DECISION MAKING AND SPECIAL POPULATIONS IN PUBLIC

HEALTH DISASTERS

Joseph J. Contiguglia MD MPH&TM MBA

Clinical Professor of Public Health

Tulane University SPH&TMFEMA EMI HIGHER EDUCATION CONFERENCE, JUNE 2012

DISASTER

OVERVIEWLESSONS FROM THE FIELD

IntroductionIts Not Your Father’s PlanetNeeds of the Population at RiskEnabling the Population at LargeMorale of the TeamExtend the Routine

OVERVIEWLESSONS FROM THE FIELD

Plan for the WorstTime is of the EssenceShelter & EvacuationYou Can’t Always Get What You

WantPlans are Nothing, Planning is

EverythingCommunications

LESSON 1ITS NOT YOUR FATHER’S PLANET ANY MORE

Population GrowthUrbanizationLife ExpectancySpecial Needs PopulationsWaterFoodDisaster FrequencyConflict

GLOBAL POPULATION GROWTH

Urban– 1800 – 3%– 2000 – 47%

http://www.census.gov/

Overall– Today – 6.8 B– 2040 – 9B

GLOBAL POPULATION GROWTH: URBANIZATION

http://www.census.gov/

GLOBAL POPULATION GROWTH: DENSITY

http://www.census.gov/

LIFE EXPECTANCY US Today 1950 1900

– Male 75.6 65.5 47.9– Female 80.8 71.0

51.7U.S. BUREAU OF THE CENSUS

SPECIAL NEEDS

AgeDisabilityMedicalAcute InjuryPsychologicalCulture & Lifestyle

WATERHierarchy of needsWHO

–78 percent of the population in less developed countries is without clean water

–85 percent without adequate fecal waste disposal

CHOLERA, 1883

THE UNWELCOME VISITOR

WORLD HUNGERPovertyEconomic

SystemsConflictClimateBut the world produces enough food

– 2720 kcal/person/dayUNITED NATIONS FOOD AND AGRICULTURE ORGANIZATION OCT 14, 2009

DISASTER TRENDS The number of people affected by

disasters is rising. Disasters are becoming less deadly. Disasters are becoming more costly. Poor countries are disproportionately

affected by disaster consequences. The number of disasters is increasing

each year.

COPPOLA, DAMON P., “INTRODUCTION TO INTERNATIONAL DISASTER MANAGEMENT 2ND ED., 2011

AFFLICTED PER 100,000

VICTIMS BY INCOME CLASS

RICH COUNTRIES

Suffer higher economic losses, but have mechanisms to absorb costs – Transfer risk to insurance and reinsurance

providers Reduce loss of life, using early warning

systems, enforced building codes, and zoning

Have immediate emergency and medical care that increases survivability and contains the spread of disease

COPPOLA, DAMON P., “INTRODUCTION TO INTERNATIONAL DISASTER MANAGEMENT 2ND ED., 2011

POOR COUNTRIES

Less at risk in terms of financial value– Little buffer to absorb financial impacts – Economic reverberations significant– Social development suffers

Lack resources to adopt advanced technologies Little ability to enforce building codes and zoning Generally do not participate in insurance

mechanisms. – Divert funds from development programs to emergency

relief and recovery COPPOLA, DAMON P., “INTRODUCTION TO INTERNATIONAL DISASTER MANAGEMENT 2ND ED., 2011

LESSON 2 OPERATIONAL FOCUS MUST BE THE

NEEDS OF THE POPULATION

HEIRARCHY OF NEEDS

SafetyWaterFoodShelter/heatClothingMedical CareEmployment

KIBEHO REFUGEE CAMP, RUWANDA, 1994

JTF SAFE HAVEN

PANAMA 1995

HEIRARCHY OF NEEDS

CompanionshipFamily envmt.StabilitySocial status & advancementChild developmentCare of eldersMid & long term plans

MEETING HUT, EMPIRE RANGE, JTF SAFE HAVEN

SCHOOL ART

KOSOVO

LESSON 3COMPLIANCE REQUIRES ENABLING

THE POPULATION AT LARGE

LESSON 4VITAL STRATEGIC GOAL IS THE

MORALE OF TEAM MEMBERS

9/11 FIRST RESPONDER ISSUES

Clearer delineation of roles and responsibilities Better clarity in the chain of command Radio communications protocols and procedures

that optimize information flow Source: McKinsey & Company, 2002.

