EMERGENCIES: REGIONAL APPROACHES TO GLOBAL PROBLEMS

Gunn S.W.A.

President, Mediterranean Burns Club
Vice-President, European Centre for Disaster Medicine

SUMMARY. Generalized global planning in the field of disasters may be remote from regional realities. Two examples of organizations responsible for successful regional endeavours are the European Centre for Disaster Medicine, and the Mediterranean Burns Club, both of which emphasize training and believe in three main principles: a) efTective disaster management requires technical training; b) such training must be interdisciplinary; c) results are better when there is maximum common interest. An analysis is made of various principles concerning the scientific and technical basis of disaster management. It is pointed out that each disaster has its own epidemiological and pathological profile. Rescue studies show that immediate rescue is paramount - external help often arrives too late. This emphasizes the need to educate the general public. Training is necessary, as promoted by the European Centre for Disaster Medicine, in order to promote the prevention and mitigation of the effects of disasters through research, training courses, publishing and international cooperation. The Mediterranean Burns Club offers a specific surgical approach to the problem. The international community must have mechanisms for planning, mobilization and co~ordination in order to achieve maximum results. It has however been found that the action of the various international organizations is more efficient and etTective when organized and applied on a regional basis.

It is a pleasure for me to appear at this final session of what has been a very successful attack on disasters.
It may surprise some of you that, for this closing plenary, an international global conference like EMERGENCY 88 should focus on regional solutions. For both Mr. Paolini of the European Community and I will look at global problems from the regional angle.
It is becoming increasingly evident that blanket remedies and global planning, while applicable in certain circumstances, are proving too dilute and too distant from country or regional realities, and that the more focussed approaches are proving more productive and realistic. By "regional" I mean a certain geographic area which, while diverse in several aspects, such as ethnic composition, shares economic, geographic, cultural and other affinities, which give it a certain, unity or regional characteristic. The Mediterranean Basin is such a region. Europe is a larger one, the Caribbean is another, etc.
The UN, the global Organization par excellence, acts through its Regional Commissions, and of course the WHO, with which I have long been associated as Head of the Emergency Relief Operations, is the most successful example of a worldwide but regionalized structure, with its 6 quasi -independent Regional Offices in Copenhagen, Brazzaville, New Delhi, Manila, Washington and Alexandria, each with its Emergency Response facility. Geneva is only the global coordinating Headquarters.
1 shall therefore base my talk on what 1 think to he successful regional endeavours. 1 hope you will forgive me for giving personalized examples - but 1 believe 1 should base myself on personal experience. 1 refer to the European Centre for Disaster Medicine in San Marino, of which 1 am Scientific Co-ordinator, and the Mediterranean Burns Club in Palermo, of which 1 have the honour to be the President.
Both of these organizations emphasize training and are based on three postulates:

1. that to be effective, disaster management needs a solid technical underpinning and a solid basis;
2. that training for such action must have an interdisciplinary-integrated approach; and
3. that results are more easily and better achieved when there is a maximum regional commonality of the problems, the participants and the responses.

1. Scientific and technical basis of disaster management

Ten principles:

Recent research and field surveys have shed new light on the effects of natural disaster and have indicated better ways of providing the appropriate response and needed emergency care. From these technical studies I would single out the following 10 principles:

1. Preparedness is possible. The greater the preparedness for probable or foreseeable events, the more effective relief operations will be.
2. Prevention of many natural disasters is also possible.
3. No two disasters are alike, but the problems that a certain kind of disaster is likely to create are quite foreseeable. Disasters have profiles.
4. Based on such profiles, the disease pattern of each kind of disaster can be formulated epidemiologically.
5. Planning and preparedness on a sectorial and international basis are possible and essential for effective action.
6. Mobilization of the appropriate manpower resources in this case doctors, nurses, nutritionists, primary health care workers - must be so organized as to be able to respond immediately to the probable and particular needs when disaster strikes.
7. Risk assessment, evaluation of the risks and effects of the intervention, and a study of the post-disaster situation are essential.
8. The post-emergency phase offers an opportunity for taking steps to mitigate the effects of a subsequent disaster.
9. The reconstruction phase starts at once.
10. Disaster management takes into full account the community and the local/national institutions involved.

Total disaster management needs sectorial research, teaching, training, field experience, community participation, and a workable cooperative network. Disaster management has now reached a certain degree of maturity, and I should like to submit that Civil Defence has now become almost a specialty. In any case there is no place for amateurism. And voluntarism does not mean amateurism.

