Summary of the Master Thesis

Public Health and Natural Disasters Disaster preparedness

and response in health systems

SIDIKA TEKELX-YEÄXL

University of Bielefeld School of Public Health

Supervisors: University of Bielefeld Prof. Dr. Ulrich Laaser

Prof. Dr. Claudia Hornberg University of Istanbul

Prof. Dr. Yakut Irmak Özden

Disasters constitute an important part of the health problems today. Worldwide each

year thousands of people die and millions of people are affected due to the consequences

of disasters. The contribution of human made and natural disasters to the global disease

burden is expected to climb from 12th place in 1998 to the 8th place in 2020 (Global

Forum Health Research, 2001).

Disasters are considered as a public health problem, because they may cause an

unexpected number of deaths, injuries, or illness in the affected community; may

destroy local health infrastructures; may have adverse effects on the environment and

the population, increasing the potential risk for communicable diseases and

environmental hazards that will increase morbidity, premature death, and diminished

quality of life in the future; may affect the psychological and social behaviour of the

stricken community; may cause a shortage of food with severe nutritional consequences;

may cause large, spontaneous or organized population movements, often to areas where

health services cannot cope with the new situation (Noji, 1997). Additionally, public

health perspective and philosophy can contribute to preparedness and prevention efforts

in struggling with disasters.

In the master thesis only natural disasters are concerned. The aim of the thesis was to

collect and present the available information to ensure an integral substructure for health

systems for disaster preparedness and response activities. For this aim many written and

on-line sources were reviewed and at the end a case study was presented. (See Annex 2)

In the content of this thesis there are several main chapters. They may be summarised as

follows: (for the whole table of contents see Annex1)

First the general information about natural disasters and information about effects and

consequences of natural disasters related with health and public health were presented

under the title “Review of Literature”. The Review of Literature has four subtitles,

namely: The Nature of Natural Disasters, General Effects of Natural Disasters on Health

and Public Health Consequences of them, Types of Natural Hazards and Their

Consequences, The Situation of the World Regarding to Natural Disasters. In this

chapter the background information about natural disasters were given. In the

subchapter, nature of natural disasters, factors that increase the severity of the

consequences of natural disasters and vulnerability factors of populations, and phases of

disaster management were noted. Rapid population growth, urbanisation, poverty and

social inequalities, environmental degradation, unsafe conditions, and lack of

opportunity are the conspicuous ones among the vulnerability factors. There is an

inverse relationship between socio-economical development and consequences of

disasters. In today’s world the urban areas have the highest disaster risk. Each year more

people begin to live in urban areas. When we consider the urban population in the world,

which was 47.2% in 2000 and estimated as 49.3% in 2005 (UN, 2003b), it would be

clearly seen why a special attention should be given to develop projects about urban

preparedness. The location of the most crowded cities of the world are in areas that are

extremely of high risk for natural disasters.

In the following subchapter, General Effects of Natural Disasters on Health and Public

Health Consequences of them, health problems common to all natural disasters were

examined without individually focusing to each type of natural disasters. The problems

common to all natural disasters are generally related with social reactions,

communicable diseases, population displacement, climatic exposure, food and nutrition,

water supply and sanitation, mental health, and damage to health infrastructure.

The subchapter, Types of Natural Hazards and Their Consequences, contain information

about different types of classification of hazards and two methods, classifying according

to origin in the nature and classifying according to onset were studied. While classifying

according to origin in the nature, detailed information about the phenomena,

vulnerability factors of populations considering the hazard, the impacts of each hazard,

and main causes of morbidity and mortality related with the hazard were given for some

selected frequent hazards, namely, tropical cyclones, tornadoes, drought, flood,

earthquakes, tsunami, volcanoes.

