40 Years of Steady Improvement in the Approach to Preparedness

In 1976, a major shift took place in the field of humanitarian disaster response. Several disasters occurred in a relatively short period of time in a same geographical region. The most significant of these were earthquakes impacting Peru in 1970, Nicaragua in 1972, and Guatemala in 1976. These caused significant devastation and loss of life, and the ministers of health in Latin America and the Caribbean subsequently called for changes in the international humanitarian response mechanism. Until that point, disaster response was mostly reactive both at the national and international levels.

Recognizing the shortcomings of an improvised disaster response, these ministers of health requested assistance from the Pan American Health Organization (PAHO) to propose ways to reduce disaster health consequences. PAHO is the regional office for the World Health Organization (WHO) in the Americas. In response, PAHO created a disaster preparedness program that improved the national capacity for responding to catastrophes. The resulting plan, passed as Resolution X at the PAHO 24th Directing Council, called on member states to, “develop plans, and, as necessary, enact legislation, set standards, and take preventive or palliative measures against natural disasters and disseminate these measures throughout the sectors concerned [with] coordinating their action with that taken by the corresponding services of the Pan American Health Organization.”² Passage of this resolution represented a turning point in disaster response strategy, switching from an ad hoc response to a systematic preparedness approach. What was considered by many as an act of God or nature became viewed as an event with consequences that could be significantly reduced by improving governmental and institutional preparedness.

In the field of public health, disasters are defined as situations in which the local health response capacity is overwhelmed to the point that external (often international) assistance is required. Typically, in these events, the number of injuries and deaths exceeds the level the emergency services can absorb. At the same time, the health system loses capacity because its infrastructure is seriously affected or completely overwhelmed and healthcare personnel have suffered injuries and deaths or are unable to work.

Hence, disasters are situations in which a system can no longer meet the demands for health and medical services. The science of disaster response integrates all existing resources to increase capacity and address the needs that could not be met using standard operating procedures. The central objective of a disaster program is to prepare entities for coordination of necessary resources to reduce the disaster’s negative impact on health. The funding needed for preparedness activities can be relatively small; what is most needed is the political support empowering the disaster management entity to assume the necessary leadership role to conduct the coordination function. It is very difficult for politicians to invest resources in the management of disasters as such events are rare and unlikely to occur during the tenure of any one individual. In addition, efforts invested in disaster preparedness are much less likely to attract the interest of voters.

More recently, the concepts reflected in Resolution X have been applied not only to “natural” disasters but to all hazards. This preparedness methodology is now widely accepted and used to address any public health event of international interest, such as a possible influenza pandemic, as described in the International Health Regulations (IHR).³ Professionals in the field of chemical and radiological disasters have also adopted similar preparedness approaches.^4–6

The first pillars of health preparedness began in the late 1970s with simulations or tabletop exercises, and drills or live exercises that included the participation of several institutions through a multidisciplinary approach. Following suit, a number of countries started preparedness planning in their hospitals and later expanded activities to other institutions such as water systems.⁷ Presently, a wealth of guidelines exist on the web covering a variety of topics, from establishing an Emergency Operations Center to describing the amount of water in liters that should be distributed to displaced populations or those in shelters.^8–10 This and other information can now be found at virtual knowledge centers such as the Knowledge Center on Public Health and Disasters.¹¹

Training in disaster preparedness has expanded over these last few decades. According to a survey performed in 2003, 70% of the faculties of medicine in Latin America and the Caribbean were teaching at least a few hours of disaster management.¹² A sample of the most frequent topics included in such trainings is listed in Table 5.1.

Health and disaster legislation has also greatly improved.^13,14 In many countries, the progressive expansion of health and disaster-related standards and legislation resulted largely in response to the occurrence of disasters. These events helped governments identify problems and propose solutions. Based on these experiences, research activities, and field work, new standards and legislation were eventually created.¹⁴ Some examples of these are found in countries where they form the basis of establishing hospital emergency committees and defining hospital construction standards. On a broader scale, subregional institutions – such as the Ministries of Health for Central America, South American Andean Countries, and South East Asia – also pass resolutions providing standards and defining the scope of regulations that form and implement a National Disaster Relief and Prevention System.

