Linking Hazards and Public Health: Case Studies in Diasters1
Using three different types of disasters, heat waves, earthquakes, and complex humanitarian crises, the speakers and Roundtable members explored the complexity of responding to health needs, the public policy underlying the response, and the short- and long-term health-related needs. Speakers discussed examples of planning and response to specific events in the United States such as the Chicago heat wave of 1995 and the Loma Prieta earthquake of 1989, as well as events occurring internationally. Discussion continued regarding how communities at all levels, from small towns and counties to major cities, may link major disasters to public health, strategies for creating a plan of action, and implementation of these programs through managing disasters as they evolve.
SOCIAL AND HEALTH EFFECTS OF A DISASTER—THE HEAT WAVE
Heat waves are often the “overlooked” natural disaster, frequently not recognized by the media or government as a public health risk and omitted from the disaster literature. Eric Klinenberg of New York University stated that one of the immediate challenges faced by individuals attempting to persuade the public and government officials of the direct health threat presented by heat waves is the lack of imagery associated with a heat wave. Often people conjure images of children playing near a fire hydrant or people sipping lemonade on a front porch as ways to skip the heat. Compare this to the image of cars twisted around trees or houses carried off their foundations down a river. While heat waves do not have the same destructive properties as a tornado or an earthquake, more lives
have been claimed in the United States over the past fifteen years by heat than by all other extreme weather events—lightning, tornadoes, floods, and hurricanes—combined (CDC, 2002). He cited an editorial in the New England Journal of Medicine, published just a few months after the Chicago disaster, which states that compared to other kinds of disasters that kill far fewer people, the heat wave in Chicago was forgotten almost as soon as the weather changed (Kellermann and Todd, 1996).
More lives have been claimed in the United States over the past fifteen years by heat than by all other extreme weather events—lightning, tornadoes, floods, and hurricanes combined.
—Centers for Disease Control and Prevention
The Furnace—The Dynamics of a Heat Wave
More heat-related deaths occur in cities than in rural areas because stored heat dissipates slower in urban areas. This is due to the density of brick and stone buildings, paved streets, and tar roofs that store heat and radiate it like a slowly burning furnace to create a “heat island.” The worst heat disasters, in terms of loss of life, occur in large cities when a combination of four factors occurs for a period of several days:
high daytime temperatures
warm nighttime temperatures which prevent dissipation of stored daytime heat
abundance of sunshine, which can increase the heat index by 15°F
Examined independently these atmospheric conditions may be of little consequence. However, in combination they can create an urban environment where infrastructure stores heat and continually releases it throughout the night until the next day, when more heat will be absorbed for the cycle to continue until temperatures drop.
The Role of Socioeconomic Factors
Socioeconomic problems are risk factors for susceptibility to heat-related illness. Klinenberg pointed out that understanding the relationship between neighborhood conditions and vulnerability can help cities target their responses to those areas with populations that may be hit the hardest. For example, lower-income individuals may not have air conditioning or may hesitate to turn it on due to cost. Often they live in high-crime areas and may be afraid to open the
windows, creating an indoor environment equivalent to a greenhouse with little air circulation and increasing temperatures. Additionally, the mentally ill, who are more likely to be alone because of difficulty in gaining and maintaining social support, may also have difficulty cooling down or avoiding severe sunburns due to their medications. The risks of social isolation incurred by groups such as the elderly and mentally ill are only compounded as neighborhoods evolve and the cultural, ethnic, and linguistic composition of the community changes.
A Public Health Policy Example: Recent Heat Waves
Within the past decade there have been two heat waves with catastrophic results: the Chicago heat wave of 1995 and the European heat wave of 2003. In July of 1995, while the entire Midwestern United States endured an abnormal increase in average temperature, the urban heat island of the Chicago area experienced the highest temperatures recorded since measurements began at Midway Airport in 1928, with daytime temperatures peaking at 106°F. Over 700 people in the city died during this heat wave that lasted about five days.
In the summer of 2003 over 35,000 people died in Europe when an abnormal weather system that lasted for about three weeks aggravated the conditions that had been set in motion by an early and unusually warm spring and low rainfall (Rasool et al., 2004). While the death rate in Chicago from 1995 was actually about identical to the death rate in France, the deaths in Chicago came after two or three days of elevated heat and humidity, whereas the deaths in Europe occured toward the end of the heat wave. Although there is some debate, the delayed deaths in Europe may have occurred due to the temperatures and unusual atmospheric conditions reaching a critical juncture, whereas the conditions in Chicago resulted from a sudden onset of extraordinary atmospheric conditions.