9/11 FIRST RESPONDER ISSUES

More effective mobilization of members More efficient provisioning and distribution of

emergency and donated equipment A comprehensive disaster response plan, with a

significant counterterrorism component. Source: McKinsey & Company, 2002.

TRAINING NEEDS

The “all hazards” modelThe concepts of prevention,

preparedness, response, and recoveryThe roles of public health, public safety,

and public worksNIMS and incident commandWMDs (sources, agents, environmental

distribution, exposure, health effects)

TRAINING NEEDSSurveillance, population and

environmental monitoringPsychosocial, mental health, riskCommunication issuesMedical countermeasuresMass casualty handling,

including dead bodiesForensic epidemiologyEvaluation

PRACTITIONER MINDSET IN DISASTER

Crosswalk needed Clinical Paradigm

– One Patient at a time– Another job well done– Spare no expense

Rescue paradigm– Life before limb– Greatest good for the greatest number– Allocate limited resources– The Expectant patient

PSYCHOLOGICAL INJURY

Stress of dealing with casualties–Fatigue

•Overworked

•Understaffed

•Sleep deprivation

PSYCHOLOGICAL INJURY PREVENTION

Training– Realistic– Accurate threat

information– Comprehensible– Related to personal welfare

Leadership– Communication– Unit cohesion– Morale & welfare

FUKUSHIMA JAPAN, 2011

WWII SUBMARINE CREW

PSYCHOLOGICAL INJURY TREATMENT

Expect large numbers of casualties

Treatment principles–Proximity–Immediacy–Expectancy

SOLDIERS RESTING ON OMAHA BEACH

WAR PSYCHIATRY, ZAJTCHUK

LESSON 5DISASTER OPERATIONS SHOULD BE AN

EXTENSION OF ROUTINE PRACTICES

LESSON 6DESIGN FOR THE WORST CASE

SCENARIO

EXPECTING THE

UNEXPECTED

THINKING THE UNTHINKABLE

DOING THE UNDOABLE

http://adeolaadesina.blogspot.com/2010/10/thinking-unthinkable-daring-undarable.html

FOR THIS JURISDICTION

FOR THESE PERILS

ACTION PHASESREADINESS

1. Prevention– Shape the Battlefield

2. Preparation– CONOPS, Assets & Infrastructure

3. Surveillance– Scope, Sensitivity, Reliability, Security &

Cycle Time

4. Identification– Specificity, Confidence, Immediacy

PREVENTIONWhat is the difference between

PREVENTION and PREPARATION?

PREVENTIONWhat is the difference between

PREVENTION and PREPARATION?– A. PREVENTION focuses on building a

resistant and resilient environment– B. PREPARATION focuses on

developing the capability for a coordinated, timely & effective response

ACTION PHASESEXECUTION

5. Notification– Timely, Robust, Orderly, Functional

6. Marshalling– “Firstest with the Mostest”

7. Early Response– Effective, Professional, Orderly

ACTION PHASESEXECUTION

8. Full Response–Big as it needs to be to minimize

casualties–Delicate as a battleship

9. Mop Up–Thorough, Quick, Disciplined

ACTION PHASESRECOVERY

10. Clean Up–Hierarchy of needs

11. Reconstitution–Ready to go again

12. Convalescence/Healing–Return of functions

ACTION PHASESRECOVERY

13. Rebuilding–For the future not the past

14. Prevention–Shape the Battlefield

OPERATIONAL COMPONENTSConcepts of operations (CONOPS)

– Effective, practical, authorized & robust

– Incorporated in law, plans & regulation

Personnel– Adequate numbers for initial &

sustained operations– Trained in appropriate skills– Authorized for time/duty required

OPERATIONAL COMPONENTSEquipment

– Available, familiar & ready Infrastructure

– Time phased logistics– Communications

Prepared Population with social tools in place

Practice & revision for evolving needs

LESSON 7TIME IS OF THE ESSENCE

COMMAND & CONTROL

Three Tyrannies– Time– Communications– Logistics

Authority– Legality & Jurisdiction

COMMAND & CONTROLLeadership

– Realistic practical planning– Capability of execution

• Concepts of Operation

• Manning

• Equipment

• Training

• Practice

• Evaluation & Process Improvement

LIFESAVER 2004

COMMAND & CONTROL Accountability

– Who– Doing What– For Which Population– With What Assets– For How Long

Integrity– Begin with the end in mind– Realistic evaluation of capability– Reporting to established authorities

Credibility– Channeled into effective community action

Worst injured usually arrive first Must guard against over

committing resources on those first victims to arrive

Must first get perspective on probable total number and types of casualties that may arrive

