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What Is Emergency Planning?

Emergency planning can be defined as the process of preparing systematically for future contingencies, including major incidents and disasters. The plan is usually a document, shared between participants and stakeholders that specifies tasks and responsibilities adopted in the multi-agency response to the emergency. It is a blueprint for managing events and, as such, should be responsive to management needs. It should specify the lineaments of action, collaboration, command, and communication during a civil contingency such as a disaster or major event; in other words, it is the framework for emergency response. The maintenance of public safety, limitation of damage, protection of the vulnerable, and efficient use of life-saving resources are some of the goals of the plan. Although the end product is a document, emergency planning is more a process than an outcome, especially as the plan itself will need to be updated over time as circumstances change.

The Evolution of Emergency and Disaster Planning

As we know it today, emergency planning for disasters derives from civil defense, a form of social organization designed to protect civilians against armed aggression. The latter is a relatively new concept that in its modern form antedates the Second World War by only a very brief period. Although there had been rudimentary forms of organization for the protection of non-combatants in previous conflicts—for example, the American Civil War of the 1860s—the attack on Guernica, in the Basque country of Spain, on April 26, 1937, by German aircraft was the first concerted aerial bombardment (it killed 1,654 civilians) and the first occasion on which this had to be countered by properly organized measures of protection. It was a curtain raiser to the bombardments of the early 1940s, in which civil defense grew enormously, although largely without the benefits of fully codified plans. During this period, civil defense operatives were responsible for search and rescue, safeguarding and accommodating the survivors of bombing raids, ensuring public safety and interdicting areas that had become unsafe.

The rather temporary apogee reached by civil defense during the Second World War was subsequently followed by reorganization in order to face the demands of the Cold War, in which civilian life was overshadowed by the threat of a thermo-nuclear exchange between the great powers. During this period, plans were usually kept secret and were predicated on the assumption—highly debatable—that citizens could be protected and given shelter against nuclear blasts and radioactive fallout.

Détente and the dissolution of the Eastern Bloc led to the gradual end of the era of civil defense, and the slow rise of civil protection, which is designed to protect people against the effects of natural, technological, and societal hazards. In its purest form, civil defense is a service provided by the central state and directed at the national level (i.e., it is fundamentally “top-down”). Civil protection is a decentralized service (i.e., “bottom-up”), in which the basis of organization is local, which usually means that it is centered on the municipal level.

Emergency planning is a relatively young field that began to develop systematically in the 1970s, coincidentally with the rise of civil protection. Initially, it did so largely in response to technological hazards such as toxic spills and industrial explosions. Later, there was an increasing emphasis on natural disasters, such as floods, storms and earthquakes.

Academic studies of disaster have a somewhat longer history than does civil defense. They began in earnest in the 1920s with the founding of a sociological approach and, in parallel, a human ecological school of thought, which was mainly based in the discipline of geography. Development was slow until the 1950s, when fear of the consequences of nuclear war gave impetus to the study of how human populations behave in crisis situations, using natural disasters as—rather inadequate—analogues for a thermo-nuclear exchange. Earlier, geographers had started to study the human dimensions of the flood problem, notably Gilbert Fowler White, whose thesis on adaptation to floods was published in 1945. Starting in the 1970s, there was a sustained increase in studies of extreme natural phenomena, which gradually came to grips with the role of such hazards to human life and activities. In the late 1970s, a school of thought developed that suggested that vulnerability, not hazards, is the real key to understanding disaster. Despite countless demonstrations of this axiom, studies of vulnerability have lagged behind those of hazard, the other principal ingredient in the making of disaster. In terms of how academic work supports emergency planning, this means that there has been a plethora of studies of the inputs to plans (see, for example, the hazard scenarios in the section “The Use of Scenarios”), but a paucity of studies of how construct and use emergency plans. On this basis, emergency planning has developed in a somewhat faltering mode, in which only some of the activities associated with it are well served with academic inputs.

From Incident to Catastrophe: The Range of Impacts

Most civil contingencies are small enough to be resolved adequately without qualitative changes in daily management procedures or quantitative changes in the availability of resources. Hence, this article will concentrate on the small minority of emergencies, usually fewer than one in ten, that are large enough to substantially disrupt daily life and normal working procedures. There is no consistently reliable way of distinguishing between major incidents, disasters, and catastrophes (but see Table 1 for an attempt at this). Nevertheless, all of these events have in common the fact that they must be resolved by the suspension of normal procedures and substitution of emergency ones. In the latter, the imperatives, tasks, and relationships between participants are sufficiently exceptional to require substantial reorganization and working methods that differ from those employed in workaday routines.

Emergency response involves a mixture of plans, procedures, and improvization. To some extent, the last of these is inevitable, but it needs to be limited by preparedness. It is axiomatic that planning and procedures should not be improvised during an emergency when they should have been thought through and created beforehand. The consequence of unwonted improvisation is inefficiency in emergency response, which may have serious or tragic consequences. A degree of uniqueness present in each new disaster means that improvisation cannot be avoided, but foresight and preparedness can constrain it to a necessary minimum. Moreover, emergencies are always occasions for learning, and a significant part of the body of experience on which plans are based comes from the mistakes, inefficiencies, and improvisations of the past. Although many publications have the phrase “lessons learned” in their titles, there is no guarantee that a lesson will indeed be learned. If that does indeed happen, measurable positive change will result directly from the lesson. For example, lack of search-and-rescue equipment may be keenly felt in structural collapses that trap people. Hence, probes, props, and personal protection equipment may be acquired and personnel trained in how to use them.

Table 1. Functional Differences between Different Sizes of Event

Incidents

Major incidents

Disasters

Catastrophes

Size of impact

Very localized

Fully or partially localized

Widespread and severe

Extremely large in the physical and social sphere

Size of response

Local resources used

Mainly local resources used, with some mutual assistance from nearby areas

Intergovernmental, multi-agency, multi-jurisdictional response needed

Major national and international resources and coordination are required

Plans and procedures activated

Standard operating procedures used

Standard operating procedures used; emergency plans may be activated

Disaster or emergency plans activated

Disaster or emergency plans activated, but huge challenges may overwhelm them

Impact on response resources needed for response

Local resources will probably be sufficient

Local resources and some outside resources needed

Extensive damage to resources in disaster area; major inter-regional transfers of resources

Local and regional emergency response systems paralyzed and in need of much outside help

Involvement of public in response

Public generally not involved in response

Public largely not involved in response

Public extensively involved in response

Public overwhelmingly involved in response

Challenges to post-event recovery

No significant challenges to recovery

Few challenges to recovery processes

Major challenges to recovery from disaster

Massive challenges and significant long-term effects

Note. Adapted from Tierney, K. (2008) Hurricane Katrina: Catastrophic impacts and alarming lessons. In Quigley, J. M., & Rosenthal, L. M., (Eds.). Risking House and Home: Disasters, Cities, Public Policy. Berkeley, CA: Institute of Governmental Studies, Berkeley Public Policy Press, 119–136.

