Public Health Management After Natural Disasters

"We lose sight of these disasters when the cameras are gone," warned Dr. Eric Noji, former Centers for Disease Control and Prevention chief of Epidemiology, Surveillance, and Emergency Response, on June 17, 2008. Noji, along with his colleagues, Drs. Frederick "Skip" Burkle and Lynn Lawry, led a timely discussion on public health management before, during, and after natural disasters. Drawing on their extensive domestic and international disaster relief experience, as well as recent crises such as Hurricane Katrina, the Sichuan earthquake, and Cyclone Nargis, the three commented on the public health consequences of natural disasters, the current state of international humanitarian assistance, and priorities for health system reconstruction.

Understanding and Preventing Public Health Emergencies

Dr. Noji opened the event by outlining the historical development of public health response to natural disasters. He specifically addressed the progress of data collection over the last 20 years, highlighting its role in aiding decision-making in the wake of a disaster as well as in mitigating future health emergencies. Noji explained that with adequate health information infrastructure, gaps can be identified; health care priorities can be established and reassessed after tracking trends; resources can be targeted appropriately; epidemics can be quickly detected; and programs can be evaluated for effectiveness. Additionally, Noji commented on the limitations of the current disaster medicine field, such as low pay for professionals, high management turnover, low institutional memory, and poor programming funding—all of which make the above goals difficult to reach. He concluded, "The bottom line is: We know what's wrong. Bottom line. What we need now are positive action[s] in response to what we already know—not rhetoric, platitude, and reciting the same old, same old."

After the Dust Settles

Dr. Frederick Burkle, senior fellow at the Harvard Humanitarian Initiative and Woodrow Wilson public policy scholar, began his presentation explaining that public health emergencies occur when disasters seriously damage health systems and its "protective infrastructure," such as water and food supply, sanitation, shelter, communication, and transportation. "One of the common themes of all complex emergencies of the last three decades is that the public health and health systems are the first to be destroyed and the last to be recovered," he said. When these factors are absent or inadequate, there are serious health consequences.

Burkle used New Orleans as example, explaining that Hurricane Katrina devastated public health and other social systems, resulting in poor access and surveillance. The result was a 47 percent mortality increase over the baseline a year after the event. As in internal conflict situations, indirect deaths and illness dramatically increase after natural disasters because health workers are sparse, mass displacement occurs, living conditions deteriorate and become overcrowded, food is hard to find, and livelihoods are disrupted. "We don't monitor [indirect consequences] very well because for the most part everybody leaves. The evaluation is over after the event and we find out what the direct effects are. But over time . . . there are more indirect mortality and morbidity than from the event itself," he stated.

Protecting the Vulnerable

Noji identified poverty and social inequality, rapid population, and environmental degradation as factors that contribute to the severity of disasters. He argued that in order to protect susceptible populations, these issues needed to be addressed through health, environmental, and foreign policy. Burkle continued this dialogue by explaining that vulnerability also depends on national, cultural, and environmental factors. During Katrina, those at highest risk were below the poverty line and had no access to a car. In many developing nations, those that live in highly populated, disaster-prone urban areas with nonexistent public health infrastructures are extremely susceptible to disaster. "Generally, disasters keep governments honest because they define public health immediately . . . by exposing the inequities and deficiencies," Burkle stated.

Effective disaster response, he maintained, is dependent on rapidly mobilizing Health Information Systems, providing essential services, and targeting at-risk groups. Burkle explained that children, the elderly, and women are almost always at higher risk. Dr. Lynn Lawry, director of Research and Education at the Center for Disaster and Humanitarian Assistance Medicine at the Uniformed Services University of the Health Sciences, echoed this, but also added that this susceptibility continues long after the immediate incident. She noted that after every hurricane she has reviewed over her career—including Katrina—rape and violence against women increased.

The Road to Recovery

Though the event discussed natural disasters worldwide, the speakers used many examples from Hurricane Katrina. Lawry reminded the audience, "Even the best societies' public heath systems can be destroyed. I think we saw this with Katrina." She noted that inadequate shelter, unclean water, and lack of security were some of the most commonly reported problems a year after the event. Furthermore, two years out, New Orleans residents were still having difficulty filling prescriptions due to the lack of healthcare providers. Lawry argued, however, that supplying basic services and security is essential to maintain the mental and physical health of populations affected by disasters. "Without adequate resources and access and availability to health care internationally, internally displaced [persons]will not have the opportunity to help themselves and they will develop reliance on already stretched local and federal funding as well as international funding," she stated.

Lawry also stressed the importance of classifying disaster victims. She explained that labeling them with such terms as "internally displaced," "refugees," and "evacuees," qualifies them for different levels of protection, funding procedures, and constraints. "Those planning and leading recovery efforts have to understand internationally displaced persons in a more global context. You can't just call them, quote, ‘evacuees' or ‘displaced', otherwise you miss all the lessons learned," she said.

Gaining Security Through Public Health

The event concluded with a discussion of long-term reconstruction. Burkle highlighted the critical need for rebuilding health and related systems in not only a timely manner, but in a way that establishes sustainable infrastructure. For poor nations, it is critical to transition from a recovery period into a development framework—a task that disaster management professionals have not figured out how to do effectively, he said. Burkle concluded by urging leaders and policymakers to frame public health as a global security issue. Traditionally, they have focused on national disaster management; yet globalization requires us to look at the bigger picture and develop stronger health infrastructures and emergency response systems worldwide.

Drafted by Kai Carter.