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Improving the Art and Science of Disaster Medicine and Public Health Preparedness

      Media reports from around the world contain stories almost daily of natural or man-made disasters and their consequences. Although it is tempting to attribute these reports to both proliferation of the modern media (with 24-hour-a-day, 7-days-a-week coverage) and the public's appetite for bad news, it is also true that natural disasters are increasing in magnitude and freqeuncy and will continue to affect immense numbers of people.
      • Hoyois P
      • Scheuren J-M
      • Below R
      • Guha-Sapir D
      The reasons for this increase are multifactorial but are based in large measure on 3 important developments that are related: (1) overpopulation,
      • United Nations Department of Economic and Social Affairs, Population Division
      (2) population migration to cities (urbanization) and to coastal areas,
      • United Nations Department of Economic and Social Affairs, Population Division
      and (3) climate change.
      • Bernstein L
      • Bosch P
      • Canzioni O
      • et al.
      The world's population is currently estimated at more than 6.5 billion and is growing, with disproportionate growth in Asia (particularly China and India), Africa, and South America.
      • Hoyois P
      • Scheuren J-M
      • Below R
      • Guha-Sapir D
      Overpopulation increases the demand for goods (eg, food, shelter) and the burden on essential services (eg, health care) and natural resources (eg, oil, coal, water). These factors, along with poverty and political instability, make for a fragile environment indeed for large populations who, in the event of disaster, have little reserve to care for themselves.
      Increased migration to cities and coastal regions, spawned by the globalization “gold rush” (ie, a phenomenon in which people move to cities in developing countries because of economic growth driven by globalization), has also made populations increasingly vulnerable to disasters. Projections from the United Nations indicate that, by 2030, 60% of the world's population will reside in cities.
      • United Nations Department of Economic and Social Affairs, Population Division
      These denser communities provide greater opportunity for transfer of communicable diseases. Vulnerability to infectious pathogens is magnified by unsafe water supplies at one end of the socioeconomic spectrum and global travel and shipping at the other.
      The third overarching development, climate change, poses great risk to coastal communities around the world, regardless of debate about its causes.
      • Bernstein L
      • Bosch P
      • Canzioni O
      • et al.
      Many cities in developing countries, particularly on the Pacific Rim, are located in marginally habitable environments, making inhabitants especially susceptible to natural disasters.
      • World Health Organization
      People in low-lying environments are more susceptible to floods, hurricanes, and some forms of infectious diseases and—particularly in the Southeast Asian Pacific Rim—are at risk from earthquakes.
      Global vulnerability to disasters is magnified by the continued threat of terrorism as well as the rise of rogue regimes and dictators who have substantial arsenals with which to inflict damage. Inadequate inventory and control of radioisotopes suitable for making weapons, as well as human rights abuses, are of paramount concern to the population at large.
      None are invulnerable to disasters. Despite the affluence of the United States, one need not look back too far to be reminded of the destruction and human suffering generated by hurricanes Hugo (1989), Andrew (1992), Floyd (1999), and Katrina (2005); the terrorist attacks of September 11, 2001; the Loma Prieta earthquake in northern California (1989); and the Northridge earthquake in southern California (1994). In each of these disasters (and despite the noble efforts of many citizens and agencies to care for the public), there were deficiencies in the way public assistance (including health care) was delivered, in part because the involved governments, nongovernmental agencies, and public were not optimally prepared.
      Although scientific and technologic advances have ensured progress in the way we address disaster medicine and public health preparedness (DMPHP), our current capacity to respond is far from optimal, in part because of inadequate systematic evaluation of the successes and failures of past and current disasters that could yield information potentially useful in preparing for the next disaster. Better coordination is needed to bring interested individuals and organizations together so they can share information and lessen the sequestration of critical information. One such effort was the American Medical Association's (AMA's) formation in 2002 of the Center for Public Health Preparedness and Disaster Response (CPHPDR). In partnership with public and private agencies and organizations, the CPHPDR is developing and implementing a comprehensive program to increase professional knowledge andpublic understanding of all-hazards preparedness and response efforts and capabilities. Among its many activities, the CPHPDR oversees the National Disaster Life Support (NDLS) program. This program, developed in concert with 4 academic institutions and introduced in 2003, provides multidisciplinary education to the prehospital, hospital, and public health communities through standardized courses and curricula.
      The NDLS training network includes 47 training centers (mostly university-based) and 1700 certified instructors. From its inception to the present, the NDLS program has trained more than 35,000 health system responders (including active-duty US soldiers) across 44 states.