There is a fundamental distinction between plans and procedures. An emergency plan should not have to teach a fireman how to put out a fire, or the police how to direct traffic. Instead, it should articulate and integrate the procedures to be used in a major emergency by assigning responsibilities and ensuring that all personnel involved in complex field operations understand both their own roles and those of other participants. Thus, one can make an analogy between the emergency response and a symphony. Individual instrumentalists have their own music (i.e., the procedures), while the conductor has the score (i.e., the plan). The common objective is to work in harmony.

Emergency and Disaster Planning as a Process

Above all, emergency planning should be a process, rather than a product or outcome. At its most essential, it must match urgent needs to available resources, and do so in a timely way that avoids procrastination and delay. Good emergency plans are realistic as well as pragmatic. For instance, there is no point in making arrangements to use resources that are not available and are not likely to be supplied within a useful time frame. Hence, plans should take account of both the limitations and the capabilities of response. At this point, it is useful to introduce the concept of thresholds (Table 2). The “bedrock” level of emergency planning is the municipal level or local area. This is because, however extensive a disaster may be, the theater of operations for managing and responding to it is always local. However, if local resources are overwhelmed, it becomes necessary to move up the scale of response to inter-municipal, regional, national, or even international responses. Each of these is associated with a threshold of capability, which is determined by the availability of trained personnel, expertise, equipment, supplies, communications, vehicles, and buildings. If the magnitude of the emergency exceeds or overwhelms local capabilities, then it is necessary to invoke higher levels of response. However, these should always aim to reinforce, not supplant the local ability to respond to the emergency. Once the outside forces have departed, inhabitants of the local area will be left on their own to manage the aftermath, and hence they need to be in good shape to do so. Supplanting local resources, decision-making capabilities, and responses will only leave the local area weaker and less able to manage the longer-term aftermath and any emergencies that may occur in the future.

Table 2. Thresholds of Capacity in Emergency Response

Local incident

Local response

A

Threshold of local capacity

Small regional incident

Co-ordinated local response

B

Threshold of intermunicipal capacity

Major regional incident

Intermunicipal and regional response

B

Threshold of regional capacity

National disaster

Intermunicipal, regional, and national response

C

Threshold of national capacity

International catastrophe

Intermunicipal, regional, and national response, with international assistance

C

Note. Simplified version: A = local response, B = regional response, C = national response.

Emergency planning is an approximate process that, in many instances, is little more than codified common sense. It also involves a collective effort and is thus a participatory process. In order to avoid sins of omission or commission, it requires experience and training. Regarding the former, the lack of a plan could be construed as negligence in the face of a demonstrable need to protect the public. Despite this assertion, some emergency managers have argued that plans tend to be unnecessarily restrictive and an improvised response is somehow stronger and more vital than one conditioned by a plan. Military strategists from Napoleon Bonaparte to Dwight D. Eisenhower have noted that, when preparing for war, plans have little value, but planning is essential. This underlines the importance of planning as a process, and above all a process of discovery. In this sense, whether or not the plan works during an emergency is of secondary importance: more vital is what the plan tells us about the needs of preparedness and organization. Moreover, emergency plans generally need to be adapted to particular emergency situations, which further underlines the view that planning is a process, and an ongoing one.

At this point, it is opportune to consider what sorts of events and situations should be the object of emergency plans.

For What Should One Plan?

Much has been made of the need for “all-hazards” emergency plans. No place on earth is entirely free from hazard and risk. Hence, all places need emergency preparedness, but few of them are likely to be subject to only one kind of hazard. An emergency plan must, therefore, be adaptable to both anticipated and unexpected hazards. For many years, the city of Florence, in Italy, had a municipal emergency plan that only addressed the contingency of flooding. In the post-War period, the largest disaster that the city had to manage was the major flood of 1966. However, during the lifetime of the plan (about 20 years), only limited flooding occurred, and the biggest emergencies were an air crash and a terrorist bomb. Likewise, on September 11, 2001, emergency coordinators in Washington, DC had to manage the response to the aircraft that crashed into the Pentagon (and the ensuing city-wide chaos) by adapting and using a plan made specifically to deal with the so-called “millennium bug,” or in other words anticipated widespread computer failure. A good emergency plan makes provision for managing all the known and anticipated hazards (the seasonal and recurrent events), while at the same time offering generic protocols to manage the unanticipated ones.

One issue that has long perturbed emergency planners is the size of event for which plans should be configured. If one assumes that recurrent hazards are in a steady state, then somewhere there should be a “happy medium,” in which an extreme event is neither too large and infrequent to be expected to occur during the life of the plan, nor too small and frequent to need significant emergency provisions. The first problem with this arrangement is that, especially regarding natural hazards, there are few cases in which an adequate magnitude-frequency relationship has been established. Hence, the likelihood of an extreme event of a given size may be conjectural, rather than scientifically determined. The second problem is that the time series of events may be non-stationary. For example, there is overwhelming scientific consensus on the occurrence of climate change, and few scientists now doubt the speed at which it is occurring. Damage tends to be a non-linear function of extreme meteorological events, in the sense that small increases in, for example, wind speed lead to disproportionately large increases in wind damage to structures. The same may be true of casualties, although here the relationship is complicated by factors of perception and behavior in people’s reaction to immediate risk.

It is often said that “we plan for the last event, not the next one.” There is indeed a tendency to base assumptions about the size and characteristics of each event that will be faced in the future on the historical record of such events in the past, particularly the recent past. What if the next event is entirely out of character? The magnitude 9 earthquake that occurred off the east coast of Japan in March 2011 caused a tsunami that was considerably higher than those that most parts of the coast had prepared for (Figure 1). People were washed off refuge mounds, and the Fukushima Da’ichi nuclear plant was overrun with water, leading to meltdown. The plant was protected against a tsunami that would have resulted from an offshore earthquake up to magnitude 7.5. Much emergency preparedness against riverine flooding is based on the notion of the 100-year flood, and the depths and geographical areas that such an event would inundate. Leaving aside the question of whether estimates of the magnitude of a flood with an approximate recurrence interval of once in a century are accurate, there is no hard-and-fast operational reason why the 100-year flood should be more significant or damaging than any other. However, it is legitimate to discuss the size of flood with a 1%, or once in a century, probability of occurring in any given year, whether or not that should be the flood for which protection measures are designed. In the final analysis, emergency planning has to be realistic. This means that it can only be applied to resources that actually exist or can be obtained within an appropriately brief time frame. On that basis, the question of what size of event to prepare for is more a policy issue than a planning one. In synthesis, the problem of how to prepare for exceptionally large events remains unresolved, both in terms of what is necessary and what is feasible.

