Public Health and Disasters

INTRODUCTION TO PUBLIC HEALTH

As early as 310 BC, a public health philosophy was exhibited by the Romans. They believed that cleanliness would lead to good health and made links between causes of disease and methods of prevention. For example, during this time an association was made between the increased death rate of persons living near swamps and sewage, and as a result the Roman Empire began working on two major public health projects in sanitation control: the building of aqueducts to supply clean water to the city and a sewage system to eliminate waste from the streets. Today, the benefits of public health infrastructure in the United States and abroad continue to strengthen the well-being of society. The impact of interventions has been great. In the past century (1900–1999), the 10 greatest public health achievements have been documented as the following¹:

• 1.Vaccination programs, meaning the eradication of smallpox; elimination of poliomyelitis in the Americas; and control of measles, rubella, tetanus, diphtheria, and other diseases around the world
• 2.Motor-vehicle safety
• 3.Safer workplaces
• 4.Control of infectious diseases
• 5.Decline in deaths from coronary heart disease and stroke
• 6.Safer and healthier foods
• 7.Healthier mothers and babies
• 8.Family planning
• 9.Fluoridation of drinking water
• 10.Recognition of tobacco use as a health hazard

Public health is founded on the efforts of a society to protect, promote, and restore the health of its citizens. Public health programs and services emphasize the prevention of disease and administration of health needs to the population as an entity, versus the study and treatment of a single patient, as is found in the discipline of medicine. Today, public health is defined as “the science and the art of preventing disease, prolonging life, and promoting physical health and mental health and efficiency through organized community efforts … and the development of the social machinery to ensure to every individual in the community a standard of living adequate for the maintenance of health.”² The mission of public health is to fulfill society's desire to create conditions so that people can be healthy. Public health is divided into the staple pillars of assessment, policy development, and assurance.³ All three of these pillars are interdependent and cyclical. Two functions address the issues of assessment: (1) monitor health and (2) diagnose and investigate. Under policy development are the functions (1) inform, educate, empower; (2) mobilize community partnerships; and (3) develop policies. The following functions define assurance: (1) link to and/or provide care, (2) ensure a competent workforce, and (3) evaluate.³

Like traditional programs in public health, ranging from maternal and reproductive health to injury control and prevention, the public health response to disasters also fulfills the same basic tenets of assessment, policy development, and assurance. This chapter introduces the reader to how public health integrates into disaster preparedness and response systems by highlighting some specific subjects relevant to those tenets. It will cover topics like the public health disaster response cycle, policies in disaster response, the provision of disaster medical services, as well as worker safety and epidemiological/data issues (Figure 1-1).

PUBLIC HEALTH RESPONSE CYCLE

Mitigation is the process of recognizing risks and vulnerabilities and then working to both reduce the vulnerability and strengthen society's ability to withstand an unstoppable event or to reduce the effects from a disaster. Public health seeks to mitigate hazards such as explosions, chemical exposures, natural disasters like floods and earthquakes, and infectious disease, as well as reducing vulnerabilities of the infrastructure such as weak assets, resources, personnel, and science. One form of mitigation may be hardening structures against blast, but also can be the placement of surveillance systems to increase early detection of infectious diseases in a hospital setting, for example. Today, these systems, as well as reporting parameters, are being put into place across the country to both recognize and protect populations from a bioterrorism event. Early warning offers the benefit of a rapid response and reduction in morbidity and mortality.

Preparedness is the process of developing a formal program of response. Preparedness has many components, including: training and staff development; identification and classification of public health resources including personnel, supplies, and facilities; development of standard operating procedures (SOPs), emergency response plans, and communications plans; and preplacement of key supplies and protective equipment. This phase should also include the participation in tabletop and functional exercises. Public health personnel must be integrated and participate with other response agencies during drills and exercises to better familiarize each stakeholder with their respective roles and abilities. In addition, this is the phase in which public health agencies would develop interagency agreements, memoranda of understanding (MOUs), and external support contracts.

The Centers for Disease Control and Prevention (CDC) is one reference source where planners can obtain basic guidelines for disaster preparedness. These include:

• 1.Form mutual-aid agreements and close relationships with local, regional, state, and federal partners.
• 2.Conduct a hazard and risk assessment.
• 3.Conduct a capacity assessment, identifying resources in your system.
• 4.Obtain those identified resources and surge capacity.
• 5.Develop plans consistent with other response organizations in your community.
• 6.Develop surveillance, registries, and data archiving systems.
• 7.Plan for public affairs and risk communication.
• 8.Ensure personnel are trained and certified to use personal protective equipment and other health practices.
• 9.Orientation for volunteers and personnel on procedures, guidelines, and command and management systems.
• 10.Participate in and conduct exercises.
• 11.Participate in after-action reviews of exercises and incidents.⁴

Response is the phase in which each agency and section with responsibility to respond activates its emergency response plan to the specific threat or situation and can incorporate local, regional, and federal response. For example, in response to a biologic or chemical terrorist event, public health agencies would respond by conducting site surveys, recommending public safety measures and communicating risk, providing epidemiologic investigations, providing medical treatment of prophylaxis for those exposed, and initiating disease prevention and environmental decontamination measures.⁵

RECOVERY

Public health agencies must identify what resources may be available to assist in restoring the operation as well as address other physically and emotionally affected populations. Public health recovery operations are multi-disciplinary and involve multiple sectors of society (law enforcement, military, public policy, public works), and they vary depending on the extent of the disaster's societal impact. Furthermore, recovery efforts comprise several components, some of which are Search and Rescue (SAR) in the case of an earthquake, bombing, or landslide; reinstitution of medical services if clinics and hospitals are destroyed; and establishment of corrupted lifelines like sanitation, electricity, and water. Those affected by the horrendous Tsunami disaster—that killed hundreds of thousands in Indonesia, Thailand, India, and so many other nations—demonstrated the international public health relief operation: an extreme example of multilateral, global relief spanning commercial and government sectors. The recovery from this disaster is ongoing and likely will last several years.

DISASTER POLICY

For weeks after the 2004 tsunami, survivors on make-shift rafts were miraculously saved and brought back to shore. At the same time, the United States faced its own disasters. Thirteen people were trapped and 6 died from mudslides in La Conchita, California; and a train disaster in Graniteville, South Carolina released concentrated chlorine fumes, leading to 9 deaths and 250 hospitalizations. Finally, in the fall of 2005 Hurricane Katrina devastated the Gulf coast of the United States, resulting in the flooding and complete evacuation of New Orleans. Although these disasters are not on the same scale in terms of death, injury, social loss, and destruction as the tsunami, they still maintain criteria that classify them as disasters.