      The CPHPDR recognizes that optimal sharing of ideas is contingent on input from and cooperation among government agencies (at all levels), physicians, basic scientists, epidemiologists, public health experts, engineers, logistics experts, economists, mass communication experts, meteorologists, and others. However, no forum currently exists in which these professional communities can share their ideas. Whereas some (eg, physicians, basic scientists, epidemiologists) publish in the indexed medical journals, others disseminate their ideas in nonindexed literature, intradepartmental or interdepartmental communications, or not at all. Consequently, cutting-edge information on DMPHP is often sequestered in metaphorical silos, out of reach of many who might benefit from it.
      Success in DMPHP also involves having people from different professional and social cultures work together, speak a common language, and avail themselves of monitoring and criticism. It is possible to approximate ideal interactions among involved groups in response to a disaster using the 5 Cs: comprehend, communicate, cooperate, coordinate, and critique (Table).
      TABLEFive Cs of Disaster Response
      • Comprehend
        • Determine the nature and magnitude of the problem, the populations at risk, and the resources needed to deal with it
      • Communicate
        • Inform the population at risk and the organizations that will help respond to the threat
      • Cooperate
        • Gain cooperation from all groups that can help evaluate and address problems; foster private-public partnerships
          More than 80% of assets for the medical and public health response exist in the private sector, and controllers of these assets need to cooperate with one another and the public sector after disasters.5
      • Coordinate
        • Establish leadership and systems to coordinate the resources and services directed at the problem and focus on improving the comprehensiveness and efficiency of the remediation efforts
      • Critique
        • Continuously evaluate responses during and after the event, both to improve the quality of responses related to the existing remediation and also to gain information and skills that apply to addressing future events
      a More than 80% of assets for the medical and public health response exist in the private sector, and controllers of these assets need to cooperate with one another and the public sector after disasters.
      • US Department of Homeland Security
      Pandemic influenza preparedness, response, and recovery guide for critical infrastructure and key resources. September 19, 2006.
      One need look no further than the more highly praised elements of the response to the recent Interstate 35W bridge collapse in Minneapolis, MN, to see the benefits associated with adherence to the 5 Cs. Conversely, the more highly criticized elements of the response to the 2005 Hurricane Katrina disaster (addressed in this issue of Mayo Clinic Proceedings
      • Khoo TK
      • Smith SA
      After Katrina: quality of life among New Orleans residents with diabetes [letter].
      ) demonstrate the problems that arise when the 5 Cs are not optimally implemented
      • Khoo TK
      • Smith SA
      After Katrina: quality of life among New Orleans residents with diabetes [letter].
      • Fragos Townsend F
      • Davis T
      • Rogers H
      • Shayes C
      • et al.
      • Committee on Homeland Security and Governmental Affairs, US Senate
      • US Government Accountability Office
      • Jenkins Jr, WO
      • Lister SA
      OpenCRS (Congressional Research Reports for the People). Hurricane Katrina: the public health and medical response. RL33096, Washington, DC: Congressional Research Service, Library of Congress, September 21, 2005.
      : many resources are not made available, those that are available are not optimally distributed, human suffering increases, and relief efforts become fiscally inefficient.
      • Khoo TK
      • Smith SA
      After Katrina: quality of life among New Orleans residents with diabetes [letter].
      • Fragos Townsend F
      • Davis T
      • Rogers H
      • Shayes C
      • et al.
      • Committee on Homeland Security and Governmental Affairs, US Senate
      • US Government Accountability Office
      • Jenkins Jr, WO
      • Lister SA
      OpenCRS (Congressional Research Reports for the People). Hurricane Katrina: the public health and medical response. RL33096, Washington, DC: Congressional Research Service, Library of Congress, September 21, 2005.
      A broad overview of the budding discipline of DMPHP reveals unlimited opportunities to study, learn, and affect change. These opportunities demand that some entity or entities lead in prioritizing and focusing future activities. Indeed, this sort of leadership is emerging; the AMA's CPHPDR is but one example. Within the federal government, the Pandemic and All-Hazards Preparedness Act provided funding for disaster medicine education to increase the medical and public health workforce.
      Pandemic and All-Hazards Preparedness Act. Pub L No. 109-417, §101 et seq.
      More recently (October 2007), Homeland Security Presidential Directive 21 (HSPD 21) identified goals for DMPHP progress and set deadlines for major milestones.