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Figure 1. The remains of the emergency management center at Shizugawa, on the northeast coast of Japan. Here, the tsunami of March 11, 2011 was higher than the building. Personnel were drowned while they struggled to broadcast warnings, although a few of them survived by climbing up the radio mast on top of the building. The size of the tsunami underlines the difficulty of estimating the magnitude of events when planning for them.

Anatomy of an Emergency Plan

Emergency and disaster planning is a relatively new field, and one that is evolving rapidly, driven by intensifying hazards, burgeoning vulnerabilities, and emerging risks. Hence, there is no established formula according to which a plan should be prepared. Nevertheless, there are canons and practices that must be respected. As noted above, a plan should focus on ensuring that a good response to threats, emergencies, and recovery processes occurs at the local level.

Emergency Planning and Emergency Management

The primary resource is information, and hence everything possible should be done to ensure that flows of vital data and communications are unrestricted and properly focussed on essential needs. Emergency management, as supported by prior and on-going planning, should ensure that organizations can work together effectively under unfamiliar circumstances, possibly including organizations that have no formal relations under normal, non-emergency circumstances. The plan should ensure that every participant in the response to an emergency has a role, and that all anticipated tasks are covered such that the risk of hiatuses or disputes about responsibilities is minimized.

One way to demonstrate the connection between emergency planning and emergency management is through the provisions to manage information. Emergency communication needs to be sustained, flexible, and clear. Decisions and communications need to be recorded. The emergency planner can help this process by ensuring that the technological means of communication are present and are robust in the face of potential failure, the protocols for sending messages are established, and the priorities for communication are known to participants.

Emergency Planning and Urban and Regional Planning

The process of formulating an emergency plan is similar, and parallel, to urban and regional planning. Sadly, the two disciplines rarely enjoy sufficient connection and interchange. This is unfortunate, because they have much in common. In emergency planning, as in urban and regional planning, perhaps 70% of the problem to be solved is spatial (i.e., geographical) in nature. The answer to the question “what is where?” is at the root of many provisions designed to manage emergency situations. Like urban and regional planners, emergency planners need to study the geography, demography, economics, social relations, and culture of the area that forms the jurisdiction of the plan. This is essential if the plan is to respond well to local hazards and vulnerabilities and be compatible with local perceptions, traditions, activities, and expectations. Other than that, the five stages of emergency planning are research, writing, publicity, operations, and revision. Research will ensure an adequate basis of knowledge of hazards, vulnerabilities, local characteristics, and capacities. Writing will create the plan, and its appendices and abbreviated aides memoires. Publicity and training will make it known to the users and the organizations they represent, and operations will test elements of the plan in terms of feasibility, appropriateness, and efficiency. Finally, the plan should be a living document; hence, it will need to be updated frequently and consistently to take account of changes and new knowledge.

The essence of emergency and disaster management is its capacity to tackle pressing needs with maximum efficiency and celerity but with scarce resources and in the absence of much necessary information. Before the event, the plan must make assumptions about what is needed during the event. Those assumptions need to be considered within the compass of what is feasible with the available human and technical resources. One reason why the plan must constantly be updated is that one assumes there will be a program of continuous improvement in the resources, and one trusts that it will take place in the light of the evolving body of knowledge of hazards and the needs that they provoke.

Plans and Relevant Legislation

Emergency plans need to be written in the light of the prevailing legislation, as well as the provisions it makes for tackling major incidents and disasters. In many countries, legislation exists at both the national level and the level of regions, states, provinces, departments, counties, or prefectures—what is known as the intermediate tier of government. In the United States, the main federal law is the Robert T. Stafford Disaster Relief and Emergency Assistance Act (the Stafford Act), which has evolved since 1974. In India, another federal republic, the national law was formulated in 2005. In the United Kingdom, the Civil Contingencies Act dates from 2004; and in Italy, a law passed in 1992 establishes the national civil protection system. In most cases, the basic law assigns responsibilities for the principal tasks to be accomplished in national emergency situations. There may be a legal obligation to draw up emergency plans, but it seldom, if ever, extends to the quality and compatibility of such plans.

Usually, compliance with legislation is simply a matter of comparative reading, or in other words ensuring that there are no glaring incompatibilities. The compliance may also have to extend to other kinds of legislation, such as that pertaining to health and safety at work, environmental protection, industrial safety, national security, and the division of responsibilities between different tiers of government. Once again, compliance can usually be assured by comparative reading, although there may be cases in which legal requirements conflict with one another, for example between environmental legislation and laws about resource utilization.

Multi-Agency Planning

One source of complexity in emergency planning is the need to integrate several dimensions into the programmed emergency response. Hierarchical divisions refer to the tiers of government—from national, through regional, to local. Geographical divisions indicate the spatial jurisdictions to which plans refer, and possibly also to questions of mutual assistance. Organizational divisions refer to the different agencies that participate in emergency responses, such as the “blue light” services (police, fire, and ambulance), technical groups, and volunteer organizations. Lastly, functional divisions indicate the different fields involved, such as government, health care, public order, public works, economy and employment, finance, and the private sector (Figure 2). The emergency plan is one contribution to the process of articulating a system of response to civil contingencies, in which an optimum balance is sought between integrating these forces and allowing them a degree of autonomy and freedom of action.

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Figure 2. The different dimensions of division and integration in emergency planning and management.

The Plan and Warning Processes

Whether natural or anthropogenic, hazards vary considerably in their predictability and the amount of lead time, if any, for preparations to take place. Nevertheless, warning and associated responses are two vital elements of most emergency plans. Short-term warning must be distinguished from the longer-term predictability of hazards. Earthquakes, for instance, are mostly predictable in terms of the basic tenets of magnitude, frequency, and location, but not with regard to impending shocks in a short time window, such as 48 hours. In contrast, with adequate monitoring using Doppler radar, warnings can be issued for tornadoes with lead times of 20–120 minutes, and remote sensing together with digital modelling can give a reliable picture of a hurricane track many hours before the storm makes landfall.

Warnings have three essential components: scientific and technical, administrative, and social (Figure 3). The absence or ineffectiveness of any of them renders the warning system inoperable. Scientific information on an impending hazard must be transformed into a message to be acted upon, and a decision must be taken to warn affected people, who must then hear and react appropriately to the warning. The emergency plan should determine how to transform information on hazards to advice or orders on how to react. It should prescribe the means of disseminating the message and monitoring the social reaction to it. In practical terms, evacuation or sheltering is usually the most appropriate reaction to warning and the best way of moving people out of harm’s way. However, the means and the routes to evacuate people must be available (or there must be appropriate, safe locations for in situ or vertical evacuation). Horizontal evacuation may require reception centers with staff, bedding, methods of procuring, preparing, and distributing food, and so on.

The Role of Information and Communications Technology

Modern emergency responses are heavily reliant on information and communications technology (ICT). Many algorithms have been written to assist emergency operations, for example, by providing an “expert system” that aids decision making, or by helping record decisions as they are made. For example, terrestrial trunked radio (TETRA) systems can be used to provide flexible communications between different services and groups of responders. Emergency plans should reflect these innovations and the opportunities they bring for sharing information and developing a synoptic picture of a rapidly evolving situation on the ground. Plans can include or refer to protocols for messaging and communications, and thus help clarify and standardize them.