LOCAL PUBLIC HEALTH RESPONSE TO THE WORST TERRORIST ATTACK IN U.S. HISTORY.

On Sept. 11, 2001, two commercial jets that were hijacked by terrorists crashed into the two towers of the World Trade Center in New York City. Within 90 minutes, both 110-story towers had collapsed. The New York State Department of Health (NYS DOH) had pre-established Emergency Operations Center committees that came together and began working within 30 minutes of the attack. NYS DOH nursing staff assisted in triaging and treating injured persons at an emergency triage center. In collaboration with the American Red Cross, the DOH also provided nursing staff for emergency shelters that housed displaced residents. Within the disaster site and surrounding community, DOH performed environmental monitoring. With losses in power and water as well as having tons of airborne contaminants in the area, DOH had its hands full with monitoring both the general public and emergency responders in addition to performing its daily activities. The DOH regularly sent faxes, e-mail alerts, and press releases containing urgent public health information and/or concerns to local hospitals and physicians. The DOH designed and implemented a rescue and recovery worker-safety plan. Additionally, the DOH initiated four disease and injury surveillance systems after the disaster, with assistance from the CDC.

What determines whether an event is treated as a federal disaster? Locally, only the governor of a state or his or her appointee can declare a federal disaster through coordination with the Federal Emergency Management Agency (FEMA) regional director through the Federal Response Plan (FRP), under the Stafford Disaster Relief and Emergency Assistance Act.⁷ The FRP under the Stafford Act is an interagency plan that outlines the delivery of federal resources to state and local governments when a disaster overwhelms the region's ability to respond self-sufficiently. When state or local resources are insufficient to respond to and recover from a disaster, the presidential declaration sets forth long-term federal disaster recovery programs.⁷ The Stafford Disaster Relief and Emergency Assistant Act's definition of a major disaster is stated in the following⁷:

Any natural catastrophe (including any hurricane, tornado, storm, high water, wind-driven water, tidal wave, tsunami, earthquake, volcanic eruption, landslide, mudslide, snowstorm, or drought), or, regardless of cause, any fire, flood, or explosion in any part of the United States, which in the determination of the President causes damage of sufficient severity and magnitude to warrant major disaster assistance under this Act to supplement the efforts and available resources of states, local governments, and disaster relief organizations in alleviating the damage, loss, hardship, or suffering caused thereby.

A major disaster declaration makes available all federal disaster relief assistance to affected communities. This can include repair, replacement, and reconstruction of public and nonprofit facilities; cash grants for personal victim needs; temporary housing vouchers or replacement accommodations; and unemployment assistance.⁸

Following the Sept. 11 attacks in 2001, the President declared the Homeland Security Presidential Directive (HSPD)-5, in which he called for the development of a new National Response Plan (NRP) “to align Federal coordination structures, capabilities, and resources into a unified, all-discipline, and all-hazards approach to domestic incident management.”⁶ The premise of this robust plan is to standardize and make seamless the manner of operations for all levels of disaster response from local to federal, as well as private and public, agencies. The NRP will establish a national framework, standardizing aspects of coordination, communications, incident management, and information sharing, as well as streamline disaster policy directives and protocols. Upon full implementation of the NRP, it will supersede the Initial National Response Plan (INRP), the Federal Response Plan (FRP), the U.S. Governmental Interagency Domestic Terrorism Concept of Operations Plan (CONPLAN), and Federal Radiological Emergency Response Plan (FRERP). The NRP also provides for guidance to initiate long-term community recovery and mitigation.⁶

When the NRP is fully implemented, the Secretary of Homeland Security will declare “incidents of national significance.” The drafted NRP in December 2004 outlined four criteria that constitute an “Incident of National Significance”:

• 1.A federal department or agency acting under its own authority has requested the assistance of the Secretary of Homeland Security.
• 2.State and local resources and authorities are overwhelmed and federal assistance has been requested by the state and local authorities.
• 3.More than one federal department or agency has become substantially involved in responding to an incident.
• 4.The Secretary of Homeland Security has been directed to assume responsibility for managing a domestic incident by the President.⁶

One specific support function most applicable to public health is called the Emergency Support Function #8 —Public Health and Medical Services, or ESF-8. ESF-8 provides supplemental assistance to State, local, and tribal governments in identifying and meeting the public health and medical needs of victims of an Incident of National Significance. This support is categorized in the following core functional areas:

• •Assessment of public health/medical needs (including behavioral health)
• •Public health surveillance
• •Medical care personnel, and
• •Medical equipment and supplies.⁶

The NRP stipulates that the coordinator and the primary agency is the Department of Health and Human Services.

OPERATING PUBLIC HEALTH

The American Public Health Association (APHA) provides principles to guide public health's response toward terrorism.¹¹ From a list of 12 principles, the following seven are of specific interest to this chapter:

• 1.Strengthen the public health infrastructure (which includes workforce, laboratory, and information systems) and other components of the public health system (including education, research, and the faith community) to increase the ability to identify, respond to, and prevent problems of public health importance, including the health aspects of terrorist attacks.
• 2.Ensure the availability of and accessibility to health care, including medications and vaccines, for individuals exposed, infected, made ill, or injured in terrorist attacks.
• 3. Educate and inform health professionals and the public to better identify, respond to, and prevent the health consequences of terrorism and promote the visibility and availability of health professionals in the communities that they serve.
• 4. Address mental health needs of populations that are directly or indirectly affected by terrorism.
• 5.Ensure the protection of the environment, food and water supply, and health and safety of rescue and recovery workers.
• 6.Ensure clarification of the roles, relationships, and responsibilities among public health agencies, law enforcement, and first responders.
• 7.Build and sustain the public health capacity to develop systems to collect data about the health and mental health consequences of terrorism and other disasters on victims, responders, and communities and develop uniform definitions and standardized data classifications systems of death and injury resulting from terrorism and other disasters.

This chapter introduces basic concepts, discussions, and recommendations regarding the following key issues arising from these selected APHA principles: (1) public health infrastructure; (2) medical services, including the distribution of drugs and supplies; (3) education, training, and communications; (4) environmental health and precautions; (5) mental health; (6) worker safety and first responders; and (7) data collection and analysis.

