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Disasters Medical humanities II

2014-2015 Prof. Marija Definis-Gojanović, MD,

Ph.D.

+Definitions

Cuny (in Prehospital and Disaster Medicine) defined a disaster as: “a situation resulting from an environmental phenomenon or armed conflict that produced stress, personal injury, physical damage, and economic disruption of great magnitude.”

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Perez and Thompson in their series on Natural Disasters, define a disaster as: “the occurrence of widespread, severe damage, injury, or loss of life or property, with which the community cannot cope, and during which the affected society undergoes severe disruption.”

+ Both of these definitions note that a disaster

disrupts the society stricken by the event.

Cuny stresses that the event resulting in a disaster does not comprise the disaster: it is what results from the event that comprise the disaster, not the precipitating event itself.

The occurrence of an event may produce a disaster.

A disaster happens when the damage rendered by an event becomes so great that the local mechanisms for response become overwhelmed and outside assistance is required to cope with the damage.

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The definition of a disaster adopted by the World Health Organization and the United Nations as established by Gunn:

“the result of a vast ecological breakdown in the relationships between man and his environment, a serious and sudden (or slow, as in drought) disruption on such a scale that the stricken community needs extraordinary efforts to cope with it, often with outside help or international aid.”

This definition also indicates that it is the damage that results from the impact on society that constitutes the disaster, not the event that is the disaster.

+Medical Disaster/Health Disaster

The most common medical definition of a disaster is an event that results in casualties that overwhelm the healthcare system in which the event occurs.

A health disaster often is considered a medical disaster.

A health disaster encompasses impaired public health and medical care to individual victims.

A medical disaster relates to the healthcare or break in healthcare to individuals as a result of an event.

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Broadened definition of a health disaster to include: a precipitous or gradual decline in the overall health status of a community with which it is unable to cope adequately.

The use of this definition requires an assessment of the pre-disaster event health status of the affected community.

By definition, the disaster begins when it first is recognized as a disaster, and is overcome when the health status of the community is restored to its pre-event state.

+Responses to disaster aim to:

1) Reverse adverse health effects caused by the event;

2) Modify the hazard responsible for the event (reducing the risk of the occurrence of another event);

3) Decrease the vulnerability (increase the resiliency) of the society to future events; and

4) Improve disaster preparedness to respond to future events.

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An event that results in a large number of casualties (mass casualties) may or may not constitute a disaster.

If local resources are unable to cope with the numbers and/or types of casualties and outside medical help is requested, then the event has created a disaster.

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Examples of events that may generate mass casualties include transportation accidents, tornadoes, terrorist bombers, avalanches in inhabited areas, etc.

The impact of such events depends upon the ability of the affected society to cope with the circumstances: whether the society remains intact and mechanisms can be developed within the infrastructure to cope with the circumstances.

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Many consider events that produce multiple or mass casualties as a disaster, since the immediately available local resources transiently may be overwhelmed; but if such events rapidly are brought under control, and the effects on the medical community are short- lived, without a need for outside assistance, there is no disaster.

+HAZARD (H)

All disasters are related to a specific hazard or combinations of hazards whether of a natural phenomenon or a result of human actions.

A hazard is anything that may pose a danger; thus, it is used in this discussion to mean a natural or manmade phenomenon or a mixture of both that has the potential to adversely affect human health, property, activity, and/or the environment.

+RISK (R) Risk is the objective (mathematical) or

subjective (inductive) probability that something negative will happen.

For example, the probability of an earthquake occurring in the northern Europe is quite low compared to such a hazard be- coming realized in California or Turkey.

The probability of a cyclone becoming realized in India or Central America is huge compared to the probability that such an event will occur in Canada

Risk applies only to one specific hazard.

+PREVENTION

To prevent means to keep the event from happening, and thus, prevention is the aggregate of approaches and measures taken to ensure that human actions or natural phenomena DO NOT cause or result in the occurrence of an event related to the identified or unidentified hazard.

It does NOT mean decreasing the amplitude, intensity, scale, and/or magnitude of the event.

+MODIFICATION

Modification of the event does not mean that the event will not occur.

Modification can change either the nature of the hazard or the risk that the hazard will evolve into an event.

