Disaster, a sudden and extraordinary misfortune that overwhelms the immediate ability to manage or compensate, has been part of human existence since the very earliest times (1, 2). No civilization in history has been immune from disaster, and today they remain a significant cause of damage to the life and health of individuals, as well as to the infrastructure and economy of communities. As mankind has developed and harnessed greater power through invention and technology, manmade disasters have become more common and, at times, just as devastating as their age-old natural counterparts (3–5). Responding to disasters, in terms of seeking shelter, providing medical assistance for oneself and others, limiting injury and death, taking care of the dead, and preventing complications in the aftermath of a catastrophic event, constitutes the discipline of disaster medicine. It is an ancient human endeavor (6) as people have attempted to respond as long as there have been disasters (6). Originating from war surgery and traumatology (7), disaster medicine has evolved considerably alongside medical knowledge and human society, and its organization has become more sophisticated.
Modern disaster planning, research, and response are centered on the disaster cycle as a model (8). The phases of the disaster cycle include the following:
- Prodrome (the phase of anticipation and possible preparation for the disaster);
- Impact (the disastrous event);
- Rescue (the immediate response, including triage and medical care for disaster victims, the phase in which timely and appropriate action may save lives);
- Recovery (longer term management of the aftermath of the disaster, returning society to its normal state);
- Quiescent (resolution of the disaster, including assessment of lasting effects).
This article focuses on the stages of impact, rescue, and reviews:
- The historic development of disaster medical response;
- The current state of affairs of disaster medical response, focusing on the perspective of the United States and the world as a whole;
- Future challenges and opportunities in disaster medicine as an introduction to the specific topics that are covered in this issue.
History of Disaster Medicine
The roots of modern discipline of disaster medicine can be traced back to the Middle Ages. In those times, orders of knights administered first aid in war and peace, but there was little in the way of organization to manage a widespread problem. The health consequences of the Black Death pandemic during the Middle Ages (9) led to the establishment of boards of public health in towns all over Europe. These boards developed principles of public health response to disaster, including reporting an epidemic, isolating victims, and collecting information on the dead (9). Later, the Great Fire of London in 1666 set in motion a series of changes leading to the birth of the London Fire Engine Establishment in 1833. Although an overall organized infrastructure for disaster response was yet to come, innovation did take place in individual aspects of disaster response, like the evacuation of casualties by air balloon in the latter part of the 18th century.
The Red Cross.
The birth of the Red Cross organization in 1863 marks the beginning of the modern era of organized response in disaster medicine. In 1859, during a battle between Austria and the Franco-Sardinian alliance in Solferino, Italy, a young Swiss man named Henry Dunant witnessed the fate of unattended wounded soldiers. Moved by the consequences of this manmade calamity, he called for the creation of national relief societies to render assistance in case of emergencies. These societies evolved into what are now the national and international Red Cross organizations. His work also paved the way for a code for treating victims of war and disaster that eventually became the Geneva Conventions (10).
St. John Ambulance Association.
In England, Sir William Monatgu, Sir John Furley, Sir Edmund Lechmere, and Col. Francis Duncan established the St. John Ambulance Association in 1877 with the aim of emergency relief in peace and war (11). Soon it took the lead in providing “first aid” instruction across England and Continental Europe (11) and is given credit for the origin of this term (11).
Emergency Management System.
Another progressive development in disaster medicine was the designation of trained response personnel as first responders in emergencies. This concept has become known as the Emergency Management System (EMS). The earliest EMS was reportedly the rescue society formed by Jaromir V. Mundy, Count J. N. Wilczek, and E. Lamezan-Salins after the disastrous fire at the Vienna Ring Theater in 1881 (12). Named the “Vienna Voluntary Rescue Society,” it served as a model for similar societies worldwide. During the first and second world wars, advances were made in military EMS, but development in the civilian setting did not occur until well into the 1950s when J. D. Farrington and Sam Banks, two civilian physicians, established a first aid training program for the Chicago Fire Department. This became the prototype for the first basic emergency medical technician training program in the United States (13).
In 1966, the National Academy of Sciences released a paper titled “Accidental Death and Disability: The Neglected Disease of Modern Society,” which ushered in the modern era of EMS in the United States. The federal government responded by creating an organized EMS and trauma system, and later that year, created the U.S. Department of Transportation (13). Among its functions, the U.S. Department of Transportation was charged with improving EMS in the United States and developing a basic emergency medical technician training curriculum (13).