PUBLIC HEALTH INFRASTRUCTURE

Formal public health programs in the United States have existed for well over 200 years. For example, the origins of the U.S. Public Health Service (USPHS) (initially known as the Marine Hospital Service) may be traced to the passage of an act in 1798 that provided for the care and relief of sick and injured merchant seamen. After its inception and over the next 200 years, the Marine Hospital Service was restructured to provide a much wider variety of essential services.

Today's USPHS is recognized worldwide. Working alongside its other federal partners and state agencies, including the DHHS (and its agencies, such as the CDC, the Food and Drug Administration [FDA]), and the U.S. Department of Agriculture (USDA), the USPHS continues to be an active partner in the nationwide system of public health at the federal level and to influence public health on a national scale. The USPHS has, until recently, provided active support and direction to the NDMS (now directly under FEMA). The USPHS continues to respond to and support operations as a partner of NDMS, providing expertise in several areas.

The U.S. public health system encompasses a broad integration of commercial, public, government, and nongovernment entities. It is as diverse as the very population it serves. It includes government public health agencies operating on federal, regional, state, and local levels; healthcare delivery infrastructure, such as hospitals and clinics; public health and health science academic institutions; community entities, such as schools, organizations, and religious congregations; commercial businesses; and the media.³ Public health is also augmented by its partnerships and increasing collaboration with expert military health institutions, such as the U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID) and other defense agencies; national institutions such as the National Institute for Allergy and Infectious Disease (NIAID), under the National Institutes of Health (NIH); law enforcement and emergency responder communities on federal (Federal Bureau of Investigation) and local levels; and the medicolegal community, which is composed of national medical examiners offices and forensic scientists.

Public health response is not centralized (for better or worse) and incorporates multiple government agencies, ranging from those involved in research and development (e.g., Bioshield at DHHS) to victim assistance (e.g., NDMS at DHS). Bioterrorist response, for example, involves an enormous breadth of players and their respective functions.⁹ The DHHS alone elicits responses from its agencies: the Agency for Healthcare Research and Quality (AHRQ), CDC, FDA, NIH, and Office of Emergency Preparedness (OEP). Other departments that participate in public health include the USDA, including its Animal and Plant Health Inspection Service (APHIS), Agricultural Research Service (ARS), Food Safety Inspection Service (FSIS), and Office of Crisis Planning and Management (OCPM); agencies under the Department of Commerce (DOC), including the National Institute of Standards and Technology (NIST); agencies under the DOD, including the Defense Advanced Research Projects Agency (DARPA), Joint Task Force for Civil Support (JTFCS), National Guard, and U.S. Army; the Department of Energy (DOE); the Department of Justice (DOJ), including the Federal Bureau of Investigation (FBI) and the Office of Justice Programs (OJP); agencies under the Department of the Transportation (DOT), including the U.S. Coast Guard (USCG); agencies under the Department of Treasury (Treasury), including the U.S. Secret Service (USSS); the VA; the Environmental Protection Agency (EPA); and FEMA.⁹

Different agencies function to deliver services to varying target audiences. For example, the target audiences of the CDC are state and local health agencies. In terms of activities, the CDC provides grants, technical support, and performance standards to support preparedness and response planning for bioterrorism; chemical and radiological incidents; natural disasters; and terrorist incidents, such as explosions, that may yield significant physical trauma.⁹ The OEP enhances medical response capabilities, such as early identification of a biologic incident, mass prophylaxis, mass casualty care, and mass fatality management.⁹ Its target audiences are local jurisdictions, including fire and police departments, emergency medical services (EMS), hospitals, and public health agencies.⁹ The DOJ helps states develop strategic plans and funds training, the obtaining of equipment, and the planning of drills and exercises for fire, law enforcement, emergency medical and hazardous response (HazMat) teams, hospitals, and public health departments.⁹ FEMA supports state emergency management agencies by providing grant assistance to sustain local-consequence management planning, training, and exercises for all disasters, including biological incidents.⁹ For example, FEMA, with the U.S. Army, conducts the Chemical Stockpile Emergency Preparedness Program (CSEPP) and the Radiological Emergency Preparedness (REP) program.¹² The goal of CSEPP is to improve preparedness in the event of an accident involving U.S. stockpiles of obsolete chemical munitions.¹² The REP carries out exercises to ensure that residents living around nuclear power plants are safe and prepared in case of a disaster.

In the event of a disaster, responders on the front line will be public health officials, health care workers (physicians, nurses, other medical professionals), public works personnel, firefighters, EMS personnel, and law enforcement officers.⁹ The core public health component will involve local public health departments, which have been described as “…the critical components of the public health system that directly deliver public health services to citizens.”¹³ A public health department is an administrative and/or service unit of local or state government that is staffed with a median of 20 people, varying between 1 and sometimes more than 20,000, with an average of 72 full-time workers.¹³ Local public health departments provide services ranging from immunizations to food and milk inspections.¹³ Most departments conduct childhood and adult immunizations, communicable disease control practices, epidemiology and surveillance, community assessment, and sexually transmitted disease counseling.¹³ Some others have injury control programs, solid waste management, and comprehensive primary care services.¹³

Health departments will likely not be the lead agency in a disaster and therefore must work closely with other organizations and fall into the incident command during an emergency.⁹ Health departments and all emergency response agencies should establish, in the planning phase, mutual aid agreements and close working relationships with key partners in their region.

Partners include emergency management agencies (EMAs); EMS; medical and behavioral healthcare providers; fire departments; law enforcement; local emergency planning committees; state, regional, and tribal public health response coordinators; neighboring health jurisdictions; humanitarian and volunteer organizations; private businesses; and academic institutions, such as schools of public health and medicine.⁹ For example, between August and September 2004, four hurricanes (Charley, Frances, Ivan, and Jeanne) ripped through Florida, ravaging hundreds of thousands of homes; displacing huge populations; and prompting the aid of 5000 FEMA workers in 15 states and 3800 National Guard members who provided security, directed traffic, and distributed supplies.¹⁴ Additionally, more than 140,000 volunteers spanning state and national volunteer organizations, such as the Red Cross and faith-based groups, arrived in Florida to lend help, ranging from preparing meals to removing trees.¹⁵ Further, the U.S. Public Health Services works alongside its other federal partners and state agencies, including the DHHS and its agencies, the CDC, and the FDA, as well as the USDA. They continue to be an active partner in the nationwide system of public health at the federal level in order to influence public health on a national scale. The USPHS has until recently provided active support and direction to the National Disaster Medical System (now directly under FEMA) in the Department of Homeland Security. They continue to respond and support operations as a partner of NDMS, providing expertise in several areas.