In terms of the hazard, it is the aggregate of all approaches and measures taken to modify the amplitude, intensity, magnitude, scale and/or the probability of the actuation of the event that would have occurred without human intervention.

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Thus, through human activities, the resulting event either may be augmented (increased) or attenuated (decreased) both in magnitude and frequency.

Risk management involves human actions that are directed towards modification of the probability that an event will become realized.

+EVENT

An event occurs when the hazard is realized or becomes manifest.

It means an occurrence that has the potential to negatively affect living beings and/or their environment.

Such occurrences have a characteristic type of onset, intensity, duration, scale, and magnitude.

Temporally, events may be sudden, gradual, slow, or delayed in onset

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Sudden-onset events include those with onsets lasting seconds to hours (e.g. earthquakes, tsunamis, cyclones, fire, etc.)

Gradual-onset events have an onset over days to weeks (e.g. floods, climate changes, epidemics, armed conflict), and may or may not present with warning of several days to weeks.

Slow-onset events have a prolonged and gradual onset (famine, drought, epidemics, nuclear contamination, etc.).

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Delayed onset events occur some time after the discovery of the likelihood that the hazard will become realized. Such events usually allow for warnings to the population that potentially will be impacted by the event (cyclones, tsunamis, burst of weakened dams, famine).

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The duration of events may be brief, short, intermediate, or prolonged.

Events of brief duration last only seconds to minutes, and therefore, necessarily must correlate with a sudden mode of onset (earthquake, tsunamis, avalanches, landslides, volcanic eruption [may go on to be prolonged], etc.).

Events of short duration continue in some form, for hours to days. Examples include tropical cyclones and floods.

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Events of intermediate duration may include epidemics, toxic or nuclear contamination, fires, etc. Intermediate duration events last days to weeks.

Events that last for prolonged periods (months to years) include drought, famine, epidemics, complex emergencies, nuclear contamination, etc.

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The scope of an event includes its:

1) amplitude;

2) intensity (amplitude / time interval);

3) scale (intensity x area impacted); and

4) magnitude (scale x total duration)

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The amplitude is the degree of departure from the point of equilibrium (pre-event state). Examples of amplitude include a flood crest, storm surge, and wave height.

The intensity consists of the amplitudes integrated over a given period of time. Examples of intensity include the amount of rain falling in an hour and the quantity of ash falling in a specific location per hour.

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The scale of an event is the intensity of the event in the geographical area involved. Examples include the incidence of a specific infectious disease in a country, the depth of rain that accumulated in a specific city in a given period of time, and the number of hectares under an accumulation of water due to flooding.

Magnitude is the total energy encompassed by the event, the combination of the integral of the amplitudes, the area involved (being studied), and total duration of the event. Examples include the kiloton explosive equivalent of a nuclear bomb explosion, and the total rainfall accumulated over an area during the entire course of a storm.

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Events may be precipitating (primary) or secondary.

Precipitating events are those responsible for initiating the damage

Secondary events occur as a result of the impact of the precipitating event.

Human actions may result in an increase in the magnitude of the damage and/or may be the nidus for the development of secondary events.

+IMPACT

Impact is defined as the actual process of contact between an event and a society or a society’s immediate perimeter.

The impact refers to both positive and negative influences produced by the event on the environment.

+MITIGATION

In this context - any process that is undertaken to reduce the immediate damage otherwise being caused by a destructive force on the society.

+PREPAREDNESS

Preparedness is the aggregate of all measures and policies taken by humans before the event occurs that reduces the damage that otherwise would have been caused by the event.

Preparedness is comprised of the ability to mitigate the immediate result of the impact of an event and our ability to alleviate suffering and accelerate recovery.

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Preparedness includes warning systems, evacuation, relocation of dwellings (e.g., for floods), stores of food, water, and medical supplies, temporary shelter, energy, response strategies, disaster drills and exercises, etc.

Contingency plans and responses are included in preparedness as used in this document and are part of overall disaster management.

Preparedness consists of actions taken before an event occurs.

+DAMAGE

Damage is defined as harm or injury impairing the value or usefulness of something, or the health or normal function of persons.

