Disasters and Their Effects on Children

Advances in Pediatrics 57 (2010) 7–31 ADVANCES IN PEDIATRICS Disasters and Their Effects on Children Julia Lynch, MDa, Joe Wathen, MDb, Eric Tham, MDb, Patrick Mahar, MDb, Stephen Berman, MDc,* a Military Infectious Disease Research Program, US Army, Medical Research and Material Command (US Army, MRMC), 504 Scott Street, Fort Detrick, MA 21702, USA b Department of Pediatrics, Emergency Medicine, University of Colorado, The Children’s Hospital, 13123 East 16th Avenue, B251, Aurora, CO 80045, USA c Department of Pediatrics, General Academic Pediatrics, The Children’s Hospital, University of Colorado, Aurora, CO, USA T he recent magnitude 7.0 Mw earthquake in Haiti on January 12, 2010, created one of the most severe humanitarian disasters in modern recorded times. According to the most recent estimates, 222,570 people died during the earthquake, with an additional 600,000 injured, and more than 1 million being internally displaced persons [1]. Some statistical models estimated that 110,000 of the injured were children [2]. These estimates rival the 230,000 who perished during the Asian tsunami of 2004. Although the destruction of the Asian tsunami occurred in more than 14 countries, the deaths and destruction of the January earthquake were centered on the tiny island of Hispaniola in the country of Haiti with the epicenter in Leogane, which is 25 km from the capital of Port-au-Prince. Although there was an overwhelming desire by physicians and other health professionals to respond to this tragedy, many of the immediate responders were poorly prepared to perform medical procedures without the support of modern facilities [3]. This included having to perform many amputations without the use of anesthesia or sedation in the immediate aftermath of the earthquake. In this article, we review disaster definitions, classifications, and measures of severity; describe the phases of a disaster; review the 10 World Health Organization emergency relief measures; discuss the role of international relief organizations; and present key issues that medical volunteers faced in Haiti. The key message of this article is to understand that although it is not possible to predict disasters of this magnitude, planning and preparation can help mitigate some of the morbidity and mortality that occur in the aftermath of such disasters. This message has been clearly stated by Benjamin Franklin: ‘‘Failing to plan is planning to fail.’’ *Corresponding author. E-mail address: Berman.Stephen@tchden.org 0065-3101/10/$ – see front matter doi:10.1016/j.yapd.2010.09.005 Ó 2010 Elsevier Inc. All rights reserved. 8 LYNCH, WATHEN, THAM, ET AL DEFINITIONS The World Health Organization and the Pan American Health Organization (WHO/PAHO) define a disaster as an event that most often occurs suddenly and unexpectedly, resulting in loss of life, harm to the health of the population, destruction of community property, and damage to the environment. The disaster disrupts the normal pattern of life, causing suffering and an overwhelming sense of helplessness and hopelessness. The impact on the socioeconomic structure of a region and environment often requires outside assistance and intervention. Although there are many definitions for disaster, there are 3 common factors. First, there is an event or phenomenon that impacts a population or an environment. Second, a vulnerable condition or characteristic allows the event to have a more serious impact. For example, the large number of collapsed buildings, including schools and hospitals, caused by earthquakes were related to substandard building practices in both China and Haiti. The damage from the 2009 earthquake in Tokyo and the 2010 earthquake in Chile had far less loss of life in large part because of the high quality of construction. Identifying these factors has practical implications for communities’ preparedness and provides a basis for prevention. Third, local resources are inadequate to cope with the problems created by the phenomenon or event. Disasters affect communities in multiple ways. Their impact on the health care infrastructure is multifactorial. They can cause an unexpected number of deaths. In addition, the large number of wounded and sick often exceeds the local community’s health care delivery capacity. The community’s capacity to care for those affected is often reduced because professionals, clinics, and hospitals have been affected or destroyed. This will have long-term consequences leading to increased morbidity and mortality. Before the January 12 earthquake in Haiti, there were only 11 hospitals in Port-au-Prince. The earthquake damaged or destroyed at least 8 of these hospitals. The remaining health facilities were quickly overwhelmed by large numbers of survivors requiring a wide range of care, particularly for trauma injuries. To help with immediate health care needs, field hospitals were established by a variety of groups (Fig. 1). The 2010 earthquake in Haiti demonstrates how a disaster becomes much more devastating when the preexisting medical system is already inadequate and poorly functional. This makes integrating and organizing outside assistance more fragmented and chaotic. The disaster can have adverse effects on the environment that will increase the risk for infectious transmissible diseases and environmental hazards. This will affect morbidity, premature death, and future quality of life. There can be shortages of food, with severe nutritional consequences. All these conditions lead to a sense of hopelessness and inability to think that the future will be better. This means that people no longer visualize their future by making plans such as finishing school, getting married, and working. This ‘‘foreshortened future’’ affects the psychological and social behavior of the community. DISASTERS AND THEIR EFFECTS ON CHILDREN 9 Fig. 1. Field hospital Haiti 2010. These are pictures taken by the team that went to Haiti from TCH. This was their field hospital. CLASSIFICATION OF DISASTERS Disasters can be divided into those caused by natural forces and those caused by humans, as shown in Box 1. Natural forces include earthquakes, tsunamis, volcanic eruptions, hurricanes, fires, tornados, and extreme weather conditions. They can be classified as rapidonset disasters such as earthquakes or tsunamis, and those with progressive onset, such as droughts that lead to famine. Natural events, usually sudden, can have tremendous effects. For instance, in December 2004, more than 230,000 people died in southern Asia as a result of a tsunami, and in February 2010, more than 220,000 people died following an earthquake in Haiti. Although similar types of disasters have predictable patterns of disruption, as shown in Table 1, the degree of severity and type of response is affected by local features. Disasters caused by humans are those in which major direct causes are identifiable intentional or nonintentional human actions. They can be subdivided into 3 main categories: technological disasters, terrorism, and complex humanitarian emergencies. LYNCH, WATHEN, THAM, ET AL 10 Box 1: Types of disasters Natural disasters  Hurricanes or cyclones  Tornadoes  Floods  Avalanches and mud slides  Tsunamis  Hailstorms  Droughts  Forest fires  Earthquakes  Epidemics