The prioritization of sick and injured people, based on the severity of their condition and chance for survival with medical intervention, is probably the most important activity done on the field (14). The modern principles of triage owe much to Baron Dominique Jean Larrey (1766–1842), a surgeon in Napoleon’s army who developed and implemented a system in which soldiers requiring the most urgent care were attended to first, regardless of rank (15, 16). His system also instituted initial treatment of the wounded still on the battlefield (16). John Wilson further refined the principles in 1846 (16). During World War I, triage was performed at distribution points in the field from which the wounded were sent to appropriate hospitals in ambulances (16). In World War II, a tiered approach to triage was introduced, with multiple points of triage, from the field to sites of more definitive care (16). Portable field hospitals were used, and medics initiated treatment in the field. During the Korean and Vietnam Wars, sophisticated triage and air evacuation procedures continued to evolve, contributing to decreased mortality rates for injured soldiers (16).
Incident Command System.
One of the fundamental developments in the organization of our current disaster response system was the introduction of the incident command system (ICS). In the fall of 1970, Southern California was ravaged by a series of wild land fires. A subsequent audit identified coordination to be a major problem in the emergency response. A consortium of state, county, and city fire departments joined together to develop the Incident Command System (ICS), a major step toward standardizing the civilian response to disasters. The system has been widely adapted by other emergency response organizations.
Baron Larrey also refined the concept and means of the transport. He developed “flying ambulances”—lightweight, two-wheeled vehicles that stayed with the troops and allowed surgeons to work on the battlefield (17). In the United States, ambulance services were organized during the Civil War by a physician named Jonathan Letterman (18), who devised a system of forward first aid stations, mobile field hospitals, and a base hospital, all linked by a proficient ambulance corps. During the Civil War, train ambulances and steamboat hospitals were also used. The form of ambulances changed with the arrival initially of the automobile and then the aircraft (19). The “medicopter” is now commonplace (20), providing invaluable services during natural disasters such as the Johnstown Flood when medical supplies required refrigeration and patients needed to be airlifted to hospitals. Advanced courses like the Critical Care Air Transport Team play an important role in educating responders and also evaluating and defining future needs.
Despite advances, emergency and disaster activities were still generally fragmented 50 yrs ago. The 1960s and early 1970s brought massive disasters in the United States that required federal government assistance with response and recovery operations. President Carter’s 1979 executive order merged many of the separate disaster-related responsibilities into a new Federal Emergency Management Agency (FEMA). FEMA began development of an Integrated Emergency Management System with an all-hazards approach that included “direction, control and warning systems, which are common to the full range of emergencies from small isolated events to the ultimate emergency—war.” In the 1990s, reforms were initiated that streamlined disaster relief and recovery operations and insisted on a new emphasis regarding preparedness and mitigation. Disaster response systems in other countries (for example, the United Kingdom) have also undergone similar reengineering as governments have intervened to coordinate multiagency efforts.
Hospitals have always been an important link in the chain of disaster response and are assuming even more importance as advanced prehospital care capabilities lead to improved survival-to-hospital rate.
Research and Education
It is only in the last 50 yrs that disaster medicine has become a distinct scientific discipline (21) through dedicated research and education efforts (22). In Europe, the first chair in disaster medicine was established in Linkopings, Sweden, and other places are following suit (23). In the United States, the Disaster Research Center, established in 1963, is the first center of its kind in the world dedicated to research and education efforts toward sociobehavioral aspects of disasters (24). Although these players in disaster response have been evolving both individually and in the context of an integrated response, increasingly, research is focusing on “the chain of medical care” and the factors that enhance a synchronized response (23).
The Current State of Disaster Medicine
The United States boasts a sophisticated disaster medical response system built on the coordinated efforts of a number of federal, state, and local government agencies (25). When disaster strikes, the first responders are emergency medical services and police and fire departments of local jurisdictions (25, 26), who aim to rapidly establish security and maintain order at the scene, rescue and triage the injured, and retrieve the dead (25). ICS is activated to enable the different responding authorities to coordinate responses. The local government executive activates the local Emergency Operations Center (25), from which the commanding members of the ICS manage operations (27). The National Incident Management System standardizes and unifies the federal, state, and local lines of disaster response (28). It maintains five functional areas: command, operations, planning, logistics, and finance/administration, for management of all major incidents. The medical command is a position within the ICS responsible for setting up all aspects of care for the injured (26). This command interacts with the incident commander and initiates triage, transport, and treatment. First responders sort victims according to the immediate need for medical attention and apply a color-coded tag to denote the victims’ condition and make them easily recognizable. A treatment area is set up to provide basic medical care. More advanced care is usually provided at the transport unit or at a healthcare facility.
