Gunn S.W.A.,(1) Masellis M.(2)

(1) President, World Association for Disaster and Emergency Medicine
(2) Secretary General, Mediterranean Club for Burns and Fire Disasters

SUMMARY. The three main objectives of medical response to a disaster are to mitigate mortality and morbidity, restore the health status to pre-disaster levels, and establish a recovery process that will promote health and a preparedness level to even beyond the pre-disaster condition. ln order to achieve these objectives, a template or standardized protocol is proposed which could be used by all disaster workers in a harmonized manner for the design, conduct, assessment and reporting of medical action in disasters. The template is a staged 13-step ladder, starting from an assessment of the pre-disaster situation and progressing through various levels to the final steps of evaluating the findings and making recommendations for future responses. The template, modelled on the Utstein Style, is based on criteria used in the social sciences, epidemiological studies, managerial decision trees, and medical and public health assessment methodologies.

However well-meaning and however well carried out, the results of medical action in a disaster situation cannot, at present, be adequately evaluated. Current research methodology and reporting of the outcome of mass medical responses remain mainly anecdotal, and much of the reported data have little external validity in their application (or not) to other emergency events, as there are no commonly established criteria, factors or yardsticks. Reporting on burned patients does not tell the whole story of a fire disaster.
The primary object of any medical response to a disaster is to mitigate the mortality and morbidity associated with that event. A secondary objective is the restoration of the health status to pre-disaster levels, and a third objective is to establish a recovery process that hopefully will promote health and a preparedness level that would be an improvement over the status ante.
To attain these objectives, and to evaluate whether they have been attained, several criteria come into play. To date, however, the severity of a health disaster and the efficacy of the response(s) to it are usually assessed according to the number of persons killed, injured or burned, or the economic cost to the social and healthcare system. Evaluation tends to ignore many other factors associated with the societal and public-health response, such as the conditions prior to the emergency, the nature of the emergency itself (other than merely stating flood, or refugees, or fire), alleviation of hunger, provision of shelter, ability to respond to residual on-going health needs, preservation of mental health, maintenance of well-being (therefore the WHO criteria of health), restoration of the commmunity's infrastructure, including the fire services, revitalization of the economy, and the return of security.
The World Association for Disaster and Emergency Medicine (WADEM) and the Nordic Society for Disaster Medicine have, therefore, established an international Task Force on Quality Control of Disaster Management, in which the Mediterranean Club for Burns and Fire Disasters is a collaborating institution. The aim is to create a template or standardized protocol which all disaster workers, from researchers to field workers, burn surgeons or fire responders, emergency managers and assessors, could use in a harmonized manner for the design, conduct, evaluation and reporting of medical action in disasters, and which would also enhance comparability, interchangeability, international collaboration, and hence efficacy.
In the past decade or so several important papers have appeared, each contributing in its own way to the construction of a scientific base to disaster medicine (Safar, Gunn, Noji, Ricci and others). But these have been separate thematic contributions (epidemiology, terminology, rescue, etc.). The template described here is a first international attempt at standardizing disaster medicine research in all its aspects, and is an open-ended project subject to revision and refinement as the work progresses. Details will be found in the April-June 1996 issue of Prehospital and Disaster Medicine, on which every reader is invited to comment; and the European Union forum was the first occasion for the programme to be presented publicity albeit briefly-outside the Task Force's workbench. Comments and contributions from knowledgeable experts will therefore be all the more welcome.

* Presented at the European Community Workshop on Disaster Medicine, Stockholm, June 1996.

The template or standard protocol for the assessment of the health consequences of disaster response is a staged approach laddered on 13 steps, starting from an assessment of the pre-disaster "normal" situation, through various levels, progressing to the final steps of evaluating the findings and making recommendations for future response(s) to similar events (Fig. 1).

THE DISASTER MEDICIT~E RESEARCH TEMPLATE

Any investigation of a disaster situation and the response to it must begin with the situation ante, the pre-disaster "normal" state of things, in our case, the pre-disaster health situation of the community or the country. This is essential in order to have a baseline in relation to which the range of disruption can be assessed and, by extension, according to which the degree of response can be evaluated. This, therefore, is Step 1 on the template. It is obvious that if a society has a well-developed and well-functioning health status (e.g. a large population immunized, or good nutritional state, etc.) the impact would certainly be different than on a society with a poorly developed health infrastructure. Note that we are talking about health infrastructure and not merely medical infrastructure. As such, other important parameters and elements come into play in health assessment, such as the country's gross national product, the per capita income, the level of literacy, the proportion of urban/rural population, etc. The approach can be modified to apply to all types of disasters, including major bums and fires. Step 1, the Pre-Disaster Health Status, therefore includes a long list of elements that would be considered in any investigation of the situation ante. These elements would, inter alia, include the following:

1. Ministry of Health data on the top five major causes of death
2. Infant mortality rates
3. Life expectancy
4. Prevalence of endemic diseases
5. Number and type of health clinics and facilities in the community
6. Number and type of hospitals and bum beds m the country
7. The degree of sophistication (or not) of the healthcare system
8. Environmental sanitation methods and facilities
9. Availability and supply of potable water, and water for fires
10. Sources and adequacy of food supplies
11. Nutritional status of the population
12. Population distribution and demography
13. Schools and literacy
14. Degree of community participation in local decision making
15. Degree of population awareness of the local risks and fire hazards
16. Degree of socio-economic stability
17. Local, national and regional transport facilities
18. Socially-focused voluntary organizations and NG0s
19. The existence or not of community health planning and preparedness
20. Newspaper, radio, television and other media civic programmes
21. Relation between the health authorities and fire departments

22. Others ...

Concerning element 15, above, it is important to gauge the degree of perception of risk and knowledge of the local hazards (volcano, factory, nuclear plant, meteorological vulnerability, etc.) that the population faces and the degree of preparedness (or indifference) it expresses.

As for Step 1, a similar inventory or check list is constructed in relation to each of the other steps. They are not mentioned in this brief presentation and will be found in the referenced issue of Prehospital and Disaster Medicine. They are equally applicable to fire disasters.
The template is based on criteria used in the social sciences, in epidemiological studies, in managerial decision trees and, of course, in medical and public health assessment methodologies. It is modelled on the generally recognized Utstein Style and respects terms and activities implemented by established disaster relief organizations. Reciprocally it aims at standardizing and generalizing the mode of action of the numerous aid organizations in order to create a harmonized, interchangeable yardstick for reporting and evaluation of medical disaster assistance, including burn therapy and fire management.
The study will remain open-ended for some time until consensus is reached that standards have been achieved and that disaster medical response can be evaluated in a reasonably scientific manner. Only when we know what we have done shall we know what we should do next time.

RESUME. Les trois buts principaux de l'intervention médicale en cas d'un désastre sont d'atténuer la mortalité et la morbidité, de rétablir les conditions sanitaires aux niveaux avant le désastre, et de promouvoir un processus de récupération qui favorisera la santé et un niveau de préparation même au-dessus des conditions existantes avant le désastre. Pour atteindre ces buts, les Auteurs proposent un protocole standardisé qui pourrait être utilisé par tous les opérateurs des désastres en manière harmonisée pour la programmation, la réalisation, l'évaluation et la description de l'action médicale en cas de désastre. Le protocole consiste en une échelle progressive à 13 échelons qui commence avec une évaluation de la situation avant le désastre et, passant par les divers niveaux, arrive aux phases finales pour évaluer les résultats et pour faire des recommandations pour les interventions futures. Le protocole est modellé sur le style de Utstein et se base sur les critères employés dans les sciences sociales, dans les études épidémiologiques, dans les arbres décisionnels des cadres, et dans les-méthodologies d'évaluation médicale et de la santé publique.

1. Burkle F.M., McGrady K.A.W., Newsett S.L. et al.: Complex, humanitarian emergencies; Measures of effectiveness. Prehospital and Disaster Medicine, 10: 48-56, 1995.
2. Gunn S.W.A.: "Multilingual Dictionary of Disaster Medicine and International Relief". Kluwer Academic Publishers, Boston, Dordrecht, London, 1990.
3. Gunn S.W.A.: Principles of the scientific basis of disaster management. Disaster Prevention and Management, 1: 16-21, 1993.
4. Masellis M., Gunn S.W.A.: "The Management of Mass Burn Casualties and Fire Disasters". Kluwer Academic Publishers, Boston, Dordrecht, London, 1992.
5. Ricci E., Pretto E.: Assessment of prehospital and hospital response in disaster. Critical Care Clinics, 7: 471-84, 1991.
6. Pretto E., Ricci E., Klain M., Safar P. et al.: Disaster reanimatology potentials: A structured interview study in Armenia. III Results, conclusions, recommendations. Prehospital and Disaster Medicine, 7: 327-38, 1992.
7. Task Force of the American Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, and the Australian Resuscitation Council: Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arresti, The Utstein Style. Annals of Emergency Medicine, 20: 861-74, 1991.
8. Task Force on Quality Control of Disaster- Management of the World Association for Disaster and Emergency Medicine: Disaster medical response research: A template in the Utstein Style Prehospital and Disaster Medicine, 11: 82-90, 1996.

9. WHO Guidelines. "World Health Statistics Annual, 1989", pp. vixxvi. World Health Organization, Geneva, 1989.