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European Workshop on Educational Aspects of Health in Disasters (Council of Europe, 1982, 50 p.)

(introduction...) Foreword Part I Part II

(introduction...)

2 - 5th March 1982
Council of Europe - Strasbourg

organized in co-operation between
The Council of Europe
Division of Higher Education and Research
and
The World Health Organization
Regional Office for Europe
and Emergency Relief Operations

with the help of
The Ross Institute of Tropical Hygiene
London School of Hygiene and Tropical Medicine, and
Ecole de Santublique
Universitatholique de Louvain

CONCLUSIONS - RECOMMENDATIONS AND PROPOSED ACTIONS

DIVISION FOR HIGHER EDUCATION AND RESEARCH

STRASBOURG
1982

Foreword

Both within Europe and, in close co-operation with non-European colleagues in countries beyond, many European workers are involved in immediate relief and in longer term prevention of the health consequences of disasters. Yet education and training for such workers is inadequate although it would greatly improve the results of their efforts. The Council of Europe and the World Health Organisation therefore combined in calling a European workshop to address the educational aspects of health in disasters. The aim was to:

i. analyse the problems, and
ii. propose a medium-term educational action programme

with a view to encouraging a more efficient employment of the European educational and research resources to increase preparedness and the capacity at all levels in dealing with health problems related to disasters.

The particular North/South aspects of the problem give this endeavour a special character, not least in view of safeguarding the health of those in third world countries, which are particularly prone to disasters.

The World Health Organisation having addressed the broader problems of the capacity to meet the health consequences of natural disasters, the present workshop has specially focused on the educational needs at post-graduate level. The method proposed for educational action is the modular training approach promoted by the Council of Europe through its European programme for the development of postgraduate training.

In bringing the conclusions and proposals of this workshop to the attention of institutions of tertiary education and research, politicians and relevant regional, national and international bodies, the organisers invite their opinions and assistance to strengthen education and training through disasters and emergencies.

Council of Europe	World Health Organisation
Division for Higher	Emergency Relief Operations and
Education and Research	Regional Office for Europe

Introduction

The workshop was convened to review the needs within Europe for postgraduate training of health professionals and others in the management of how to cope with the health problems created by disasters. The workshop reviewed both past experience and likely future needs for trained staff. Disasters place unfamiliar demands on health staff, and are often quite different from those for which they are prepared by their basic training and orientation, at present. Consequently, further education in these problems is essential if costly and tragic errors are to be avoided. The workshop defined the specific training needs and formulated outline (recommendations) proposals to meet those needs.

Objectives

In defining the training needs in Europe for health problems of disasters, the workshop will concentrate particularly on two types of disaster: the acute catastrophe which may occur within or outside Europe and the longer term disaster creating massive refugee health problems, often in the third world, but in which many European health workers become involved. In both these situations it is clear that many who are faced with solving the health problems are inadequately trained for the task.

The workshop will analyse past experience, define the likely scale and level of manpower needs for the future, and how they should be trained. The workshop will then outline the required short courses and course modules in terms of objectives, target groups and content. It will decide on European curriculum improvements that can be developed as a series of European intensive courses with a view to including them in European university and post-experience courses in this field.

This initial planning workshop comprises the first in what are conceived of as a series to upgrade teaching and thus the management of health in disasters. It will define the curricula of a set of possible courses, but in two cases it will not be working from a vacuum. In each of the areas of refugee health and in the management of acute disasters a course has already been held in Europe. Subsequent courses are planned, and it will be possible to add to those courses more specific course-workshops to translate the lessons of these specific courses into modules or curriculum units which can be incorporated into teaching in other countries (see Appendix II).

This co-operative effort should stimulate positive developments regarding health preparedness teaching methods; mobility of teachers, researchers and students; quality of training programmes; the process of innovation; communication between educational institutes and society; the pooling of international expertise; the process of technology transfer and transfer of know-how; student guidance; development aid; information for decision-makers and educational planners; improvement of the cost/efficiency ratio; the need for an awareness for disaster planning and rapid assessment techniques.

Types of disasters

The workshop was aware of the great range of disasters, extending down to large-scale accidents such as train crashes. The form of the meetings was, however, on disasters where the existing structure of life of the community is disrupted overall and resources are overwhelmed by the very scale of the disaster. Among those considered were:

- acute castastrophes:	earthquakes
	floods
	tidal waves, etc;
- displaced persons eg due to drought;
- refugees;
- civil unrest;
- epidemics as constituting natural disasters;
- man-triggered disasters;
- nuclear accidents;
- consequences of nuclear war.

Although the workshop was conscious of the problems posed by nuclear disasters, the issues raised were considered to be sufficiently different to warrant special deliberation elsewhere.

In discussion it become apparent that European health personnel are involved in two major categories of disasters, differing in their location and needs:

- Acute catastrophes may be experienced in many parts of the world; here the prime need is for prompt relief. In practice this means that European workers are largely involved in their own countries’ disaster situations.

- The longer term refugee or displaced persons due to drought or war disasters are, by contrast, much more frequent in third world countries. European workers are generally becoming more involved in such situations through inter and non-governmental organisations.

The two categories of workers who require training are therefore clearly demarcated.

(introduction...)

When looking at health manpower sent to disasters it is logical to divide them into those involved in European disasters and those going to third world countries.

European disasters

Within Europe the personnel demand was for short sudden impact disasters. Where they existed, the main burden of relief, fell upon civil defense and other organisations which can act appropriately. Training here is not exclusively a postgraduate matter and the workshop was conscious that training within organisations needs to be closely integrated with courses of the types proposed.

