1.

0 Introduction: A Brief History

Why begin with history?
History allows us to view how public health approaches to medical disaster
response emerged. This understanding helps us appreciate the usefulness and significance of
Disaster Public Health and puts into context the conclusions drawn from previous disasters,
current challenges and future developments.
One of the earliest papers published about the public health impact on disaster management
can be dated back to the early 1970s. Below are three lessons learnt from the 1970s.
1970
A tropical cyclone hit the coast of Bangladesh in 1970, resulting in over 250,000
deaths. Results of health surveys in the disaster-affected communities demonstrated
the complicated matrix of needs and risks faced by different stakeholders in disaster
situations. The publication highlighted the value and necessity of early on the spot
needs assessments in providing valid and timely data for disaster relief. (Sommer &
Mosley, 1972)
1972
Dr. Western, an epidemiologist, highlighted that the health of a population
exhibits patterns of morbidity and mortality specific to disaster type and disease
profile of a particular region. (Sommer & Mosley, 1972)
1976
Publications following a major earthquake that caused an estimated 23,000 deaths in
Guatemala served as the cornerstone studies in the short history of evidence-based
medical and public health response in disaster situations. Publications following the
earthquake highlighted:

The significant logistical challenges and deficiencies in the international

relief system.
(Spencer et al., 1977; de Ville de Goyet et al., 1976)
The plausible use of disaster research methodology in identifying risk
factors associated with specific negative health outcome associated with
the disaster, and hence, effective, targeted interventions could be
implemented as means of health protection.

1.1 Disaster Epidemiology

The technical discipline that had driven those early publications was the study
of epidemiology itself, which assumes that adverse health outcomes do not occur randomly
within a population, but follows a predictable pattern.
Epidemiology is the study of how disease is distributed in populations and the factors that
influence or determine this distribution.
This means that although a population might be exposed to disaster hazards, not everyone
will be affected by disasters in the same way or to the same magnitude.
For example, if you live in a well-engineered, earthquake resistant concrete building, your
risk of being injured by collapsing houses during an earthquake is lower than those who live
in makeshift shelters built of lumber and bricks. So, we can identify risk factors as to why
certain people are more prone to the negative health impact of disasters to devise ways to
protect those people before disaster strikes.
Take-Home Message
Epidemiologic methodologies adopted in the disaster context are useful to measure and
describe the adverse effects of disasters on human populations. The purpose of disaster
epidemiology is to minimize the preventable loss in quality of life that results from disasters.

1.3 Contributions of Disaster Epidemiology (I)

Imagine what disaster relief looked like before these myths were debunked! International
relief groups flooded into the hot-spot of affected communities with surgeons and nurses.
We cannot take for granted the lessons learnt from early disaster epidemiology studies:
1. Although every disaster led to its unique pattern of health needs, commonalities exist
whereby relief/medical supplies could be prepared ahead of time for dispatch in times
of crisis.
2. Although major disasters were often followed by generous donations of relief items
from the international community, the logistical challenges and the lack of rapid onthe-ground needs assessments meant that many of these items could not benefit the
disaster-affected population. As a result, aid-responders and beneficiaries were
supplied with non-essential pharmaceuticals and inappropriate donation items.

1.4 Contributions of Disaster Epidemiology (II)

One significant milestone in disaster response that illustrates the applications of disaster
epidemiology studies is the development of standardised evidence-based protocols.
The image shows large boxes of Emergency Health Kits in front of a UN aircraft ready to be
deployed to Myanmar during the relief effort for Cyclone Nargis in 2008.
Photo by Fred Urlep, World Health Organization Some rights reserved.
Emergency Health Kit
Standardised lists of essential drugs, medical supplies and relief-equipment began to emerge
for use in post-disaster situations in need of humanitarian help. These lists were developed
using data generated from disaster epidemiology studies, and were compiled after rounds of
rigorous field-testing and modifications. The WHO, Office for the UN High Commissioner
for Refugees (UNHCR) and the London School of Hygiene and Tropical Medicine codeveloped one such list, naming it the Emergency Health Kit in 1984. The kit evolved into
the New Emergency Health Kit in 1990 and later again into the New Emergency Health
Kit 98 in 1998.
(WHO, 1998)
The Interagency Emergency Health Kit 2011 is the current version of the kit. It was
devised by multiple UN agencies and international NGOs such as Medecins Sans Frontieres
and International Federation of Red Cross and Red Crescent Societies. In general, the kit
includes medicines, disposables and instruments that meet the primary health needs of 10,000
people for three months. The kit is primarily intended for displaced populations without
medical facilities. They can also be used for initial supply of primary health care facilities
where the normal system of provision has broken down. The kits are not designed for
immunisation programmes, cholera, meningitis or specific epidemics.
(WHO, 2011)
Disaster epidemiology studies continue to drive research and debates about the content of the
Emergency Health Kit.
In fact, the Emergency Health Kit is only one example. The preparation and modification of
similar disaster response units for immediate deployment by international relief
organisations is also a result of the relief workforces appreciation of evidence-based disaster
response. Later in this course, we will take a look at The SPHERE Project, which is one of

