Annals qf the MBC - vol. 5 - n' 1 - March 1992

SUMMARY. A new discipline needs a sound scientific base, technical underpinning, proper conceptual framework and organized management. In disaster medicine all the medical and multisectoral aspects of emergency management are essential if disaster preparedness and response are to be more efficient and more effective. The authors outline 10 principles as a scientific base to the newly evolving discipline of disaster medicine.

Emergency aid is as old as humanity. As long as man has had a heart and a physiological reflex for protection, he has had compassion and an urge to help those who suffer. Nothing new there. But what is new is the accelerating process of change that has seen the emergence of Disaster Medicine as a gradually, and now rapidly, developing science. It has not, however, always been so; indeed it has taken society enormously long - up to the last two decades or so of our century - to mould this humane, ad hoc, unorganized - not to say disorganized - assistance into something organized and conceptualized, a technically underpinned action that is evolving into the discipline of Disaster Medicine.
In fact one of the pleasures of Disaster Management, and in particular of Disaster Medicine, is that one witnesses the unfolding of a new science right in front of one's eyes. This is very challenging and exciting.
A cursory look at the past is instructive. Perhaps the earliest organized aid was that of hunters and warriors, helping dress each other's wounds. The caves of primitive Lascaux and the exquisite pottery of classical Greece are but eloquent witnesses. Military medicine grew out of that, and in modem times of course Florence Nightingale put the stamp of feminine sensitivity on mass casualty care.
From frontline care we gradually proceeded to transnational action with the founding of the International Red Cross and the formulation of international humanitarian law. National Red Cross -and later Red Crescent - Societies sprang up from this, with subsequent federation into the League following World War 1.
In all this international reorganization the medical profession as such had little involvement, a pattern that has only recently begun to change. What has not changed is the predominantly humanitarian core of disaster assistance, whether in natural catastrophes or man-made disasters.
World War 11, like all wars, brought its horrors and some beneficial consequences. Towards the end of the conflict UNRRA - the United Nations Relief and Rehabilitation Administration - became the first disaster management enterprise on a global'scale and still holds the record of having dispensed the most massive aid: 20 billion dollars in today's currency during a period of 31 /2 years of its operation over a vast area extending from the Mediterranean to the Pacific. The birth of the United Nations and of the World Health Organization were the other momentous events in the aftermath of war, and their Constitutions have a capital bearing on disaster management.
First of all, WHO redefined health as---astate of complete physical, mental and social well-being and not merely the absence of disease or infirmity". The victims of disasters are thus lacking in well-being and deserve care. More specifically, Article 2 of the WHO Constitution states that the Organization "... shall furnish appropriate technical assistance and, in emergencies, necessary aid The UN Charter has similar instruments concerning man's right to protection.
One of us (WG) is honoured to have been asociated with the UN system and in particular with WHO for many years, and it is our belief that it is through the moral and intellectual impetus of these global Organizations that Disaster Management is gaining institutional expertise. Disaster Medicine, as distinct from trauma management and clinical emergency medicine, is now enjoying an increasingly important place in overall health and development planning. The scene is now set for the new science.
Let us define the new science. Disaster Medicine has been defined as follows:
Thestudy and collaborative application of various health disciplines, e.g. paediatrics, epidemiology, communicable diseases, nutrition, public health, emergency surgery, social medicine, community care, international health, to the prevention, immediate response and rehabilitation of the health problems arising from disaster, in cooperation with other disciplines, involved in comprehensive disaster management.
It is necessary to have standardized approaches and harmonized definitions of concepts and specialized terms in established disciplines, and at its 1991 meeting the WHO Expert Committee on Emergency Relief Operations endorsed this definition and included it in its official Report. The definition is also espoused by the Commission of European Communities which is currently compiling the Lexicon of all the terms likely to be encountered in civil protection 'and management of major emergencies.
Disaster Medicine, then - some are already talking of Disaster Health - is more than the age-old bandaging of wounds and the providing of emergency relief. To be an effective and efficient managerial system, it has to be an extended method comprising all the phases and facets of the disaster cycle, including preparedness, prevention, immediate response, relief, reconstruction, rehabilitation and development. For disaster is an anthropocentric, sociocentric phenomenon. If a cyclone or an earthquake does not touch man or his social structures, it remains a merely meteorological or geophysical phenomenon.