The emergency plan should either prescribe or describe the structure of command and management to be utilized in the case of a disaster or major incident. Modern information technology has tended to flatten the chain of command and has given rise to a more collaborative form of management, which lessens the reliance on militaristic principles of “command and control.” Nevertheless, there will need to be a web of formal relationships between different organizations and units that participate in the response to disaster. The focal point of many of these is the emergency operations center (EOC), which is usually also the “natural home” for an emergency plan, or in other words, the place where it is most appropriate to draw up and maintain such an instrument. The EOC needs to be a center of communications and management, one that has functional autonomy (e.g., its own electrical generator and fuel stocks).

In a fully functional civil protection system, emergency resource hubs such as EOCs usually operate as a nested hierarchy. They will function within the compass of plans made at different levels of government and by different jurisdictions. It follows that the emergency plans themselves will need to ensure interoperability and a rational division of responsibilities, so that all tasks can be covered in emergencies of different sizes. Once again, this involves comparative reading of plans and, preferably, some national guidelines for ensuring compatibility.

Specialized Emergency Planning

A further issue is the need for emergency planning in different sectors. The United Kingdom’s Civil Contingencies Act of 2004 obliges the providers of fundamental services in the private sector to draw up emergency plans. This is necessary, as much of the nation’s critical infrastructure is run by private-sector operators. Industrial firms also need plans, so that they can cope with technological failures and their consequences, and commercial companies need to ensure business continuity. Emergency plans are needed in both hospitals and the health systems of which they form a part. Hospital plans should state the preparations needed for internal and external emergencies. The former refers to contingencies such as fire, structural collapse, or contamination, and the latter mainly deals with the need to cope with mass casualty influxes. In addition, public transport services need emergency plans to guarantee the movement of people and goods during a crisis and its aftermath. For example, the plans for an airport should be integrated with those of the city and region in which it is situated. Finally, there is an increasing realization that emergency plans are needed to protect cultural heritage, which includes a huge variety of sites and artefacts, many of which have highly specialized conservation requirements. Loss of cultural heritage in disasters such as floods and earthquakes can deal a catastrophic blow to the intellectual and artistic life of a country by obliterating or damaging an irreplaceable legacy.

Among specialized emergency plans, it is worth singling out those required for educational institutions. The collapse of thousands of schools in earthquakes in Pakistan (2005) and China (2008), and the consequential loss of thousands of young lives, underlines the importance of providing a safe education to pupils and students. This is a moral requirement, as well as one that all parents would support. Despite this, emergency planning for schools tends to be neglected and underrated. It is not merely a question of evacuation. Plans need to assess hazards and design strategies to manage situations safely. As in other forms of emergency planning, scenarios are needed. In one exemplary case, a school has developed different strategies to manage the response to floods and earthquakes, both of which threaten it. As teachers are in loco parentis for their young charges, there is a requirement to ensure that school students are looked after in safety throughout an emergency. Schools and other educational institutions have been the target of natural hazards such as earthquakes, tornadoes, landslides, floods, and snowstorms; terrorism, such as marauding gunmen; and structural collapse and fire. When many young lives are lost the sense of moral inadequacy can be universal, but not enough has been done to ensure that emergency planning for schools is transformed into universal practical measures to protect children and young adults.

The art of emergency planning involves “anticipating the unexpected.” For example, one important aspect that is often overlooked is veterinary planning. This has three main categories: domestic, farm, and wild animals. Many people will not evacuate in the face of a major threat unless they can take their pets with them, and hence, provision needs to be made to accommodate domestic animals. In pastoral areas, farm economies are dependent on the care and welfare of animals, which can be trapped and drowned by floods, frozen by blizzards, affected by epizootic diseases, or deprived of feedstock. Planning to manage wild animals mainly refers to threats to the human population posed by ecological disruption in disasters due, for example, to the migration of dangerous reptiles or the possible spread of rabies. Another form of planning that is roundly neglected is that associated with prison populations. In floods, storms, and earthquakes, these individuals have been either confined to dangerous localities or released indiscriminately into the community. Prisoners have human rights, including the right to custodial safety, but to release hardened criminals into society may pose risks to the general population. Finally, during the difficult circumstances engendered by disaster, pharmaceutical emergency planning is needed in order to ensure continuity of medication for patients who depend on medical drugs.

Using the Plan in an Emergency

One ingredient of most emergency plans is a stipulation of the alert and call-up procedures for personnel. These need to be integrated with the potential phases of warning, which at their simplest are hazard watch (impact is possible or likely) and hazard warning (impact is highly likely or certain). A part of the plan may be dedicated to the preparations to be made before impact, if time is likely to be available to carry them out. Examples include putting up mobile flood defenses, marshalling and readying vehicles and equipment, and testing and readying the means of field communication. The impact phase of a disaster is usually a period, more or less brief, characterized by dynamic evolution and acute shortage of information. One of the first needs is for an assessment that determines whether to move into emergency mode. The declaration of a state of emergency allows the formal abandonment of normal working procedures and the immediate adoption of those that pertain strictly to the disaster. Hospital beds will be cleared, leave will be cancelled, personnel will move to predetermined locations, lines of communication will be opened, and so on. The emergency phase may continue for hours or days, and in exceptional cases for weeks. However, it should end with a formal declaration of “stand-down,” as prescribed in the plan, which releases personnel for leave and ordinary duties.

Testing and Revising the Plan

In most parts of the world, major incidents and disasters are, thankfully, rare, although they may be an ever-present threat. The emergency plan therefore needs to be tested under hypothetical conditions. Exercises and drills can be divided into table-top, command post, and field-based simulations. The last category is clearly the most onerous, and it may require up to six months of meticulous planning. Generally, none of these methods is capable of testing the whole plan, and so elements of it must be selected for verification by simulation. One common element is the ability of different organizations to work together under specific, unfamiliar circumstances; for example, the ability of different medical response organizations to set up and run a field hospital together. Exercises need to be designed with clear, well formulated objectives, and the progress of the simulation needs to be carefully monitored so that any need for improvements can be detected and communicated to participants in post-exercise debriefings and reports. All of this needs to be done in an atmosphere of constructive support, and certainly not recrimination, as the aim is not to examine but to help participants improve their performance during future emergencies. Simulations need to be treated as learning processes, from which it may be possible to derive improvements to the plan. One hopes that in real emergencies it will also be possible to learn lessons and improve the emergency plan on the basis of real experience. One such lesson is that personal familiarity with other participants in emergency operations greatly improves the ability to work together. This underlines the value of emergency simulations and drills.