the most widely known and internationally recognised sets of common principles and
universal minimum standards in disaster and medical humanitarian response.
Take-Home Message
Early disaster epidemiology studies served as the cornerstone for evidence-based disaster
response protocols. Negative health impact and human suffering brought about by disasters
could only be minimised through informed decisions, as opposed to taking actions based on
intuition or assumptions about the peoples needs. The development of the Interagency
Emergency Health Kit 2011 is an example of applying research to maximise the effectiveness
of medical and relief efforts.

1.5 Public Health: The Health of Populations

What is public health?
Unlike clinical medicine, where physicians and allied health professionals
focus on treating diseases and managing the health of individuals, public
health professionals focus on optimising the health of populations.
Public health has been defined as:
The science and art of preventing disease, prolonging life and promoting
health through the organised effort of society.
(WHO, 2004; Sir Donald Acheson)
The field of public health comprises evidence-based methods, decisionmaking and the application of theories in the society. Effective public
health practice is a multi-disciplinary effort in making health a priority for
all by understanding the determinants of health, addressing health
disparities, identifying disease risk factors and implementing preventative
strategies.

1.6 The Public Health Concepts of Health

What is health?

Public health professionals adopt the World Health Organization definition

of health:
a state of complete physical, mental and social well-being and not merely
the absence of disease or infirmity.
Of note, the definition not only focuses on negative health but also
the positive aspect of health. It implies that actions should always aim to
minimise diseases andmaximise attainment of potential health. Although
this definition has been criticised for over 60 years since its formulation in
1948, and alternative proposals have been published, it remains the
working definition of health internationally. (Official Records of the World
Health Organization, 1948)
Whats the implication for disaster management?
In the context of disaster response, this definition of health implies that it
is important to address all three fundamental components of health: our
physical, social and mental well-being. Traditional disaster response
programmes focus heavily on safeguarding physical health (e.g. injury
management, communicable disease control & food access etc), but the
mental and social aspects have often been overlooked. Research
supporting post disaster interventions and related policy developments
has been limited. In recent years, the need for psychological programmes
has increasingly been recognised. The publication of the Inter-Agency
Standing Committee Guidelines on Mental health and Psychosocial
Support in Emergency Settings is a good example.

Take-Home Message
One way to understand the impact of disaster is through the definition of
health as a state of complete physical, mental and social well-being and
not merely the absence of disease or infirmity. (WHO, 1946) Based on
this, we have covered how psychotropic medication has been added to the
Interagency Emergency Health Kit.

1.7 Determinants of Health

What puts ones state of health at risk?
The social ecological approach in public health connotes that our health is
governed by many external factors, not just our individual biological
makeup or lifestyle choices. Hence, blaming individuals for having poor
health or crediting them for good health is inappropriate. This framework
proposes that other social, economic, political and environmental factors
are important determinants of health as well, which are things that
make people healthy or not. (World Health Organization, 2014)
Take-Home Message
An individual may be free of physical and mental health symptoms.
However, the socio-ecological approach to health suggests that changes in
various levels of health determinants during a disaster pose significant
health risks. For example, a disaster causes partial or complete
breakdown of transportation networks that limit access to health services,
the disappearance of social services such as police or fire stations, and
the closure of important infrastructural facilities such as banks and
hospitals.

