 272; objectives 231–2; organisational structure 237; PPRR cycle 43; principles 232–333; processes 233–5; radiological weapons 279–80; resourcing 239; transport disasters 270–1 recovery managers 236 Red Cross (ICRC) 5, 52, 59, 60, 126 reduce, reuse, recycle practices 141 redundancy 170 referral pathways 126 refugees 108 regional agreements 59 rehabilitation 230–1 reluctant communities 151–2 remediation 173 reporting disasters 24–5 reports 190–1, 194, 317 rescue 200 rescue workers 338 Research Committee on Disasters 4 research issues 311 research programs 328–30 resilience: CI protection 172; definition 8, 169–70; disaster management 39; facilitative capacity 231; prevention strategies 147–50; psychological 247–8, 249; social cohesion 109 resilient communities 43, 111–12 resilient health care (RHC) 131–2, 133 resilient societies 149–50 resourcefulness 170 resources: allocating 73; community wellbeing 250; losses 130; preparing 174–5; recovery 239 resourcing business continuity 85–6 respiratory infections 256 responders 197–8 response evaluations 316

Index  349 response leadership 303–5 response management 200–3, 262 response pathways 126 responses: biological weapons 279; chemical weapons 277–8; CI protection 173; conflict, terrorism and mass shooting 273; disaster management 50; industrial disasters 268–9; mass burns 274–5; mass gatherings 272; PPRR cycle 43; preparedness 43; radiological weapons 279–80; transport disasters 270–1 responsiveness 234 reviews 99–100, 317–18 R factor infection rates 290 Richter scale 14 Rimstad, R. 194 risk 70–2; and crisis communication 98–100; definitions 8, 70; describing 77; professional obligations 64; ranking 77; spectrum 73; understanding 75 risk analysis 271 risk assessments 71, 160, 334 risk-based disaster management 41, 44 risk management 70–9; context 75; definition 8; and disaster management 72–3; processes 78–9; standards 72–3; vulnerability to disasters 38 risk register 77 risk-taking behaviour 149 robustness 170 rodents 259 roles and responsibilities 194, 197 Rouse, W. B. 132–3 Royal Australian College of General Practitioners (RACGP) 293 Rumsfeld, D. 339 rural communities 126 Rwanda civil war 214 safety and security 141–2, 197–8, 213 ‘safety-one’ (Hollnagel) 133 ‘safety-two’ (Hollnagel) 133 Salama, P. 217 Sandman, P. P. 98 sanitation 261–2 sarin attacks (Tokyo 1995) 203, 276 SARS virus: animal (coronavirus) virus 288; contact tracing 176–7; cross-border transmission 62; health systems 62, 64, 130; pandemic control 176; psychosocial effects 289 satellite imagery 190 scalable escalation plans 40, 55 Scandinavian Journal of Public Health 30 scene medical management 199–200 Schultz, J. M. 258

Scully, P. 249 search and rescue services 200 secondary traumatic stress (STS) 247 self-deploying teams 221 self-sufficient teams 213, 216 Sendai Framework for Disaster Risk Reduction 2015–2030 (UN 2015) 28, 44, 59, 120–1, 121, 334 sense-making evaluation 313 services 111, 202, 238, 336 ‘72-hour kit’ disaster supplies 175 Seveso dioxin release (Italy 1976) 268–9 Seville Agreement (ICRC 1997) 59 Shakespeare-Finch, J. 249 Shizugawa hospital (Minamisanriku, Japan) 10–11 Sierra Leone 290 silent disasters 11 simulations see exercises Singapore SARS epidemic (2003) 62, 176, 177 single purpose organisations 50 situation reports (SITREPS) 190–1, 194 Slovic, P. 70 social action 329 social capital 108–9 social change 335–6 social cohesion 109, 110, 185 social environment 149, 185 social functioning 30 social media 95, 96, 336, 337 social order 329 social relationships 328 social support 32, 249 social vulnerability 152, 153 socio-demographic characteristics 106–8 socio-economic status 107 sociological frameworks 4 socio-technical system failures 38 Solid, S. J. M. 194 Song, M. 205 sources of risk 75, 77 South Asia earthquake (2005) 216 space shuttle accidents (NASA) 313 Spanish flu (H1N1 1918–19) 284, 287 special needs groups 106–7 special purpose organisations 50 spectators 198 Sphere Project 168, 217–18, 241, 283–4 spree killing 272–3 staff engagement 142 see also healthcare workers stagnant water 259, 261 stakeholders: community engagement 105; consulting 78–9; health DRM 123; operational policies 338–9; planning