Damage is the negative result of the impact of an event on the society and environment.

Damage may manifest in multiple ways and forms.

Events may produce damage that may or may not be of sufficient magnitude to result in a disaster.

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It is the amount and characteristics of the damage that result from an event, tempered by the place of occurrence, society and culture, level of development, and degree of preparedness that determine whether an event results in a disaster.

Damage may involve humans, other creatures, and/or the environment.

The severity of the damage is a function of the magnitude of the event buffered by the resilience of the society and the environment impacted.

+VULNERABILITY AND RESILIENCE

In this context, vulnerability means the susceptibility of the population and environment to the type (nature) of the event.

The resilience of the population/environment against the event is its pliability, flexibility, or elasticity to absorb the event.

+RESILIENCE

Resilience has two components:

1) that provided by nature

2) that provided through the actions of humans.

It is comprised of:

(1)the absorbing capacity

(2)the buffering capacity

(3)response to the event and recovery from the damage sustained.

+DISASTER MANAGEMENT

Disaster Management is the aggregate of all measures taken to reduce the likelihood of damage that will occur related to a hazard(s), and to minimize the damage once an event is occurring or has occurred and to direct recovery from the damage.

The effectiveness of disaster management determines the final result of the impact of the event on the environment and society impacted.

+DISASTER RESPONSE

Disaster Response is the aggregate of all measures taken to cope with the damage sustained.

The effectiveness of disaster response is part of disaster management that determines the final result of the impact of the event on the environment and society impacted.

+RECOVERY

Recovery occurs when all of the damage from an event has been repaired or replaced

In the context of a disaster, recovery means bringing all of the societal components back to their pre-event status.

All of the responses (interventions) to the damage sustained must have goals that contribute to the recovery of the society affected.

+Roles and duties of doctors during

extraordinary circumstances

Local organizations must foster a spirit of collaboration in the response to a disaster.

It is also the responsibility of each agency involved in the emergency to recognize that the primary purpose of coordination is to achieve maximum impact with the given resources and to work with one another to reach this endpoint.

+Consequences of disasters on health services

Disasters can cause serious damage to health facilities, water supplies and sewage systems. Structural damage to facilities poses a risk for both health care workers and patients.

Limited road access makes it at least difficult for disaster victims to reach health care centers.

Disrupted communication systems lead to a poor understanding of the various receiving facilities’, military resources’ and relief organizations' actual capacity. Consequently, the already limited resources are not effectively utilized to meet the demands.

+Consequences of disasters on health services

Increased demands for medical attention:

Climatic exposure because of rain or cold weather puts a particular strain on the health system;

Inadequacy of food and nutrition exposes the population to malnutrition, particularly in the vulnerable groups such as children and the elderly; and

If there is a mass casualty incident, health systems can be quickly overwhelmed and left unable to cope with the excessive demands.

+Consequences of disasters on health services

Population displacement:

A mass exodus from the emergency site places additional stress and demands on the host country, its population, facilities and health services, particularly.

Depending on the size of the population migration, the host facilities may not be able to cope with the new burden, and

Mass migration can introduce new diseases into the host community.

+Consequences of disasters on health services

Major outbreaks of communicable diseases:

While natural disasters do not always lead to massive infectious disease outbreaks, they do increase the risk of disease transmission. The disruption of sanitation services and the failure to restore public health programmes combined with the population density and displacement, all culminate in an increased risk for disease outbreaks.

The incidence of endemic vector-borne diseases may increase due to poor sanitation and the disruption of vector control activities.

+Role of emergency health services in disasters

To minimize mortality and morbidity, it is also necessary to organize the relief response according to three levels of preventive health measures:

Primary prevention is the ultimate goal of preventive health care. It aims to prevent the transmission of disease to generally healthy populations.

Secondary prevention identifies and treats as early as possible diseased people to prevent the infection from progressing to a more serious complication or death.

Tertiary prevention reduces permanent damage from disease such as a patient being offered rehabilitative services to lower the effects of paralysis due to polio or land mine injuries.

+The role of the military in disaster responseThe military’s hierarchical command structure allows it to

respond to disasters in a rapid and coordinated manner.