Disaster can be defined as:

"The result of a vast ecological breakdown in the relations between man and his environment, a serious and sudden event (or slow, as in drought) on such a scale that the stricken, community needs extraordinary efforts to cope with it, often with outside help or international aid."
The definition implies an emergency of such magnitude that would require outside help or international relief. We shall discuss later the improvements in international relief as part of the technical advances in disaster management.
Disasters are always sad and destabilizing situations, and disaster response has not always been successful. To be more successful the knowledge and mechanisms have to be based on more solid, scientific precepts. There are positive developments in this regard, and we should like to highlight three areas where the scientific basis of disaster management is being strengthened. We shall discuss (a) the scientific approach, (b) epidemiological advances, and (c) training for disaster management.

a. The scientific base

An undeniable progress now in process is the increasing technicization of disaster management. However humanitarian disaster medicine may be -and it is predominantly humanitarian - it must strengthen its scientific base and develop a strong technical structure. This applies as much to disaster management in the wider sense as to disaster medicine in the specific sense. Research and field surveys over the past few years have shed new light on the effects of disasters and have indicated better ways of providing the appropriate response. From these studies and personal experiences we would enunciate 10 principles for the scientific basis of disaster management:

1. Preparedness is possible and essential. The greater the preparedness for foreseeable or probable events, the more effective relief operations will be.
2. Prevention of many natural disasters is possible, while prevention of all man-made disasters should be possible.
3. No two disasters are alike, but the problems that certain categories of disaster are 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 preparation on a sectOral, national and international basis are possible and essential for effective- multidisciplinary response.
6. Mobilization of multisectoral manpower resources (in the case of medical action: nurses , doctors, nutritionists, social health workers, paramedics) must be organized, so as to be able to respond immediately to probable, less probable and particular needs when disaster strikes.
7. Risk assessment, evaluation of the risks, estimation of the effects of one's intervention, and a study of the post-disaster situation are essential.
8. The post-emergency phase offers a rare opportunity for taking steps to mitigate the effects of a subsequent disaster. Each disaster is a lesson.
9. The reconstruction phase starts at once and it is part of development.

10. Disaster management takes into full account the community and the local/national institutions involved.

The more one provides a scientific base, the more one becomes convinced that for truly effective disaster management, the key is preparedness and prevention, rather than post hoc, firefighting-type emergency response. Our postulate No. 1.
For this kind of scientific approach and technical underpinning, special studies, surveys, bench and applied research, social and natural science investigations and managerial applications are necessary. One particular endeavour that has proved most promising in disaster medicine is epidemiology.

b. Disaster epidemiology
c. Training

Epidemiology is "the medical discipline that studies the influence of such factors as the lifestyle, biological constitution and other personal or -social determinants on the incidence and distribution of disease." By extension, disaster epidemiology can be viewed in a broader perspective that links data collection and analysis to an urgent decision-making process. It is not management, but a tool for it. The effects of disasters can be studied by epidemiological methods. Such studies have included the public health effects of specific disasters; analysis of risk factors for adverse social and health effects; clinical investigation of the impact of diagnostic and therapeutic methods; the effectiveness of various types of assistance; and the long-term influence of relief operations on the restoration of pre-disaster conditions.
Based on such studies, disease profiles for each type of disaster have been formulated and have already borne results in their application. We know from these studies, for example, that although both earthquakes and flash floods result in great numbers of deaths, the disease patterns they cause are entirely different: multiple trauma for the first, and communicable diseases for the second. And as a corollary, you need more surgeons and fracture splints after an earthquake, and more internists and antibiotics after a major flood. Also, hospital admissions jump up impressively immediately after an earthquake, but return to normal pre-seismic conditions within 4-6 days of the impact. Whence the quasi uselessness of mobile hospitals flown from overseas after an earthquake, as they almost invariably arrive late and are of little use.
Descriptive and analytical epidemiological studies have already resulted in improved disaster response and better preparedness levels. Antiscismic housing design and antiflood structures owe much to such studies besides, of course, to the appropriate construction and planning advances. However, while science. natural disasters, have been extensively investigated, man-made disasters have been more difficult to conceptualize as they include such diverse events as conflicts, mass exodus, nuclear explosions, technological accidents and environmental disasters that threaten the ecological balance of a community. More studies are needed here.
To carry out more studies, and to put into operation what is learnt, it is necessary to have trained people.
In the past, the traditional response to disasters has depended more on goodwill than on knowledge. While such outpouring of personal and international solidarity has brought great comfort to stricken populations, the effective results have been hampered by a lack of trained personnel at all levels.
This is now changing, as change it must, if disaster action is to benefit from technical knowledge and managerial knowhow, besides humanitarian compassion. Several universities have introduced training programmes and research projects are being carried out in many countries. Courses are conducted in disaster health at the European Centre for Disaster Medicine, and in management at the Asian Disaster Preparedness Centre in Bangkok, at the Pan African Centre for Disaster Preparedness Centre in Bangkok , at the Pan African Centre for Emergency Preparedness in Addis Ababa, at the Pan American Health Organization in Washington, and elsewhere. Specialized training is provided by such centres as the Mediterranean Burns Club in Palermo, Italy, while the United Nations programme of the International Decade for Natural Disaster Reduction provides facilities for trainees from developing countries. The Osaka Declaration is a landmark.
Scientific investigation generates its own language and literature. Works on a harmonized terminology have already been mentioned. Serious periodicals are published, such as the quarterly "Prehospital and Disaster Medicine" by the World Association for Emergency and Disaster Medicine, and the "Natural Hazards Observer" by the University of Colorado, while several books have dealt with general or particular aspects of major emergencies. Examples are: "Major Chemical Hazards", "Refugee Community Care", "Epidemiologic Surveillance after Natural Disaster", and "Mitigating Natural Disasters - A Manual for Policy Makers and Planners". A rich programme of international conferences is constantly adding to the training facilities and expert communications in disaster management.
All these are healthy signs of a new and vigorous Reproduced from S.W.A. Gunn: Multilingual Dictionary of Disaster Medicine and International Relief, copyright by kind permission of Kluwer Academic Publishers, Dordrecht, London and Boston. (See review in Annals of the MBC, Jan. 1989.)