The emergency plan should be a living document. In fact, there is nothing worse than the “paper plan syndrome”—or its modern digital equivalent—in which the plan is formulated and relegated to a desk drawer (or a hard drive) without being used or updated. Such plans can do more harm than good when they are eventually put to the test by a crisis. As time wears on, both small and large changes will occur. Hence the plan should include provisions, not only for disseminating it and training its users, but also for a process of constant updating, with checks at regular intervals, perhaps every six months.

The next section will discuss the contents of emergency plans in more detail.

The Use of Scenarios

Hitherto in this entry, emergency plans have been viewed as if they consist of nothing but collections of generic provisions for managing a notional crisis. These are necessary, in that the plan may need to be adaptable to unexpected crises. However, many—perhaps most—emergencies are predictable events, at least in terms of what is likely to happen. Not all disasters are cyclical events (those of seasonal meteorological origin are the closest to this), but many are recurrent according to established magnitude-frequency relationships, although, as noted, these may be imperfectly known. Over the last 30 years or so, knowledge of natural hazards has increased spectacularly. The threats, probabilities, time sequences, and effects of floods, landslides, storms, earthquakes, volcanic eruptions, and so on, are now much better understood than was the case half a century ago. Unfortunately, despite calls in the early 1980s to make it a central issue, understanding of vulnerability to natural hazards has not evolved at the same pace. In most places, vulnerability, not hazard, is the key to disaster potential; this is unfortunate and needs immediate improvements in research. Nevertheless, in places where hazards are recurrent, emergency planning against them should be based on scenarios. These will enable urgent needs to be foreseen and situations to be anticipated by providing the right resources in the right place and at the right time. Hence, scenarios should be a vital ingredient of emergency plans.

A scenario is a postulated sequence or development of events. Scenarios can be used to reconstruct past disasters, where the evolution of these is incompletely known. However, the main use in emergency planning is to explore possible future events and outcomes. A scenario should not be a rigid prediction of future developments. It is instead an exploratory tool. In most scenarios, there is not one outcome of developments, there is instead a range of outcomes. To establish this is to think creatively about the future.

Typically, an emergency planning scenario will be based on a “reference event,” or possibly more than one event. This will be a disaster that in the past affected the area covered by the plan, and which it is deemed may be repeated in the future. Efforts must be made to assemble a plausible set of hazard data that represent the range of possibilities for the physical impact: for example, the wind speed, precipitation, and track of a storm, or the magnitude and epicentral location of an earthquake. The nature of the built environment, the economy, demography, and social characteristics of the area, and the assets at risk will all have changed since the reference event. Modern conditions must be added to the scenario. This then needs to be developed as a temporal sequence of evolution in terms of hazard occurrence, the impact on vulnerable people and assets, and the response of emergency services (Figure 4). Because aggregate patterns of human behavior change during the day, the week, and possibly also the year, several runs of the scenario may be needed. For example, an earthquake scenario may use the last seismic disaster as its reference event, but the future projection may need to be made for an earthquake that occurs during the night, on a working day, and on a holiday, as there will be different effects on people and the buildings and structures that they use.

It is opportune to use a simple systems theory methodology to construct the scenario. The inputs are the reference event and accompanying conditions (social, environmental, economic, etc.). The output is the outcome of the disaster and its management. The throughputs and transformations are the evolution of the scenario over time. One can, if necessary, construct subsystems that embrace, for example, the health system response to the disaster, or the impact on local civil aviation. The point of using scenarios in emergency planning is to be able to explore and anticipate needs generated by predictable future disasters. Hence, the scenario should produce a range of possible outcomes and should be used as an exploratory tool. It should be used in conjunction with an audit of emergency resources designed to answer the question of whether they are sufficient and appropriate to match the anticipated needs.

Emergency planners need not be frightened of the unknown. There has been much debate on the existence of so-called “black swans,” or unanticipated events. These may be all very well in economics, but in disaster management the black swan has become extinct, and its ecological niche has been occupied by the red herring—or thus is the present author’s opinion. This means that there is very little in future events that will not have occurred in some form in the past. The scale and configuration may be different, but the components are present in the historical record. However, this should not be interpreted as a call to look resolutely backwards. Scenario builders will require considerable skill if they are to make a reliable assessment of the magnitude and consequences of future events. This underlines the value of scenario methodology as an exploratory tool, in which known regularities and established evidence are projected into a hypothetical future space and allowed to develop in an “envelope” of possible developments.

The Uses and Abuses of Emergency Plans

One way of extending the emergency plan into the crisis phase, and adapting it to rapidly changing needs, is to continue the planning process during the emergency (Figure 5). Strategic planning is essentially about finding resources and ensuring that the assemblage of response units, plans, and initiatives is generally going in the right direction, so that it will meet the needs of the population affected by disaster. Tactical planning is largely about apportioning resources so that they can be used on the ground by operational units. Operational planning is about assigning tasks, constituting task forces, and monitoring the evolution of the situation so that tasks are set and accomplished. At all three levels, the permanent emergency plan is a backdrop to activities. It should neither be slavishly and rigidly followed nor ignored. One hopes that it will ensure that fundamental tasks are apportioned, responsibilities are clear, and appropriate action is stimulated.

Emergency planning should be a co-operative effort in which the users and beneficiaries of the plan are stakeholders who have an interest in ensuring that the plan works well. It is also important to create and maintain interoperability, so that emergencies that require large-scale responses do not lead to chaos and to groups of people working at cross purposes.

A Variety of Administrative and Political Contexts

One example of success in ensuring co-operation is the introduction and diffusion of the incident command system (ICS) in the United States since 1970, when it was first devised as a measure to combat wildfire in California. ICS is a modular system that is usually implemented at the site of an incident and can be aggregated to higher levels. It has been codified by the U.S. Federal Emergency Management Agency and is available online at National Incident Management System, which ensures a degree of interoperability among many different forces. This is highly necessary, as in a major incident or disaster, scores of agencies and organizations may work together—not at cross purposes, one hopes!

In Europe, interoperability is gaining ground, but the diversity of legal and administrative systems among the states of Europe, and the different histories of civil protection that they enjoy, means that the process is slow and complex. During the response to the earthquake in Haiti on January 2010, field hospitals sent from European countries lacked interoperability of equipment and procedures, because they were functioning according to different, not entirely compatible, standards. Thus, they experienced difficulty in supporting each other’s work.

According to the International Federation of Red Cross and Red Crescent Societies, internationally reported disasters in 2002 affected 608 million people worldwide and killed 24,532—well below the preceding decade's annual average mortality of 62,000 (IFRC 2003). Many more were affected by myriad local disasters that escaped international notice.

Disaster has multiple and changing definitions. The essential common element of those definitions is that disasters are unusual public health events that overwhelm the coping capacity of the affected community. This concept precludes the universal adoption of a threshold number of casualties or victims. What would be a minor incident in a large country may constitute a major disaster in a small isolated island state. Not only are "quantitative definitions of disasters unworkably simplistic" as noted by Alexander (1997, 289), but when based on the economic toll or the number of deaths, they are also misleading with regard to the immediate health needs of the survivors or their long-term impact on the affected country.