Military services generally have easy access to resources and are equipped to perform vital functions in disaster response such as resource distribution, security services, search and rescue, logistics assistance, transportation to otherwise unreachable communities and field hospital staffing and management.

If the political climate allows for collaboration, the host country’s ministry of health and the lead health agency should consider coordinating with the military in the response to a disaster as well as in the disaster preparedness plan.

+Disaster preparedness

The health objectives of disaster preparedness are to:

Prevent morbidity and mortality;

Provide care for casualties;

Manage adverse climatic and environmental conditions;

Ensure restoration of normal health;

Re-establish health services;

Protect staff; and

Protect public health and medical assets.

+Policy development

National governments must designate a branch of the ministry or organization with the responsibility to develop, organize and manage an emergency preparedness programme for the country.

This group must work with central government, provincial and community organizations and NGOs .

+Vulnerability assessment

Potential hazards for the community are identified and prioritized in a vulnerability assessment.

Once the vulnerabilities are identified, the assessment must also recommend how to address each of the vulnerabilities.

+Disaster planning A disaster’s outputs plan must provide:

An understanding of organizational responsibilities in response and recovery;

Stronger emergency management networks;

Improve community awareness and participation;

Effective response and recovery strategies; and

A simple and flexible written plan.

+Training and education

must provide the important skills and knowledge needed to show an effected community how it can participate in emergency management and also show it the appropriate and critical actions needed in an emergency.

+Monitoring and evaluation The objective is to measure how well the disaster

preparedness programme has been developed and is being implemented.

International Federation of Red Cross and Red Crescent Societies - created preparedness and ‘press the button’ response systems with equipment ready for immediate use.

Between disasters, the International Federation pays a lot of attention to training volunteers in the community.

During a disaster, the International Federation uses Regional Disaster Response Teams (RDRT) and Field Assessment and Coordination Teams (FACT).

+Facility-based health care—key points All services should function effectively and be

well coordinated to achieve the following:

Comprehensive care—looking for other conditions that a patient may not report such as depression with persistent headaches or abdominal pain (summarization);

Continuity of care—following up referrals, defaulters of TB treatment or immunization; and

Integrated care—linking curative with preventive care at every opportunity such as combining child immunization with antenatal clinic days.

+Mass Casualty Incident (MCI)

is any event where the needs of a large number of victims disrupt the normal capabilities of the local health service

Requires:

1.the pre-establishment of basic guidelines and principles of an Incident Command System (ICS),

2.triage and

3.patient flows according to the hospital’s plan

+The incident command system

is composed of five major components:

Incident command;

Operations;

Planning;

Logistics; and

Finance

+Triage

In a disaster medical response, triage sorts and priorities victims for medical attention according to the degree of injury or illness and expectations for survival.

Triage reduces the burden on health facilities.

Triage categorization of patients is based on the following criteria:

The nature and life-threatening urgency

The potential for survival

+Triage classification system

Immediate medical care;

Delayed care;

Non-urgent or minor; and

Dead or ‘near dead.’

+Medical response

Fairness: This value requires that health care resources be allocated fairly with a special concern that those most vulnerable are treated fairly.

Respect for Person: This value states that each person is a unique individual and is to be valued de spite gender, ethnicity, age, reli gion, social status, economic value or any other variable.

Solidarity: Each person makes a commitment not only to family and loved ones but also to the commu nity.

Limiting Harm: Each physician and health care professional com mits to “do no harm.”

+Medical response

“Procedural Values” :1.Reasonableness: treatment decisions are to be

based on science, evidence, practice, experience 2.Transparency/Openness: open to public discussion

and scrutiny3.Inclusiveness: any decisions are to be made

explicitly with the intent of including the views of health care workers and the public

4.Responsiveness: mechanisms to address comments, recommendations, disputes and complaints

5.Responsibility: health care workers and the public have an obligation to participate to the extent possible in discussions and to offer their opinions and recommendations

+Medical profession and human rights

“It is my aspiration that health will finally be seen not as a blessing to be wished for, but as a human right to be fought for.”