Medical Services

A biologic attack could result in the infection thousands of people without any indication in the first few hours of how many people are infected.¹⁶ For example, one hypothetical scenario depicted a national and global spread of smallpox, resulting in 15,000 cases and 2000 deaths.¹⁷ It is therefore recommended to provide mass prophylaxis to the population—the use of antibiotics being the primary key to survival for most people.¹⁶ Some believe that vaccines are not the first line of defense against biological threats but can be used for control of a smallpox epidemic, prophylaxis against anthrax in combination with antibiotics, control of global pandemic infections, and pre-exposure prophylaxis for high-risk workers in laboratory and health care environments.¹⁸

Because most public health departments, hospitals, and local institutions lack the amount of drugs needed for a national emergency, federal medical resources are available through the Strategic National Stockpile (SNS), formerly named the National Pharmaceutical Stockpile (NPS). After institution of the Homeland Security Act of 2002, the DHS and CDC began to jointly manage the SNS, with the DHS defining the goals and performance requirements of the program and being responsible for administering the actual deployment of the 12-hour push package.¹⁹ The cache of medical supplies includes antibiotics, chemical antidotes, antitoxins, life support medications, intravenous administration and airway maintenance supplies, and medical/surgical items that can be delivered in the event of a national emergency within 12 hours to strategically designated warehouses across the United States and its territories.¹⁹ The SNS is not meant to be a first response tool but rather to augment and restock existing state and local health agencies' medical supplies. The SNS program conducts quarterly quality assurance checks, rotates materials, performs a full annual inventory of all package items, and regularly inspects environmental conditions, security, and overall package maintenance.¹⁹ Deployment of the SNS is made when the state governor's office directly requests assets from the CDC or DHS.¹⁹

Once the SNS cache has been delivered, several key steps must be taken to effectively use it: officially receive the supplies and unload them; have adequate personnel for packaging, distributing, dispensing, tracking, and storing the supplies; have the local public health department assign dosages; and provide communication and security.¹⁶

There are additional public health issues beyond these logistics that should be taken into account when distributing mass prophylaxis to the public. They include dividing the population into groups who require medication first, a step that is politically sensitive and should be decided before a biologic attack happens.¹⁶ Also, public health personnel should be ready to distribute clear agent-specific and drug information, to make available multilingual staff and handouts, to handle the needs of special populations, to provide personal protective equipment (PPE) for people at staffing and dispensing centers, and to provide security in case of crowd panic.¹⁶

Disasters cause various patterns of injury and disease, ranging from blast injuries by a terrorist bombing to ventilatory failure from the chemical release of a nerve agent. As a result, responses significantly vary in terms of how widespread the response is (local to international), which personnel are used to respond, the duration of the response, and what medical management must be used to treat those affected or exposed.

For example, some infectious diseases require a larger response, for which the help of national and sometimes international partners and resources is needed to identify the agent, conduct surveillance, report, and treat the range of people who may be infected. Such responses may vary in location and size. However, natural disasters, such as hurricanes, call for a different type of medical response altogether, in which medical problems seem to arise out of environmental hazards resulting from the natural disaster's aftermath. For instance, injuries and deaths occur because victims fail to evacuate and take shelter, do not take precautions in securing property, and do not follow guidelines for food and water safety or injury prevention during the recovery phase.²⁰ Injuries from a hurricane can result from near-drowning; electrocution; lacerations from flying debris; blunt trauma or bone fractures from falling trees and other heavy objects; stress-related disorders; heart attacks; gastrointestinal, respiratory, vector-borne, and skin diseases; toxic poisoning; fires; bites from displaced wild animals, such as animals and snakes; and even improper use of mechanical equipment, such as chain saws and power tools.²⁰

Chemical and radiological incidents have more specific medical issues, including the recognition of patterns of injury, prophylaxis, and antidotes. Managing a volume of exposed patients in a limited healthcare environment can be challenging and can include issues of decontamination; on-site prehospital management; transportation; the use of PPE; and treatment of patterns of injury specifically associated with chemical and radiological sequelae, such as skin lesions, blisters and burns, nervous system disorders, inhalational injuries, and acute radiation syndrome. Some disasters fall into less specific points for medical management due to the nature of the event.

Consider the blackout on Aug. 14, 2003, in the Northeastern United States and Southeastern Canada (Ottawa and Toronto) that affected 50 million people and a total of 240,00 square kilometers in areas including New York, New Jersey, Vermont, Michigan, Ohio, Pennsylvania, Connecticut, and Massachusetts.²¹ The blackout, suspected to have been caused by a downed 340,000-volt power grid, caused the shutdown of 21 power plants across the nation.²² The blackout affected all electrical functions, shutting down computers, trapping passengers in high-rise elevators, stalling subways, and disrupting airport control and landing procedures, hospital activities, food refrigeration, traffic operations, and most channels of communication. Facilities with backup generators were able to continue operations, but only sparingly. In the United States, three people died as a result of the blackout and one firefighter was injured. In Ottawa, a teenager died from fire-related injuries and another person died after being hit by a car. In New York during the 30-hour period of no electricity, 3000 fires were reported, mainly from people using candles, and EMS personnel responded to 80,000 calls to 911, double the average.²²

On the other hand, finite, sudden disasters causing immediate injury and mortality (such as terrorist bombings, transportation disasters, and building collapses) require a more robust response capacity at a local and perhaps regional level. This differs from the national and sometimes international assistance required after large-scale natural disasters that affect vast regions of terrain, as was seen in the case of the 2004 tsunami disaster, as well as in several instances of floods, hurricanes, and even complex humanitarian emergencies overseas. In the case of an explosion, trauma systems must be equipped and ready to accept incoming patients, manage the bulk of patients with minor wounds who will flood the nearest hospital, and prepare for possibly unexpected rates of casualty flow. Physicians should be prepared to treat hundreds of trauma patients, which may be complicated by loss of utilities, difficulty in reaching hospitals, or possible damage to hospital facilities.²³ The physically injured from high-energy disasters, such as earthquakes, tornadoes, or explosions, will most likely be treated at regional trauma centers for severe injuries. In the United States, there are 600 regional trauma centers.²⁴ They coordinate EMS, including paramedics and air medical transport. A regional trauma center is composed of paramedics and emergency medical technicians (EMTs) who transport injured victims to trauma teams that include a trauma surgeon, emergency physician, several trauma nurses, and specialized personnel. Up to 16 physicians in various specialties, from neurosurgery to obstetrics, comprise a trauma team ready to receive injured patients in the operating room and critical care unit.²⁴

For disease outbreaks, the provision of medical services and public health capabilities is considerably great and involves a large network of local to sometimes international response. When severe acute respiratory syndrome (SARS) made its way onto the global front as a highly threatening disease in November 2002, it crippled the Asian healthcare system and brought to light serious questions about the U.S. public health system's ability to respond to a similar crisis at home. SARS had the greatest impact on Asian countries, with 7782 cases and 729 deaths, challenging Asian healthcare systems, adversely affecting Asian economies, and testing the effectiveness of international health codes.²⁵ SARS is part of the coronavirus family. Within 2 to 10 days after infection, the affected person can develop symptoms including cough, fever, and body aches that are indiscriminate from other respiratory illnesses, appearing as an atypical pneumonia.²⁵ The fatality rate from SARS is 11% and can be greater than 50% for people older than 65.²⁵ SARS is a person-to-person transmitted disease that is acquired primarily through direct and indirect contact with respiratory secretions and/or contaminated objects.

