1. Public Health Disaster Consequences of Disasters Eric K. Noji, M.D., M.P.H. Medical Epidemiologist Centers for Disease Control & Prevention Washington, DC Second Annual John C. Cutler Global Health Lecture and Award University of Pittsburgh 29 September 2005

2. This lecture has been supported by John C. Cutler Memorial Global Fund, Graduate School of Public Health, University of Pittsburgh Coordinated through the Global Health Network Supercourse project, WHO Collaborating Centre, Uni. Of Pittsburgh Faina Linkov, Ph.D. Eugene Shubnikov, MD, Mita Lovalekar, M.D., Ronald LaPorte, Ph.D. www.pitt.edu/~super1/

3. Definition of Disaster A disaster is a result of a vast ecological breakdown in the relation between humans and their environment, a serious or sudden event on such a scale that the stricken community needs extraordinary efforts to cope with it, often with outside help or international aid Source: EK Noji, The Public Health Consequences of Disaster

4. Disasters and Emergencies Natural Disasters Transportation Disasters Terrorism Technological Disasters Pandemics

5. 1994-2004: A Decade of Natural Disasters 1 million thunderstorms 100,000 floods Tens of thousands of landslides, earthquakes, wildfires & tornadoes Several thousand hurricanes, tropical cyclones, tsunamis & volcanoes Sources: CDC & EK Noji, The Public Health Consequences of Disaster

6. Factors Contributing to Disaster Severity Human vulnerability due to poverty & social inequality Environmental degradation Rapid population growth especially among the poor Sources: CDC & EK Noji, The Public Health Consequences of Disaster

7. Influence of Population Growth Urban dwellers: 1920: 100 million 1980: 1 billion 2004: 2 billion 2004: 20 cities with >10 million people Sources: CDC & EK Noji, The Public Health Consequences of Disaster

8. Political destabilization in the post Cold War era with increased regional violence

9. Escalating ethnic based conflicts with civilians as military targets

10. Forced Migration

11. Emerging themes in Epidemiology The role of the applied epidemiologist in armed conflict Sharon M McDonnell, Paul Bolton, Nadine Sunderland, Ben Bellows, Mark White and Eric Noji For more information visit http://www.ete-online.com/content/1/1/4 (biomed central) http://www.ete-online.com/content/1/1/4

12. Epidemiology and its applications in measuring the effects of disasters EpidemiologyEpidemiology – The quantitative study of the distribution and determinants of health related events in human populations

13. Disaster Epidemiology Assessment and Surveillance Assessment and Surveillance Injury and disease profiles Injury and disease profiles Research methodologies Research methodologies Disaster management Disaster management Vulnerability and hazard assessment Vulnerability and hazard assessment

14. Disaster Epidemiology Purpose: –Identify requirements, local capabilities, gaps –Avoid unnecessary and damaging assistance Victims Needs Available Services Data for Decision-Making

15. "The reason for collecting, analyzing and disseminating information on a disease is to control that disease. Collection and analysis should not be allowed to consume resources if action does not follow." William H. Foege, M.D. International Journal of Epidemiology 1976; 5:29-37

16. Objectives of Health Information Systems in Emergency Populations Establish health care priorities Follow trends and reassess priorities Detect and respond to epidemics Evaluate program effectiveness Ensure targeting of resources Evaluate quality of health care

17. Myths and Disaster Realities 1)Myth: Foreign medical volunteers with any kind of medical background are needed. Reality : The local population almost always covers immediate lifesaving needs. Only skills that are not available in the affected country may be needed. Few survivors owe their lives to outside teams

18. 2) Myth: Any kind of assistance is needed, and it’s needed now! Reality: A hasty response not based on impartial evaluation only contributes to chaos Un-requested goods are inappropriate, burdensome, divert scarce resources, and more often burned than separated and inventoried Not wanted, seldom needed – used clothing, OTC, prescription drugs, or blood products; medical teams or field hospitals.

19. 3) Myth: Epidemics and plagues are inevitable after every disaster. Reality: Epidemics rarely ever occur after a disaster Dead bodies will not lead to catastrophic outbreaks of exotic diseases Proper resumption of public health services will ensure the public’s safety –Immunizations, sanitation, waste disposal, water quality, and food safety Caveat: Criminal or terror-intent disasters require special considerations

20. 4) Myth: Disasters bring out the worst in human behavior. Reality: While isolated cases of antisocial behavior exist, the majority of people response spontaneously and generously “40-60% Drop in murder rate surprises NYC” - “fewest since 1958”. - USA Today 03/25/2002 Kenyans line up for 2-3 km in August heat to donate blood after US Embassy bombing

21. 5) Myth: The community is too shocked and helpless Reality: Many find new strengths Cross-cultural dedication to common good is most common response to natural disasters Thousands volunteer to rescue strangers and sift through rubble after earthquakes from Mexico City, California, and Turkey. Most rescue, first aid, and transport is from other casualties and bystanders

