Public health issues in disasters
Eric K. Noji, MD, MPH
Objective: This article outlines a number of important areas in grounds. Some similarities exist, however, among the health effects
which public health can contribute to making overall disaster of different natural disasters, which if recognized, can ensure that
management more effective. This article discusses health effects health and emergency medical relief and limited resources are well
of some of the more important sudden impact natural disasters managed. (Crit Care Med 2005; 33[Suppl.]:S29 –S33)
and potential future threats (e.g., intentional or deliberately re- KEY WORDS: disasters, natural, earthquake, flood, volcano, tor-
leased biologic agents) and outlines the requirements for effective nado, hurricane, typhoon, cyclones; disaster epidemiology; disas-
emergency medical and public health response to these events. ter medicine; emergency; mass casualty incident; homeland
Conclusion: All natural disasters are unique in that each affected security
region of the world has different social, economic, and health back-
T hroughout history, natural di- days (11). Good disaster management re- the incidence of diarrhea, respiratory in-
sasters have exacted a heavy toll quires accurate information and must link fections, and other communicable dis-
of death and suffering (1). Most data collection and analysis to an immedi- eases. A good system of water supply and
recently, the Bam earthquake in ate decision-making process (12). The over- excreta disposal must be put into place
Iran resulted in thousands of deaths, inju- all objective of disaster management from a quickly (20). No amount of curative
ries, and homelessness (2) (Table 1). The public health perspective is to assess the health measures can offset the detrimen-
problem has not improved much despite needs of disaster-affected populations (13, tal effects of poor environmental health
much attention by the international scien- 14), match available resources to those planning (21). Important postdisaster en-
tific community (3). Global climate change needs, prevent further adverse health ef- vironmental interventions include access
brings the potential for severe weather fects, implement disease control strategies to adequate sources of potable water; and
events and flooding, and the introduction for well-defined problems, evaluate the ef- the collection, disposal, and treatment of
of tropical vector-borne diseases into more fectiveness of disaster relief programs (15), excreta and other liquid and solid wastes
temperate regions (4, 5). Increasing popu- and improve contingency plans for various (22). This is achieved through installa-
lation density near coasts, in floodplains, types of future disasters (16). Common pat- tion of an appropriate number of suitably
and in regions of high points to the prob- terns of morbidity and mortality after cer- located excreta disposal facilities such as
ability of future catastrophic natural disas- tain disasters can be identified (17) (Table toilets, latrines, or defecation fields; solid
ters with millions of casualties. 2). Effective emergency medical response waste pickup points; water distribution
Disasters affect a community in numer- depends on anticipating these different points; and availability of bathing and
ous ways. Roads, telephone lines, and other medical and health problems before they washing facilities and of soap together
transportation and communication links arise (18) and on delivering the appropriate with effective health education. The con-
are often destroyed (6). Public utilities and interventions (relief supplies, equipment, trol of disease vectors such as mosqui-
energy supplies may be disrupted (7). Sub- and personnel) at the precise times and toes, flies, rats, and fleas is an important
stantial numbers of victims may be ren- places where they are needed most (19). part of an environmental health approach
dered homeless (8). Portions of the com- to protecting community members from
munity’s industrial or economic base may
CRITICAL PUBLIC HEALTH disease (23).
be destroyed or damaged. Casualties may
INTERVENTIONS AFTER Water and Excreta Disposal. Adequate
require medical care, and damage to food
DISASTERS quantities of relatively clean water are
sources and utilities may create public
preferable to small amounts of high-
health threats (9, 10). The more remote the Critical public health interventions af- quality water. Each person must receive a
area, the longer it takes for external assis- ter disasters focus on the following areas. minimum of 15 to 20 L of clean water per
tance to arrive, and the more the commu-
day for their domestic needs (24). Unfor-
nity will have to rely on its own resources,
Environmental Health: Water, tunately, it is frequently difficult to pro-
at least for the first several hours, if not
Sanitation, Hygiene, and Vector vide even these minimum quantities of
water to disaster-affected populations
Management
(25). During this early acute phase, la-
From the Centers for Disease Control and Preven-
tion, Atlanta, GA. General Issues. Overcrowding and re- trine construction begins, but initial san-
Copyright © 2005 by the Society of Critical Care sulting poor water supplies and inade- itation measures may be nothing more
Medicine and Lippincott Williams & Wilkins quate hygiene and sanitation are well- than simply designating an area for def-
DOI: 10.1097/01.CCM.0000151064.98207.9C known factors that are known to increase ecation, hopefully segregated from the
Crit Care Med 2005 Vol. 33, No. 1 (Suppl.) S29
, community’s source of potable water. friends; 5% to 10% were living in parks, damaged housing is to diminish as much
Construction of one latrine for every 20 city squares, and vacant lots; and the re- as possible the penetration of wind and
persons is recommended but is rarely mainder were living in schools and other rain into the structure. In these situa-
achieved in camp settings (24). public buildings (26). Regarding tempo- tions, plastic sheeting for roof and win-
Shelter. Surveys of settlements and rary living space allocations, 3.5 square dow repairs along with the required ma-
towns around Managua, Nicaragua, after meters is the absolute minimum floor terials for attaching them to the damaged
the December 1972 earthquake indicated space per person in emergency shelters structures are often provided by relief or-
that 80% to 90% of the 200,000 displaced (24). The first priority in areas where ganizations. Most people who lose their
persons were living with relatives and large numbers of people are living in homes will initially be able to take shelter
with friends and relatives (27). Only when
housing losses reach more than approxi-
Table 1. Selected natural disasters 1970 –2004 mately 25% will there be a need to find
other forms of shelter (26).