350  Index processes 159, 161; political environment 186 standards: disaster health management 217–18; education programs 322 Standards Australia 44 standing capacity 240 stand up/down 137–8 stockpiles 175, 210, 292 storms 257–8 strategic partnerships 338 strategic responses 152, 198 Strengthening of the Coordination of Humanitarian Emergency Assistance (UN) 215 stress 100, 243–4 Sundnes, K. O. 9, 30, 311 supplies 131, 135 support agencies 216 surges 134–6, 199 surgical approaches 140–1 surveillance 173–4, 177, 292 survivor guilt 32 Swine flu (H1N1 2009) 285, 287, 289, 292 Sydney polluted water supply (Australia 1998) 15 systems flow 136 Tacloban (Philippines) 221 tactical responses 198 ‘task force’ approaches 50 task-specific training 323 Tasman Bridge disaster (Australia 1975) 154 Taubenberger, J. K. 286 team leader development 323 technical expertise 339 technical standards 220 technological changes 336–7 technological dependence 24 technological disasters 13 Tedeschi, R. G. 248 television 95 Telford, J. 218, 239, 240 terrorism 194, 272–3 t’Hart, P. 312 thunderbolts (no-notice exercises) 326 time-limited decisions 306 Tokyo (sarin attacks 1995) 203, 276 Tools, Words are Important (WHO 2003) 7 Toussaint L’Ouverture airport (Haiti) 186 Townshend, I. 109 Townsville Hospital (North Queensland, Australia) 141, 142 training 55, 85, 174, 200, 205, 320–4 transport disasters 269–70 Traub, M. 199 traumatic experiences 244, 246

travel restrictions 288–9 triage 199–200 trust 92–3, 97–8, 100, 306 Tsunami Evaluation Coalition 217–18, 240 tsunamis 10–11, 15, 16, 153, 240, 258–60, 333 tuberculosis (TB) 11, 287–8 Tuckey, M. 249 tweeting 99 24 hour news cycle 336 see also media Typhoon Haiyan (2013) 256 Typhoon Yolanda (2013) 220, 221 undersea cable damage (2006) 171 UN General Assembly Resolution 46/182, Strengthening of the Coordination of Humanitarian Emergency Assistance 215 UN High Commissioner for Refugees (UNHCR) 51 Union Carbide chemical disaster (Bhopal 1984) 26 United Nations Disaster Assessment and Coordination (UNDAC) 189–90, 215 United Nations International Strategy for Disaster Reduction (UNISDR) 5, 7 United Nations (UN): ‘cluster’ system 214–15; Emergency Relief Coordinator (ERC) 59; Inter Agency Standing Committee (IASC) 59; organisation of international cooperation 51 United Nations World Conference (Sendai, Japan 2015) 44 United States (US): Centres for Disease Control (CDC) 96; Department of Defense 172; domestic laws 61; Ebola outbreak (2014) 96; HIV and AIDS data 177 ‘unknown unknowns’ (Rumsfeld) 339 unmanned aerial vehicles 190 urban environments 126 van den Brink, M. 148 Varpio, L. 105 victim identification 138 Victoria influenza pandemic (Australia 2009) 292 viruses 286–8 volunteer firefighters 126, 249 volunteer organisations 52–3 volunteers 52, 139–40, 198–9 Von Moltke, Helmuth 165 von Schreeb, J. 211 VUCA (volatility, uncertainty, complexity and ambiguity) 71–2 vulnerability: assessing 76–7; defining 8, 106, 152–3; healthcare systems 64; and modern systems 38; and resilience 33

Index  351 vulnerable countries 121 vulnerable people 60 walking wounded 134, 198, 203, 278 warm zones (CBR) 277 wars 37–8 water supply 259, 261 water transportation incidents 270 Waugh, W. L. Jr. 205 weapons of mass destruction (WMD) 276 weather conditions 270 welfare 195 Wenchuan earthquake (China 2008) 261 West African Ebola epidemic (2014–15) 60, 97, 137, 221–2, 290, 291 what if-based approaches 339 whole-of-community leadership 307 WHO PAHO Guidelines for the Use of Foreign Field Hospitals (WHO 2003) 218–19 winter flu 287, 292 Wisner, B. 106 Words are Important (WHO) 7 work-as-done/imagined concepts 133 working practices 140–1 workplace connectedness 249

workplaces 32–3 World Association for Disaster and Emergency Medicine (WADEM) 52, 311 World Bank 52 World Conference on Disaster Reduction (2005) 120–1 World Economic Forum 211 World Food Programme (WFP) 211 World Health Assembly (2011) 121 World Health Organization (WHO): biological weapons 278; Centre for Research into the Epidemiology of Disasters (CRED) 23; EMT guidelines 169, 219; health system 119–20; international cooperation organisation 51; pandemics 211, 284–6, 291; TB deaths 11; Western Pacific region 121 World Risk Report 2014 (WRR) 121 World War II 38 Wynia, M. K. 65 Yangtze ferry disaster (China 2015) 270 Zaire cholera epidemics (1994) 214 Zeebrugge ferry disaster (Belgium 1987) 270