The last subchapter of Review of Literature is Situation of the World Regarding Natural

Disasters. In this subchapter, the historical context of natural disasters and the current

situation were presented with numbers, figures and tables. Changing trends in the

numbers and consequences of natural disasters were also mentioned. According to the

records, the number of the phenomena increased in the last decades. (Fig. 1, 8, 9 and

Table 3 in the full form of the thesis) There are discussions about the reasons for this

increase. There is no evidence about the reasons of the increase in geological hazards,

but about climatic hazards, the obvious increase in the hydrometeorelogical events turns

the attention to the changes in the environment and climate. (UN-ISDR, 2002) More

researches about the reasons of this increase are needed. There are also other trends

about natural disasters. The consequences of natural disasters are more severe, mainly

due to increasing vulnerability of populations. Because of this increase in vulnerability

the number of affected people from natural disasters has increased dramatically. (Fig.8

in the full form of the thesis) Increased economical loss is also an important changing

trend about natural disasters. (IDNDR-DIRDN, 1996) The main reasons for this trend

are urbanisation, increased material value especially in urban areas and industrialised

countries, the concentration of too many political, industrial, financial or other resources

in one urban area, domino effect, and globalisation effect. Major natural disasters in the

world and types of natural disasters ranked by mortality and affected population are also

examined in this subchapter. Among all hazards, drought, earthquake, windstorm, and

flood seem to be the most lethal ones and they affected the largest numbers of people

according to the records of the last century. (Fig.13 & 14 in the full form of the thesis)

But according to some sources earthquakes present the greatest risk of death for those

affected. (Guha-Sapir & Lechat, 1986)

The second main chapter is, The Aspects and Concepts of World Health Organisation

and its Related Departments About Mitigation, Preparedness and Response Projects. In

this chapter WHO’s and its related sections’ concepts about preparedness, mitigation

and response projects will be dealt with as a model. Thus, we still cannot successfully

predict or prevent the occurrence of natural disasters. Therefore, disaster preparedness

and response activities are the main tools of humans to cope with natural disasters.

Health systems require special attention in these activities due to the vital functions they

perform. There is not a single muster for preparedness and response projects that could

be adapted to all natural disasters and to all countries. As well as the hazards and their

consequences, the societies are also unique. Therefore, vulnerabilities arise from the

characteristics of the societies and regions. Because of this reason, each country has to

develop its own disasters preparedness and response program according to its society, its

geographical conditions, and the risk it has. Despite these differences the general idea

and the aspects for the main components of such projects are the same and past

experiences from each hazard and from different countries are the most valuable

information sources for every country. For sharing these information and experiences in

international level UN and WHO can play an important role. These information and

experiences may constitute the background of national or regional programs.

After mentioning management sequence of disasters and emergencies, mitigation,

preparedness, which are pre-disaster activities or activities in risk reduction phase, and

response activities of the sequence were dealt in this chapter. For the pre-disaster

activities following steps, which are explained in details in the full form of the thesis,

may provide a basic model. Namely: 1. Develop policy 2. Assess vulnerability 3.

Prevent/ Mitigate hazard 3. Plan for disaster 4. Train and educate 5. Monitor and

evaluate. Mitigation activities in most cases refer to reduction of the vulnerability of the

system (e.g., improving and enforcing buildings code), but in some cases they refer to

reduction of the magnitude of the hazard (e.g., by diverting the flow of a river). (PAHO,

2000a) In the subchapter, Mitigation activities, vulnerability of health services,

evaluation of vulnerability, and reduction of existing vulnerability were explained. The

vulnerabilities, which can be eliminated or reduced, are the theme of the mitigation, but

for the ones that cannot be avoided, the communities should be prepared. The aim of

emergency preparedness is to develop emergency plans, to train personnel at all levels

and in all sectors, educating communities at risk, and to monitorize and evaluate these

measures regularly. (WHO, 1999) In the subchapter, Preparedness Activities, steps of

the preparedness process (emergency planning, training and education, monitoring and

evaluation) were dealt. The principles of emergency and disaster planning in the health

sector and responsibilities of health sector (management/treatment of casualties,

epidemiological surveillance and disease control, basic sanitation and sanitary

engineering, health management in shelters or temporary settlements, training health

personnel and the public, logistic resources and support) were also noted in this

subchapter. The following subchapter is, Response Activities. The performance of

response activities relies on mitigation and preparedness activities and also the capacity

and accessibility of services among affected country before the disaster. Therefore

improving health systems and health of populations have important roles in coping with

disasters. In this subchapter main components of response activities were dealt.

Coordination of disaster response, Management of mass casualty, Epidemiological

surveillance and disease control, Environmental health management, Food and nutrition,

Planning, layout, and management of temporary settlements and camps, Communication

and transport, Managing humanitarian relief supplies, International humanitarian

assistance, Re-establishing normal health programs were themes of this subchapter.