Classification of Disasters

In the early 1970s, a series of well-publicized disasters (the civil war and resulting famine in Biafra, the cyclone in Bangladesh, and the earthquake in Peru) triggered the scientific interest of the international public health community.

Disasters can be classified as natural disasters, technological disasters, or complex emergencies. The latter include civil wars and conflicts. These classifications are arbitrary and refer to the immediate trigger—a natural phenomenon or hazard (biological, geological, or climatic); a technologically originated problem; or a conflict. In reality, all disasters are complex events stemming from the interaction of external phenomena and the vulnerability of man and society.

The human responsibility in so-called natural disasters is well acknowledged. The term natural disaster remains commonly used and should not be understood as denying a major human responsibility for the consequences.

Distribution and Risk Factors

Health and relative economic losses of natural disasters disproportionately affect developing countries (Alexander 1997; UN/ISDR 2004). More than 90 percent of natural disaster–related deaths occur in developing countries. Even though the economic losses are far greater in industrial countries, the percentage of losses in relation to gross national product (GNP) in developing countries far exceeds that percentage in industrial countries (figure 61.1). At an individual level, a sudden reduction of US$5,000 from an annual income of US$50,000 is worrisome; however, the ongoing loss of US$50 from a monthly income of US$100 may be catastrophic.

Figure 61.1

Disaster Losses, Total and as Share of Gross Domestic Product, in the Richest and Poorest Nations, 1985–99

For this reason, statistics of economic damage and mortality alone are not true indicators of the effect of disasters on the health and development of people and communities.

Disaster impact statistics show a global trend: more disasters occur, but fewer people die; larger populations are affected, and economic losses are increasing (IFRC 2000).

Geographic Distribution of Risk

Natural disasters do not occur at random. Geological hazards (earthquakes and volcanic eruptions) occur only along the fault lines between two tectonic plates on land or on the ocean floor. However, the local population often does not recognize the implications (the risks), as shown in the December 2004 tsunami in the Indian Ocean.

Hydrometeorological hazards do not follow a well-established distribution. Although the areas subject to seasonal flood, drought, or tropical storms (cyclones, hurricanes, or typhoons) are well known locally, global warming may possibly redraw the map of climatic disasters. As the National Research Council (1999, 34–35) notes, "This change is far from uniform. A pattern of response `modes' appears to be involved, in which warming is concentrated in northern Asia…while large regions of the northern Pacific and North Atlantic Oceans and their neighboring shores have actually cooled." El Niño–related fluctuations in relation to the gross domestic product (GDP) of Ecuador are shown in figure 61.2.

Figure 61.2

Annual Growth of Gross Domestic Product and Occurrence of Major Natural Disasters in Ecuador, 1980–2001

The risk of massive technological disasters, such as the catastrophic release of chemicals in Bhopal, India (methyl isocyanate), in December 1984, is serious in countries with significant industry (WHO 1992, 1996). Very few countries are immune to public health risks from hazardous chemical substances (from insecticides to industrial by-products) or discarded radioactive material from therapeutic or diagnostic use. Technological hazards increase rapidly with the unregulated industrialization of developing countries and the globalization of the chemical industry, suggesting that chemical emergencies may become a major source of disasters in the 21st century.

Factors Affecting Vulnerability

Vulnerability to all types of disasters—and to poverty—is linked to demographic growth, rapid urbanization, settlement in unsafe areas, environmental degradation, climate change, and unplanned development.

Age

The importance of age as a factor of vulnerability can be significant in situations where physical fitness is necessary for survival. The higher fatality among children, elderly, or sick adults following the 1970 tidal wave in Bangladesh (250,000 fatalities) and the 2004 tsunami in Asia (more than 180,000 dead or missing) illustrates this point.

Gender

Reports on immediate morbidity and mortality according to gender are not as conclusive. An Inter-American Development Bank paper indicated that 54 percent of the 3,045 people who died as a result of Hurricane Mitch in Nicaragua were male (IDB 1999). Stereotypes of gender vulnerability at the time of impact often do not apply. Depending on the type of disaster, far more significant vulnerability factors than gender or age are the time of day of the impact (and, therefore, the occupational activity of each group) and the structural vulnerability of housing, factories, and public buildings, including the location of the victims within the buildings. Following disasters, increased vulnerability of women is commonly noted in temporary settlements, where violence and sexual abuse are common. Specialized health care also may not be available (Armenian and others 1997).

Poverty

Economic vulnerability might play a much greater role than age and gender. What has been noted regarding the greater vulnerability of poor countries also holds true at the community and family levels. Disasters predominantly affect the poor. Poverty increases vulnerability because of the unequal opportunity for healthy and safe environments, poor education and risk awareness, and limited coping capacity. A notable exception was the 2004 tsunami in Banda Aceh, Indonesia, where the middle- and upper-class neighborhood close to the shore was particularly affected.

A major example is the settlement of a large number of economically disadvantaged populations in highly vulnerable locations, particularly urban areas. Following Hurricane Mitch in Tegucigalpa, Honduras, families that were relocated from flooded areas to safer (but inconveniently remote) ground were rapidly replaced by new illegal settlers. In 2003, families killed by a landslide in Guatemala had been warned about their vulnerability but were unable to afford resettlement in safer (and more costly) areas. Subsidies alone may not have prevented this effect, given the overarching issue of land ownership by a few in Central America.

Short-Term Health Burden

Losses fall under three categories, which may have both direct and indirect components:

  • lives and disabilities (both direct damage and an indirect consequence)

  • direct losses in infrastructure and supplies (direct impact)

  • loss or disruption in the delivery of health care, both curative and preventive (indirect impact).

The immediate health burden is directly dependent on the nature of the hazard. National health budgets of developing countries are, in normal times, insufficient to meet the basic health needs of the population. In the aftermath of a major disaster, authorities need to meet extraordinary rehabilitation demands with resources that often have been drained by the emergency response (as distinct from the resources destroyed by the event). Beyond the immediate response, decision making in the allocation of resources among sectors is mostly influenced by the magnitude of the economic losses rather than by the health statistics (principally the disability-adjusted life year, or DALY, losses) or social costs.

Earthquakes

As noted by Buist and Bernstein (1986), in the past five centuries, earthquakes caused more than 5 million deaths—20 times the number caused by volcanic eruptions. In a matter of seconds or minutes, a large number of injuries (most of which are not life-threatening) require immediate medical care from health facilities, which are often unprepared, damaged, or totally destroyed, as was the case in the earthquake in Bam, Iran, in 2003. In the aftermath of that earthquake, which resulted in 26,271 deaths, the entire health infrastructure of the city was destroyed. All traumas were evacuated by air to the 13 Iranian provinces long before the arrival of the first foreign mobile hospitals. Table 61.1 illustrates the accelerated pace with which priorities evolve and overlap in the first week following an earthquake.