Third world disasters

A questionnaire was sent to the main European nongovernmental agencies who sent health personnel during 1980-81 to third world disasters, those who replied gave information on more than 700 personnel; of these the largest single group sent to work in the field were nurses (see Table 1). Less than 17% were from professional groups such as nutritionists, water and sanitation engineers, dentists, etc.

Table 1
BREAKDOWN OF HEALTH PERSONNEL

Doctors	33%
Nurses	50%
Other	17%

This is significant because skills in the provision of water supplies, sanitation, logistics, transportation and nutrition, agriculture and administration were needed as much if not more than basic curative care. In future, therefore, either agencies should send a larger proportion of appropriate people, or doctors and nurses need to be given a wider training to encompass these necessary skills.

Over three-quarters of those sent went to refugee camps or war situations in Africa and the Far East with virtually none going to acute disasters (see Tables 2-3). In the past the relief phase in the latter situation generally is too short for help from outside to arrive in time and in these situations the work therefore was done by local organisations.

Table 2
GEOGRAPHICAL DISTRIBUTION OF HEALTH WORKERS

Africa	50%
Asia	40%
Middle East	7%
Latin America	2%
Other	1%

Table 3
PERSONNEL SENT TO DIFFERENT TYPES OF DISASTERS

“Camp” (refugees or displaced persons)	66%
War	21%
Famine	0%
Natural (sudden)	13%

Deficiencies in quality

European disasters

Common failures are:

· delay in assessing the severity of the situation;
· poor co-ordination and planning
· delay in providing first aid
· ignorance of the principle of triage
· poor logistics of supply and referral
· inappropriate relief arriving too late
· personal difficulties of relief workers
· failure to understand the relationship of disaster
· relief to primary health care.

Some of these issues were discussed at the WHO workshop on natural disasters held on 22-25 November at Rabbat (see Appendix IV).

Disasters in the third world

As stated earlier large numbers of European personnel are sent overseas having been recruited by mainly nongovernmental agencies. While there has been some improvement, these workers are often poorly prepared for those tasks which are asked of them. Often too, they are young, inexperienced and poorly briefed.

Common failures are:

· Overemphasis on disease

· Overemphasis on working in clinics as against in the community

· Using inappropriate high technology

· Cultural insensitivity

· Ignoring local resources especially manpower and equipment

· Providing a level of health care which cannot be maintained after the emergency.

· Ignorance of community health including epidemiology, water, sanitation, nutrition and tropical diseases

· Lack of emphasis on training.

Educational needs for health problems of European disasters

When disasters occur they affect everyone in the immediate area, and leadership is required from educated members of the community. The workshop therefore emphasised the need for an increased awareness in European universities of the problems of disasters.

There is a need to promote studies in subjects relating to disasters - their analysis, prediction and prevention, issues in relief and rehabilitation, and the health problems of disaster-prone areas in Europe. Both research and teaching in these areas should be undertaken by European universities.

Personnel in the health sector have a vital role to play in all disaster and emergency planning and action. There is therefore a need for the provision of systematic postgraduate training for medical doctors, veterinarians and pharmacists. Bearing in mind, however, that nurses and public health officers are essential, the training should be open also to these groups.

Such training would also form a sound basis for the supplementary education of health personnel, who might be employed by governments or international agencies for disaster prevention and relief action in developing countries. A short one-week modular course would be sufficient to meet these needs.

The workshop noted with concern that, in general, within Europe the level of education of health personnel in public health and community medicine which is offered by the medical, nursing and veterinary schools is inadequate. This defect becomes crucial in emergencies and disaster situations.

Within Europe there are several geographically defined areas with a high risk of such natural disasters as earthquakes. The workshop considered that the education of relevant personnel in these areas, even at undergraduate level, should include adequate and relevant education on coping with the more prevalent local disasters. Members of many professions - engineering, environmental, social sciences, agriculture for example - have an effect on health in disaster situations and education on coping with health in disasters should not be confined to the traditional “health professions”.

Because of the relative infrequency of major disasters in Europe and the difficulty of access to some refugee communities, there is a need to pool knowledge on a European basis. In the case of high level health officials and of teachers of veterinary public health, for example, courses provided by one or two centres in Europe. Much teaching material for use in national courses may also be most effectively prepared on a European basis.

Throughout Europe there is a need for evaluation teams and where a centralised epidemiological service exists its members should have particular expertise in the assessment and evaluation of disaster work and may need appropriate training. However, at present the problem in most countries is to create such an organisation in the first place.

The workshop was well aware of the important role that the police, fire brigade and military play in assisting with many acute disasters in their own countries. It is likely that they will continue to be involved and more information on their training courses, especially that of the military, would be useful.

Projection of educational needs for European personnel going outside Europe

During the acute phase which at most lasts for a few weeks there is an immediate need for personnel who have considerable training and experience in the assessment of health priorities and planning interventions: they also need special skills such as survey techniques, provision of water supplies, sanitation, implementation of feeding programmes, and the treatment of war injuries where relevant.

Ideally multidisciplinary teams, who have been trained together, should be sent and include an administrator, water engineer, nutritionist etc as well as nurses and doctors.

While ideally the need of this phase should be met by local health services, they are usually already overstretched and so it is likely that their role will be limited to general supervision by senior health administrators, who may or may not be trained in the general principles of disaster management.

Europeans already involved in long-term health work in third world countries may make major contributions during a refugee crisis and should also receive modules of training, even in Europe.