TRIAGEAMBULANCE AT TAN SON

NHUT, VIETNAM, 1966

TRIMODAL DEATH DISTRIBUTION

Death ( seconds-minutes):– Injuries to great vessels, heart, brain/high

spinal cord

Death ( minutes-hours):– Epidurals/subdurals, hemo/pneumothorax,

splenic/hepatic lacerations, pelvic/long bone fx’s, multiple organ injuries

Death (several weeks):– Sepsis, MOF

INITIAL CAREThose arriving alive:

– Immediate: needing immediate intervention for airway/control hemorrhage

– Delayed, Minimal, Expectant

Only way to improve is to perform resuscitative (salvage) surgery farther forward– Reduce time from injury

to salvage surgery

EARLY, ADEQUATE SURGICAL

TREATMENT

Most important steps are airway & hemorrhage management

Initial Rx will determine late infection Wounds debrided non-viable tissue

– Tissues with good blood supply are best able to resist infection

MEDICAL RESPONSE

Control of disease/injury–Limit exposure

•Individual protection

•Mass protective measures–Evacuation

–Quarantine

MEDICAL RESPONSE

Early identification of population at risk

Effective communication–Population at large–Population at risk–Emergency workers

MEDICAL COMMAND

LESSON 8BREAKING UP IS

HARD TO DOWarningShelter &Evacuation

BEICHUAN EVACUATION FOLLOWING EARTHQUAKE

LESSON 9YOU CAN’T ALWAYS GET WHAT

YOU WANT

FALL BACK!

Change process to maintain standards of outcome Deliberate decisions by authorized leadership Coordinated pullback to maintain new standards

– Carefully planned– Capable of support– Personnel trained & equipped

Optimize outcome under evolving conditions

RETREAT FROM RICHMOND

http://www.picturehistory.com/product/id/29344#

INTEGRATION OF ALTERNATIVE CARE

PhasesStandardsEvaluation

LESSON 10PLANS ARE NOTHING, PLANNING

IS EVERYTHING

GEN GEORGE PATTON

RECOVERY-BASED MANAGEMENT Primary focus on disaster events Basic responsibility to respond Fixed, location-specific conditions Responsibility in single agency Command and control, directed operations Established hierarchical relationships

– Focused on hardware and equipment

Specialized expertise Urgent, immediate, and short time frames

PREVENTION-BASED MANAGEMENT Focus on vulnerability and risk Exposure to changing conditions Changing, shared or regional, variations Multiple authorities, interests, actors Situation-specific functions Shifting, fluid, and tangential relationships Moderate and long time frames

TERRORISM

DISASTER

ETHICAL OBLIGATION IN DISASTER, A.M.A., JUNE 2004

Individual obligation to provide urgent medical care during disasters

Even in the face of greater than usual risks to their own safety, health or life.

ETHICAL MANDATEOptimal balance between potential

outcomes security/survival & liberty

Clinical paradigm– Focus on individual patient

Rescue Paradigm– Save lives and minimize aggregate

morbidity– Focus on community welfare

ETHICAL MANDATEInfectious disease

–Isolation–Quarantine–Prophylaxis

Mass casualties–Decontamination, Evacuation

& Treatment

LESSON 11COMMUNICATIONS: A BRIDGE

OVER TROUBLED WATERS

MEDIA PUBLIC INFORMATION TACTICAL CONSIDERATIONS

MEDIA PUBLIC INFORMATION TACTICAL CONSIDERATIONS

1. TARGETED2. SPECIFIC3. AUTHORITATIVE4. CONCISE

THE ROLE OF MEDIATHE MAIN source of health info

for the public in a non-disaster setting

THE ONLY source of ANY info in a disaster setting

Studies indicate that panic is rare

MAINTAIN SITUATIONAL AWARENESS

Bear! Bear!

Halloween of the Future

“If we don’t deal with these issues now, then our children will face them in the future.”

TRICK OR TREAT

OUTCOME

Shape the BattlefieldBack to the Future“The good news to a hungry

person is bread .” – Desmond Tutu

DESMOND TUTU

HERDING CATS

SUMMARY LESSONS FROM THE FIELD

IntroductionIts Not Your Father’s PlanetNeeds of the Population at RiskEnabling the Population at LargeMorale of the TeamExtend the Routine

SUMMARYLESSONS FROM THE FIELD

Plan for the WorstTime is of the EssenceShelter & EvacuationYou Can’t Always Get What You

WantPlans are Nothing, Planning is

EverythingCommunications

QUESTIONS?