Human-provoked disasters Technological/industrial disasters  Leaks of hazardous materials  Accidental explosions  Bridge or road collapses, or vehicle  Collisions  Power cuts Terrorism/International violence  Bombs or explosions  Release of chemical materials  Release of biologic agents  Release of radioactive agents  Multiple or massive shootings  Mutinies  Intentional fires Complex emergencies  Conflicts or wars  Genocide Technological disasters are most often industrial events resulting from unregulated industrialization and inadequate safety standards. Examples include the radioactive leak in the Chernobyl nuclear station in Ukraine (1986) and the toxic gas leak in a Bhopal factory in India (1984). Both of these disasters were associated with many deaths as well as long-term health effects in the affected population. The threat of terrorism has also increased owing to the Disaster type Effect Immediate deaths Severe lesions Increased risk for transmissible diseases Damage to health centers Damage to water supply Food shortage Significant population displacements Complex emergency Earthquake Strong winds Floods Gradual floods Mud slides Volcanic eruptions Numerous Numerous Few Numerous Few Numerous Numerous Numerous Numerous Moderate Few Few Few Few This risk applies to ALL significant disasters, and increases with overcrowding and deterioration of sanitary conditions Moderate; can be severe if health centers are military targets Severe Severe Frequent Severe Severe Severe but localized Severe (only for equipment) Severe but localized Severe Severe Slight Severe Slight Severe Frequent Frequent Severe but localized Not frequent May result from economic and logistic factors Not frequent Frequent; increased likelihood in severely damaged urban areas DISASTERS AND THEIR EFFECTS ON CHILDREN Table 1 Frequent effects of disasters Not frequent Frequent 11 12 LYNCH, WATHEN, THAM, ET AL spread of technologies involving nuclear, biologic, and chemical agents as well as the use of explosives and firearms. Explosive or blast events are the most common type of terrorist event causing morbidity and mortality. The term complex humanitarian emergency describes the situation resulting from either an international or civil war. War often results in a staggering loss of civilian lives. There is a disruption of the basic societal infrastructure, including food distribution, water, electricity, sanitation, and health care. In addition, the ability to carry out an emergency relief response is hindered by a lack of security as well as political instability. Both natural disasters and complex emergencies can force many people to leave their homes. The specific job of the office of the United Nations High Commissioner for Refugees (UNHCR) is to register and assist displaced populations and individuals. This office recognizes 2 categories of affected people: refugees and internally displaced persons (IDP). Refugees flee their countries because of war, violence, famine, or wellfounded fear of persecution for political, ethnical, religious, or nationality reasons. A person recognized as a refugee is entitled to certain protections under the terms of international humanitarian laws. IDPs leave their homes for similar reasons but do not cross the boundaries of their countries. These individuals do not receive the same kind of legal protection, so helping them can be much more difficult. The current worldwide number of IDPs can be monitored by accessing information available at http://www.internaldisplacement.org. PHASES OF DISASTERS Because relief interventions in emergencies evolve as a continuum, it is useful to prioritize activities and resources according to 4 phases: planning, response, recovery, and mitigation/prevention. Planning comprises all the activities and actions taken before a disaster. Base the planning on the analysis of the community’s or organization’s risk for exposure to specific types of disasters. Plans should take into account the frequency of occurrence of each type of disaster, the anticipated magnitude of effect, the likelihood that there will be an advanced warning, characteristics of the populations most likely to be affected, the amount and types of resources available within the community or organizational structure, and the ability to function independently without additional outside resources for periods of time. The response phase includes all activities and actions taken during and immediately after a disaster. This includes notification of the organizations involved in disaster response, setting up of initial communication networks, initial search and rescue, disposal of the dead, damage assessment, evacuation, sheltering, and other multiple activities. The response phase is characterized by initial chaos, high crude mortality rate (CMR), and hopefully, rapid assessments of the situation by specialized response teams. The response phase is often complicated by the lack of functional communications and central organization. The response phase lasts until the initial casualties have been either DISASTERS AND THEIR EFFECTS ON CHILDREN 13 rescued or acknowledged as lost, and enough resources have been made available to allow the population to assess damages and begin planning restoration and recovery. This phase can last hours to weeks. During the first few days following a disaster, local communities must usually rely on their own resources and disaster plans. The recovery phase is the period in which the affected organization or community works toward reestablishing self-sufficiency. This is the period of new community planning, rebuilding, and reestablishment of government and public service infrastructure. The health status of the affected population begins to return to predisaster conditions and the outside support services are gradually withdrawn. During the mitigation and prevention phase, all aspects of emergency management are scrutinized for ‘‘lessons learned,’’ and the lessons are then applied in an effort to prevent the recurrence of the disaster itself or to lessen the effects of subsequent events. Mitigation includes preventive and precautionary measures such as changing building codes and practices, redesigning public utilities and services, reviewing mandatory evacuation practices and warning policies, and educating members of the community. Mitigation and planning are continuous processes, as lessons learned from a previous disaster are included in planning for the next one. SEVERITY OF A DISASTER As was demonstrated in Haiti, the more fragile the pre-event health status of the affected population and inadequate the predisaster infrastructure, the more severe the disaster. Disaster severity will, therefore, vary according to its magnitude and the vulnerability of the population. When assessing the outcome of a disaster, public health officers describe its severity by the number of human lives lost using the CMR. CMR is usually defined as the number of deaths per 10,000 inhabitants per day. In developing nations, the reference CMR value varies from 0.4 to 0.7 deaths per 10,000 people per day. A CMR above 1 death per 10,000 people per day is considered a humanitarian emergency. To assess the progression of a disaster and the effectiveness of relief interventions, measure the CMR over several appropriate