RESUME Toute nouvelle discipline a besoin d'une base scientifique solide, d'un support technique, d'un cadre conceptuel approprié et d'une gestion organisée. Dans la médicine des catastrophes tous les aspects médicaux et multisectoriels de la gestion des urgences sont essenticls si la préparation et la réponse aux désastres seront efficaces. Les auteurs indiquent 10 principes comme base scientifique de cette nouvelle discipline de médecine des catastrophes en évolution.

1. Baskett P.J., Weller R.: "Medicine for Disasters", Wright, London and Boston, 1988.
2. Clarke R., Ehrlich A., Gunn S.W.A. et al.: "London Under Attack. Report of the GLAWARS Commission", Blackwell, Oxford and New York, 1986.
3. De Br-uycker M., Greco D., Lechat M. et al.: The 1980 Earthquake in Southern Italy. Bull. W1d H1th Org., 61: 102, 1983.
4. Gunn S.W.A.: International Cooperation in Disaster Medical Relief. The Role of UNDRO, In "New Aspects of Disaster Medicine", Ohta M., Ukai T., Yamamoto Y. (eds.), Herusu, Tokyo, 1989.
5. Gunn S.W.A.: La M&decine des Catastrophes. Une Nouvelle Discipline. Helv. Chir. Acta, 52: 11, 1985.
6. Gunn S.W.A.: The scientific basis of disaster medicine: a new discipline. Japan. J. Acute Med., 15: 1721, 1991.
7. Gunn S.W.A.: "Multilingual Dictionary of Disaster Medicine and International Relief', Kluwer Academic Publishers, Dordrecht, London, Boston, 1990.
8. Gunn S.W.A.: Quantifiable Effects of Nuclear War on Health and Society. Ann. Mediterr. Burns Club, 1: 175, 1988.
9. Gunn S.W.A., Manni C.: Training for Health Disasters. Disaster Management, 2: 102, 1989.
10. Marshall V.C.: "Major Chemical Hazards". Wiley, New York and Chichester, 1987.
11. Pan American Health Organization: "Epidemiologic Surveillance After Natural Disaster", Washington, 1982.
12. Simmonds S., Vaughan P., Gunn S.W.A.: "Refugee Community Health Care", Oxford University Press, Oxford and New York, 1985.
13. United Nations: "Mitigating Natural Disasters. A Manual for Policy Makers and Planners", UNDRO, Genova, 1991.
14. World Health Organization: Basic Documents, WHO, Geneva, 1988.
15. Yamamoto Y., Morikawa M.., Makino T., Otsuka T.: The International Medical Cooperation by Japanese Government on Disaster Relief and the Future of this Program, In "New Aspects of Disaster Medicine", Ohta M., Ukai T., Yamamoto Y. (eds.), Herusu, Tokyo, 1989.