Although great progress has been made in preparedness, issues first identified in the 1980s remain as significant challenges. For example, nongovernmental organizations (NGOs), representatives from governments, and United Nations (UN) agencies met in Costa Rica in 1986 and established a series of specific recommendations to guide direct international donations (see Table 5.2).¹⁵

Although these approved policy guidelines have been updated over time, relief agencies remain far from being compliant with the recommendations. Examples of such noncompliance are reflected in the continually perpetuated disaster myths and misconceptions of disaster management realities, which contradict these recommended standard procedures (see Table 5.3).

In the 2010 Haitian earthquake, more than 400 health and medical groups provided services. While several were excellent, many of them were of questionable skill and efficiency, and some may have actually inflicted harm.¹⁶

From Preparing the Response to Mitigating the Impact

In a perfectly designed health disaster preparedness plan, all existing resources, including those at the local, national, and international levels, are used in the most efficient way to minimize the number of lives lost, contain diseases, and limit disabilities. However, preparedness has it limits as reality has shown. The Mexico City earthquake of 1985 illustrated the limits of preparedness, when one of the best-prepared medical response teams in the city was killed in a hospital collapse. Almost 20 years later, Hurricane Ivan struck Grenada in 2004 (a Caribbean island of 90,000 inhabitants). The country suffered such a level of destruction that no response could be generated from the island’s resources, regardless of its previous preparedness level. The 2010 earthquake in Haiti destroyed most public buildings and homes in the capital. The 2011 Tōhoku earthquake and tsunami in Japan that caused a nuclear reactor breech and released radiation surprised authorities who did not plan for a combination mega-disaster with all three events taking place nearly simultaneously.

These extreme situations illustrate the limits that preparedness can achieve. If destruction is complete and only victims remain after a major disaster, such as in the Philippines after Typhoon Haiyan in 2013, there is little that a preparedness approach can offer, no matter how well developed it is. These types of situations require a different perspective and new approach. The new approach developed after the 1985 earthquake in Mexico is based on the concept of mitigation, emphasizing protection of infrastructure and the health system.

In 1987, the UN Assembly adopted a resolution launching the International Decade for Natural Disaster Reduction.¹⁷ Its goal was to reduce loss of life, property damage, and social and economic disruption caused by disasters, especially in developing countries. The resolution establishing the International Decade for Natural Disaster Reduction was implemented in 1990.¹⁸ The concept of mitigation was born.

Later, the mitigation approach helped produce the concept of risk reduction, which recognizes the importance of moving beyond preparedness. Risk can be defined as a function of the hazard and vulnerability in which the hazard is an environmental (e.g., earthquake or hurricane), technological (e.g., chemical or radiological accident), or political (e.g., war or civil strife) event. The essential idea of mitigation focuses on separating the hazard (an earthquake or biological agent) from the vulnerability of the institution or the system. If a building collapses, it is not attributed to the earthquake; rather, it was a consequence of poor building design or failure to use appropriate shake-resistant construction techniques.

Since the late 1980s, an ongoing effort has existed in the health sector, especially in Latin America and the Caribbean, to protect health facilities so that life-saving functions can continue after a disaster. In the beginning, efforts centered on mitigating and refurbishing health facilities. Currently, the approach includes a more comprehensive vision, not just focusing on the construction aspects (structural and nonstructural dimensions), but also considering the functional aspects of a hospital.^19,20 In this context, “functional” refers to all organizational components needed to provide service.

Enormous progress has been achieved in the field of mitigation. For example, methodologies now exist that can produce a vulnerability analysis for buildings. This is the detailed study on how a building would perform if a maximum magnitude event (such as an earthquake or hurricane) occurs. The information generated by these analyses provides guidance on how to improve construction and revise existing building codes.

Mitigation can be a very efficient strategy. For example, some structures have been protected from collapse through targeted adjustments, such as retrofitting. The cost of the additional construction requires a relatively small financial investment compared with the overall value of the building. However, mitigation can be expensive when applied to existing facilities in poor condition and it frequently reaches the point at which it is too expensive to be considered. Hence, a lower cost approach is needed to reduce vulnerability.