United Nations Secretary General, Kofi Annan

+ What is the link between health and human rights? There are complex linkages between health and human

rights:

- Violations or lack of attention to human rights can have serious health consequences;

- Health policies and programmes can promote or violate human rights in the ways they are designed or implemented;

- Vulnerability and the impact of ill health can be reduced by taking steps to respect, protect and fulfil human rights.

+What is meant by “the right to health”?

“The right to health does not mean the right to be healthy, nor does it mean that poor governments must put in place expensive health services for which they have no resources. But it does require governments and public authorities to put in place policies and action plans which will lead to available and accessible health care for all in the shortest possible time. To ensure that this happens is the challenge facing both the human rights community and public health professionals.”

United Nations High Commissioner for Human Rights, Mary Robinson

+The right to the highest attainable standard of health Opening text of the Constitution of WHO (1946)

“The States Parties to this Constitution declare, in conformity with the Charter of the United Nations, that the following principles are basic to the happiness, harmonious relations and security of all peoples.”

+ Criteria by which to evaluate the right to health:

(a) Availability. Functioning public health and health-care have to be available in sufficient quantity.

(b) Accessibility. Health facilities, goods and services have to be accessible to everyone without discrimination. Accessibility has four overlapping dimensions:

Non-discrimination; Physical accessibility;Economic accessibility; Information accessibility.(c) Acceptability. All health facilities, goods and services

must be respectful of medical ethics and culturally appropriate, sensitive to gender and life-cycle requirements, as well as designed to respect confidentiality and improve the health status of those concerned.

(d) Quality. Health facilities, goods and services must be scientifically and medically appropriate and of good quality.

What is meant by a rights-based approach to health?

Justice as a right, not as charity

A rights-based approach to development describes situations not simply in terms of human needs, or of developmental requirements, but in terms of society’s obligations to respond to the inalienable rights of individuals; empowers people to demand justice as a right, not as charity; and gives communities a moral basis from which to claim international assistance when needed.

Kofi Annan, UN Secretary-General

+ Rights-based approach to health? Substantive elements to apply, within these processes,

could be as follows:✓Safeguarding human dignity.✓Paying attention to those population groups considered

most vulnerable in society. ✓Ensuring health systems are made accessible to all, in

law and in fact, without discrimination on any of the prohibited grounds.

✓Using a gender perspective, recognizing that both biological and socio-cultural factors play a significant role in influencing the health of men and women.

✓Ensuring equality and freedom from discrimination.✓Disaggregating health data to detect underlying

discrimination.✓Ensuring free, meaningful and effective participation of

beneficiaries of health development policies or programmes....

+ Rights-based approach to health? .......✓Articulating the concrete government obligations to

respect, protect and fulfill human rights.✓Identifying benchmarks and indicators to ensure

monitoring of the progressive realization of rights in the field of health.

✓Increasing transparency in, and accountability for, health as a key consideration at all stages of programme development.

✓Incorporating safeguards to protect against majority threats upon minorities, migrants and other domestically “unpopular” groups in order to address power imbalances.

A key factor in determining if the necessary protections exist when rights are restricted is that each one of the five criteria of the Siracusa Principles must be met.

Possible “ingredients” in a rights-based approach to health:

Right to healthInformationGenderHuman dignityTransparencySiracusa principles

Benchmarks and indicators

AccountabilitySafeguardsEquality and freedom from

discriminationDisaggregation

Attention to vulnerable groupsParticipationPrivacyRight to educationOptimal balance

between public health goals

and protection of human rightsAccessibilityConcrete government obligationsHuman rights expressly linked

+Human Rights & Medical Personnel

An inadequate level of health care can lead rapidly to

situations falling within the scope of the term

“inhuman and degrading treatment”

CPT 3rd General Report

Human rights and International Conventions concerning medical personnel

The UN Universal Declaration of Human Rights clearly stipulates „No one shall be subjected to torture or cruel, inhumane or degrading treatment or punishment“.

The World Medical Association's (WMA) "Declaration of Tokyo" in 1975 states: "The physician shall not countenance, condone or participate in the practice of torture or other cruel, inhuman or degrading procedures, whatever the offence of which the victim of such procedure is suspected, accused or guilty, and whatever the victim's belief or motives, and in all situations, including armed conflict and civil strife."