Complicating Factors in the Chicago Heat Wave of 1995
While high temperatures and unusual weather conditions are essential components of a heat wave, there are often a number of compounding issues, such as a lack of communication between government officials and a failure of critical infrastructure. With no official disaster plan in place to address the crisis, the effect of the heat in Chicago was compounded by a number of complicating factors:
Communications: During a 5-day period in which not only were there 700 more deaths than during a normal period, but also thousands more were hospitalized, some paramedics who first arrived on the scene reported that their own departments refused to release additional ambulances and staff to cope with the workload.
Power failure: When ConEd power failures knocked out fans and air conditioners that summer, 49,000 households were affected, and hundreds of Chicagoans died (Careless, 2004).
Inadequate facilities: City officials did not release an emergency heat warning until July 15, the last day of the heat wave. Because of the delay in issuing an excessive heat advisory, emergency measures such as Chicago’s five cooling centers were not fully utilized, severely taxing the medical system as thousands were taken to local hospitals with heat-related problems.
Lack of understanding: Klinenberg stated that a large part of the problem was with reporting and recognition—a failure and in some cases a refusal to recognize the extent of the damage and the potential for further risks, such as the difficulty experienced by paramedics attempting to convince high-ranking officials that the health problems they were addressing constituted a disturbing trend and a serious threat.
The “Social Autopsy” of the 1995 Chicago Heat Wave
In situations such as the aftermath of the Chicago heat wave of 1995, Klinenberg proposes that the affected community analyze the response and results of a disaster immediately after it occurs, which Klinenberg called social autopsy. He expressed the idea that this is especially important because excessive heat disasters are one of the few disasters where deaths are preventable, and also suggests that being relatively open with the results of such an evaluation will allow community leaders to generate a general understanding about public health.
The Effects of Chicago Autopsy Results
While the Chicago heat wave was a terrible disaster, Klinenberg noted that this event could be thought of as leading to a checklist for the new Chicago disaster response plan. Various groups such as the Department on Aging now compile lists of elderly people who live alone and might need assistance so workers can call or visit those residents to alert them that a dangerous weather system is on the way. Similarly, the city now also opens up a heat line for updated safety information. Another crucial step was the implementation of a monitoring system for emergency room admissions and the activity of paramedics, as the danger posed by a weather system can immediately be understood by monitoring the health impacts reported by front line responders.
Bringing New Life to Disaster Response
According to Klinenberg, before a heat wave has arrived a city should examine its infrastructure such as water systems and communications to deter-
mine how, when and where response systems will be needed and how to make them easily accessible and moderately simple to implement. Another critical question that cities need to address is deciding at what point in the slow onset of an event such as a heat wave it must be addressed as an imminent threat. The corollary to this is how to acknowledge and publicize the imminent threat without creating undue public alarm. Once a heat wave is declared a public health emergency, the response plan can be implemented. Klinenberg also emphasized the need to perform a social autopsy after the disaster, when the protocols have been carried out and the damage has been tabulated, to dissect the response and provide immediate feedback.
Applying Lessons Learned to Other Disasters
During a time of crisis, it may be useful to use the lesson learned from one disaster for responding to other disasters. For example, a participant who is a staff member from the Office of Emergency Management for New York City noted that following the 1999 Chicago heat wave, the city of New York created a network to address the special needs of the elderly and the particularly vulnerable in the event that a similar event happened in New York City. The at-risk individuals were identified because they were receiving home-based care or nursing services, having contact with the Department for the Aging, or participating in activities at senior citizen centers. While this network was designed to respond to potential heat waves, its was fully tested following the World Trade Center (WTC) attacks. When implemented on September 11, the Office of Emergency Management needed to contact the 3500 individuals within the affected area to ensure that the individuals were receiving care. Within 2 hours of the disaster, a call center was initiated, and within 24 hours, all but 30 individuals were contacted. A joint team of Red Cross volunteers and construction workers began to locate the remaining individuals because the EMS and the police were occupied with events at the WTC site. The participant noted that the use of the call center was successful; however, as this example illustrates, there needs to be more flexibility in the planning as events unfold. For example, the use of able bodied volunteers to check on vulnerable populations while emergency personnel are busy with the crisis.