From Mitigation to Resilience

In the late 1990s and early 2000s, the increasing engagement of financial institutions in risk reduction opened the door to considering new incentives and justifications for such activities in addition to typical health-centered metrics such as lives saved. Participating institutions included the World Bank through its Global Facility for Disaster Reduction and Recovery and regional banks in Asia and Latin America.^21,22

Increasingly, studies demonstrate that the perception commonly accepted 40 years ago, that it is too costly to make a society resilient to disasters, does not hold true. Contrary to earlier thoughts, if mitigation is part of the development process, it is not too costly to make a society disaster resistant. For example, when hazards are taken into account before construction begins, the increase in expenditures represents less than 4% of the total construction cost.²³

Although cost is an essential factor in justifying risk reduction, it is not the only element. It would be unacceptable to construct a critical facility, such as one providing an emergency service, in so suboptimal a manner that it collapses during an earthquake simply due to financial considerations.

The integration of these financial and other technical considerations is an extremely positive step, as it allows development professionals to include “risk reduction” in their projects. The end result is an improvement in society without increasing the risk from disasters. For example, development professionals have begun to take into consideration locating critical services on higher ground, instead of flood prone areas. With these advances, it is possible to design technical tools and to train experts to conceive new development projects in such a way that they will remain functional even after a major event occurs.²⁴ The objective is no longer simple mitigation, but to build resiliency by considering vulnerability in a more comprehensive way through the risk reduction approach.

Although at the time of this writing the risk reduction approach is still in the initial stages of development, it has already generated some results. The World Bank established an online tutorial for “Strengthening essential public health functions,” and one of these essential functions refers to disasters.²⁵

This tool allows the user to estimate a country’s level of preparedness and some aspects of risk reduction. Another example is the WHO/PAHO Hospital Safety Index.²⁶ This instrument allows trained local professionals to assess the safety level of health facilities. By applying this tool, government authorities can determine the likelihood that health and medical facilities will remain functional during and after exposure to known hazards.

Additional medical tools have also been developed to improve the quality of patient care. These instruments provide guidance on how to ensure quality care in disaster situations. For example, the U.S. Institute of Medicine within the National Academies has proposed a series of protocols referred to as “Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response.”²⁷ Many organizations have succeeded at improving the quality of care under catastrophic conditions. In 2012 and 2013, groups such as the ICRC (the International Committee of the Red Cross), MSF (Médecins Sans Frontières), and AusAID (Australian Agency for International Development) have developed their own guidelines, especially for the delivery of care during armed conflicts.

The UN launched a 2-year campaign in 2008 called “Hospitals Safe from Disasters” to ensure that these institutions are prioritized in reducing their vulnerability to hazards. Spearheaded by WHO and the UN International Strategy for Disaster Reduction (UNISDR), “the campaign will focus on structural safety of hospitals and health facilities, on keeping health facilities functioning during and after disasters, and on making sure health workers are prepared when natural hazards strike.”²⁸

However, simply having safe structures and processes may not be comprehensive enough or may not apply to a given situation. For example, countries with very weak economies could not expect to have a state of the art safe society in a decade. However, these countries could improve their overall disaster readiness by increasing their resilience. UNISDR defines resilience as the ability of a system, community, or society exposed to hazards to resist, absorb, accommodate to, and recover from the effects of the hazard in a timely and efficient manner, including through the preservation and restoration of its essential basic structures and functions. The principle is to permit a community to experience the disaster with the capacity to absorb the impact without sustaining significant permanent damage. The first practical definition and documentation of resilience was achieved by the United Kingdom’s Department for International Development in 2011.²⁹ Hundreds of such projects now exist, created by this British agency in support of community resilience.

Although this topic has been proposed previously in other forms, the concept of resilience goes far beyond what has been done to date by the humanitarian community. It requires that all development activities fully embrace disaster risk and ensure that all tools are used in an integrated manner.