22. WHAT DOES THE FUTURE HOLD?

23. Increasing disaster risk Increasing population density Increased settlement in high-risks areas Increased technological hazards and dependency Increased terrorism: biological, chemical, nuclear? Aging population in industrialized countries Emerging infectious diseases (SARS) International travel (global village)

24. Increasing Global TravelIncreasing Global Travel Rapid access to large populationsRapid access to large populations Poor global security & awarenessPoor global security & awareness...create the potential for simultaneous creation of large numbers of casualties

25. Health Information Needs in Emergency Populations Establish health care priorities Establish health care priorities Follow trends and reassess priorities Follow trends and reassess priorities Detect and respond to epidemics Detect and respond to epidemics Evaluate program effectiveness Evaluate program effectiveness Ensure targeting of resources Ensure targeting of resources Evaluate quality of health care Evaluate quality of health care

26. Final Thought NOTHING REPLACES WELL TRAINED, COMPETENT AND MOTIVATED PEOPLE! NOTHING! PEOPLE ARE THE MOST IMPORTANT ASSET

27. EXTRA SLIDES Please refer to Cutler lecture website http://www.publichealth.pitt.edu/specialevents/cutler2005/webcast.html to obtain full version of the lecture

28. Epidemiologic Methods in Disasters After a disaster (Reconstruction Phase): Conducting post-disaster epidemiologic follow-up studies Identifying risk factors for death & injury Planning strategies to reduce impact-related morbidity & mortality Source: EK Noji, The Public Health Consequences of Disaster

29. Epidemiologic Methods in Disasters After a disaster (Reconstruction Phase): Developing specific interventions Evaluating effectiveness of interventions Conducting descriptive & analytical studies Planning medical & public health response to future disasters Conducting long-term follow-up of rehabilitation/reconstruction activities Source: EK Noji, The Public Health Consequences of Disaster

30. Epidemiologic Methods in Disasters Challenges for Epidemiologists Applying epidemiologic methods in the context of: Physical destruction Physical destruction Public fear Public fear Social disruption Social disruption Lack of infrastructure for data collection Lack of infrastructure for data collection Time urgency Time urgency Movement of populations Movement of populations Lack of local support and expertise Lack of local support and expertise Source: EK Noji, The Public Health Consequences of Disaster

31. Epidemiologic Methods in Disasters Challenges for Epidemiologists Selecting study designs: Cross-sectional: Cross-sectional: Studies of frequencies of deaths, illnesses, injuries, adverse health affects Limited by absence of population counts Case-control: Case-control: Best study to determine risk factors, eliminate confounding, study interactions among multiple factors Limited by definition of specific outcomes, issues of selection of cases & controls Source: EK Noji, The Public Health Consequences of Disaster

32. Epidemiologic Methods in Disasters Challenges for Epidemiologists Selecting study designs: Longitudinal: Longitudinal: Studies document incidence and estimate magnitude of risk Limited by logistics of mounting a study in a post-disaster environment and subject follow-up Source: EK Noji, The Public Health Consequences of Disaster

33. Epidemiologic Methods in Disasters Challenges for Epidemiologists Need standardized protocols for data collection immediately following disaster Need standardized protocols for data collection immediately following disaster Need standardized terminology, technologies, methods and procedures Need standardized terminology, technologies, methods and procedures Need operational research to inventory medical supplies and determine 1) actual needs, 2) local capacity, 3) needs met by national/international communities Need operational research to inventory medical supplies and determine 1) actual needs, 2) local capacity, 3) needs met by national/international communities Need evaluation studies to determine efficiency and effectiveness of relief efforts and emergency interventions Need evaluation studies to determine efficiency and effectiveness of relief efforts and emergency interventions Source: EK Noji, The Public Health Consequences of Disaster

34. Epidemiologic Methods in Disasters Challenges for Epidemiologists Need databases for epidemiologic research based on existing disaster information systems Need databases for epidemiologic research based on existing disaster information systems Need to identify injury prevention interventions Need to identify injury prevention interventions Need to improve timely and appropriate medical care following disaster (search & rescue, emergency medical services, importing skilled providers, evacuating the injured) Need to improve timely and appropriate medical care following disaster (search & rescue, emergency medical services, importing skilled providers, evacuating the injured) Need measures to quickly reestablish local health care system at full operating capacity soon after disaster Need measures to quickly reestablish local health care system at full operating capacity soon after disaster Source: EK Noji, The Public Health Consequences of Disaster

35. Epidemiologic Methods in Disasters Challenges for Epidemiologists Need uniform disaster-related injury definitions and classification scheme Need uniform disaster-related injury definitions and classification scheme Need investigations of disease transmission following disasters and public health measures to mitigate disease risk Need investigations of disease transmission following disasters and public health measures to mitigate disease risk Need to study problems associated with massive influx of relief supplies and relief personnel Need to study problems associated with massive influx of relief supplies and relief personnel Need cost-benefit and cost-effectiveness analyses Need cost-benefit and cost-effectiveness analyses Source: EK Noji, The Public Health Consequences of Disaster