time intervals. For example, during the month following the massive movement of Rwandan refugees to Eastern Zaire, the CMR in that region was 40 to 60 times above the Table 2 Crude mortality rate: baseline and after humanitarian disaster Date Origin Host country CMR crisis CMR baseline 1991 1991 1994 Somalia Iraq Rwanda Ethiopia Turkey/Iraq Zaire 4.7 4.2 34.0 0.6 0.2 0.6 Data from Toole MJ. Mass population displacement—a global public health challenge. Infect Dis Clin North Am 1995:9(2):353–66. LYNCH, WATHEN, THAM, ET AL 14 corresponding reference value. The CMR is usually highest during the initial phase of a disaster (Table 2). The immediate mortality in any type of disaster is not higher in a specific age range; instead, it usually reflects the age distribution of the overall population. However, later the mortality rate is disproportionately higher among the youngest and oldest people. Fig. 2 shows this phenomenon related to a refugee crisis in Northern Iraq in 1991. Although children aged 0 to 5 years accounted for only 18% of the total refugee population, they accounted for 64% of the overall refugee mortality rate. The most vulnerable groups include children, especially those displaced from their families; women who are pregnant, lactating, or live without their spouse; individuals living in households headed only by women; disabled individuals; and the elderly. In addition to disproportionately high mortality rates, children displaced from their family are at high risk for a number of adverse consequences, including rape, torture, robbery, and exploitation in child labor, 0 to 5 years 15 to 44 years 6 to 14 years 45 years or more 70% 64% 60% 50% 42% 40% 33% 30% 23% 18% 20% 7% 10% 5% 8% 0% Population distribution Deaths distribution Fig. 2. Mortality rate per age group: refugee crisis Northern Iraq (1991). (Data from Toole MJ. Mass population displacement—a global public health challenge. Infect Dis Clin North Am 1995;9(2):353–66.) DISASTERS AND THEIR EFFECTS ON CHILDREN 15 child trafficking, and child soldiering. Additionally, because of certain physical and physiologic characteristics, infants and children are more vulnerable to the release of toxic substances and the overcrowding associated with the displacement of large populations. Consequently, in all disaster response planning, it is critical to attempt to reunite children with their families as soon as possible and pay special attention to reducing their vulnerability. Trauma is often the leading cause of mortality from the immediate impact of a disaster. After the initial impact phase, there are 5 leading medical problems that have consistently been found to be the major causes of mortality in postwar or post–natural disaster settings: diarrhea and dehydration, measles, malaria, respiratory infections, and malnutrition. Unique features in each disaster (eg, climate, topography, preexisting social structure, and physical conditions) affect the proportion of deaths associated with each of these, as well as other causes. Fig. 3 shows the number of natural and complex disasters in the world between 1985 and 1995. Malnutrition, although not identified as a significant immediate cause of death, is the most important factor correlated to the high mortality rates attributable to transmissible diseases. A study including 41 displaced populations (Fig. 4) showed a clear correlation between the CMR (ie, death from all causes) and the prevalence of malnutrition. ESSENTIAL EMERGENCY RELIEF MEASURES At a World Health Organization conference, international relief experts identified 10 essential emergency relief measures to consider when responding to a disaster. Each of these measures is described in the following sections. These interventions are not intended to be implemented in strict order; rather, priority for each intervention should be suited to the particular needs relating to each individual emergency situation. The immediate goal for any intervention in humanitarian emergencies is to reduce the number of deaths. Although 60 50 40 30 20 , 10 0 1985 1986 1987 1988 1989 1990 Complex Disasters 1991 1992 1993 1994 Natural Disasters Fig. 3. Number of natural and complex disasters worldwide, 1985–1995. 1995 LYNCH, WATHEN, THAM, ET AL 16 16 14 12 CMR 10 8 6 4 2 0 <5% 5-9.9 % 10-19.9 % 20-39.9 % >or=40 % Malnutrition Prevalence Fig. 4. Effects of malnutrition on mortality rates during disasters. Malnutrition ¼ <80% weight/height WHO reference population; CMR ¼ crude mortality rate (deaths per 1,000 individuals/month) in relation to malnutrition prevalence. both conflict and natural disasters can result in immediate deaths, there are many preventable deaths that occur in later phases of a disaster over a longer time period. Interventions that are based on speculations rather than on accurate information obtained in the place of the disaster are likely to waste time and valuable resources, ultimately increasing the suffering of the affected population. Unpredicted effects may require urgent attention. For example, compromise of a water supply system is unlikely to be a predicted effect of a storm-related mudslide. However, if the regional system for water pumping or purification is in the mudslide zone, the shortage of safe water becomes the key issue that must be addressed to prevent disease and excessive mortality in the affected population. Resources need to match both the need and the time frame to be useful. For example, trauma is likely to be the major cause of death immediately after an earthquake. If trauma surgery teams and field hospitals arrive a week after the earthquake, most of the trauma-related deaths will already have occurred and very little benefit will be obtained from this highcost resource. Do a Rapid Assessment of the Emergency Situation and the Affected Population An assessment should accurately define what is needed, so that limited resources will be efficiently used to minimize morbidity and mortality as well DISASTERS AND THEIR EFFECTS ON CHILDREN 17 as reduce the likelihood of additional problems/complications during subsequent phases of response. National level Assessments are typically done by expert teams focused on promptly defining the event magnitude, the environmental conditions and infrastructure damage, the major health and nutrition needs of the affected population, and the local response capacity. Community level In the immediate aftermath of a disaster, the initial response will primarily come from local resources. Communities must be prepared to do a local assessment of disaster impact. Health care professionals should be prepared to assess the health issues in their community, and understand how information will be shared with higher levels of authority, to contribute to regional or national assessments. Assessments need to be an ongoing process so that the quality and specificity of data will improve during the rescue and recovery phases. This is especially important whenever any major change occurs, such as an aftershock earthquake. Information gathered through these assessments should be used by the resource managers to determine the allocation of resources in any large-scale disaster. Provide Adequate Shelter and Clothing Shelter and clothing is essential as exposure to the climatic conditions in disaster situations can