THE ROLE OF INFRASTRUCTURE DURING A DISASTER
Infrastructure and public health are not necessarily thought of as interconnected areas, although their relationship to one another can be profound, especially in disasters. Part of the traditional purpose of infrastructure is to protect human health, and so disaster planning needs to be explicitly incorporated into infrastructure design, operations, and maintenance. In addition, infrastructure services are interrelated, which has implications for public health. Discussions of
infrastructure tend to dissect and analyze infrastructure sectors individually. The impact of transportation, utilities, and communications upon each other, however, should be examined as a whole, since these services serve and impact the same customers, noted Rae Zimmerman of New York University’s Wagner Graduate School of Public Service.
Infrastructure Under Non-Disaster Conditions
In urban areas the quality of the built environment, which includes infrastructure, dramatically affects the health status of all urban residents. Zimmerman stated that air and water quality, for example, encompasses infrastructure-related public health issues for all urban residents on a day-to-day basis:
Under non-disaster conditions transportation is the single largest contributor to emissions of several air quality pollutants, and similarly, the generation of electric power is a key contributor to several air quality pollutant emissions (Wright, 2005:580, based on U.S. EPA information).
There are an estimated 1.3 million cases of water-related disease in the United States (quoted in Zimmerman, 2004:86, citing Water Infrastructure Network, 2000:1-2 and Payment et al., 1997). Infrastructure-related factors associated with these diseases can include poorly-planned population expansion that is not accompanied by increased water and wastewater treatment capacity or defects in engineered systems such as water treatment and distribution or waste water management systems.
These are just two examples of the multitude of public health issues that relate to infrastructure.
Infrastructure in the Short and Long Term
Infrastructure decisions rarely reflect an emphasis on public health, and people making those decisions often have little training in public health areas. In addition, regulators and planners in infrastructure areas often do not coordinate with public health professionals, and thus, all of the short- and long-term effects of the interaction between environment, infrastructure, and health may not be considered.
The short-term effects of these decisions are that in times of disaster, structural damages may not be avoided as effectively as they might otherwise be, such as the collapse of freeways or buildings in an earthquake, and the long-term effects and their impact on health are often not tracked. In the area of infrastructure design this can be demonstrated by examining the collapse of the Cypress and Embarcadero Freeways during the Loma Prieta earthquake of 1989. These two double-decker freeways suffered severe structural damage (Figure 2.1). Sev-
eral thousand people were injured and dozens were killed in that earthquake (Tubbesing, 1994). Zimmerman pointed out that accounts of the collapse indicated that the short-term decisions made about construction of infrastructure and later retrofitting only one side of the freeway may have contributed to instability.
Government and industry tend to focus on immediate rather than long-term impacts, e.g., giving greater emphasis to the effects and cost of initial construction under normal conditions of use rather than to structural stability in the event of a hypothetical disaster in the future. Policy is designed accordingly and thus may not properly identify or address many important areas related to disasters. Effective environmental and public health regulations for infrastructure must involve collaboration between all involved parties, proper analysis of short- and long-term environmental and health impacts, and the development and implementation of effective policies that respond accordingly, concluded Zimmerman.
Infrastructure Organization and Management
The manner in which infrastructure is organized and managed can have a direct impact upon the vulnerability of a society in times of disaster. The dramatic centralization of virtually all areas of infrastructure has become a conscious policy for economic and managerial reasons. Figure 2.2 illustrates this concept of centralization. As communities move from a small population density to a much higher population density, there is, for example, an evolution in the provision of water supply services, from wells to community water supply systems to urban water treatment plants. Similarly, the natural evolution of wastewater treat-
ment is a movement from septic tanks to package plants to large wastewater treatment plants, and transportation has grown from horse-drawn trolleys, to cars and buses, and more centrally controlled or managed large high speed trains and airplanes. With electric power, individual stoves have given way to electric heating capacity provided via overhead electric power lines followed by underground lines, and from smaller electric power plants to larger ones based on energy sources such as coal or nuclear power, noted Zimmerman.
Society is also becoming increasingly reliant upon infrastructure networks that often span large distances, stated Zimmerman, noting that the United States has almost 4 million miles of highway, 10,000 miles of track for city and regional rail, 22,000 miles of track for long distance passenger travel, and 170,000 miles of freight railroads (summarized in National Research Council, 2002). Beyond transportation, the United States boasts close to 1 million miles of water supply line and similar numbers for wastewater piping, providing a convoluted set of networks vulnerable to natural and terrorist threats.
In addition to vulnerabilities created by the extensive network of distribution systems, interdependencies found among the separate components of infrastructure can also potentially create vulnerabilities due to cascading and escalating effects. The individual units of infrastructure are each vulnerable independently to physical and electronic disruptions, and a dysfunction in one can have severe consequences in the others. While one aspect of a region’s or the nation’s infrastructure may be more sensitive to a disruption, they are all dependent upon one another to varying degrees.