An international outbreak of SARS took place from February through deep into the spring of 2003. When an infected physician who treated SARS patients in China stayed at a hotel in Hong Kong on travel, those who resided at the hotel acquired the disease and subsequently departed to Vietnam, Singapore, and Toronto, Canada, seeding secondary outbreaks.²⁵ Cases spread from Asia to 26 countries, and at is peak in May 2003, hundreds of cases of SARS were being reported each week.

To prevent and control the spread of SARS, public health efforts of case identification and contact tracing, transmission control, and exposure management were utilized. Case identification and contact tracing is “defining what symptoms, laboratory results, and medical histories constitute a positive case in a patient and tracing and tracking individuals who may have been exposed to these patients.”²⁵ Transmission control is “controlling the transmission of disease-producing microorganisms through use of proper hand hygiene and personal protective equipment, such as masks, gowns, and glo es.”²⁵ Exposure management separates those infected from noninfected individuals through the use of quarantine, which restricts movement of those who are not ill but were exposed to the disease agent and are potentially infectious.²⁵

EDUCATION, TRAINING, AND COMMUNICATIONS

Tabletop exercises are one form of disaster planning education. Participants of a tabletop exercise are broad and may include government officials (mayors, city council members, risk manager), public works/utilities personnel (water superintendent, gas company representative), law enforcement (police chief, sheriff), community services (Red Cross representative), emergency management (emergency program manager, National Guard representative), fire department representatives (fire chief, dispatcher), emergency medical/health personnel (emergency medical coordinator, public health official), and public information officers.¹² The tabletop exercise, which commonly includes senior-level officials, prompts participants to discuss how their respective agencies or units might react to a specific set of scenarios, emphasizing higher-level policy and procedural issues.¹² Unlike full-scale exercises or field exercise drills, such as a hospital disaster simulation in which operations are evaluated on scene and equipment is deployed, tabletop exercises do not involve management of equipment or personnel, but are rather classroom-type exercises held in a classroom setting.¹²

Full-scale exercises engage tactics, techniques, and procedures that could be used in an actual incident and are designed to be realistic.¹² In May 2000, May 2003, and most recently May 2005, FEMA led three exercises called the Top Officials (TOPOFF1, TOPOFF2, and TOPOFF3), which were large-scale, “no-notice” field drills involving federal, state, and local agencies. TOPOFF1 in 2000 was jointly led by FEMA and DOJ and was conducted in three cities: a biological weapons incident in Denver, Colo., a chemical incident in Portsmouth, N.H., and a mass casualty radiological incident in the Washington, D.C. region.¹² In 2003, the TOPOFF2 4-day drill involved a Radiological Dispersal Device (RDD), or “dirty bomb,” release in Seattle, Washington, and a biologic incident involving Yersinia pestis, or Pneumonic Plague, in Chicago.²⁶ TOPOFF3 was the largest U.S. counter-terrorism exercise to date. It exceeded 10,000 players, and involved 275 federal, state, local, and private organizations, as well as international partners Canada and the United Kingdom, with 13 countries sending representative observers. The exercise simulated a chemical release attack in New London, Connecticut, and a biologic attack in New Jersey.

Physicians and other healthcare providers are oftentimes on the front line when detecting a disease outbreak and play a primary role in early detection of the disease:

“Health-care providers should be alert to illness patterns and diagnostic clues that might indicate an unusual infectious disease outbreak associated with intentional release of a biologic agent and should report any clusters or findings to their local or state health department.….”^23,27

Physicians and other healthcare providers are recommended to maintain a high level of suspicion for rare disease, ascertain thorough patient histories, and evaluate occupational and environmental exposures.²⁸ The CDC indicates the following three signs of a possible intentional biological release, emphasizing physicians should stay alert for the following²⁷:

• 1.An unusual temporal or geographic clustering of illness (e.g., persons who attended the same public event or gathering) or patients presenting with clinical signs and symptoms that suggest an infectious disease outbreak
• 2.An unusual age distribution for common diseases
• 3.A large number of cases of acute flaccid paralysis with prominent bulbar palsies, suggestive of a release of botulinum toxin

Most of the knowledge base and skills needed to treat patients after a terrorist or nonterrorist disaster involves an extension of everyday tools that physicians already possess.²³ What is necessary is to “fill in the blanks,” as proposed by the American Medical Association.²³ This may include symptoms to become familiar with for early recognition of an unusual infection, guidelines to manage chemical- and radiation-contaminated patients, and protocols to triage and treat acute trauma patients after an explosion. To this extent, professional organizations and societies have become involved in the development of education on disasters and terrorism, and a great degree of seminars, distance learning programs, books, periodicals, web sites, and self-study material have been organized to educate healthcare providers.²³ Such steps have been taken not only in physician communities but also in nursing, physician assistant, and technician communities through the same routes of education and training. Notable experts have commented that public health Internet sites, such as the CDC's bioterrorism web page, have kept the public informed and have helped keep physicians aware of the latest developments and recommendations in bioterrorism.²⁸

In times of disaster, there is an essential need to communicate certain health matters to the public. Public health officials often gain and transmit information from a range of various sectors²⁰:

• •The public (most importantly)
• •Hospitals and their emergency departments
• •Community providers
• •Social service agencies
• •First responders, such as fire, police, and EMS
• •National Guard representatives
• •Local and regional laboratories
• •Policy makers, such as public officials, mayors, and governors
• •Traditional partners, including the American Red Cross and the public works system