1.8 Three Domains of Public Health

The three domains of public health illustrate the multi-disciplinary
nature of this field and its potential applications in medical and
humanitarian response in disasters. In summary, the three domains
are: health protection, health improvement and health services.
Health protection
This domain involves the prevention and control of infectious diseases,
the regulation and monitoring of environmental health hazards such as
air, water and food quality, and response to chemical or technological
emergencies (e.g. bioterrorism and radiation disasters).

Health improvement
This domain involves actions to reduce health inequalities. It combines
different sectors (such as housing and education) to ensure that policies
and health promotion and education activities at the population level will
empower and support individuals to make informed lifestyle choices.
Health services
This domain focuses on the policies and delivery of health services. It
promotes evidence-based clinical practices, governance and resource
allocation.
Of note, the three domains of public health are not mutually exclusive to
each other; they overlap and are often interdependent. Some common
tools which support the domains are illustrated at the centre of the Venn
diagram. Click to learn more about these tools.
Epidemiology
The branch of medicine studying the distribution and determinants of
health-related states.
Biostatistics
The application of statistical techniques to research related to the health
field.
Clinical trials
Clinical trials are part of epidemiology. They are a specific type of clinical
research that conducts comparisons between treatments. It serves three
major purposes: confirming the safety of treatment, identifying side
effects and comparing the effect of a new treatment with the existing
standard procedure. This produces evidence-based interventions in
disaster response.
Law and Ethics
Law provides a framework for what can and cannot be done. Specifically,
public health law is the study of the legal power and hence the duties of
the state in providing conditions where people stay healthy. Ethics
provides a guiding principle on deciding what is right and wrong. In
healthcare, it relates to how professionals behave, based on professional

bodies definition of what is right, fair and just when serving the general
community.
1.10 Solution: Characteristics of Disasters
Despite the different definitions of disaster that exist for different fields
of studies (e.g. engineering, sociology etc), these definitions are often
similar in the following ways:
Human impact of the event:
Disasters and catastrophes must have an impact on human lives.
For example, an earthquake that occurs in the middle of the Indian
Ocean where there are no human inhabitants would not be
considered a disaster, but a natural phenomenon.

1. Temporal characteristics of the event:

While unpredictability is a characteristic of disasters, associated
human health outcomes are known. With technological
advancements, the occurrences of certain disasters, such as
drought, famine and cyclones, are predictable and their potential
adverse health outcomes can be prevented. Instead of passively
responding, disaster preparedness (which will be discussed in future
lessons) compresses actions that can be taken before disasters to
protect populations health.

2. Need for external assistance:

In disasters, populations often require help beyond existing
infrastructure and systems to cope with disasters.

1.11 The Anatomy of Disaster

Basic structure of a disaster
Pre-impact phase
This phase involves the period of time before the occurrence of a disaster.
It has the greatest potential for preventing the negative health impact of
disasters.

Disaster preparedness refers to activities taken by healthcare and

public health professionals to ensure that timely and efficient
response systems are in place in times of disaster. It also includes
actions taken at the community and individual level to protect
against, and minimise physical and emotional damage resulting
from disasters.

Mitigations are measures taken to reduce the health risk of the

population posed by these hazards. Both the natural and built
environment can be a hazard if appropriate measures are not taken
to protect the population from being exposed.

Impact phase
This phase involves the period of time during and immediately after a
disaster, when rapid needs assessment and search and rescue relief work
takes place.

Disaster response is actions taken to react to an emergency or

disaster. These actions include initial assessments as well as search
and rescue immediately after the disaster.

Post-impact phase
This phase involves the period of time after the impact of a disaster and
relief effort has reached equilibrium, or stabilised. During this phase,
efforts are focused on long-term rehabilitation and recovery.

Disaster recovery is measures taken by national leaders and

community stakeholders to help the population return to the
normal state before the disaster struck.

Mitigations are measures taken to reduce the health risk of the

population posed by these hazards. Both the natural and built
environment can be a hazard if appropriate measures are not taken
to protect the population from being exposed.

The disaster cycle

The basic structure of disasters can also be understood as a cycle. The
disaster cycle illustrates that there are five phases at which medical and
humanitarian disaster response can take place in a disaster scenario,
namely 1) event or impact, 2) immediate relief, 3) needs assessment, 4)
programme modification & reassessment and 5) long-term strategic
development.