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

COUNCIL OF EUROPE WORKSHOP
2-5 March 1982
Timetable

Session

Monday 1 March
Tuesday 2 March		Chairman - Professor Bradley
09.00 - 09.30		Registration	Council of Europe
09.30 - 10.00	1	WELCOME
10.00 - 10.30	2	STATEMENT OF AIMS AND OBJECTIVES	David Bradley
		David Bradley will set out the purpose of the workshop, explain both its background and structure, describe the mode of working and the output expected from it. He will also refer to subsequent proposed follow-up of the workshop.
10.30 - 11.00		Coffee
11.00 - 12.30	3	REVIEW OF DISASTER AND REFUGEE SITUATIONS 1980 - 81	Tim Lusty
		This is a strictly factual session to build up as full a picture as possible of who from Europe, went to where and to do what, with what training.
12.30 - 14.00		Luncheon
14.00 - 15.30	4	EUROPEAN MANPOWER PROBLEMS IN DISASTER RELIEF EFFORTS	Marc de Bruycker Adriano Mantovani Stephanie Simmonds
		This session looks at quality rather than quantity. In this session the deficiencies of present performance will be examined from four viewpoints: those who have made a special study of acute disaster and of refugee situations, a European country that has recently suffered from an acute disaster, and a developing country that has had many agencies working on its famine and refugee situations.
15.30 - 16.00		Coffee
16.00 - 17.00	5	DISCUSSION OF LIKELY MANPOWER NEEDS BY PERFORMANCE AND ROLE	Plenary
		This is an attempt to define who will need training: how many, from what countries, with what experience and what qualifications, for all the relevant forms of disaster.
Wednesday 3 March		Chairman - Professor Lechat
09.00 - 11.00	6	WHAT TEACHING PROGRAMMES HAVE ALREADY BEEN HELD?	Stephanie Simmonds
		A background paper giving a factual review on a world scale of the courses held in terms of size, frequency, duration, type of students, objectives and content.
11.00 - 11.30		Coffee
11.30 - 12.30	7	WHAT COURSES ARE NEEDED FOR THE FUTURE?	Plenary
		This will be a broad plenary discussion and in particular will go beyond the areas covered so far. Other aspects of disaster that nobody has considered can be brought up and aired generally, with a view to picking up the conclusions in session 14, for subsequent exploration by the Council of Europe. The discussion will also focus on the needs defined in session 5.
12.30 - 14.00		Luncheon
11.00 - 17.00	8	DISCUSSION OF THE NATURE AND CONTENT OF THE COURSES	Plenary
		The general aspects of each curriculum will be discussed in plenary. This is important to avoid the curricula reflecting only the views of the small working groups.
Thursday 4 March
09.00 - 12.30	9	GROUP WORKING SESSIONS
		The morning session of group working should lead to a clear draft curriculum following a standard layout which will be developed prior to the meeting. The group reports will consist largely of these course specifications, together with problems and other issues arising from the discussion. It is hoped that the reports can be produced early in the afternoon and typed for distribution in the evening. Each will then be revised in plenary session next day.
12.30 - 14.00		Luncheon
14.00 - 17.00	10	Free for report writing
Friday 5 March		Chairman - Dr. Gunn
08.30 - 09.30	11	Reading of reports individually	Rapporteurs
09.30 - 11.00	12	DISCUSSION OF PROPOSED CURRICULA FOR ACUTE DISASTER SITUATIONS
11.00 - 11.30		Coffee
11.30 - 13.00	13	DISCUSSION OF PROPOSED CURRICULA FOR REFUGEE CAMP SITUATIONS
13.00 - 14.00		Luncheon
14.00 - 18.00	14	DISCUSSION OF GENERAL RECOMMENDATIONS FINALISATION OF REPORT AND CLOSURE OF MEETING
		The aim will be to push each curriculum as far along as is feasible but also to recommend a set of disaster-related areas for subsequent study. It is believed Chat while the 2 areas of special concern to the organisers can be pushed a long way forward, other areas will emerge which cannot be pursued in detail at this meeting

European Workshop on educational aspects on health in disasters

Participants

Professor David J BRADLEY - Director - Ross Institute -
	London School of Hygiene and Tropical Medicine - London
Dr. Marc de BRUYCKER - Centre for Research on the Epidemiology
	of Disasters - Ecole de Santublique - Bruxelles
Dr. Bruce DICK - Refugee Health Group, Ross Institute -
	London School of Hygiene and Tropical Medicine - London
Mr. Jean DOUARD - Ex. Service national de la protection civile -
	Paris - ex. charge de mission UNDRO - Gen
Dr. Michel GILLET - Centre d’Epidologie des catastrophes -
	Bordeaux
Mr. Niels Flemming HOLM - Directorate for Civil Defence and
	Emergency Planning - Risskof (Denmark)
Dr. T LUSTY - Ross Institute - London School of Hygiene and
	Tropical Medicine - London
Professor Adriano MANTOVANI - Istituto di Malattie infettive -
	Profilassi E polizia Veterinaria - Bologna (Italy)
Professor IR L J MOSTERMAN - Director - International
	Institute for Hydraulic and Environmental Engineering -Delft (NL)
Miss Stephanie SIMMONDS - Co-ordinator, Refugee Health Group,
	Ross Institute - London School of Hygiene and Tropical
	Medicine - London

3 March 1982

Professor Michel F LECHAT - Director - Centre for Research on
	the Epidemiology of Disorders - Ecole de Santublique -
	Bruxelles
Miss Elisabeth BURGE - Ross Institute - London School of Hygiene
	and Tropical Medicine - London

Council of Europe:	MM Jean-Pierre Massu/TD>
		Halvor Lervik
		Georges Carayannis

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

Course No.	Level needed
1	National	Planned attempts
2	National	Planned, Netherlands
3	European, international	Held in Belgium
4	National
5	European	Expertise exists
6	National
7	Some countries	Exists in France and UK
8	Some countries	Planned, Netherlands
9	National	Held regularly in UK

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:

- the general health aspects of natural and man-made disasters: assessment of needs	3 hours
- Epidemiological approach to disasters
- Health information systems in disasters
- Control of communicable diseases in disasters	2 hours
- Basic emergency cases; essentials of triage; tagging; life-maintaining procedures	2 hours
- Environmental health protection in disasters; identification and control of environmental hazards; shelter, water supply, sanitation and disposal of the dead	2 hours
- Nutritional problems in disasters including refugee camps; basic nutritional requirements; techniques of feeding and rehydration; organisation of food aid; nutritional education	2 hours
- Disaster preparedness; stress reactions of the community; cultural patterns and management of disasters; team work; interdisciplinary aspects of disaster management; the role of national and international agencies including nongovernmental organisations	2 hours
- special protection for disaster work; the pros and cons of voluntary work	2 hours

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:

- Generic training	3 hours	(2) *
- Control of epidemic in disaster situations	3 hours	(5)
- Disease problems associated with stray and wild dogs	2 hours	(4)
- Rodent control	2 hours	(2)
- Destruction of carcasses and other infected material	2 hours	(4)
- Disinfection processes	2 hours	(4)
- Problems of animal shelters and feeding	2 hours	(4)
- Veterinary medicine in emergency situations	3 hours	(4)
- Food hygiene and animal slaughter in emergencies	4 hours	(4)
- Co-operation with other professional bodies	1 hour	(2)

* 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

6. Title of course: Short course on disaster planning and action

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.