Although the situations are often initially envisaged as short-term emergencies they usually continue for a year or more: there is therefore a need for a steady flow of European personnel who have attended short courses.

In practice it is not realistic to provide manpower norms as the number required will depend on the severity of the situation and the local resources of both manpower and supplies. Generally it is important not to create an artificially high staffing ratio which cannot be maintained once relief teams leave.

The quality of health personnel sent is as important as quantity. There is a need for a greater emphasis of community health skills. In particular staff capable of training refugee and local people have a vital role both in promoting self reliance and in reducing the number of overseas personnel needed.

In view of the longer term commitment in these situations, it is essential that overseas personnel have the skills to co-ordinate the work with the host government’s health plans. From this it is clear that the training of European workers should include a discussion of transcultural problems.

European health workers who become involved in short-term assignments to refugee situations overseas present peculiar problems. Firstly, it is difficult to identify them prior to their becoming involved overseas and secondly, it is often difficult to obtain release of the workers from their permanent post once they have been trained. Nevertheless experience in several countries has shown that there is a large demand from potential volunteers for short courses. Government and health authority views on releasing staff can also be changed. Agencies concerned with refugee relief may also consider maintaining an expert team with good experience, to help plan, evaluate and take a leading part in field work.

Type of post-graduate training needed within Europe

The workshop defined the more important training needs for those directly and indirectly concerned with health, with emphasis on professional health workers and public health engineers in order to keep the topic within manageable proportions.

The workshop was aware that, in relation to disasters within Europe, there are more radical approaches to education for health promotion in disaster situations. For example, emphasis could be placed on training of primary school teachers, of journalists and of those who produce television material, with a view to spreading awareness of the problems to a very wide audience and to the young. There was also a need for those administratively responsible for disaster planning in each country to be more aware of health issues.

The workshop accepted the importance of these routes of communication and was also aware of the importance of social studies of disasters and of work on disaster prevention and and preparedness. All these could, and often did, affect health indirectly. They were not pursued in detail by the workshop because they lay outside the competence of its members and there was a danger of attempting to cover the whole multi-faceted topic and of failing to concentrate adequately to make an impact.

In relation to disasters in developing countries, the ability to intervene on such a broad front is more limited and health professional workers are the main European personnel involved.

It was found convenient to classify the teaching needed by the type of disaster, since more potential students have an orientation primarily towards either the European or the third world scene. Some division was also made between short courses, complete in themselves, and modules for insertion into longer courses; but to some extent these are interchangeable.

The need for some grounding in the subjects at undergraduate level, the need for many more courses for epidemiologists and other trainees, and the concern for nuclear problems, were all accepted but were beyond the scope of this workshop.

In relation to acute disasters, especially in Europe, there was a clear need for modules suited to post-graduate doctors, veterinarians and public health engineers. Nurses, nutritionists and social workers needed either a module or short course depending on whether they were already in a longer post-graduate course.

Specific short courses were needed by various specialist groups, and to illustrate this the workshop drew attention to the need for short courses directed to teachers of veterinary and of human public health, to senior health officials involved in health aspects of disasters, and to accident surgeons whose skills often lead them to be placed in key positions in disasters. There was also a need for a short course to provide an introduction to disaster problems for a variety of health professionals. At this level it was unnecessary to have different courses for different disciplines.

Many courses and all the modules were designed for use at national level. They need replicating in many European countries, even though benefit could be gained from sharing teaching materials. Other short courses, such as for teachers of veterinary public health, or for senior health officials involved in disaster health, were sufficiently specialised that a single course, or few, within Europe would suffice. These topics were specially suitable for courses supported by the Council of Europe.

The overall aim is for all public health specialists to have an understanding of the health problems of disasters. The needs may be illustrated from the veterinary profession.

In the veterinary services of Europe, there is a need for training in disaster work for:

a. those veterinarians working in areas with a high risk of natural disaster;

b. those with a higher probability of being called in to disaster work such as veterinarians employed in the public service and in the military;

c. those with special bilateral twinning arrangements with those working in high risk areas.

In the case of preparation for work in refugee, famine, and other “chronic disaster” problems of developing countries, the needs fall into two clear categories. Firstly, all training courses for professional health workers in such fields as tropical public health and tropical public health engineering need to include a module on refugee health. Secondly, the numerous health workers who go out to refugee situations in the tropics, often under the sponsorship of non-governmental organisations, are in great need of short courses.

Importance of co-ordination in any disaster

The diverse forms of relief in any disaster situation can only be co-ordinated adequately and rapidly if personnel and services are highly organised; the importance of planning delivery of aid, of briefing teams properly and preparing them psychologically for this work cannot be stressed enough. Close liaison with international organisations and a preliminary assessment of local needs by a specially designated person(s) to pinpoint the best forms of intervention is highly desirable. If the trained personnel from the courses proposed are to be utilised adequately, proper organisation is crucial.

Postgraduate training needed within Europe for work in disasters

A. In relation particularly to acute disasters, especially in Europe:

I. Modules for incorporation into longer courses for:

1. courses for doctors studying public health
2. public health engineering courses

II. Short courses for:

3. senior health officials involved in health aspect of disasters
4. accident surgeons
5. teachers of veterinary public health
6. members of the medical and other health professions (introductory)

B. In relation particularly to chronic disaster problems, especially in the third world for:

I. Modules for incorporation into longer courses in

7. tropical medicine and tropical public health
8. tropical public health engineering

II. Short courses for:

9. medical and nursing and other health volunteers

No doubt many other courses and modules are possible, but the small differences from the types described above do not need separate presentation. Also, the persons who may find the above courses useful are likely to include disciplines other than the ones specifically mentioned.