increase caloric requirements and lead to death. Community level Find short-term shelters for all homeless individuals, particularly focusing on vulnerable populations. Shelters should be appropriate for the climate and focus on providing a safe environment from subsequent events related to the disaster. After an earthquake, shelters should be established in locations that would not have potential for further damage from collapsing buildings or falling debris from anticipated aftershocks. During times of flooding, it is important that shelter for the displaced individuals is located in an area that is not at risk of rising floodwaters. Displaced victims will not use these shelters if they do not feel safe. Keep individuals within their communities and family networks as much as possible. In general, it is recommended to direct resources to rebuilding within the community, rather than building large camps or temporary settlements outside the disaster area. Schools are often used as emergency shelters following a disaster; however, it is important for children to return to as normal a routine as possible as early as possible. This means that schools should be reopened as soon as possible and teachers should be trained to understand stress reactions and recognize when additional help is needed. Provide Adequate Nutrition Large-scale bulk food requirements are typically calculated based on a minimum of 2000 kcal per person per day. 18 LYNCH, WATHEN, THAM, ET AL Community level Communities must plan to distribute food equitably and include vulnerable groups. As global food resources improve, establish targeted supplemental and therapeutic feeding programs for malnourished individuals. Provide Elementary Sanitation and Clean Water The estimated minimum requirement for water is 3 to 5 L per person per day of clean water. Community level Reestablish supplies of clean water and effective sanitation and waste disposal services as soon as possible. Consider how to address the needs of vulnerable groups related to access, safety, and security in the planning process. Set Up Diarrhea Control Program An increase in diarrheal disease is a predictable outcome of disasters because of infrastructure and health care services disruption. Community level Rapidly implement community-based education on appropriate household sanitation measures, diarrhea prevention, and household case management, particularly for young children with diarrhea. Health care centers should anticipate the needs for additional cases of dehydration, using appropriate low-cost strategies (oral rehydration solution/oral rehydration therapy [ORS/ORT]) and recognize possible cases of cholera and dysentery. Immunize Against Measles and Provide Vitamin A Supplements Measles has been a major source of mortality among crowded, displaced populations in which malnutrition is prevalent. Therefore, measles immunization is the only vaccine that is routinely considered for use as a preventive measure immediately following a disaster. Because vitamin A deficiency is common and contributes to measles-related mortality, consider mass distribution of vitamin A for vulnerable populations. National level National and international agencies must work together to determine if measles immunization or vitamin A distribution is necessary following a particular event. If necessary for all or part of the affected population, national authorities should establish the central logistics (eg, cold chain, personnel, materials) to manage a mass immunization/distribution campaign. Community level Health officers must immediately assess the available cold chain as part of its health care assessment. Health care professionals must monitor for cases of measles and develop a plan for mass immunization and/or mass distribution of vitamin A to the vulnerable groups in their community. DISASTERS AND THEIR EFFECTS ON CHILDREN 19 Reestablish and Improve Primary Medical Care Immediate casualties (rescue phase) of a sudden impact disaster are likely to include a limited number of trauma victims. In most disasters in fragile communities, the larger number of disaster-related deaths (ie, deaths above the baseline CMR) will be a result of preventable causes of mortality in the weeks and months following the impact. These casualties can largely be prevented by community health education and access to appropriate primary care. Community level Health professionals should know the emergency transport and response systems in their community. Health care interventions during the rescue phase should include minimizing loss of life caused by the direct impact of the event (eg, trauma, drowning). After the rescue phase, health care resources should be focused on reestablishing and improving the access and quality of primary care, particularly for the most vulnerable groups. Set Up Disease Surveillance and Health Information Systems Effective health information and disease surveillance systems are necessary to monitor effectiveness of health interventions and reassign priorities. National level Health authorities should use available information to define initial priorities in the use of limited resources. They should develop specific surveillance guidelines for each disaster to track relevant disease/mortality trends. Community level Every health care delivery setting should immediately implement a simple but effective health information collection system based on established WHO, PAHO, or governmental guidelines. Health care professionals should know how to share this information regularly with regional and/or federal health authorities. Organize Human Resources The initial shock of an event can make it difficult for a disaster-affected population to effectively respond in a quick and organized fashion. Having a predefined emergency plan with clearly identified leaders can help the local community to cope until more external resources arrive. Community level Have an emergency plan and predefined community leaders for the following:      Conducting rescue operations Conducting assessments (eg, health services, transportation, food, sanitation/ water systems) Organization of food and water distribution, and the sanitary program Health services management Corpses and gravesite management LYNCH, WATHEN, THAM, ET AL 20  Identification of unaccompanied minors and other extremely vulnerable individuals (eg, elderly or persons with a disability) and plans for caring for these individuals. Coordinate Activities National level In a large-scale disaster there will be many national and international agencies attempting to assess, develop plans, and establish priorities for funding at national and regional levels. Most effective relief efforts require effective collaboration among many agencies, each bringing their own expertise and experience. However, all of these agencies will ultimately depend on accurate assessments from the affected communities to make appropriate decisions. Community level Develop local emergency plans that link into regional and national plans and agencies. Understand the mechanisms for communicating information (eg, assessments, surveillance data) during disasters. Build relationships with key individuals within and outside the community before a disaster occurs. INTERNATIONAL RELIEF ORGANIZATIONS When