Through communication with the media, public health agencies can set up a network, delivering health reports regularly so that the general public can receive important updates and educational messages.²⁰ These messages must be factual and credible to the public and delivered through advance protocols, in which a single public information officer has been appointed to deliver the information.²⁰ Some likely public health information might include food and water safety, injury prevention measures, and warnings that, for example, increase timely evacuation from hurricanes and shelter against tornadoes.²⁰ Also, information should contain facts about the expected hazards (natural, man-made, or technological disaster), safety precautions, and requirements for evacuation or shelter-in-place.²⁰ All messages should be clear (messages in writing should be understood and bilingual, if needed) and concise; technical information should be translated into simple language for a general audience. Importantly, the sender of information should verify that the transmitted message has been received and understood by the intended audience. When the public heeds the actions and recommendations made by public health officials, those messages have been adequately delivered to the audiences.²⁰ Experts emphasize that warning messages should not be withheld until the last minute. This has been documented to happen out of fear that panic will overwhelm the public and lead to more deaths and injuries than the actual disaster.²⁰

Internally among public health systems and partners, secure and redundant lines of communication should be set up during a disaster. These include computers with a CD drive, e-mail capability, continuous online Internet access, and security software to protect sensitive data from intruders.²⁰ Fixed facilities such as hospitals and health departments should have a standby source of power to operate electrical and communication systems in case a disaster strikes the main source.²⁰ Communication equipment that has been used for public health response includes radio equipment, such as two- way radios, pagers, broadcast radios, televisions, and satellites; wire lines, such as telephones, facsimile machines, and computer modems; and a combination of both radio and wire lines, including cellular and satellite telephones.²⁰ However, it is important to realize that in times of disaster, routine communications like these may not be readily available, especially to the public and private sectors. Such was the case in the London Bombings on July 7, 2005, when private businesses found it nearly impossible to access e-mails or make mobile phone calls, as cellular networks were congested from a surge in traffic.

ENVIRONMENTAL HEALTH AND PRECAUTIONS

Environmental health precautions after a disaster will decrease illness, injury, and death. The risks of infection increase in the days after a disaster due to disrupted water supplies and the problem of sanitation control. These include maintaining water and food safety, proper sanitation and waste disposal, and the control of vector populations.²⁰ The environmental health priorities of most heath departments include the following²⁹:

• 1.Ensuring an adequate supply of safe drinking water
• 2.Providing food protection measures
• 3.Ensuring basic sanitation services
• 4.Promoting personal hygiene
• 5.Assisting the efforts of first responders by providing health risk consultations or advising on exposure pathways
• 6.Providing information to emergency managers to help assess the scale of the emergency to ensure an effective response

Landesman²⁰ recommends a three-tiered approach to reduce exposure to environmental hazards:

• 1.Measures of control that involve preventing the hazard in question from being released or occurring; controlling its transport; and keeping people from being exposed, such as cleaning, treating, and collecting clean water
• 2.Establishing multiple barriers, meaning setting up redundant obstacles to separate unsanitary conditions from human contact that can sometimes be a matter of public works engineering
• 3.Distance between hazards and populations

Quantitative analyses must be used in a survey fashion to identify existing disposal facilities and procedures in a community; to determine how to deliver sanitation coverage; and to distribute safe drinking water and establish water consumption rates. Consumption of and contact with contaminated water supplies from run-off sewage and disrupted sewage systems can lead to fecal-oral diseases such as cholera, typhoid fever, hepatitis A, and shigella.²⁰ Public health notices to boil water, avoid certain foods that may have spoiled, and that provide locations of potable water are key to environmental safety. Improper food storage, for example, is often associated with Bacillus cereus, Clostridium perfringens, Salmonella, Staphylococcus aureus, and group A Streptococcus. ²⁰ Sufficient shelter must take into account weather conditions during the disaster, such as warm or cool climates. Insufficient housing can expose people to environmental conditions that make them susceptible to frostbite, hypothermia, heat stroke, and dehydration.²⁰ Especially important to take into account are educational messages and warnings about carbon monoxide poisoning and untrained use of mechanical power generators. Pest control to reduce infestation of rat and mosquito populations is also important.

MENTAL HEALTH

Several studies describe, characterize, and propose interventions for mental health issues encountered after a disaster. Experts note the wide range of questionnaires, surveys, interviews, and psychiatric classification systems used to document postdisaster psychological sequelae and note the difficulty in cross-comparison and generalization of these findings toward many disasters.²⁹ Although the disaster community agrees that effects of mental health require more investigation, they also agree that “the worst scars in disasters are psychological and social scars.”³⁰ Mental health issues stemming from disasters are becoming increasingly integrated into postdisaster assessment, with more emphasis on mental health being an urgent aspect of public health relief.

The mental health community stresses that providers and disaster relief personnel need to have a meaningful understanding of the psychological and social needs of victims in a disaster.³⁰ Disasters can provoke specific emotional reactions that take on a variety of different psychological responses, affecting primary victims (those directly involved in the disaster) and secondary victims (such as relatives, co-workers, and schoolmates). Other people who can experience mental health issues include onlookers, rescuers, body handlers, health personnel, evacuees, and refugees.³⁰ It is important to realize that most adults and children will experience normal stress reactions for several days after a disaster (Box 2-1 ).³¹ One should note that normal stress reactions can also spawn personal introspection, growth, and resilience.

BOX 2-1. NORMAL STRESS REACTIONS AFTER A DISASTER.

• Temporary emotional reactions

  • Shock
  • Fear
  • Grief
  • Anger
  • Hopelessness
  • Emotional numbness
• Cognitive reactions

  • Confusion
  • Disorientation
  • Worry
  • Memory loss
  • Unwanted memories
• Physical reactions

  • Tension
  • Fatigue
  • Difficulty with sleeping
  • Change in appetite and sex drive
  • Interpersonal reactions to relationships at work and school or within a marriage or family (these may be characterized by distrust, irritability, isolation, judgmental attitude, and being distant)

The three forms of mental health problems that may follow a disaster are acute stress reactions, posttraumatic stress disorders (PTSDs), and adjustment disorders or enduring personality change.³⁰ Acute reactions are characterized by absence of emotion; lack of response to external stimuli; total inhibition or outward activity and random movements; persons being stunned or shocked; and psychosomatic symptoms such as tremor, palpitations, hyperventilation, nausea, and vomiting.³⁰ PTSD is defined as³²:

An anxiety disorder (and diagnostic construct used in the Diagnostic and Statistical Manual of Mental Disorders-IV) that can develop after exposure to a terrifying event, or ordeal in which grave physical harm occurred or was threatened. The criteria for PTSD require:

• A.Exposure to a traumatic event
• B.Reexperiencing of the event
• C.Persistent avoidance of stimuli associated with the trauma
• D.Persistent increased arousal
• E.Duration of B, C, D of more than one month
• F.Clinically significant distress or impairment

One of three survivors experiences severe stress that can lead to PTSD, anxiety disorders, or depression. Severe reactions possibly leading to PTSD include dissociation, intrusive reexperiencing (nightmares), extreme attempts to avoid disturbing memories (substance use), extreme emotional numbing, hyperarousal (panic attacks, rage), severe anxiety (extreme helplessness, compulsions, or obsessions), and severe depression. The mental health ramifications are possibly greater for those who witness or are involved with certain experiences from a disaster. Some examples include loss of loved ones; life-threatening danger or physical harm (especially to children); exposure to gruesome death, bodily injury, or dead and maimed bodies; extreme environmental or human violence and destruction; and loss of home.³¹ Inherently, specific individuals might have a typically higher risk of severe stress and lasting PTSD, such as those with a history of exposure to other traumas, chronic medical illness and psychological disorders, chronic poverty, and recent emotional strain.³¹ On the other hand, the National Center for PTSD states that some factors might be protective, including social support, higher income and education, successful mastery of past disasters and traumatic events, reduction of exposure to trauma, and provision of regular and factual information about the emergency.

At a recent national workshop on mental health and disasters, experts recommended some early intervention actions.³² Early intervention is defined as³²:

The provision of psychological help to victims and survivors within the first month after a critical incident, traumatic event, emergency, or disaster aimed at reducing the severity or duration of event-related distress. For mental health service providers, this may involve psychological first aid, needs assessment, consultation, fostering resilience and natural supports, and triage, as well as psychological and medical treatment.

Interventions include provision of the following:

• 1.Basic needs
• 2.Psychological first aid
• 3.Needs assessment
• 4.Rescue and recovery environment observation
• 5.Outreach and information dissemination
• 6.Technical assistance, consultation, and training
• 7.Fostering resilience and recovery
• 8.Triage
• 9.Treatment

In regard to training, there are specific issues to consider when conducting mental health studies in foreign nations. International authors agree that a definite level of cultural social awareness, support for indigenous and local authorities, multi-integration into capacity and infrastructure rebuilding, understanding of the political dynamic (especially in regions where there is conflict), and assessment of mental health based on scientific and clinical knowledge are imperative from an ethical standpoint and will increase the success of the program.³³

WORKER SAFETY AND FIRST RESPONDERS

In the United States, there are more than 1 million firefighters, with about 75% of those on a volunteer-basis; 556,000 full-time law enforcement personnel at police departments; 291,000 full-time sheriff's personnel; and more than 155,000 nationally registered EMTs.³⁴ These first responders are faced with dual functions: report the first observations about the environment and its risks and simultaneously carry out prehospital tasks. Because the disaster scene is dynamic, with active primary and secondary hazards, emergency responders must characterize the site, where oftentimes the evidence of the causative agent is not yet determined and therefore situational awareness is imperative. This poses emotional, mental, and physical challenges where dangers are likely to arise.

Disasters present emergency responders with primary hazards stemming from the actual causative agent. For example, the release or spillage of a chemical can cause toxic injury, whether it is by a physical asphyxiant (e.g., hypoxemia from inert gas in an enclosed space such as a silo), respiratory irritant (e.g., pulmonary damage and inflammatory response from chlorine or phosgene), or systemic toxicants (e.g., upper airway or alveolar injury or skin or neurological damage from organophosphates, volatile hydrocarbons, or hydrogen cyanide).

Emergency first responders are also jeopardized by secondary risks on site. These hazards can take the shape of several types of environmental risks. For example, rescue personnel can be in danger of confronting hazards from disasters such as riots, explosions and fires, road accidents, farm accidents, factory accidents, and railroad disasters.³⁵ Consider a scenario in which an overturned tanker truck has caused a major road accident; emergency personnel are likely to confront vehicle fires, fuel explosions, the instability of overturned vehicles and truck loads and cargo, the dangers of traffic control and safety, and exposure to release of toxic and dangerous chemicals. Explosions present the first responder with the potential of building collapse, secondary explosions, and toxic smoke release hazards.

First responders are trained to use PPE for a chemical, biological, or radiological event, either intentional or unintentional (as is the case with an industrial accident). Toxic agents can be “invisible” to the senses, and the quantity, type, and time of exposure are not easily known. The National Institute of Justice (NIJ) states: “The purpose of personal protective clothing and equipment is to shield or isolate individuals from the chemical, physical, and biological hazards that may be encountered during hazardous materials operations.”³⁶ PPE consists of a wardrobe of clothing and gear that allows the responder to confront and thwart exposure and to function normally. NIJ categorizes PPE into the three following basic categories³⁶:

• •Respiratory equipment (e.g., air purifying respirators and supplied air respirators)
• •Protective garments (e.g., encapsulated suits, coveralls, and overgarments)
• •Other protective apparel (e.g., protective hoods, boots, and gloves)

The NIJ Guide for the Selection of Personal Protective Equipment for Emergency First Responders is a good resource for more thorough and detailed information on PPE.³⁶

As the National Institute for Safety and Health points out, large incidents (such as the terrorist attack on the World Trade Center), unlike smaller-scale disasters (such as localized traffic accidents and explosions), pose serious challenges that make it more difficult to protect the responder from injury, illness, and death. Large-scale disasters can do the following³⁷:

• •Affect, injure, or kill large numbers of people
• •Cover large geographical areas
• •Require prolonged response operations
• •Involve multiple, highly varied hazards
• •Require a wide range of capabilities and resources not routinely maintained by local response organizations
• •Attract a sizable influx of independent (“convergent”) volunteers and supplies
• •Damage vital transportation, communications, and public works infrastructures
• •Directly affect the operational capacity of responder organizations

Therefore, responder safety also requires human resource management, in which thoughtful planning can help one to operate in a chaotic, multiagency environment. This includes charting out the chronology of the response (short-term and extended); setting reasonable and efficient work shifts to prevent the exhaustion of personnel; controlling the perimeter and scene to manage convergent volunteers; inventorying and providing access to PPE and resources; and developing highly skilled “disaster safety managers” who possess experience, knowledge, and tactical skills to respond to hazards on site.³⁷ Importantly, and not often considered to be a life-saving function, is the need to manage health and disaster information flooding the scene. This includes the delivery and sharing of critical information among multiple agencies of all types and levels in addition to making sense of overabundant information. This information can include reports of the changing conditions of the disaster scene; data on the number of available workers and their respective health conditions; and standard data on the number, type, and availability of PPE and important resources.³⁸