The proposed courses can be found detailed in Appendix III.

Draft recommendation (1)

1. Whilst recognising the notable achievements of certain institutions of higher education and research in the management of health problems related to disasters, the workshop drew attention to the inadequacy of educational facilities and resources in the training of personnel concerned with such emergencies. At least nine different modules or short courses were identified by the participants as needed and it was strongly recommended that the Council of Europe, through its channels of communication and through its own work programme support those courses that are already in existence or currently being planned and encourage the development of courses which are either not currently provided or which require duplication in other countries. The workshop asked that research related to health aspects of disasters be promoted. It was felt useful to address the workshop’s recommendations to the ad hoc Committee of Experts on Earthquake Research set-up by the Committee of Ministers of the Council of Europe.

2. In view of the infrequency of major European disasters, the difficult assess to tropical refugee situations and the limited staff with experience, self-teaching acquires particular importance and the workshop strongly recommended the Council of Europe to encourage the development of case studies, visual aids, and other teaching materials in the form of educational packages that could be made available to European and other countries. Funding such work and encouraging others to do so is a highly cost-effective method of increasing the impact of the limited number of teaching staff in Europe and elsewhere with relevant experience.

3. In view of the limited facilities and expertise in Europe there is a need to encourage the interchange of both materials and teaching staff between the institutions of higher education and research in Europe concerned with education for health-related problems in disasters. The workshop, therefore, recommends the Council of Europe to sponsor and encourage others to sponsor such interchange by providing scholarships for and funding the exchange of teaching staff between institutions both for purposes of teaching and to enable those planning new courses to visit and participate in programmes which are already operational.

4. The workshop recommended that the Council of Europe should co-operate with ASPHER (the Association of Schools of Public Health in Europe) to promote and co-ordinate the development in Europe of courses concerned with disaster health, to encourage participation in these courses and to avoid unnecessary duplication. It is recommended that a meeting of representatives of the schools of Public Health in Europe be organized to discuss the feasibility of introducing appropriate teaching of health management of disasters in their schools and the appropriate way for actually implementing the programs outlines by the workshop. The association of schools of Public Health in the European region, ASPHER, is the appropriate organization to sponsor this meeting in co-operation with the regional office of WHO for the European region. The General Assembly of ASPHER in September 1981 formally approved holding such a meeting with the Council of Europe and regional office of WHO to discuss such issues.

5. The workshop recommended that programmes for the education of public health engineers and veterinary doctors will take due regard to the health problems related to disasters. The Council of Europe and the WHO are recommended to promote an exchange of views on these teaching aspects among institutes for public health engineering and veterinary education and between institutes for public health engineering education, veterinary schools and schools of public health.

6. Meetings between the groups currently involved in teaching disaster management should be supported on a regular basis to improve co-ordination. Existing programmes should be evaluated to determine current training deficiencies, needs and possibilities for improvements.

7. In order to evaluate the progress of these recommendations and to provide a formal channel through which disaster problems in Europe can be identified, it was considered that the workshop should reconvene on a regular basis.

Acknowledgements

We should like to acknowledge the valuable contribution made by various participants in providing the following publications, copies of which are available from the Council of Europe Secretariat:

1. Problemi veterinari delle zone terremotate:
		Prof. Adriano Mantovani
2. A short account of the veterinary problems met from 29 November to 9 December 1980 in the area of Alta Irpinia affected by the earthquake:

Prof. Adriano Mantovani

3. Lignes directrices pour l’action vrinaire en cas de catastrophe naturelle:
		Prof. Adriano Mantovani
4. Principales maladies d’intt vrinaire qui peuvent se produire a l’occasion de dstres naturels:

Appendix I: Programme and list of participants

Scientific Committee

W Gunn, World Health Organisation - CH
M Lechat, University of Louvain - B

COUNCIL OF EUROPE WORKSHOP
2-5 March 1982
Timetable

Session

European Workshop on educational aspects on health in disasters

Participants

3 March 1982

Appendix II: Courses held on health in natural disasters

Courses held on health in natural disasters and on refugee health care

WHO course on Health Aspects and Relief Managements in Natural Disasters, Centre for Research on the Epidemiology of Disasters, University of Louvain, Brussels, Belgium

· Held in October 1980; further course planned for Turkey 1982

· Two weeks residential

· Sponsored by the World Health Organisation

· Course Director - Professor Lechat

· Participants: 30 senior health officials from 20 disaster-prone countries

· Cost - sponsored by WHO

· Aims of course - exchange of knowledge and information regarding emergency preparedness; identify health problems and managerial deficiencies; provide elements of relief co-ordination and promote a professional approach based on assessment of needs and use of local resources

· Subject covered included:

- medical and nursing care
- communicable diseases and surveillance
- surveys, famine relief and nutritional problems
- refugee camps
- environmental health protection
- medical supplies
- international assistance

· Lectures, simulation exercise, group discussions

Courses held at the Institute for the Study and Epidemiology of Disasters, University of Bordeaux, France: the epidemiology of disasters and training in emergency medicine

· Held in November 1979, yearly since thus and planned to continue annually

· Three weeks residential

· Course Director: Professor M Gillet

· Participants: 15-30, mainly doctors, a few (± 20%) post basic nurses

· Aims of course: training in:

- emergency care
- epidemiology and planning
- general epidemiology of disasters

· Subjects covered include:

- overview
- general studies of disaster situations
- types of disasters - natural, man-made and technological
- disaster and prevention
- epidemiology and planning
- behavioural and sociological aspects of disasters
- emergency medicine in disaster situations.