Each disaster, that is experienced, makes us more informed for the next one and gives us

the opportunity for better preparedness. The best thing we can achieve with mitigation

of natural disasters is learning lessons from past events and experiences. Therefore the

two earthquakes that occurred in Turkey in 1999 were noted about in this study to learn

lessons.

In the last part of the thesis, in conclusions and recommendations, evaluation and

summary of the given information was made. In addition, some recommendations that

would be useful for the future programs were noted in the last part. After assessing the

aspects and concepts of WHO and drawing lessons from the cases, which are dealt with

in this thesis, the following recommendations may be made for the future preparedness

and response programs.

First of all, a functional disaster preparedness and response programs in health systems

should be a part of a national program. It should be considered that non-structural

options in other sectors such as limiting types of land use, legislative interventions or

providing tax incentives that direct development away from hazard-prone areas are the

cheapest and final measures. It should be considered that with today’s technology

structural measures, which have direct influence on mortality and morbidity, are

available, but a definite, planned and controlled application of them is needed. However,

experiences from the past events show that for strategically buildings or structures such

as hospitals, schools, highways, bridges, over crossings, etc., which must stand against

hazards to go on serving or not to disrupt the services, stronger measures than other

buildings should be taken. Once these measures are obtained, they should be monitored

to make adjustments according to technological developments or to repair possible

damages that may occur with time. Such extra structural and non-structural measures

should also be applied to industry establishments, which may cause a threat to the

public’s health. The buildings, in which many people are present, such as cinemas,

shopping centres, etc. should be included in such applications and mitigation programs.

These interventions may seem as not related with health systems, but although they are

not the responsibility of health systems, they have some influence on health related

subjects. Besides their direct influence on the number of deaths and injured, some of

them are the prerequisites of the continuance of the services that health systems give.

Additional to the general preparedness process that was explained above, here are some

details, which should be kept in mind during the constitution of preparedness and

response programs according to the past experiences: As mentioned before strategically

buildings, especially health services need extra structural measures and maintaining the

application of these measures are the responsibilities of health services. Despite these

extra measures and prepared plans, it should be kept in mind that there is not a guaranty

of standing of the buildings against hazards and the operating of the plan free of

problems. Therefore, plans should contain all eventual events and problems and the

personnel who will be included in them should be familiar to the plan and disasters.

Selecting experienced personnel and placing them in positions, in which they will adapt

easily and serve effectively in disaster situations would be useful for this point. For such

placements encouraging methods should be used instead of charging people with

obligatory duties. Regular education programs for such personnel may develop their

knowledge and do not let disaster to be outside the agenda. Having enough knowledge

about the injury spectrum of eventual disasters in the country is of great use to cope with

them. Forming simple common therapeutic procedures for such injuries before a disaster

strikes may also make the work of medical staff easier. Alternative plans, which do not

rely only on local hospitals and conventional emergency teams, should be developed to

intervene even in very chaotic situations that may eventually occur after phenomena

with high magnitudes. These alternative plans have a particular importance in

metropolises, which have similar situations like the ones in previous pages. In the

preparedness plan, eventual needs that will exist or increase after the disasters such as

dialysis units or rehabilitation facilities for the disabled should be considered. Contrary

to what is believed in general, the need for extra personnel does not occur only in

immediate post disasters situation. The arrangements for supplying enough personnel for

mid term and long term should be planned in the preparedness program. From the past

experiences it was seen that loss of buying power, increased poverty, which may arise or

increase as the consequences of disasters, limit people’s access to health services.

Therefore, additional measures to obtain the accessibility to health services should be

taken. Public health surveillance may be an effective tool that can be used to respond to

the disruption and destruction that disasters bring. (Noji, 1997)

The past experiences show that hospitals or other health services do not only suffer from

structural damages. The non-structural damages, in- and out-side the health services may

also disrupt the operation of these services. Therefore this point should be considered

while selecting the location of health services and their construction. For example places

for airway transportation in each hospital should be organised considering different

scenarios during a disaster. Other alternatives like seaway should be developed. As well

as the outside arrangement, the inner arrangement of health services is also vital for the

continuance of the services during disasters. Special arrangements for heavy

instruments, dangerous materials, strategic objects for the services, etc, may help health

services to avoid from the destruction or effects of disasters.