Table 61.1

Health Priorities Following Earthquakes.

After a few weeks, national political solidarity and external assistance wane, and the local budgetary resources are drained. At the same time, health authorities face the overwhelming task of providing services to a displaced population, rehabilitating health facilities, restoring normal services, strengthening communicable disease surveillance and control, and attending to the long-term consequences, such as permanent disabilities, mental health problems, and possibly long-term increases in rates of heart disease and chronic disease morbidity (Armenian, Melkonian, and Hovanesian 1998).

Tsunamis

Earthquakes on the ocean floor may cause catastrophic tidal waves (tsunamis) on faraway shores. Waves caused by the seismic event crest at less than a meter in open seas, but they are travel several hundred kilometers per hour, so when they reach shallow waters, they can be 10 meters high. Damage on the coast can be extensive. Usually, the number of survivors presenting severe injuries is small in proportion to the number of deaths.

Volcanic Eruptions

Volcanoes persist as a serious public health concern, though they are often overlooked by authorities and communities lulled by long periods of inactivity. Eruptions are preceded by a period of volcanic activity, which provides an opportunity for scientific monitoring, warning, and timely evacuation.

Some issues, such as ash fall, lethal gases, lava flow, and projectiles, although of concern to the public, are of minimal health significance: Ash fall causes a significant burden on medical services but is unlikely to result in excess mortality or significant permanent problems. However, ash fall affects transportation, communications, water sources, treatment plants, and reservoirs. Studies by Bernstein, Baxter, and Buist (1986) following the 1980 eruption of Mount St. Helens (United States) reviewed the transient, acute irritant effects of volcanic ash and gases on the mucous membranes of the eyes and upper respiratory tract as well as the exacerbation of chronic lung diseases with heavy ash fall. Concentrations of volcanic gases are rapidly diluted to nonlethal levels, which lead to inconvenience but negligible morbidity for the general public. Lava flows present little health risk because of their very slow speed of progression. Mortality caused by ballistic projectiles from a volcanic eruption is minimal.

Attention to these public concerns may distract the authorities from preparing for the greatest factors of mortality: the pyroclastic flows (Mount Pelé in Martinique, in 1902, with 29,000 deaths) and lahars. Lahars are mud flows or mud and ash flows caused by the rapid melting of a volcano's snowcap, as in Colombia in 1985 (23,000 deaths), or caused by heavy rains on unstable accumulations of ash, as in the Philippines in 1991. Historically, pyroclastic explosions or lahars have caused about 90 percent of the casualties from volcanic eruptions.

Potential contamination of water supplies by minerals from ash; displacement of large populations for an undetermined period of time (over five years in Montserrat, a small island in the Caribbean); accompanying sanitation problems; and mental health needs are of great public health significance (PAHO 2002a). Among the long-term problems, the risk of developing silicate pneumoconiosis requires further investigation. 1

Climatic Disasters

Many communities and health services have learned to live with seasonal floods of moderate intensity. Periodically, the magnitude of the phenomenon exceeds the local coping capacity and overwhelms the resources of the health systems. The health burden associated with seasonal floods is well known locally: increased incidence of diarrheal diseases, respiratory infections, dermatitis, and snake bites. The actual risk of compromised water supplies depends on the level of contamination of the community's water supply before the disaster, compared with contamination after the flooding. Saline contamination is a long-term issue following sea surges and tsunamis. Prolonged flooding endangers local agriculture and occasionally requires food assistance on a large scale. The primary factors of morbidity remain overcrowded living conditions and poor water and sanitation in temporary settlements and other areas where water and sanitation services have deteriorated or are suspended.

Mortality and morbidity caused by tropical storms (hurricanes in the Atlantic Ocean and typhoons in the Pacific Ocean) result from, in increasing order of importance, high winds, heavy rainfall, and storm surge. When Hurricanes Mitch and George hit the Caribbean in 1998, traumatic injuries (lacerations or electrocution) caused by high winds of up to 150 miles per hour were relatively few; deaths from extensive rainfall (leading to flash floods and landslides) constituted the bulk of the more than 13,000 fatalities (PAHO 1999). In the Bangladesh delta, storm surges up to 6 meters traveled unimpeded over hundreds of kilometers and claimed between 250,000 and 500,000 lives in 1970 and up to 140,000 lives during five cyclones in the 1990s—primarily during one storm in 1991. Another cost is the need for specialized psychosocial assistance to large numbers of the population who survive the sustained violence of nature.

Cumulative mortality caused by small, undocumented mudslides and rockslides from water-saturated, unstable slopes probably approach the toll from well-known landslides (earthquakes in Peru in 1970 and in El Salvador in 2001, and the rains in Caracas, Venezuela, in 1999). Morbidity problems are often minimal, as survivors in the path of the landslide are few.

Impact on Communicable Diseases

Disasters related to natural events may affect the transmission of preexisting infectious diseases. However, the imminent risk of large outbreaks in the aftermath of natural disasters is overstated. Among the factors erroneously mentioned is the presence of corpses of victims, many buried beneath rubble. Dead bodies from a predominantly healthy population do not pose a risk of increased incidence of diseases (Morgan 2004). Catastrophic incidence of infectious diseases seems to be confined to famine and conflicts that have resulted in the total failure of the health system.

In the short term, an increased number of hospital visits and admissions from common diarrheal diseases, acute respiratory infections, dermatitis, and other causes should be expected following most disasters (Howard, Brillman, and Burkle 1996; Malilay and others 1996). This increase may reflect duplicate reporting (diarrhea cases were reported through both the emergency and the routine surveillance systems in Maldives after the 2004 tsunami), a temporary surge in surveillance, and medical attention available to an otherwise underserved population rather than representing a genuine change in the epidemiological situation.

In the medium term, heavy rainfalls may affect the transmission of vectorborne diseases. Following an initial reduction as mosquito-breeding sites wash away, residual waters may contribute to an explosive rise in the vector reservoir. When associated with a breakdown of normal control programs, this rise in the vector reservoir may lead to epidemic recrudescence of malaria or dengue. Retrospective studies (Bouma and Dye 1997; PAHO 1998; UN/ISDR 2004, 156) all confirm a direct but delayed relationship between the intensity of rainfall (regardless of the existence of flooding) caused by the El Niño phenomenon and the incidence of malaria. Flooding has contributed to local outbreaks of leptospirosis (in Brazil and Jamaica, for example; PAHO 1982) and hepatitis A in Latin America and Africa (WHO 1994).

In summary, what can be expected and prevented is a local surge in problems that the health services are normally used to handling.