· Lectures, groups discussions, simulation exercices and practical experience in emergency medicine

Courses held on refugee health care

“Health Care in Refugee Camps”

Ross Institute of Tropical Hygiene,
London School of Hygiene and Tropical Medicine,
University of London, UK.

· Held annually since 1980

· One-week non-residential course in June

· Held in collaboration with the World Health Organisation and United Nations High Commissioner for Refugees

· Course Director - Stephanie Simmonds

· Participants - 50-80, mainly nurses and doctors, some nutritionists, environmental health engineers and administrators

· Aim of course - to demonstrate usefulness of community health care so that potential workers will have an appreciation for the activities they will need to be involved in

· Subjects covered include:

- overview of world refugee problem

- role of international organisations

- cultural, political, social and economic factors

- health planning

- practical epidemiology including census and surveys

- control of communicable diseases including immunisation

- environmental health

- feeding programmes

- health centre activities including curative care

- health management

- training refugees

- personal health care

· Lectures, case studies, films and group discussions Pre- and post-course evaluation

· Register of potential field workers for use by the Red Cross, Oxfam and Save the Children Fund

“Overseas Refugee Health Programme”

Division of Population, Family and International Health
School of Public Health
University of Los Angeles at California, USA

· Held annually since 1980

· 10 sessions every Tuesday 17.00-19.00 between April and June

· Course Director - Professor Derrick Jelliffe

· Participants - about 30, mixture of MPH students and undergraduates

· Aim: make different groups aware of health problems and outline approaches to solving them

· Subjects covered include:

- organisation of health services
- surveillance
- infections
- appropriate health services
- contributions of voluntary agencies
- feeding programmes
- environmental health
- health education
- training
- long-term considerations

· Case studies and discussions

· Student evaluation by take-home examination, problem solving exercise

Refugee health care

Subject also taught on the:

- Master of Science in Community Health in Developing Countries, Ross Institute, London School of Hygiene and Tropical Medicine;

- Overseas Doctors’ Course, Institute of Tropical Hygiene, Heidelberg, Germany;

- Diploma in International Health Development, Royal Tropical Institute, Amsterdam, Netherlands;

- Tropical Institute, Basle, Switzerland.

Other courses held

- National Red Cross societies, some societies only;

- International Red Cross (ICRO and League) held a seminar in 1981 to decide on policies on approach to health problems. Monograph still to be published as a guide to national societies in training health personnel for emergency actions;

- Most other voluntary agencies tend only to give (brief) briefing sessions en-route to airport;

- Disaster management and preparedness, Oxford Programme of Development Workshops 1982, Faculty of Architecture, Planning and Estate Management, Oxford Polytechnic, Oxford, United Kingdom, 24 January - 2 April 1982 of which three weeks include health topics. Aimed at public health officials, planners, engineers;

- Pan American Health Organisation, disaster preparedness especially in the Carribean.

Appendix III: Course proposals

Details on course requirements

The following nine courses and modules listed cover many of the most urgent needs in postgraduate education of health related personnel. In some cases the courses already take place in one or even two countries of Europe (see pages 10-15). Others could be readily started given adequate funding, and yet others are far from implementation. Table 4 lists the present status of the nine courses.

Table 4

There is therefore a need to replicate the courses in 3, 7 and 9. Those numbered 5 and 6 need stimulation and assistance and the new modules will benefit from encouragement.

COURSE SHEETS

1. Title of course: Module on the public health aspects of disasters

Duration and timing: 15 hours

Type of teaching institution: schools of public health

Type of student: Master in Public Health and similar

Purpose:

1. To provide postgraduate students in public health with the basic aspects of health management of disasters

2. To prepare them for participation in disaster rescue and relief

Detailed aims: -

Curriculum related to competency aimed at:

2. Title of course: Module on public health engineering; rapid environmental assessment

Duration and timing: 20 hours including some field and laboratory exercises

Type of teaching institution: -

Type of student: Graduate public health engineer (or civil or agricultural engineer)

Purpose: To assess environmental factors after a disaster

Detailed aims: To provide a base for preventive health measures, if needed, and to obtain data for repair works

Curriculum related to competency aimed at:

- Quick map changes in morphology (land-slides, silt accumulation, breaches in dams) as far as they present potential dangers

- Assessment of water supply and sewage systems (pipe breaks, pollution of supplies, changes in ground-water levels) and of the resulting biological and chemical water quality

- Assessment of air quality (dusts, smoke, fumes)

- Inspection of potential dangers due to stores of chemicals and other goods in industrial and commercial establishments

3. Title of course: Short course on health management for disasters

Duration and timing: 2-3 weeks (10-15 working days)

Type of teaching institution: School of public health

Type of student: Senior health administrators

Purpose: To promote a professional approach to the management of disaster-related health problems

Curriculum related to competency aimed at:

- Health aspects of disasters - general introduction, the health aspects of disasters, from prevention and pre-disaster preparedness to post-impact rescue, short-term relief and long-term rehabilitation

- The epidemiological approach to disaster management - methods and techniques for the systematic assessment of needs and optimal use of local resources

- Emergency care in disasters - inventory of the major medical and nursing care. Care problems associated with immediate rescue and short-term relief, with special emphasis on the logistics of organisation of triage, evacuation and second-level care. Emergency medical care as part of primary health care

