Summary

E. Pretto¹, C. Ugarte², J. Levett³, Y. Oka⁴, K. Shoaf⁵ and Secretariat

¹E.A. Pretto M.D., M.P.H, is Principal Investigator, Disaster Reanimatology Study Group and Associate Director, Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, USA.

²C. Ugarte is Director, Direccion Nacional Preparacion contra Desastres, Lima, Peru.

³J. Levett is Director of International Affairs, National School of Public Health, Ministry of Health and Welfare, Athens, Greece.

⁴Y. Oka is a Research Associate from the Department of Architecture, University of Tokyo, Tokyo, Japan.

⁵K. Shoaf is from the Department of Community Health Sciences, School of Public Health, University of California, Los Angeles, USA.

Dr B. Mulyadi, Director for Private and Specialty Hospitals, Directorate General of Medical Care and Secretary of the Crisis Centre, Ministry of Health, Jakarta, Indonesia, presented a case study from his country. He explained the vulnerability factors that make his country one of the areas of the world most prone to disasters and described a comprehensive emergency management system for the health sector which is built on a model of "escalation" from daily routine emergencies to full-fledged disaster management. He also touched on the multisectoral distribution of roles and responsibilities and focused on those of the health sector and the means it has to implement these tasks in collaboration with the military and volunteer organizations. He concluded that the main reason behind the success of the disaster management system in Indonesia is its decentralization to community level and its fully integrated approach from vulnerability reduction through the whole range of emergency management.

Dr J.L. Poncelet, Head, Disaster Preparedness Program for South America, PAHO/WHO, Quito, Ecuador, spoke about the impact of earthquakes on Latin American countries and cities and the development of management policies being adopted in those countries. The emphasis has shifted over the years from disaster response to preparedness and now to mitigation. In this development it was found that plans for preparedness often existed but failed because of lack of skills or clearly defined responsibilities. Also, the increasing specialization among disaster experts creates new problems of coordination for preparedness. Within this coordination, tasks should be delegated to each sector which will have its own responsibilities.

He stated that the emphasis for disaster management is also changing from the national to the regional and community level. Waiting for government orders before reacting and employing resources is a frequent and deadly phenomenon after disasters. Local authorities, such as the mayor, should be empowered to make the necessary decisions, based on local input and timing. He also stated that natural disasters are not really all that natural because a large part of the vulnerability is created by humanity. In the future, national mechanisms must be adapted to this delegation of authority, and managerial functions at different levels should be defined. Training programmes should include behavioural aspects during disasters. However, obtaining support from the top political level remains important and should be obtained with information, training and involvement.

In the brief discussion on this paper it was re-emphasized by Dr Poncelet that medical and public health specialists, as well as those from other sectors, have to speak to politicians and administrators to obtain their concurrence and support ahead of the disaster. Dr Goncharov added that politicians want to save and not spend money; some would rather wait until the disaster happens.

Dr E. Pretto presented a poster entitled "Essential elements for community and hospital earthquake preparedness". Health disasters can be defined as mass casualty events that overwhelm or destroy local emergency health care delivery systems. Until recently, "medical" response in disaster was limited to public health support of uninjured survivors. Disaster medicine research was the domain solely of epidemiology and sociology. Earthquake research involved mostly preventive and structural engineering. Early observations of death in earthquakes suggested there might be a population of victims who survive the initial impact but who die hours to days later from life-threatening injuries and a delay in receiving emergency medical care. It was suggested that a significant proportion of these deaths could be prevented with more rapid and better organized resuscitation efforts starting with uninjured co-victims as the ones giving the initial help.

The chairperson (poster session rapporteur) comments that mass training in first aid of the communities at risk is an important idea, but that it has largely been untested. Little research into the effectiveness of training lay persons in first aid has been done. The little research that does exist indicates that training may not be sufficient to prepare an individual to react in an emergency situation. It would be good to see a project like this funded to an extent that the idea is not only piloted but truly tested as to its possible effectiveness in a disaster situation.

Professor A. Minasyan from Armenia spoke on "The system of emergency medical care in disasters and catastrophes in Armenia". He began his presentation by reminding the audience of the Chernobyl accident and the resulting immediate and long-term effects on the health of the people. He stressed that scientifically based and efficient organization of medical care during emergencies is a decisive factor in saving lives. Professor Minasyan added that during the first hour of a disaster, quick situation analysis should be followed by prompt relief measures provided to the victims. All these measures are possible at present in Armenia with the formation of disaster committees at three levels and an efficient preparedness plan for all disasters which was developed after the Chernobyl nuclear power station accident and the Spitak earthquake in Armenia. The major objective of this plan is to provide early, efficient and specialized medical care, with an early rescue service using surface and air transport.