DATA COLLECTION AND ANALYSIS

Public health detection and analysis follow key functional areas that involve the development and use of surveillance systems, analysis via algorithms and statistical methods, and investigation of disease and injury with great emphasis on critical agents.⁵ Biological agents of highest concern, as categorized by the CDC, are B. anthracis (anthrax), Y. pestis (plague), variola major (smallpox), C. botulinum toxin (botulism), Francisella tularensis (tularemia), filoviruses (Ebola hemorrhagic fever, Marburg hemorrhagic fever), and arenaviruses (Lassa [Lassa fever], Junin [Argentine hemorrhagic fever], and related viruses).²⁷

Epidemiology in bioterrorist incidents is not too different from standard epidemiological investigations.³⁹ First, laboratory and clinical findings are used to confirm that an outbreak has occurred, using case definitions to determine the number of cases and attack rate. To characterize unusual levels of activity, the attack rate for the disease in question is compared against that of previous years to measure deviation from the norm. The outbreak can then be characterized in terms of time, place, and person, lending crucial data to determine the origin of the disease.³⁹ By analyzing data of cases over time, an epidemic curve can be calculated that will allow for differentiation between an outbreak and normal pattern of disease.³⁹ However, if an intentional release of a biological agent is suspected, time is of the essence, and as previously emphasized, early detection is key. Therefore, the development of surveillance systems, including syndromic surveillance systems and real-time computer models, are being developed. Surveillance “concentrates on the incidence, prevalence, and severity of illness or injury due to ecological changes, changes in endemic levels of disease, population displacement, loss of usual source of health care, overcrowding, breakdowns in sanitation, disruption of public utilities, monitors increases in communicable diseases, including vector-borne, waterborne, and person-to-person transmission” and ultimately helps one to determine an association between exposure and outcome, whether that outcome includes specific injuries, illnesses, or death.²⁰ In setting up a surveillance system, managers should consider using existing systems, such as those used to track reportable diseases, or developing temporary systems to track specific injuries and illnesses before, during, or after the disaster.²⁰ Primary and secondary sources of data need to be identified and can vary from patient medical records (primary) to victim surveys and interviews (secondary). Primary data collection methods are direct observations or surveys, and secondary methods are interviews with key informants or review of existing records.²⁰

Data sets can be obtained from numerous places, including state hospitalization data, hospitals and clinics, private providers, insurance companies, temporary shelters, first responders, and mobile health clinics.²⁰ Increasingly, nontraditional data sources such as worker sick days from employer records are being used to screen for disease outbreaks. Next, case definitions need to be developed for uniformity of reporting outcomes. Finally, appropriate analytical methods should be used and can include descriptive measures, geographical analysis of spread, rates of disease or death, or an analysis over time measuring total numbers of cases and rates of appearance.²⁰ It is also important to remember that in a disaster situation, rigorous epidemiological approaches may not be time-conducive and that there will be an immediate need to quickly collect key, important data that may be perishable as time goes on and populations change in exposure and impact to the hazard. As a result, disaster situations invoke the use of “quick and dirty” data collection, “quick” being simple and flexible and “dirty” being that some quantitative data are rough estimates gathered to answer immediate questions.¹⁸

Increasingly, for bioterrorism purposes, health departments are developing and testing syndromic surveillance systems. Syndromic surveillance is “an investigational approach where health department staff, assisted by automated data acquisition and generation of statistical alarms, monitor disease indicators continually (real-time) or at least daily (near real-time) to detect outbreaks of diseases earlier and more completely than would otherwise be possible with traditional public health methods (e.g., by reportable disease surveillance or telephone consultation).” Syndromic surveillance uses nontraditional data sources, or those other than laboratory data. These data reflect events “that precede clinical diagnosis, such as emergency department chief complaints, clinical impressions on ambulance run sheets, prescriptions filled, retail drug and product purchases, school or work absenteeism, and constellations of medical signs and symptoms in persons seen in various clinical settings.”⁴⁰

PUBLIC HEALTH ASSESSMENT.

CDC deployed field teams to New York City emergency departments on Sept. 14, 2001, to conduct surveillance for possible covert biological releases. For the first two weeks, epidemic intelligence service officers (EISOs) staffed 15 hospitals for 24 hours and then provided 18-hour coverage at 12 hospitals for the remaining 30-day surveillance period. The teams entered data on-site and reported data to the New York City departments of Health and Mental Health each morning and followed up on significant cases. Between Sept. 13 and Oct. 12, 68,546 emergency department visits were recorded, with trauma as the highest syndrome-to-none-ratio (SNR) found (18.6%), followed by exacerbation of a chronic respiratory condition (7.6%). Diarrhea/gastroenteritis (4.4%) and upper and lower respiratory infections (4.2%) were also reported. Children younger than 15 years presented most often with respiratory syndrome complaints (67%) and rash syndromes (59%). Those between 25 and 64 years old made up 80% of inhalational visits and 75% of anxiety visits. Analyses were also specifically conducted for home postal codes within a two-mile radius of the World Trade Center and revealed that persons in the two-mile radius were no more likely to have a syndrome of bioterrorism interest than those who were outside of that proximity. However, the study found that people in close proximity to the towers on Sept. 11 were 61.5 times more likely to visit the emergency department for smoke/dust inhalation complaints than people from other areas. Overall, no health data to support a bioterrorist release were found.⁴¹

CONCLUSION

Historically, promoting and managing the health of a society have shown to increase the welfare of the community. This discipline, called public health, is a broad one, encompassing multiple sectors of the community and professional fields; government and nongovernment agencies; and local, regional, federal, and sometimes international institutions. Collectively, these groups respond to disasters to study, reduce, and develop ways to mitigate adverse health effects in the future. This chapter has summarized phases of the disaster cycle, the players involved, and the basic policy of disaster declaration and response. Additionally, we have reviewed components of public health infrastructure, provision of medical services, education and communications in disasters, mental health issues, worker safety, and finally the value and techniques of data collection and analysis.

It is recommended that the newcomer to public health and disaster medicine review the many references in this chapter and refer to resources on the Internet. Importantly, responders should be proactive and become trained, well-informed, experienced providers and openly disseminate factual knowledge to the community and their peers. This is the beginning to a more efficient, life-saving public health response to disasters.