The local people should also be educated about what to do during and after disasters.

Health-related parts of this public education for disaster awareness are the responsibility

of health systems. Instead of showy commemorations, preparedness programs may be

practiced, especially in schools, hospitals, or other related sectors, on anniversaries of

past events.

Another point to be mentioned is the importance of the organisation, communication,

co-ordination, and co-operation in disaster preparedness and response programs.

Organisation was defined as the foundation stone and co-operation, co-ordination, and

communication were defined as the corner stones of such programs. Without them it is

impossible to operate preparedness and response programs effectively.

Special institutions and organisations may be founded or the existing ones may be

supported for improving the ability of the central and local authorities in these main

components of an effective response to disasters. Authorities from health sector also

should be included to these institutions and organisations.

The last point is that there is little information available about the kind of injuries

resulting from natural disaster, especially about earthquakes. The occurrence

mechanisms of these injuries are also very important for prevention possibilities. The

registrations are often not good in disaster situations and there are not so many

epidemiological researches about them. Despite increasing need, great amount of money

and resources are allocated for direct action, without investment in research to enhance

the impact of the action, whereas epidemiological researches can be used to measure and

describe the adverse health effects of disasters and the factors that contribute to those

effects. These investigations may help to assess the needs of disaster-affected

populations; match available resources to needs; prevent further adverse health effects;

evaluate program effectiveness; and permit better contingency planning. (Noji, 1997)

Therefore it should be understood that researches, both during the response activities

and at later periods, have vital functions for future disasters. International concepts

should be ensured to make investigations during the response activities and more

sources should be allocated to these subjects. After each disaster assessments and

publications made by national authorities and sharing of these assessments with other

countries in conferences or other scientific meetings, would be of great use.

ANNEX 1:

CONTENTS

1. Introduction

1

2. Method and Definitions

6

3. Review of Literature

10

3.1 The Nature of Natural Disasters 10 3.2 General Effects of Natural Disasters on Health and Their Public Health Consequences

16

3.3 Types of Natural Hazards and Their Consequences 19 3.3.1 Classifying according to origin in the nature: Climatic-, Geological-, Biological Hazards

21

3.3.1.1 Climatic Hazards 21 3.3.1.2 Geological Hazards 28 3.3.2 Classifying According to onset: Sudden Onset/Progressive Onset 39 3.3.2.1 Sudden Onset Natural Hazards 39 3.3.2.2 Progressive Onset Natural Hazards 40 3.4 Situation of the World Regarding to Natural Disasters 40 3.4.1 The Historical Context of Natural Disasters in the World 40 3.4.2 Overlook to the Current Situation of the World About Natural Disasters 43 3.4.3 What do Natural Disasters Cost to the World? 46 3.4.4 Major Natural Disasters in the World 49 3.4.5 Types of Natural Disasters Ranked by Mortality and Affected Population 50

4. The Aspects and Concepts of World Health Organisation and its Related

Departments About Mitigation, Preparedness and Response Projects

53

4.1 Responsibilities and Aims of WHO and UN about Disasters 54 4.2 Mitigation, Preparedness and Response Activities According to WHO’s and It’s Related Departments’ Publications and Documents

56

4.2.1 Mitigation Activities 58 4.2.1.1 Mitigation Activities in Drinking Water and Sewerage Services 59 4.2.1.2 Mitigation Activities in Health Services 60

4.2.2 Preparedness Activities 66 4.2.2.1 Emergency Planning 67 4.2.2.2 Training and Education 69 4.2.2.3 Monitoring and Evaluation 70 4.2.2.4 Emergency and Disaster Planning in the Health Sectors 70 4.2.3 Response Activities 77

5. Learning Lessons from Past Events: 17 August and 12 November 1999 Earthquakes in Turkey

83

5.1 Why to Take Earthquake as an Example 83 5.2 Why is Turkey/Marmara Region an Important Example to Work on? 85 5.3 The Days 17 August and 12 November 91 5.4 The Situation After the Earthquakes 93 5.4.1 The General Situation 93 5.4.2 The Situation of Health of Populations and Health Services in the Disaster Areas

97

5.5 Lessons from 17 August and 12 November 1999 Earthquakes for the expected Earthquakes in the Same Region and Other Ones

107

6. Conclusions and Recommendations

111

7. References 118

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