Approximate The decision to provide shelter at all
Year Event Location Death Toll can have significant long-term conse-
quences, especially in poor communities.
1970 Earthquake/landslide Peru 70,000
1970 Tropical cyclone Bangladesh 300,000
For example, simple shelters provided on
1971 Tropical cyclone India 25,000 an emergency basis may unintentionally
1972 Earthquake Nicaragua 6,000 evolve into permanent shantytowns or
1976 Earthquake China 250,000 squatter settlements and end up attract-
1976 Earthquake Guatemala 24,000 ing many more homeless people to the
1976 Earthquake Italy 900
1977 Tropical cyclone India 20,000 site.
1978 Earthquake Iran 25,000
1980 Earthquake Italy 1,300 COMMUNICABLE DISEASE
1982 Volcanic eruption Mexico 1,700
1985 Tropical cyclone Bangladesh 10,000 CONTROL AND EPIDEMIC
1985 Earthquake Mexico 10,000 MANAGEMENT
1985 Volcanic eruption Columbia 22,000
1988 Hurricane Gilbert Caribbean 343
1988 Earthquake Armenia SSR 25,000 Epidemics
1989 Hurricane Hugo Caribbean 56
1990 Earthquake Iran 40,000 Natural disasters are often followed by
1990 Earthquake Philippines 2,000 rampant rumors of epidemics (such as
1991 Tropical cyclone Bangladesh 140,000 typhoid or rabies) or unusual conditions
1991 Volcanic eruption Philippines 800
1991 Typhoon/Xood Philippines 6,000 such as increased snakebites and dog
1991 Flood China 1,500 bites. Such unsubstantiated reports gain
1992 Hurricane Andrew USA 52 great public credibility when printed as
1993 Earthquake India 10,000 facts in newspapers or reported on tele-
1995 Earthquake Japan 6,000
1998 Hurricane Mitch Central America 10,000
vision or radio (28). For example, after
1999 Earthquake Turkey 18,000 disasters in developing countries, any dis-
1999 Earthquake Taiwan 1,000 ruption of the water supply or sewage
2001 Earthquake India 20,000 treatment facilities has usually been ac-
2003 Earthquake Algeria 3,000 companied by rumors of outbreaks of
2004 Earthquake Iran 25,000
cholera or typhoid (29). Such rumors
Data from Office of U.S. Foreign Disaster Assistance: Disaster history: Significant data on major may well have reflected psychologic fears
disasters worldwide, 1900 –Present. Washington, DC, Agency for International Development, 2004; and and anxieties about a disastrous event
National Geographic Society: Nature on the rampage, our violent earth. Washington, DC, National rather than the true perception of an
Geographic Society, 1987. imminent problem. However, informa-
Table 2. Short-term effects of major natural disasters
High Winds
Effects Earthquakes (Without Flooding) Tsunamis Floods/Flash Floods
Deaths Many Few Many Few
Severe injuries requiring extensive care Overwhelming Moderate Few Few
Increased risk of communicable Potential (but small) risk following all major disasters (probability rises as overcrowding diseases
increases and sanitation deteriorates)
Food scarcity Rare Rare Common Common
(May occur because of factors other than food shortage)
Major population movements Rare Rare Common Common
(May occur in heavily damaged urban areas)
Modified from Office of Emergency Preparedness and Disaster Relief Coordination: Emergency Health Management After Natural Disaster. Washington,
DC, Pan American Health Organization, 2002.
S30 Crit Care Med 2005 Vol. 33, No. 1 (Suppl.)