Human rights violations under military regime

An extreme case in recent history occurred in Nazi death camps

US soldiers in Vietnam

Since the September 11 attacks, terrorism has been linked inextricably to the public mind (in the west) to people from middle-eastern and Muslim backgrounds Abu Ghraib and Guantanamo

Military medical personnel are placed in a position of a "dual loyalty" conflict.

+ Dual Obligations Primary duty to the patient and secondary duty to

employer and/or society

Clinical independence is essential for both therapeutic care and forensic documentation

Complicity may result in criminal prosecution

Forensic clinicians have a duty to the court and must inform individuals of their role and any limits of confidentiality

Consensus in international ethical precepts that legal and other imperatives cannot oblige health professionals to act contrary to medical ethics

+ Human Rights and human experimentation

on 16 December 1966, the International Covenant on Civil and Political Rights was adopted by the United Nations General Assembly, which came into force ten years later, on 23 May 1976

Article 7 was influenced by the events that led to the Nuremberg Code, as well as by other inhuman practices during World War II. It lays down that

"no one shall be subjected without his free consent to medical or scientific experimentation.“

+ Human Rights and human experimentation

Declaration on the Human Rights of Individuals who are not nationals of the country in which they live, proclaimed by the General Assembly on 13 December 1985. Article 6 lays down that

"no alien shall be subjected without his or her free consent to medical or scientific experimentation"

+ Poverty

Poverty is general scarcity or dearth, or the state of one who lacks a certain amount of material possessions or money.

Absolute poverty or destitution refers to the deprivation of basic human needs, which commonly includes food, water, sanitation, clothing, shelter, healt care and education.

Relative poverty is defined contextually as economic inequality in the location or society in which people live.

+ Poverty

The World Bank estimated 1.29 billion people were living in absolute poverty in 2008. Of these, about 400 million people in absolute poverty lived in India and 173 million people in China.

In terms of percentage of regional populations, sub-Saharan Africa at 47% had the highest incidence rate of absolute poverty in 2008. Between 1990 and 2010, about 663 million people moved above the absolute poverty level.

Still, extreme poverty is a global challenge; it is observed in all parts of the world, including developed economies. UNICEF estimates half the worlds children (or 1.1 billion) live in poverty.

+ Human migration

is the movement by people from one place to another with the intention of settling temporarily or permanently in the new location. The movement is typically over long distances and from one country to another, but internal migrations is also possible.

Migration has continued under the form of both voluntary migration within one's region, country, or beyond and involuntary migrations (which includes the slave trade, trafficking in human beings and ethnic cleansing).

+ Human migration

The World Bank Migration and Remittances Factbook of 2011 lists the following estimates for the year 2010: Total number of immigrants: 215.8 million or 3.2% of world population. Often, a distinction is made between voluntary and involuntary migration, or between refugeesfleeing political conflict or natural disaster vs. economic or labour migration, but these distinctions are difficult to make and partially subjective, as the various motivators for migration are often correlated. The World Bank report estimates that as of 2010, 16.3 million or 7.6% of migrants qualified as refugees.

+ Human trafficking

is the trade in humans, most commonly for the purpose of sexual slavery, forced labor or commercial sexual exploitation for the trafficker or others; or for the extraction of organs or tissues, including surrogacy and ova removal; or for providing a spouse in the context of force marriage.

Human trafficking can occur within a country or trans-nationally.

+ Human trafficking

Human trafficking is a crime against the person because of the violation of the victim's rights of movement through coercion and because of their commercial exploitation. Human trafficking is the trade in people, and does not necessarily involve the movement of the person from one place to another.

Human trafficking represents an estimated $31.6 billion of international trade per annum in 2010. Human trafficking is thought to be one of the fastest-growing activities of trans-national criminal organizations.

+ Human trafficking

Human trafficking is condemned as a violation of human rights by international conventions. In addition, human trafficking is subject to a directive in the European Union.

Slave trade and human trafficking are forbidden by the Protocol to Prevent, Suppress and Punish Trafficking in Persons, especially Women and Children (also referred to as the Trafficking Protocol) was adopted by the United Nations and came into force in 2003.