local resources are insufficient, assistance from multiple national or perhaps multinational organizations will be needed. Each involved organization has its own institutional structure and culture, in addition to other features, such as capacity for response, technical and logistic resources, and thematic or regional approach. Several international agencies may have activities in the country before the event. In response to the disaster, these agencies may retarget their resources in the country to emergency relief. Effective coordination and cooperation among involved organizations are essential but very difficult to achieve in the chaotic situation of a massive emergency. There are 2 major types of organizations that can get involved in assistance when a disaster occurs: governmental and nongovernmental organizations (NGOs). GOVERNMENTAL ORGANIZATIONS National Ministries These are agencies at the national ministry level that have authority for disaster planning and response. Nations should establish a health disaster coordinator within the Ministry of Health (MoH). The health disaster coordinator not only coordinates health-related relief efforts in the event of a disaster, but also continuously updates emergency plans and conducts preparedness training for health care professionals. The Pan American Health Organization PAHO is an international public health agency serving as the Regional Office for the Americas of WHO. It provides health policy guidance and technical assistance in disaster planning and response. More information is available at www.paho.org. DISASTERS AND THEIR EFFECTS ON CHILDREN 21 World Health Organization WHO provides technical advice and develops health policies relating to disasters. More information is available at www.who.int. SUMA SUMA (Humanitarian Supply Administration System, developed by PAHO) facilitates the reception, inventory, and rapid distribution of essential humanitarian supplies and equipment. In the event of a disaster, PAHO can send SUMA-trained staff to the affected country to assist in managing the inflow of supplies. United Nations The UN is a multinational organization that functions mainly through its subagencies, which are independently funded. More information is available at: www.un.org. The Office of the United Nations High Commissioner for Refugees The Office of the United Nations High Commissioner for Refugees (UNHCR) is mainly responsible for providing needed food, supplies, and other material, but it also plays a central role in protecting and advocating for displaced populations. More information is available at www.unhcr.org. World Food Program The World Food Program (WFP) coordinates the delivery of food to regions in need around the world. More information available at www.wfp.org. United Nations International Children’s Emergency Fund The United Nations International Children’s Emergency Fund (UNICEF) was created by the UN General Assembly to advocate and protect children’s rights, to help fulfill their basic needs, and to provide opportunities for maximizing the development of their potential. When an emergency occurs, UNICEF focuses on ensuring that basic needs of women and children are fulfilled and on protecting their basic rights. More information is available at www.unicef.org. Office for the Coordination of Humanitarian Affairs In 1998, the Office for the Coordination of Humanitarian Affairs (OCHA) was established by the reorganization of the UN Department of Humanitarian Affairs (DHA). Its mission was expanded to include the coordination of humanitarian response, policy development, and advocacy. OCHA’s tasks are done through the Inter Agency Permanent Committee that includes multiple participating organizations, such as UN agencies, funds, and programs, the Red Cross, and NGOs. More information is available at http://ochaonline.un.org. Foreign Organizations That Provide Help in Case of Disaster Table 3 identifies some of the governmental agencies of developed countries that provide funding and technical help to countries affected by humanitarian emergencies. LYNCH, WATHEN, THAM, ET AL 22 Table 3 Foreign agencies for disaster assistance US Agency for International Development - Office for Foreign Disaster Assistance (OFDA) Canadian International Development Agency (CIDA) European Commission Humanitarian Organization (ECHO) United Kingdom Department for International Development (DFID) Japan International Cooperation Agency (JICA) http://www.usaid.gov/our_work/humanitarian_ assistance/disaster_assistance/ www.acdi-cida.gc.ca http://ec.europa.eu/echo/about/actors/ specialised_agencies_en.htm www.dfid.gov.uk http://www.jica.go.jp/worldmap/english.html PAHO and WHO have developed guidelines to assist disaster-affected countries in managing donor offers from various agencies, according to the 1999 PAHO publication Humanitarian Assistance in Disaster Situations: A Guide for Effective Aid. Military Help Both local and foreign military can be mobilized to assist in the response to natural disasters or complex emergencies. Certain unique features make military organizations useful in a disaster. Advantages Speed: Few organizations are capable of implementing a large logistic response as rapidly as the military. Security: The military can secure a specified environment, population, and material. Transportation: Their fleet of planes and helicopters, as well as land and naval equipment, enable them to transport resources readily. Logistics: They have experience in maintaining supply lines in problematic environments and situations. Command, control, and communication: They have a well-defined and responsive organizational structure. Self-sufficiency in the field: When military arrive to the region where the event has occurred, they are capable of fulfilling the needs of their own personnel. Specialized units: They often have specifically trained and equipped units. These include engineers who can provide technical assistance and preventive medicine teams capable of rapidly performing epidemiologic evaluations and surveillance, outbreak investigations, vector control, and water purification and treatment. Field hospitals and capacity for medical evacuation: Hospitals can be helpful in certain circumstances. See the WHO-PAHO guidelines for the use of field hospitals in sudden-impact disasters (as mentioned above). Shortcomings Despite all the advantages mentioned previously, the use of the military can have significant shortcomings and limitations in some situations. DISASTERS AND THEIR EFFECTS ON CHILDREN 23 Medical care: Field hospitals are designed for the care of soldiers wounded in combat (ie, for the care of wounds suffered by healthy adults). During a disaster, primary care and preventive interventions for women and children are major needs. Logistics: Supplies available in the military response system may not be appropriate for a disaster in terms of prevailing diseases or types of food. Political objectives: The military are an asset of governments; in addition, certain humanitarian objectives can be subordinated to other political or strategic goals. The presence of the army in certain scenarios can cause tension in certain groups of the population and compromise relief workers who, for their own safety and function, wish to be considered neutral. Cost: Military activities are expensive. NONGOVERNMENTAL ORGANIZATIONS NGOs are nonprofit organizations working on a full-time basis in assistance for appropriate development. Thousands of NGOs, both international and national, are functioning throughout the world. Most NGOs are small agencies focusing on very specific development projects (eg, providing education, working tools, or training in sustainable development). Only a few of them have the resources required for supporting activities targeted to promote development and to respond to disasters in multiple countries or regions. Although NGOs may receive contributions from individuals, most of their funds come from the governments of industrialized countries. These governments distribute their money for assisting projects through contracts with NGOs. Unlike the International Committee of the Red Cross (ICRC), some NGOs maintain a ‘‘right to interfere.’’ This means they can operate across borders without written approval of their hosts. Although usually looking for the neutrality of the ICRC, some NGOs may be more willing to report any perceived injustice. They perform well in emergencies within their area of specialty (eg, water provision, food distribution), but most cannot achieve self-sufficiency in an emergency setting and rely on UN, military, or other agencies for security, transportation to remote sites, communication, support of logistics, or medical care for their own personnel. NGOs have an enhanced ability to provide person-to-person assistance because they are likely to have a predisaster relationship with the affected communities and understand the local culture and public health issues. They can also shift easily from disaster relief to development, and are willing to make a long-term commitment to community development and rebuilding. International Committee of the Red Cross The ICRC is a hybrid agency: neither private nor controlled by a government. A number of its characteristics are unique; its mission is defined by the international humanitarian law passed by the 1949 Geneva Convention and the two 1977 protocols. The ICRC gets involved mainly when civil disturbances are present; it has the right and duty to intervene across borders when national or international conflicts break out, regardless of whether a ‘‘state of war’’ has been declared. The ICRC brokers relief assistance during war, assures legal protection 24 LYNCH, WATHEN, THAM, ET AL for victims, and monitors the way Prisoners of War are managed. Also, the ICRC plays a critical role in reuniting families. The ICRC strives to preserve its neutrality, which is essential for its mission and enables its members to work unarmed in war regions under the control of any of the involved parties. The ICRC provides a complete account of its activities to all the parties involved in the conflict. It will refuse to participate in any activity that can be seen as showing favoritism. This may include transportation in vehicles belonging to one of the parties or joining efforts with groups that have their own interests. The ICRC is usually self-sufficient and can use its own resources for air lifts, communication, and logistics. It will participate only if all parties involved in the conflict sign an agreement recognizing and showing respect for its neutrality and mission. The ICRC is related to but independent from the Red Cross and the Red Crescent Societies national agencies. These organizations provide assistance primarily to victims of disasters or wars within their own nations. They have a similar commitment with neutrality, provision of assistance based only on the need, and independence from national governments. Coordinating the activities of all these organizations poses a tremendous challenge. Following a natural disaster the host nation’s government/agencies and military are likely to have operational command. Most nations now have defined governmental authorities responsible for global disaster planning and response, as well as coordinators for individual sectors such as health. External agencies or governments play a supportive role in providing technical assistance and resources. In complex emergencies related to a conflict, the armed forces or government authorities will have the command of operations, including the coordination of humanitarian help. The coordination in this scenario can be particularly difficult if the hostile groups are stationed nearby and try to block assistance of civilians. In this context, humanitarian help can be used as a political and strategic instrument. MEDICAL VOLUNTEERING Following a disaster, many pediatricians and other health professionals volunteer for a limited time. During the initial response phase, the greatest pediatric needs include air transport teams, surgical teams (a surgeon, operating room [OR] nurse, anesthesiologist, and critical care pediatrician), as well as pediatricians with training and experience in emergency medicine and critical care. Volunteers may have to be self-sufficient for a period of time in terms of food, water, and shelter. Volunteers should work through an established NGO or governmental agency rather than simply ‘‘show up’’ to help. Volunteers should be prepared to respond quickly, as the quicker the response teams can provide appropriate care, the more effective they can be at saving lives and limiting morbidity. Part of preparation is anticipating the types of injuries that will be seen with different types of disasters. When sending a response team into a disaster during the acute response phase, it is important to have the personnel with the ability to treat the most likely injuries DISASTERS AND THEIR EFFECTS ON CHILDREN 25 seen with the specific type of disaster. In a major earthquake like the one in Haiti in January 2010, one would expect most of the casualties to be secondary to traumatic injuries related to collapsed buildings. Therefore, a team should be prepared to have personnel and supplies that can be used to treat crush injuries and a large number of open wounds, along with a variety of orthopedic injuries. In a disaster involving an explosion (large industrial accident or terrorist attack), the pattern of injuries would include many of the same traumatic injuries as seen in an earthquake, but would also include a large number of burns and blast injuries such as blast lung. Personnel required in this type of disaster should include those with training in caring for burns as well as experience with other traumatic injuries. In the first days following the Haiti earthquake, there were a large number of complex orthopedic injuries that required emergent treatment. These included open fractures, traumatic amputations, and crush injuries. The treatment of these injuries included fracture reductions, wound debridement, and amputations. Thus, it was essential to have personnel with the training to perform the needed procedures. Personnel with training in emergency medicine, general surgery, and orthopedics are best suited to be part of the initial response team when a large number of traumatic injuries are expected. Supplies that were essential in caring for these patients included plaster splinting/casting supplies, wound dressing supplies, and medications for pain control and sedation. When caring for open