Professor Minasyan suggested a further number of activities such as training of health and rescue staff, stockpiling appropriate emergency drugs, strengthening the information system and carrying out research activities. In response to a question from the audience, Professor Minasyan said that training in disaster medicine is being provided to medical and non-medical personnel in emergency schooling supported by the United States Agency for International Development.

Dr V.A. Astakhov, Deputy Director, Far-Eastern Regional Urgent Medical Care Centre, Khabarovsk, Russian Federation, highlighted features of the medical consequences of earthquakes in the far-east region of Russia, an area quite heavily at risk. He advocated the establishment of an Asia-Pacific Centre for Disaster Management and suggested that the WHO Centre for Health Development, Kobe, should play an important role in such a centre.

Professor Y. Nagasawa presented an interesting poster mainly concerned with logistics which, however, some participants found difficult to understand. It was also said that the actual condition and situation of health care facilities (after the earthquake) was not as clear or simple as was shown by the model.

The model showed several problems concerning the provision of health care after a large disaster: facilities, communication system (telephone, radio, etc.), transportation of patients, and triage. These problems are interrelated and cannot be discussed without mentioning others.

Dr G. Ochi of the Department of Emergency Medicine, Ehime University School of Medicine, Ehime, Japan, et al presented a poster "The Importance of Modern Means of Communication (the GHDNet)" with a proposal for various media being utilized for information management during a disaster situation. The proposal presented ideas for utilizing satellite broadcasts, wireless devices and the Internet, as well as traditional media, for both coordination during a disaster and transmitting information to the public. This project apparently has been designed in and for Kobe but is adaptable for other places.

Such a system for information transfer should be most helpful during the first two days after a disaster of overwhelming scale. For example, 58 hospitals in Osaka, a neighbouring prefecture of Kobe, sent medical teams during the month following the earthquake. However, only four of the 58 sent their teams to Kobe during the first 48 hours. The remainder waited for a request or command to help Kobe. They had no way of knowing that the local government there was too heavily damaged to make contact with surrounding cities to ask for help just after the earthquake. Tragically, the information systems did not exist.

In the case of the sarin attack by Ohmu-Shinrikyo in Tokyo in March in 1995, the headquarters of Tokyo Police Office announced at 11:00 a.m. that sarin was suspected of causing the injuries to the subway passengers. This was two-and-a-half-hours after the first patient had been taken to an emergency medical centre. The delay in the information meant that the chance to administer pralidoxime methiodide, an antidote of sarin to many patients, was lost.

If accurate and timely information were available in disasters, needless morbidity and mortality would be prevented. Thus, establishing a reliable system for telecommunication in the emergency and disaster field is one of the most important problems we face.

Professor K. Hayashi, Director, Public Health Research Institute, Kobe, Japan, et al, presented a poster on the problems of hygiene and sanitation after the Great Hanshin-Awaji Earthquake. This poster presented a very important topic. As the sewage system was destroyed by the Kobe earthquake, sanitation became a serious problem quickly. Pictures and data were presented about the lack of sanitary facilities after the earthquake in Hyogo Prefecture. Planning for the disruption of sewage is an important component of a disaster plan. An available source of portable latrines and special collection vehicles are ways of planning for such an eventuality. Ordinary waste-collecting vehicles cannot carry toilet waste.

Additional plans might include education of the public about alternative means of disposing of both solid and liquid waste in the aftermath of an earthquake, such as having a supply of plastic garbage bags on hand for waste disposal. It is also important that public health agencies have a plan for screening water and sanitation facilities and the authority to shut down those that pose a hazard. After the Northridge earthquake, a major activity of the environmental health department of the Los Angeles County Department of Health Services was to shut off drinking fountains and water-dispensing machines that may have been contaminated.

In the discussion an argument proposed by Professor Wölfel, "The model's case should not occur: engineering can solve the problem" was countered by another opinion, "Even with modern technology, it is impossible to fully protect all the hospital functions from an earthquake, if it occurs just below it. The point is to decentralize functions of disaster medical care rather than putting up a large Disaster Medical Centre".