Our surveys have shown that each kind of disaster has its own epidemiological profile and pathological characteristics, and these similarities and differences are very important in planning, in prevention and in relief operations. These studies have indicated new avenues for action and have helped dethrone many an entrenched myth.
The consequences of a disaster can be immediate, or secondary, delayed, and these differ with each type of disaster. This applies equally to medical disasters for we know now the similarities and differences of disease following floods, drought, earthquakes, etc,
Take hospital admissions following an earthquake - assuming that hospitals have escaped damage, there will be a rush of in-patient and out-patient arrivals. We now know that once the rush is over, admission patterns revert to normal as early as the 4th - 5th day after the earthquake, as shown in these figures from Guatemala.

Immediate rescue is paramountl and it is important to note that any help coming from outside the region almost invariably arrives too late. Expatriate teams and foreign donors should fashion their assistance accordingly, if they are to be of any effect. Again in order to maximize local help, it must be realized that in extracting the trapped and the injured, 90% of the first helpers come from the village, and 76.2% from the inhabitants of the,,same building. Extraction with unsophisticated means - hands, shovels, ladder - account for the largest 'number rescued (96.8%), as opposed to the use of sophisticated measures, such as tractors or cranes (3.2%). Even the country or the regional neighbours will be too late. Here what counts is community response. And here is where education of the public finds its shining place.

I was saying that disaster management should be multidisciplinary. Here is an example from the engineering and construction industries: the relation between the number of storeys of a building and the number of victims in an earthquake.
These examples that I have chosen are not the expressions of haphazard decisions or quality judgements. They are based on quantified, objective studies and research, and it is my plea that more of this kind of scientific work is necessary if our emergency action is to be of any meaning. To do this, we need basic studies, applied studies, epidemiology, training courses, teachers, trained personnel.
My second example will address this question of training.

II. Training

Disasters are becoming more frequent, more serious and more deadly. 1 think 1 have sufficiently shown the need for studies and training in this field. Within the United Nations several agencies, such as ICDO, are conducting training courses and UNDRO has been bringing its share to this endeavour. 1 think we have been reasonably successful in getting some institutions to introduce higher studies in this sector.
As an example let me cite the European Centre for Disaster Medicine, with which, after many years at WHO, 1 am currently associated. CEMEC is an intergovernmental venture, under the aegis of the Council of Europe, and housed in the Republic of San Marino. Its aim is to promote the prevention and mitigation of the effects of natural and technological disasters through research, investigations, training courses, publishing and international cooperation. The same applies to the Mediterranean Burns Club, dealing with the surgical approach to a civil defence problem. It is my conviction that it is through this kind of approach that we shall be able to make disaster relief more effective.

III. International aid

Following a disaster, international relief is expected and often provided generously. The international community must therefore have its mechanism for planning, mobilization and co-ordination, in order to maximize the effort - an effort that comes from numerous sectors, such as civil defence, transport, meteorologists, communications, etc.
Generally speaking, four different systems are involved in international assistance - historically most of the m- born of a disaster - to alleviate disaster. The ICRC was born on the battlefield of Solferino, the European Community after centuries of conflict, the United Nations after the Second World War, Oxfam following the famines in Bangladesh, etc.
1 think it is worth recalling the make-up of the international aid community. The following diagram shows the four principal mechanisms of international aid: (1) the inter-governmental organizations, (2) Red Cross, (3) the NG0s, and (4) direct bilateral assistance.
This is the pattern of involvement of the international aid and donor community. But however international these organizations may be, it has been found that their action is more efficient and more effective when organized and applied on a manageable, regional basis.

RÉSUMÉ. La planification globale généralisée dans le camp des désastres peut sembler loin des réalités regionales. Il existent deux examples d'organisations responsables d'initiatives régionales réussies; le Centre Européen de la Médecine des Désastres, et le Club Méditerranéen des Brûlures. Tous les deux soulignent l'importance de la formation professionnelle et ils croient en trois principes fondamentaux: a) la gestion efficace des désastres requiert une formation technique; b) cette formation doit être interdisciplinaire; c) les résultats sont plus favorables quand il y a le maximum d'interêt commun.
L'auteur analyse les différents principes de la gestion des désastres. Il relève que chaque désastre a un profil épidémiologique et pathologique propre. Les études des secours montrent que le secours immédiat est de la plus haute importance - le secours qui vient d'ailleurs arrive souvent en retard. Cela souligne l'importance d'éduquer le grand public. La formation professionnelle est necessaire, comme elle est promue par la Centre Européen de la Médecine des Désastres, pour promouvoir la prévention et la réduction des effets des désastres à travers la recherche, les stages, les publications et la coopération internationelle. Le Club Méditerranéen des Brûlures offre une approche chirurgicale spécifique au problème. La communauté internationale doi - t avoir des mécanismes pour la planification, la mobilisation et la coordination pour arriver aux résultats maximums. On a cependant trouvé que l'action des différentes organisations internationales est plus efficiente et plus efficace quand elle est organisée et appliquée sur base régionale.

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