- Hospital preparedness for disaster - special questions of hospital planning for disasters. Hospital administration in the case of disasters, specific procedures and management of personnel

- Surveillance of communicable diseases in comprehensive review of communicable diseases, including animal diseases, as possibly associated to natural and man-made disasters. Organisation of epidemiological surveillance, including the setting up of an appropriate health information system in situations of natural disasters - relations with veterinary public health

- Nutritional problems in disasters - basic nutritional requirement, methods and surveys for nutritional surveys, organisation of a food distribution system, general policy of food replenishment of seeds and livestock and economic marketing

- Refugee camp - general review of the refugees’ problems - specific questions raised by temporary relocation of populations, including control of communicable diseases, environment, out food supply - organisation of refugee camps accelerated - training of local and expatriate personnel for the management of refugee camps

- Disaster and the community - short-term and long-term effects of disasters on the socio-economics structure community. The impact of natural and man-made disasters on the socio-economic development, specific mental and psychological problems in situation of disasters

- Environmental health protection - inventory of environmental health in natural and man-made disasters. Surveying methods. Environmental priorities according to the different sequences of the relief activities. Maintenance and/or re-establishment of appropriate water supply

- Medical supplies - essential drugs, packing, shipping and sorting

Control of unsollicited drugs

- Manpower in disasters - management of personnel in the resume - short-term and long-term relief phases. Handling of volunteers - Inventory and review of teaching material available for training of disaster personnel

- Health planning for disaster - health problems in disasters in relation to other community problems resulting from disasters. The health components of planning for disaster

- International assistance - the role of national and international official and non-governmental organisations inter-agency co-ordinators

4. Title of course: Short courses for accident - Emergency - Specialists

Problem oriented courses and related issues suggested for training of senior health officials. This course is intended for senior health officials who are likely to be involved in the planning and emergency provision of health services following disasters.

Its objectives are:

1.- To transfer knowledge and promote exchange of information between health officials regarding emergency preparedness for natural disasters and disaster relief co-ordination.

2.- To identify the health problems and managerial deficiencies most common following natural disasters and discuss technical solutions.

3.- To provide the elements for the establishment of national focal points for disaster relief co-ordination in the health sector.

4.- To promote a professional approach to the management of disaster related health problems based on the systematic assessment of needs and optimal use of local resources.

The course addresses the main aspects of disasters from pre-disaster preparedness to rescue, short and medium terms relief and long term rehabilitation.

An essential feature of this course should be its multiplying effect. By supplying the participants with appropriate teaching material, it should be repeatable on a national basis, being adopted to the various levels of the health services.

5. Title of course: Short course on veterinary public health in disaster situations

Duration and timing: 3 days

Type of teaching institution: A school of veterinary public health (one or two courses in Europe probably sufficient)

Type of student: Teachers and co-ordinators of veterinary public health

Purpose: To provide training for teachers of veterinary public health workers to prepare for work in emergency disaster situations

Detailed aims:

Curriculum related to competency aimed at:

* Veterinary officials working in endemic areas should have analogous classes for 5 days made up as in brackets

Those requiring specialisation in particular aspects may need twice the time specified on certain topics

Duration and timing: 1 week

Type of teaching institution: Universities/medical schools/public health schools

Type of student: Medical doctors, veterinarians, pharmacists, nurses, public health officers, policy makers, senior planners and health professionals

Purpose:

1. To create awareness of disaster situations
2. To introduce students to roles and functions of health personnel in a disaster environment

Detailed aims:

- Through case-studies develop emergency relief measures appropriate to national plans

- Be able to implement relevant technical aspects

Curriculum related to competency aimed at:

- Definitions and characteristics of natural and man-made disasters

Training and phases in disasters

- National disaster planning and preparedness measures

- International disaster relief

- Acute medical care in disasters/emergencies; triage

Search, rescue and evacuation
Emergency transportation and communication
Emergency hospital system
Provision of medical supplies

- Epidemic surveillance and control

Vital statistics

- Food and nutrition in disasters

Emergency feeding
Medical problems in a famine

- Water supply, sanitation, waste disposal, vermin control

- Care of the homeless, shelter, emergency housing of refugees

- Mental health in disasters

- Medical views on radiological and chemical hazards

- Public health related services and training of the community.

7. Title of Course: Module on the epidemiology of chronic disasters in a tropical public health course

Duration and timing: 2 weeks

Type of teaching institution: University

Type of student: Doctors training in tropical public health with additional training to cope with famine, refugee camps or epidemic situations

Detailed aims:

Curriculum related to competency aimed at:

- Epidemiology of planning:

- Methodology of evaluation including health indicators and specific criteria
- Training in epidemiological investigation
- Methodology of nutritional surveillance

- Training in specific medical problems

- Methods for the standardisation of diagnostic and therapeutic techniques
- Training in resuscitation and basic surgery under “primitive” conditions
- Methods of mass vaccination
- Methods of mass nutrition

- Training in hygiene

- Studies of hygiene among refugee groups with particular reference to the management of water supplies and sanitation

- Organisation and logistics of refugee camps

- Organisation and logistics of supplies and field hospitals

8. Title of course: Module in public health engineering for refugee communities

Duration and timing: 12 hours

Type of teaching institution: Public health (and related) engineers

Type of student: Post-graduate and relief administrators

Purpose: To assure people who have had to leave their homes a healthy habitat in a different environment

Detailed aims:

Curriculum related to competency aimed at:

- Available solutions: rehousing in the provisionally repaired home, in temporary buildings spread over a wider area, concentrated in camps

- Siting: protection against floods and landslides, accessibility and availability of services; relation with the master plan for definitive reconstruction; survey techniques

- Layout: taking care of the need for central services. For large camps division into identifiable blocks is necessary for psychological and administrative reasons

- Equipment: facilities for solid waste and fire-fighting management. Clinics and wards, administration, police and correction facilities. Desirability or non-desirability of fencing all or parts of the camp

- Housing: orientation with regard to sun and prevailing winds; ventilation; pest and vermin control; communal or individual cooking and washing facilities

- Water and waste-water: the need to disrupt the infection chain by water-related vectors; installation of short-term water systems; later full-scale installations using appropriate technology

- Impact of the camp on its environment and the population living there. Prevention of health changes caused by their mutual relations

- Food technology

9. Title of course: Short course on health care in refugee and camp situations

Duration and timing: 1 week

Type of teaching institution: Institutes teaching public health for developing countries or public health courses in Europe which have students from developing countries

Type of student: Doctors, nurses, nutritionists, water engineers, health educators and administrators

Purpose: To demonstrate usefulness of community health so that potential workers will have an appreciation of the activities in which they will need to be involved

Detailed aims:

1. Awareness of the concept of community health

2. Introduction to the technical skills required to help solve the priority health and disease problems

Curriculum related to competency aimed at:

- Overview of world refugee problem
- Role of international organisations
- Cultural, political, social and economic factors
- Health planning
- Mapping
- Practical epidemiology including estimating numbers, census and surveys
- Control of communicable diseases including immunisation
- Environmental health including location of sites
- Feeding programmes
- Health centre activities including curative care
- Health management
- Training refugees
- Personal health care

Appendix IV: Summary report of the “Workshop for preparedness in facing health problems from natural disaster emergency situations, WHO Regional Office for Europe, Rabat - 22-25 November 1981”

Workshop for preparedness in facing health problems
from natural disaster emergency situations
(Rabat 22-25 November 1981)

SUMMARY REPORT

This meeting was convened with the financial support of the Commission of the European Communities and the Office of the United Nations Disaster Relief Co-ordinator, and with the technical assistance of the WHO collaborating centre on disaster epidemiology at the University of Louvain, Brussels. It brought together 55 physicians, teachers and senior officials from 13 countries, as well as representatives of 5 international organisations other than WHO. Its purpose was to review the current state of preparedness for dealing with health problems associated With emergency situations and, more specifically, to identify the measures that should be taken immediately after the disaster in order to:

- reduce the number of people killed or injured at the time, or who die as the result of their injuries;
- make services for assistance to survivors more effective;
- preserve the existing health facilities or enable them to be restored as soon as possible.

The participants stressed at the outset that natural disasters are part of a continuum, ranging far beyond the emergency situation to encompass prevention before the catastrophe to long-term rehabilitation after it. Emergency measures cannot be dissociated from this context; and it is important to recognise that effective relief depends on sound preparation, just as prevention or alleviation of the effects of future disasters depend on experience gained during earlier ones.

Furthermore, although they are very important, health problems are only part of the disaster picture. Other problems include reactivation of the economy, protection of the agricultural or industrial capacity, maintenance of law and order, and restoration of social structures. Also, the effectiveness of health action is entirely dependent on the functioning of administration, transport, communications and an entire network of services. It is therefore essential that the health intervention forms part of a whole series of measures to deal with the emergency situation.

Referring to a number of case studies conducted in countries of the Mediterranean basin following earthquakes, and their own experience, the participants then discussed the different problems encountered in dealing with emergency situations due to disasters.

The problems were studied from five points of view, by five working groups which considered the experience acquired by different groups of people, namely:

- people who were on the spot during an earthquake and were able to observe the reactions of the population during and after the disaster;

- people who were not on the spot but who were responsible for taking immediate emergency action (eg provincial administrators for the disaster area who received the first requests for assistance);

- people at a central level with responsibility for overall co-ordination of relief in the country and submission of requests for international aid (eg ministries of health or offices of the Red Cross or Red Crescent);

- people who came to the area immediately after the disaster, with the relief teams;

- people responsible for external aid.

It emerged from the group discussions that the problems of emergency assistance could be considerably reduced if efforts were made in three areas as follows:

- greater participation by health professionals in planning for emergencies;

- greater use of local resources of the community concerned for the provision of emergency assistance;

- better information for channelling of emergency aid.

The above requirements are complementary, and while it is essential that they be met in assistance after earthquakes, which are among the natural catastrophes that pose the greatest problems in providing emergency medical care, they apply equally to other disasters.

Conclusions and recommendations

1. Studies have shown that if first aid is to be effective it must be provided within hours of the disaster; it should therefore be an integral part of primary health care. Consequently, health staff at all levels who work in disaster risk areas should have the necessary training to enable them to work in emergencies. The content of the training should be developed on the basis of actual experience in recent situations.

2. Local health facilities (hospitals, health centres, dispensaries) should be designed to serve as meeting points and as “survival centres” or “action centres” for emergency care and co-ordination of health services on the site. During the first few hours they should also serve as focal points for collection and transmission of data on the severity and extent of the material damage and on the number of victims.

3. To allow for cases where the local health facilities are destroyed or put out of service, arrangements must be made for the twinning or preferably networking of units in areas which may or may not be contiguous, depending on the available means of access and communication, so as to allow rapid intervention by substitute facilities.