wounds, the ability to appropriately irrigate and clean wounds can greatly reduce subsequent secondary infections of these wounds. Response teams should come prepared with supplies that would be able to provide pressure irrigation of wounds with either clean water or saline, antibiotic ointments, and large supplies of wound dressings. A large number of the orthopedic injuries can be treated with casting or splinting. Plaster casting material is far superior in this setting because casts made of fiberglass cannot be easily removed without a cast saw, whereas patients/families can be instructed to remove a plaster cast by soaking it in water. Adequate sedation for painful procedures such as amputations and fracture reductions can be safely obtained using either ketamine intravascularly or intramuscularly. Ketamine is the ideal sedative in this situation, as the safety profile is such that it can be used when minimal monitoring equipment is available because it causes minimal respiratory or cardiovascular effects. Procedural sedation with ketamine is a basic skill set of pediatric emergency medicine–trained physicians and can provide adequate sedation and analgesia for most of the procedures that will be needed during the response phase. Box 2 provides a list of pediatric equipment that, if possible, should be brought in. An article in the New England Journal of Medicine by the Israeli mobile hospital reviews the ethical dilemmas encountered in Haiti when the need for care far exceeded the capacity [4]. Among the recommended equipment, elements for proper airway management in children are crucial. A major challenge of any disaster response is gathering, organizing, and moving supplies to the affected area. Resource LYNCH, WATHEN, THAM, ET AL 26 Box 2: Recommended equipment to bring for pediatric emergencies in disaster situations Airway Management/Breathing  Tongue blades  Suctioning machine (portable, battery powered)  Suction catheters: Yankauer, 8, 10, 14F  Simple face masks: infant, child, adult  Pediatric and adult masks for assisted ventilation  Self-inflating bag with 250-mL, 500-mL, and 1000-mL reservoir  Optional for intubation  Laryngoscope handle with batteries (extra batteries AA, laryngoscope bulbs) Miler blades: 0, 1, 2, 3 Macintosh blades 2, 3 Endotracheal tubes, uncuffed: 3.0, 3.5, 4.0, 4.5, 5.0, 6.0; cuffed: 7.0, 8.0 Laryngeal mask airways Stylets: small, large Easycap (ETCO2 analyzer), 2 sizes Adhesive tape to secure endotracheal tube (ETT) Circulation/intravascular access or fluid management  IV catheters: 18-, 20-, 22-, 24-gauge  Butterfly needles: 23-gauge  Intraosseous needles: 15- or 18-gauge, or Eazy IO device  Boards, tape, tourniquet IV  Pediatric drip chambers and tubing  5% dextrose in normal saline and half normal saline  Isotonic fluids (normal saline or lactated Ringer’s solution)  Medications: epinephrine, atropine, sodium bicarbonate, calcium chloride, lidocaine, D25, D10 Miscellaneous  Broselow tape  Nasogastric tubes: 8, 10, 14F  Splints and gauze padding  Rolling carts with supplies such as abundant blankets  Warm water source and portable showers for decontamination  Thermal control (radiant cradle, lamps)  Geiger counter (if suspicion of radioactive contamination)  Personal protective equipment (PPE)  Pain\Sedation medications: ketamine, morphine, ketoralac DISASTERS AND THEIR EFFECTS ON CHILDREN 27  Other potential medications: albuterol, keflex, ancef, Ceftriaxone, Diazepam  Surgical equipment for amputations, incision and drainage of wounds, laceration repairs  Headlamps with replacement batteries  Scissors  Plaster for casting, not fiberglass (hard to remove) Monitoring equipment  Sphygmomanometer/Blood pressure cuffs: premature, infant, child, adult  Portable monitor/defibrillator (with settings <10)  Pediatric defibrillation paddles  Pediatric electrocardiogram (ECG) skin electrode contacts (peel and stick)  Pulse oxymeter with reusable (older children) and nonreusable (small children) sensors  Device to check serum glucose and strips to check urine for glucose, blood, etc. management within the hospital and other facilities or agencies may prove to be a decisive factor in whether a mass casualty event can be handled. Communication in a disaster situation is essential among disaster relief team members as well as with coordinating groups and logistical support personnel in home countries. Modern technology has provided many different types of communication devices, which have different advantages and disadvantages. Radios are useful for short-range communications when a disaster relief team is separated. However, they are limited by range and will not allow communication with the other teams or organizations that are a long distance away. Satellite phones are ideal for communication with the team as well as with the home country. They provide a reliable method of communication when telephone services are not working or there is no infrastructure, because they rely on orbiting satellites to transmit data. However, they are a scarce resource as well as an expensive resource. The main drawback for many portable satellite phones is that the phone’s antenna needs an unobstructed view of the sky. Cellular phones are an ideal method for communication. Voice calls can be made to team members as well as to coordinate in the home country. E-mail and SMS texting are other methods of communicating through the cellular network. Haiti was the first disaster where social media was widely used. For example, our team from The Children’s Hospital was able to arrange the evacuation of a patient via a Blackhawk helicopter to the USNS Comfort through SMS texting and electronic mail alone. With the availability of smart phones such as the RIM Blackberry and the Apple I-phone, access to the mobile Internet has allowed the use of the Internet for communication using electronic e-mail or other social media. Because the voice cellular circuits in Haiti were congested during the day, we communicated with team 28 LYNCH, WATHEN, THAM, ET AL members as well as the United States almost exclusively via SMS text messaging and e-mail through our smart phones. However, cellular technology is dependent on a cellular infrastructure and network that has survived a disaster. Another disadvantage of cellular phones is that different countries have different cellular standards that are not compatible with each other. For example, although the countries of Haiti and the Dominican Republic are on the same island of Hispaniola, each country has a different cellular standard. Haiti uses the GSM (Global System for Mobile Communications) standard, and the Dominican Republic uses the CDMA (Code Division Multiple Access) standard. We encountered relief workers from the Dominican Republic who could not communicate in Haiti because they did not have the right equipment for Haiti. The availability of the Internet through various means including satellite links and data over cellular networks has allowed for many novel methods of communication over the Internet. There are traditional methods such as electronic mail. Web blogs also allow relief workers as well as those affected by the disaster to reach out to the world. Other social media tools such as Facebook and the microblogging service Twitter allow almost instantaneous updates