Shift in the Institutional Approach

Both governmental and regional institutions have significantly improved their disaster management efforts over the last 40 years. In a recent WHO survey report, 85% of the Ministries of Health globally have policies or programs related to disaster preparedness.³⁰ In Latin America and the Caribbean region, all countries with more than 20 million inhabitants have a formal multidisciplinary disaster agency and a staffed national disaster coordination office within the Ministry of Health.^31,32 The goals of these groups are civil protection and disaster risk reduction at the national level. These departments within the Ministries of Health are the designated entities for protecting the public’s health from the consequences of disasters. The national disaster coordination office’s mission is to ensure the synchronization of all governmental disaster reduction efforts. These agencies promote preparedness and risk reduction responsibilities across all sectors, such as a federal emergency management agency or other organizations that provide civil protection. Over the last few years, especially since the adoption of the international health regulation renewed mandate, Ministries of Health have developed centers that catalogue information and coordinate responses for events with international consequences.³³ Such events include epidemics and any event occurring at a border, such as a volcanic eruption. In some countries, like the United States, the offices responsible for IHR and disaster management are integrated into the same department within the government.

Although these achievements represent a major step forward in national preparedness, the sustained improvement in quality and institutional continuity of these offices still relies on the frequent occurrence of disasters. In fact, the rate at which disasters occur has a substantial impact on institutional development of these agencies. Just as these national disaster programs and offices were established or have been significantly strengthened as the consequence of a catastrophe, they have also experienced reductions in their capacity or disappeared entirely when such events do not occur for prolonged periods. This tendency has been noted in both wealthy and developing countries. In the latter, a change of government is another common reason for reducing the disaster preparedness investment or for assigning new personnel with no experience to these offices. In countries where the percentage of career disaster employees is small (staff that earned their position rather than being politically appointed), it is difficult to maintain a capable disaster management program. The absence of a disaster in such countries is a threat to institutionalizing preparedness and changes the nature of the roles and functions within these offices. With time, these agencies focus increasing attention on smaller events. When a government institution attends only to smaller emergencies, it loses its perspective and hence its capacity for cross-cutting coordination – its main function. Over time, the institution will isolate itself from other administrative entities and it will lose its close relationship with the top authority.³⁴

On the international scene, similar progress and challenges exist. In 1974, the international community made a significant commitment with the creation of the UN Disaster Relief Organization (the precursor entity to the Office for the Coordination of Humanitarian Affairs, OCHA) as a way to improve the international response to disasters. The reaction to the 2004 tsunami in Southeast Asia clearly showed that OCHA and many other agencies could successfully deliver aid, but also suggested that a stronger mechanism is needed to make the international response more efficient. Establishing a mechanism that attracts and coordinates more UN agencies (as is intended by UN humanitarian reform efforts) is an important step, but remains insufficient on its own.

Even in an ideal situation, in which all UN agencies and major NGOs agree to coordination using a single unified command structure, planners could not guarantee the most effective response. Instead, the efficiency of international assistance is mostly dependent on the recipient country’s capacity to absorb, coordinate, and distribute the deluge of resources that could reach the affected population. Any international response effort that is not strictly and exclusively complementary with the national response will result in competition with, and disruption of, the country’s relief activities. In other words, the best international humanitarian response is the one that complements the local response. The only exception to this is when no local organization exists or when the local authority is the reason for the chaos, such as in some complex public health emergencies (see Chapter 27). Even in those rare situations when the local population relies primarily on an international response, the objective must remain to rebuild the local response capacity that existed before the disaster. International assistance cannot be considered successful if the recipient country is left with minimal institutional capacity when support is withdrawn.

Institutionalization of Knowledge

Four decades ago, disaster-related issues were viewed simplistically, primarily guided by the lack of resources and the limited number of professionals in the field. The decision-making process was also less complex, because those issues that could be addressed were solved quickly and efficiently because few people were involved. Today, with the availability of more human and financial resources, institutions are compelled to both raise and respond to more complex issues. As a consequence, this expansion of the field requires a lengthy and more sophisticated consultation process, through networks of various professionals and professional associations.

The knowledge base for the field of international humanitarian assistance increases every day. This explosion of information is reflected not only in the number of experts in the field, but also in the number of related scientific and technical publications. A few examples are listed in Table 5.4.

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