4. If external aid is to be effective, it must be given in response to specific requests and meet specific needs. Although, in the first few hours following a disaster, aid can be given to meet what are presumed to be the essential needs (rescue work, first aid, food, shelter), any overhasty and disorganised relief work carried out subsequently will only add to the confusion and cause chaos. It is therefore essential to channel the provision of external aid on the basis of information that is as correct as possible. In many cases it would certainly have been preferable to delay some outside interventions and thereby make them more effective, rather than acting in haste. It would undoubtedly be worthwhile to conduct studies in the countries at risk in order to decide which measures should be taken without delay, even on the basis of uncertain information, and those for which it would definitely be preferable to obtain additional Information even if this caused some delay.

5. Areas at particularly high risk of earthquake should be surveyed in advance with reference to: density of population, geographic situation, microzones, housing, vulnerable structures (public buildings) and the environmental hazards of industrial facilities, power plants, dams, piping systems, etc, and risks for specific population groups. The resulting “risk maps” should facilitate planning of appropriate measures for prevention (reinforcement or reconstruction), evacuation or rescue. Particular attention should be paid to hospitals.

6. In the same way an inventory of medical resources (infrastructure, equipment, personnel) should be prepared and kept up to date, to allow immediate mobilisation of available facilities. A list should also be made of suitable helicopter landing sites; added to this should be an inventory of standard supplies, equipment, tools and materials for survival, to allow rescue of the victims and effective medical care. In case this material should be lacking, arrangements should be made to construct depots at suitable locations throughout the territory.

7. Emergency health measures should be planned not only at national or provincial levels, but also at local and decentralised levels, to ensure that whatever measures are decided upon are implemented as rapidly as possible. This “micro-planning” calls for prior education of the public and this, in the short term, encourages local communities to assume responsibility for emergencies and, in the long term, helps to prevent the development of attitudes whereby the victims regard themselves purely as recipients of aid.

8. A system for rapid assessment of losses and damage is essential to channel the first aid and external assistance. An information system of this sort, which cannot be improvised, should be Incorporated in the information system for the basic health services. Also, because of the multidimensional nature of the problems caused by a disaster, the degree of uncertainty, and the urgent need for rapid action, the information should be identified, collected and analysed by specially qualified people. Assessment of losses and damage is often beyond the capacity of the local community and hence specialised staff or techniques (epidemiological evaluation by sampling, aerial reconnaissance) must be used.

9. Forecasting indexes and indicators for epidemiological evaluation (mortality, morbidity) in emergency situations should be simple and resiliant and allow immediate decision-making .

10. Information collected at the local level must be communicated to the higher level from a single source responsible for this function. This helps the national authorities both to direct and to channel external aid so as to meet the real needs. Machinery should be established at national level for declining or reorienting unsuitable offers of assistance.

11. External aid to the population in the disaster area should be appropriate to the needs and not duplicate the local human and material resources. It is particularly important to maintain strict control on the entry of volunteers whose services have not been requested.

12. Epidemiological surveillance (in the broad sense, as applied to all aspects of health) is an essential emergency response measure. It will not be effective, however, unless data on the situation before the emergency are available. The arrangements should be part of the area health information system, which should as far as possible be in existence prior to the disaster.

13. To strengthen co-ordination between human and veterinary epidemiological surveillance, it is recommended that more research be undertaken in this field, particularly with reference to long-term effects. Health authorities should pay particular attention to the veterinary aspects of natural catastrophes.

14. The epidemiological surveillance must not be confined to the emergency phase, but continue through the intermediate phase of restoration of normal conditions and subsequent rehabilitation. A system for evaluation of the impact of assistance is a key requirement, in the medium and long term. It is recommended that detailed epidemiological studies be conducted, in conjunction with WHO and specialists, on recent earthquakes in the Mediterranean basin. It would be very useful to establish a standing interdisciplinary consultative group, which could collaborate in such studies with the authorities of the countries concerned.

15. The measures for protection of the population in each country should be the subject of specific legislation, setting out the functions to be performed, the authorities responsible for them and the sources to be made available to them.

16. A system of international co-operation that could be mobilised immediately, be constantly on the alert, and be available to all the countries at risk, on request, might be more valuable than emergency services as such.

17. The effectiveness of international aid to a disaster stricken country naturally depends to a large extent on the machinery established beforehand to ensure co-ordination between the activities of the different international or government bodies involved and rapid communication with the country.

18. WHO should prepare guidelines for countries at risk, setting out the activities to be performed by the primary health services, the preventive measures to be taken by communities and the instructions to be followed by health staff at all levels.

19. WHO-sponsored courses should be organised to train teachers who could provide instruction on health problems in relation to natural catastrophes. Training standards should be established.

20. For countries so wishing, it would be useful to carry out a survey on their present capacity to deal with health problems due to disasters and to evaluate the changes that take place following the present workshop. The outcome of the survey and the results of the implementation of the recommendations should be the subject of a future workshop.

21. WHO should co-ordinate the work of other international bodies; there is a need to clarify their responsibilities, particularly in order to simplify the work of governments. WHO should organise for countries so requesting a technical group on evaluation and identification of appropriate international aid.

22. Noting the proposal of the Italian participants to convene a further WHO-sponsored workshop in Italy in 1982 on the same topic, with the specific objective of evaluating the results and implementation of the recommendations, it would be advisable in the meantime to make a survey of the capacity to deal with health problems due to earthquakes. The findings of the survey should provide a basis for the discussions at the next workshop.