The individual units of infrastructure are each vulnerable independently to physical and electronic disruptions, and a dysfunction in one can have severe consequences in the others.
Infrastructure: Choices and Trade-Offs
Difficult choices often have to be made regarding risks and benefits when considering the effects of infrastructure options upon the health of a population, such as the use of diesel fuel for emergency power back-up to generators versus the health effects that may result from diesel fuel emissions. Decisions made by government and industry must involve the decoupling of infrastructure and shift our dependency from centralized energy sources to renewable energy sources such as solar, waste, wind, and other relatively newer technologies that can operate in a decentralized manner, stated Zimmerman. This will ensure that the infrastructure systems crucial for the day-to-day functioning of our communities and the nation can withstand a disaster and maintain the trust of the public.
COMPLEX DISASTERS AND PUBLIC HEALTH
There isn’t a single internationally adopted definition of what constitutes a complex disaster, stated Jean-Luc Poncelet, of the Pan American Health Organization (PAHO). A complex emergency is a term primarily used by the United Nations (UN) that refers to a crisis that overwhelms nations due to civil disturbances, war, deep political crisis, etc. Due to the chaos, the entire nation becomes dysfunctional and humanitarian intervention from a foreign source is needed.
The health risks associated with complex emergencies tend to be very poorly documented and often biased. This is because the majority of the morbidity and mortality information is provided by non-national, well-meaning individuals, but often with little or no knowledge of the origin of the conflict, the traditions and culture, or even the language. This can result in the production of copious amounts of data that are only partially analyzed and are frequently distorted, observed Poncelet. Thus, PAHO and the World Health Organization (WHO) as
part of their mission focuses on strengthening the national capacity to respond to crises. Even though this may be difficult because in a complex emergency there is no government, the fate of the government is at stake, or the authority itself is part of the conflict.
The Risks of International Assistance
An increasing number of people and organizations are intervening in the humanitarian field. On the one hand, this is beneficial because it brings attention to the situation that is occurring. On the other hand, the complications involved in attempting to communicate with and coordinate the efforts of large numbers of international organizations can become more of a burden than a blessing, noted Poncelet. All of them attempt to assist countries in their specific field, so efforts can become extremely complicated, especially if there is a strong political or media influence, as is commonly present in a complex emergency.
The weakening of remaining local response capacity by setting up parallel coordinating mechanisms is perhaps the greatest risk of international assistance. The risk is that organizations and individuals believe that just because there are good intentions, beneficial short-term results, and excellent specialists this automatically means that they are going to do a good job, observed Poncelet. The involvement of the local and usually fragmented network is critical to attaining any level of success. International helpers can actually become a burden on the national system. This would occur in a situation such as the deployment of expensive field hospitals that arrive late and then remain in the country after stabilization with high maintenance costs. Poncelet posed the question of why send 300 people for one week who don’t speak the language and don’t know the context, to assist in a complex emergency; a situation that has happened repeatedly. Unfortunately, common sense is often abandoned in the rush for visible action to satisfy the international public, and not the local needs. The money used for a large scale operation could have been used toward people and supplies in smaller quantity for a longer period of time. It would have been less visible internationally, but more effective locally.
Direct and Indirect Impacts
The direct impact of these conflicts on public health is usually measured by the mortality, noted Poncelet. For example, in Bosnia, the mortality of traumas in 1992 increased dramatically within the time-span of a few months, from 22 percent mortality of trauma cases to 78 percent mortality, an increase that was directly linked to the civil war and international intervention.
Hospitals and the Red Cross Society emblems were previously considered to be safe harbors even during a complex emergency; however, over the last 5–10 years there has been an increasing trend towards targeting the health
services themselves as a war tactic. For example, the killing of victims in ambulances, hospitals staff being given instructions not to attend to parts of the population by the leadership of a guerilla movement, and massacres taking place in hospitals have become more commonplace.
Indirect impacts do not provide stark images. They are silent, but the most serious ones to be attended by humanitarian health professionals. They vary in origin, including:
long-term interruption of health services due to impairments in access or security
the need for provisional housing
interruption of infrastructure, such as water systems, electricity, transportation
general insecurity and psychological impact of events on population and staff
limited access to food due to lack of income, lack of adequate stores, destruction of crops, etc.
Poncelet observed that the disruption of basic needs and supplies can often prove far more devastating than the direct impact of the disaster itself. For example, the major issue for victims of the 1996 earthquake in El Salvador was not a lack of physicians or medications. Rather, the lack of access to water for drinking, sterilization in hospital procedures, cooking, and cleaning proved to be the most disruptive to citizens.