from the field. Haitians and relief workers were able to keep their families and loved ones up to date using social media tools such as Facebook and Twitter. One of the most novel uses of social media was the adoption of the Ushahidi technology to Haiti (http://haiti.ushahidi.com/main). Ushahidi was originally developed for people to report ethnic violence in Kenya so it could be tracked. Using an instance of Ushahidi developed specifically for Haiti, Haitians could send a Creole text message on their cellular phones to the Ushahidi phone number asking for help. The message would be translated to English by translators, mapped, and assigned to a relief organization such as the US military, the United Nations, or other NGOs to complete the task (http://haitirewired. wired.com/profiles/blogs/ushahidi-amp-the-unprecedented). Mental Health Considerations Disaster response providers, especially those coming from developed countries to disasters occurring in developing counties, are often thrust into a high-stress situation with exposure to situations they may have never experienced before. The degree of destruction and death will likely be much greater than what the health care providers are accustomed to dealing with in their daily lives. The emotional impact of large-scale destruction, suffering, and death will elicit different responses in different people, but all volunteer providers should recognize how their experiences can affect their well-being both emotionally and physically. The emotional stress experienced by disaster response providers has been well documented after events such as 9/11 and Hurricane Katrina [5–8]. The affect of stress is amplified by the long hours of intense work experienced during the response to a disaster. Environmental conditions (such as extreme heat/cold/rain/flooding), lack of sleep, and inadequate nutrition impair Behavioral           Increase or decrease in activity level Substance use or abuse (alcohol or drugs) Difficulty communicating or listening Irritability, outbursts of anger, frequent arguments Inability to rest or relax Decline in job performance; absenteeism Frequent crying Hypervigilance or excessive worry Avoidance of activities or places that trigger memories Becoming accident prone Physical          Gastrointestinal problems Headaches, other aches and pains Visual disturbances Weight loss or gain Sweating or chills Tremors or muscle twitching Being easily startled Chronic fatigue or sleep disturbances Immune system disorders Psychological/Emotional        Feeling heroic, euphoric, or invulnerable Denial Anxiety or fear Depression Guilt Apathy Grief Thinking      Memory problems Disorientation and confusion Slow thought processes; lack of concentration Difficulty setting priorities or making decisions Loss of objectivity Social Isolation Blaming  Difficulty in giving or accepting support or help  Inability to experience pleasure or have fun   DISASTERS AND THEIR EFFECTS ON CHILDREN Table 4 Common stress reactions Adapted from The US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA), and Center for Mental Health Services (CMHS). Available at: http://mentalhealth.samhsa.gov/publications/allpubs/SMA-4113/default.asp. Accessed September 2, 2010. 29 30 LYNCH, WATHEN, THAM, ET AL a provider’s ability to deal with the stressful situation. Crisis response workers and managers, including first responders, public health workers, construction workers, transportation workers, utilities workers, and other volunteers, are repeatedly exposed to extraordinarily stressful events. This places them at higher than normal risk for developing stress reactions [9]. It is important for all disaster response providers to recognize the potential emotional stress they will be entering before arriving on scene. Stress prevention and management needs to be considered and addressed from the start of the deployment to prevent problems. By anticipating stressors and individuals’ responses to these stressors, the response team and individuals can potentially prevent a crisis within the team of care providers. The US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA), and Center for Mental Health Services (CMHS) have published a guide focusing on general principles of stress management and offers simple, practical strategies that can be incorporated into the daily routine of managers and workers. It also provides a concise orientation to the signs and symptoms of stress. This can be found online at http://mentalhealth.samhsa. gov/publications/allpubs/SMA-4113/default.asp. Although most people are resilient, the stress response becomes problematic when it does not or cannot turn off; that is, when symptoms last too long or interfere with daily life. Table 4 provides a list of the common stress reactions. SUMMARY Disasters are, to a great extent, beyond our control and inevitable; however, we can be better prepared for the consequences and thus reduce the degree of human suffering. As Vernon Law [10] has said, ‘‘Experience is a hard teacher. She gives the test first and the lessons afterwards.’’ Knowledge and understanding are needed for more effective preparation and planning. Pediatricians have a special role in the planning and preparation process to ensure that the needs of children are adequately considered in this process. Pediatric volunteers should be prepared for their experiences from the standpoint of training, available materials and resources, and mental health considerations. Acknowledgments This article has been adapted from the American Academy of Pediatrics manual on disaster training for developing countries entitled ‘‘Pediatrics in Disasters.’’ References [1] ReliefWeb. Haiti: Earthquake Situation Report #25. Available at: http://www.reliefweb.int/ rw/rwb.nsf/db900sid/EGUA-836R39?OpenDocument&;RSS20&RSS20¼FS. Accessed March 2010. [2] Available at: http://www.google.com/hostednews/afp/article/ALeqM5hOiPk5G7TMLjYsBb Z1ajaBMS_lWg. Accessed March 2010. [3] Sontag D. Doctors haunted by Haitians they couldn’t help. New York Times. February 12, 2010. Available at: http://www.nytimes.com/2010/02/13/world/americas/13doctors. html?hp. Accessed March 2010. DISASTERS AND THEIR EFFECTS ON CHILDREN 31 [4] Merin O, Ash N, Levy G, et al. The Israeli Field Hospital in Haiti—ethical dilemmas in early disaster response. N Engl J Med 2010;362(11):e38. [5] Levenson RL Jr, Acosta JK. Observations from ground zero at the World Trade Center in New York City, part I. Int J Emerg Ment Health 2001;3(4):241–4. [6] Centers for Disease Control and Prevention (CDC). Mental health status of World Trade Center rescue and recovery workers and volunteers—New York City, July 2002-August 2004. MMWR Morb Mortal Wkly Rep 2004;53(35):812–5. [7] Bills CB, Levy NA, Sharma V, et al. Mental health of workers and volunteers responding to events of 9/11: review of the literature. Mt Sinai J Med 2008;75(2):115–27. [8] Palm KM, Polusny MA, Follette VM. Vicarious traumatization: potential hazards and interventions for disaster and trauma workers. Prehospital Disaster Med 2004;19(1):73–8. [9] Pan American Health Organization. Stress management in disasters. Washington, DC: Pan American Health Organization; 2001. [10] Nathan, David H. The McFarland Baseball Quotations Dictionary. McFarland & Company; 2000. ISBN 9780786408887.