      Specifically, HSPD 21 dictates that, within 1 year of October 2007, the Assistant Secretary for Preparedness and Response introduce criteria for developing disaster-related medicine and public health as a formal discipline (as distinguished from a specialty) and develop curricula for training programs. Within this same 1-year period, the government must establish a national disaster university as a component of the Uniformed Services University of the Health Sciences.
      One of the deficiencies in DMPHP noted by the CPHPDR was the lack of a central coordinating journal (or journals) in which to share DMPHP information. As a result, bits and pieces of relevant information were published in a variety of journals, with little opportunity for broad-based sharing among multi-specialty experts. To address this issue, the AMA and CPHPDR in 2007 launched a new scientific publication, Disaster Medicine and Public Health Preparedness, an official AMA publication, charged with establishing and advancing the art and science of DMPHP. The new journal, recently indexed by the National Library of Medicine, will pioneer development in the growing discipline of DMPHP and serve as an example and test case for DMPHP journals that follow. If journals of this genre are to succeed and flourish, they will need to overcome the obstacles imposed by information silos and to persuade experts from disparate fields to relinquish some of their provincial turf, publicly share ideas, and develop a common idiom to encourage communication regarding disaster preparedness.
      The CPHPDR and the Disaster Medicine and Public Health Preparedness journal staff recognize that many responses to disasters are best studied in real time, which could require restructuring the approach to evaluation, including the way in which journals investigate disaster responses. As a test case, the Disaster Medicine and Public Health Preparedness staff asked experts to offer immediate analysis of the shooting of college students and faculty at Virginia Polytechnic Institute and State University (ie, Virginia Tech).
      • Kaplowitz L
      • Reece M
      • Hershey HJ
      • Gilbert CM
      • Subbarao I
      Regional health system response to the Virginia Tech shootings.
      The journal also dispatched investigational teams immediately after the category EF5 tornado destroyed most of Greensburg, KS.
      • Ablah E
      • Tinius AM
      • Konda K
      • Synovitz C
      • Subbarao I
      Regional health system response to the 2007 Greensburg, Kansas F5 tornado.
      Articles related to both events were published within weeks of the disasters. Although these methods must be evaluated and refined, and they resemble a journalistic approach, the restructured approach envisioned by the CPHPDR and the journal staff is anything but traditional journalism. Instead, rapid recording and analysis of responses to disasters by experts could evolve into a novel modern science.
      The combined efforts of the CPHPDR and federal initiatives are merely initial steps in a long journey to improve the study and application of DMPHP. These efforts build on the prior and ongoing contributions of such other groups as the American Red Cross, US Coast Guard, World Association for Disaster and Emergency Medicine, and the journal Prehospital and Disaster Medicine. The collective goals of these initiatives are to focus the field, to obtain greater contributions from talented people of diverse backgrounds, and to encourage communication among them. This new direction for DMPHP has received written support (published in Disaster Medicine and Public Health Preparedness) from the secretaries of the US Departments of Homeland Security
      • Chertoff M
      Department of Homeland Security [letter].
      and Health and Human Services
      • Leavitt M
      Department of Health and Human Services [letter].
      ; from the World Health Organization
      • Alwan A
      World Health Organization [letter].
      ; from the presidents of the American Red Cross,
      • McGuire J
      American Red Cross [letter].
      AMA,
      • Plested III, WG
      American Medical Association [letter].
      and American Nursing Association
      • Patton RM
      American Nurses Association [letter].
      ; and from the chief executive officer of the American Public Health Association.
      • Benjamin G
      American Public Health Association [letter].
      With the support and cooperation of these influential individuals and organizations, we believe the evolving field of DMPHP can move more directly to mature study and remediation of problems.
      Just as the discipline of biochemistry (and its accompanying journals) once evolved from the interests of individual experts in organic chemistry, zoology, botany, and other fields, and the discipline of genomics from the interests of individual biochemists, geneticists, pharmacologists, and others, we envision that the discipline of DMPHP will evolve in response to proper input and nurturing from experts with diverse backgrounds.
      • Subbarao I
      • Lyznicki JM
      • Hsu EB
      • et al.
      A consensus-based educational framework and competency set for the discipline of disaster medicine and public health preparedness.
      • American Medical Association, American Public Health Association
      It is hoped that more journals focusing on this discipline will emerge, as will professional organizations and training programs. If successful, this scholarly intercourse and sharing of resources will yield benefits for humankind worldwide.

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        • Hoyois P
        • Scheuren J-M
        • Below R
        • Guha-Sapir D
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        • United Nations Department of Economic and Social Affairs, Population Division
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        • American Medical Association, American Public Health Association
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