Long-Term Impact and Economic Valuation

In addition to the delayed impact on transmission and control of endemic diseases and the burden of disabilities (paraplegia, amputation, burns, or chronic or delayed effects of chemical or radiological exposure), the health sector bears a significant share of the economic burden. Disasters must be seen in a systemic (that is, intersectoral) manner: what affects the economy will affect the health sector—and vice versa. After the emotional response of the first few days, decision makers in a crisis react primarily to political and economic realities, not to health indicators. Economic valuation of the social burden—that is, placing a monetary value on the cost—becomes a critical tool as the various sectors compete for scarce resources. The health sector, in particular, must learn how to use this tool in spite of being absorbed by its immediate relief responsibilities.

Valuation of Disasters

The Economic Commission for Latin America and the Caribbean (ECLAC) has developed over the decades a methodology for the valuation of disasters (ECLAC 2003). This tool, intended for reconstruction, has also proved its usefulness by developing historical records of major events, particularly of the health burden expressed in economic terms.

Valuation is made using all possible sources of information, from georeferenced satellite mapping and remote sensing to more conventional statistical data, direct observation, and surveys, with a reliance on information gathered immediately after the event. Economic valuation rests on the basic concepts of direct damage and indirect losses.

Direct damage is defined as the material losses that occur as an immediate consequence of a disaster. 2 Direct damage is measured first in physical terms. The physical loss includes assets, capital, and material things that can be counted: hospital beds lost, equipment and medicines destroyed, damaged or affected health service installations (number and type of installations, stocks of medicines, laboratory facilities, operating rooms, and so on), and pipes and water plants destroyed.

The physical plant then is valued both in terms of discounted present value and estimated replacement cost. Reconstructing facilities with the same vulnerability and level of service as before would be unacceptable; the affected health infrastructure must be replaced by more resilient and efficient installations to ensure better and sustainable service. This need is most evident in developing countries where impacts tend to be concentrated in those most at risk (the poor, marginalized, and less resilient sectors of the population).

Indirect effects refer to production of goods and services that will not occur as an outcome of the disaster, reduced income associated with those activities not occurring, and increased costs to provide those goods and services.

In the case of health services, indirect effects encompass both the income losses associated with the diminished supply of health care services and the increased costs of providing the services following the disaster. Indirect effects are valued at the current market value of goods or services not produced and the costs associated with the necessary provision of services under emergency, disaster-related conditions. Both components of the cost of illness—the cost of treatment and the cost of lost opportunities (lost income and employment, loss of time and productivity)—are sharply increased. The social burden is heavier on the poorest, who are unable to adjust their willingness to pay to absorb the additional expenses of alternative (private) providers of care.

The same approach applies to the economic valuation of lives lost. Kirigia and others (2004) found a statistically significant impact of disaster-related mortality on the GDP of African countries. One single disaster death reduced the GDP per capita by US$0.01828. Lost lives are given a higher economic value in places where productivity is high.

Because economic valuation uses standard sectored procedures that allow comparability of results, it can be used in the decision-making process and for policy formulation since it identifies sectors, geographical areas, and vulnerable groups that are more severely affected economically. Over the years, a number of conceptual improvements have been made to allow for the measurement of aspects not included in national accounting systems—to bring attention to environmental losses as a cross-cutting issue; to highlight the contribution of specific groups, namely women, as agents for change; and to focus on the better management of both the emergency and the reconstruction processes. It is also a valuable tool for preparedness and mitigation of future damage.

Table 61.2 summarizes the valuations made by ECLAC over the years for LatinAmerica and the Caribbean in terms of deaths, affected populations, and economic losses (2003 values). Of interest are the decrease in the number of deaths and the increase in total damage (in particular, indirect damage) over time.

Table 61.2

Impact of Disasters in Latin America and the Caribbean.

The distribution of direct and indirect damage in the health sector also varies. According to ECLAC (2003), direct damage between 1998 and 2003 in Latin America ranged from 44.6 percent to 77.2 percent of total damage.

Specific Damage to the Health Infrastructure

Damage to housing, schools, channels of communication, industry, and so on contributes to the health burden. However, the following analysis focuses on the health infrastructure (understood as health care facilities, including hospitals, health centers, laboratories, and blood banks) and the drinking water and sanitation infrastructure.

Damage to Hospitals and Health Installations

Most data and examples presented here come from Latin America and the Caribbean because of the disaster reduction programs in the health sectors of those regions. In the past two decades, damage to approximately 260 hospitals and 2,600 health centers resulted in interruption of services at a direct cost of US$1.2 billion. In the 1985 earthquake in central Mexico, 5,829 beds were destroyed or evacuated (PAHO 1985), at a direct cost of US$550 million (ECLAC 1998). Hurricane Gilbert (1988) damaged 24 of the 26 hospitals on Jamaica, and the El Salvador earthquake (2001) resulted in the loss of 2,000 beds—40 percent of the country's hospital capacity (PAHO 2002b). The health burden is not limited to the loss of medical care. The control of communicable diseases and other public health programs suffer from loss of laboratory support and diagnostic capabilities of hospitals. Further research on the actual impact of these losses, in terms of DALYs, is essential.

A common misperception is that damage to critical health facilities is promptly repaired. Experience shows that damaged health infrastructure recovers at a slower pace than infrastructure in other service sectors, such as trade, roads, bridges, telecommunications, and even housing. For example, as a result of the earthquake that affected El Salvador in 1986, renovation of the general hospital, the most sophisticated referral hospital in the capital, was completed 15 years after the earthquake. The only national pediatric facility was fully rehabilitated and strengthened six years after the earthquake. Two years after the earthquake of 2001 in El Salvador, several key hospitals still remained vacated or services were transferred to unsuitable temporary facilities. The factors are many: low priority assigned to a nonproductive sector, the sector's inexperience in developing comprehensive proposals for funding, conflicting attempts to use the reconstruction process to influence the ongoing reform and decentralization processes, the novelty of the engineering and design issues for safe hospital construction, the complicated negotiation process for loans, and the administrative inexperience of the health sector in executing large investment projects. Indeed, few large health installations have been built directly by developing countries in the past decades.

Damage to Water and Sewage Systems

The primary goal of water and sewage systems is to safeguard the public health of the population. For that reason, these systems are considered part of the health infrastructure.

The developmental burden is significant. In the past 30 years in Latin America and the Caribbean alone, an estimated 400 urban water supply systems and 1,300 rural systems (in addition to 25,000 wells and 120,000 latrines) were severely damaged, at an estimated cost of almost US$1 billion—a major setback to efforts to expand coverage and improve those services. In severe flooding, the sudden interruption of these basic services coincides with the direct effect on the transmission of waterborne or vectorborne diseases. In the case of earthquakes, the number of people who are adversely affected by water shortage may far exceed those injured or suffering direct material loss.

As in the case of health care facilities, the rehabilitation of public water systems is slow, particularly for community-owned or community-operated rural systems, which may not be repaired for decades. The foregoing demonstrates the need for water authorities to harmonize their short-term objectives, which are oriented almost exclusively to increasing the coverage of these services, with the long-term objective of reducing vulnerability to extreme natural hazards.

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