We prefer to see victims attended by hospital physicians, but what will save the largest number of lives is the fixing of the pipelines that will ensure the functioning of the kitchen, the laundry, and the sterilizers.
Public Health Needs
It is important to divide the needs of individuals suffering during and after a complex emergency into two categories: short-term and long-term needs. Short-term refers to the more immediate assistance, an area of specialty better attended by humanitarian professionals. These professionals are trained to address the most urgent requirements of victims, such as food, water, shelter, sanitation, medication, epidemiological surveillance, and logistics. The specialists dealing with long-term issues are from a completely different professional background. Poncelet pointed to the situation in Angola. After years of civil war, the system in place is dealing with issues that cannot be only attended to by humanitarian specialists. Most of these must be dealt with by long-term specialists such as
developers and planners. These professionals have the knowledge to deal with chronic issues in complex situations such as the implementation of functioning health care programs with local resources. The setting up of the response to a crisis is the business of humanitarian professionals and the running of the extended crisis must be dealt with by developer specialists.
The division of labor between the different specialties is something that deserves more attention than it commonly receives, stated Poncelet, presenting a challenge for international aid organizations. The nature of a complex emergency is that it is usually a long-lasting event, with no possibility of being resolved in a few months, like in the case of the aftermath of a tornado or a flood. Humanitarian specialists are the most visible respondents but must also stay true to their area of expertise. Poncelet also noted that in order for the response to be most effective, both groups must be present as soon as possible, meaning that groups who are working on the long-term challenges should also be present during the early stages of the response and integrated into the work of the humanitarian specialists in order to coordinate their efforts to provide a long-term solution and not just a momentary lift.
Effect on Mental Health
The provision of mental health services has traditionally been overlooked as a priority need in the case of complex disasters. However, this view is changing with an accumulation of research on long-term coping and functioning skills of affected populations, noted Poncelet. Depression and post-traumatic stress disorder (PTSD) are common disorders in war-torn regions and soldiers returning from wars. The impact of wars on mental health can linger for years after the war ends, with affected populations having a lower level of social functioning than non-affected populations. Poncelet asserted that more emphasis should be placed on long-term effects, such as a reduction in resilience due to the absence of a structured environment, schools, and family.
Mental health has traditionally been overlooked as a priority need for providing assistance in the case of complex disasters.
NGOs and Complex Disasters: Challenges
The mission of PAHO/ WHO is to face natural disasters and complex emergencies as part of the inter-America system and as a regional office of the World
Health Organization. The goal of the organization, as stated by Poncelet, is to work with local authorities primarily before disasters in the areas of prevention, mitigation, and preparedness, but also to aid in the response to disasters, based on the local response capacity.
PAHO as a Model of Preparedness and Response
PAHO/WHO, in coordination with other governmental and non-governmental organizations, views preparation as its best investment. This includes such activities as:
helping to implement and continuously strengthen national disaster programs
training health sector personnel
inter-institutional and inter-sectoral coordination mechanisms
The level of the response from PAHO/WHO is dependent first upon the local response to a disaster and then, to a lesser degree, the extent of the international response.
All aspects of potential needs cannot be prepared for in every locality, admitted Poncelet; therefore, PAHO also devotes some of its energies to regional response mechanisms. A great deal of this effort is devoted to the coordination of international health assistance. This allows for technical cooperation between local and international officials with an independent assessment of specific needs in the current situation and the ability to mobilize international resources to complement the local and national response, if necessary.
If You Don’t Know, Don’t Go
In summary, Poncelet put forth three major points regarding complex disasters and their impact on public health: the need for quality information, protection of public health services, and availability of appropriate and timely expertise.
In most complex disasters only fragmented information is available, and this information must be viewed with caution because of the risk of potential bias in reporting. As discussed above, to avoid this risk it is necessary to have studies done locally with local users, asserted Poncelet. Also important is the protection and utilization of the existing public health services, even if they are not in the conflict areas.
The final point is evaluating the appropriateness of expertise. As mentioned previously, it is important to delegate responsibility and ensure that people who are in charge of the humanitarian help and quick response act only in the realm of their expertise and at the same time have them working much more closely
with developers. These two groups of people working together are the only alternative to assist countries in crisis.
Poncelet suggested that the best method of alleviating some of the strain on public health posed by a complex emergency is to help the remaining local structure to respond and prepare for a crisis as poorly coordinated international intervention can prove more dangerous than effective.