Depending on the size of the event and the capacity of the responding agencies, the state and federal governments may mobilize additional resources to assist the local responders (29). The Emergency Preparedness and Response directorate of the Department of Homeland Security is responsible for coordinating the government’s disaster response. It includes FEMA, which until it was incorporated into Emergency Preparedness and Response in March 2003, had the lead in developing and maintaining the Federal Response Plan.
The National Disaster Medical System, created approximately 18 yrs ago (30), is a section within the U.S. Department of Homeland Security (Federal Emergency Management Agency, Response Division) that is responsible for coordinating the federal medical response to major disasters (31). The 12 essential functions in the Federal Response Plan range from mass care to transportation, urban search and rescue, environmental health services, and health and medical services (32). The health and medical services function is called Emergency Support Function-8. Emergency support function-8 provides four principal types of services: preventive health services, environmental health services, medical services, and mental health services (32). The components of Emergency Preparedness and Response include the following: 1) prehospital treatment, which is medical response to a disaster area in the form of teams, supplies, and equipment; 2) evacuation, which is patient movement from a disaster site to unaffected areas; and 3) hospitalization, which is definitive medical care at participating hospitals. The system develops and maintains Disaster Medical Assistance Teams (33), which are groups of professional and paraprofessional medical personnel designed to provide medical care during a disaster (34).
Disaster medical response capability varies widely among nations (35), and the factors that influence it are various. They include the types of hazards that affect a particular geographic location (36), the organization of government, and the availability of human, technologic, and economic resources (35). Resources are particularly important because poverty and vulnerability are strongly associated in disaster. Most of the developed nations have advanced disaster response capabilities. Studies of the applicability of disaster management principles applied in developed countries to other areas have yielded positive results.
In the United Kingdom, the Civil Contingencies Secretariat was set up to improve the United Kingdom’s “resilience” against disruptive challenges through working with others to anticipate, assess, prevent, prepare, respond, and recover. Resilience has been defined as “ensuring that the country is prepared to detect, prevent, and respond to major emergencies.” These could range from floods, through outbreaks of human or animal disease, to terrorist attacks. The Civil Resilience Directorate was established in June 2003 to coordinate the Office of the Deputy Prime Minister’s resilience programs. The Office of the Deputy Prime Minister in the United Kingdom works to ensure that all local and regional stakeholders are equipped and trained for disaster of all kinds. Other active organizations are the British Red Cross and the St. John Ambulance Association.
The inhabitants of the Australian continent are vulnerable to a range of natural and technologic disasters. In response, they have developed an efficient system of response: Australia’s Emergency Management System (37). Multiple agencies coordinate the response in the event of a disaster. At the national level, the National Emergency Management Committee is responsible for policy development, and the Australian Disaster Medicine Group is responsible for the health aspects of the response (37). Each state has an operational authority that activates the appropriate disaster plans (37). Similarly, the local government is responsible for coordinating disaster response within their jurisdiction (37). This shared understanding of roles, responsibilities, and plans makes it an efficient system (37).
The geographic situation of India places it in the way of natural hazards like floods, earthquakes (Gujarat 2001), and drought. A National Crisis Management Committee, composed of high-ranking government officials, coordinates and implements disaster response measures. Various international agencies play a role too whenever the local capacity is overwhelmed.
Various international agencies have been playing a role to provide assistance to nations with lesser developed disaster medical systems. The threshold to intervene depends on the when the victim nation’s capacity to respond is overwhelmed. This, in turn, depends on a number of factors that include economic resources, the resilience of infrastructure, and the level of local responder training (35).
As a result of its presence in most countries throughout the world, the United Nations (U.N.) is best suited to be involved in the international disaster response system in various countries (35). The various U.N. bodies that may play a role in disaster medical response include United Nations Development Program (UNDP), United Nations Office for Coordination of Humanitarian Affairs, World Food Program, and the U.N. High Commissioner for Refugees (35). Originally established to promote development activities in developing nations, UNDP has increasingly become involved with disaster response and recovery activities. This evolution resulted from the realization that in developing nations, sustainable development is strongly related to disaster risk reduction and effective disaster response coordination (35). The Emergency Response division was created within UNDP in 1995, and in 1997, the responsibilities of the Emergency Relief Coordinator were formally transferred to the UNDP. The Emergency Relief Coordinator is also the head of the U.N. Office for the Coordination of Humanitarian Affairs and also coordinates U.N. activities with other humanitarian agencies through the Interagency Standing Committee (35). The World Bank and International Monetary Fund may provide financial assistance during disaster response and recovery (35).
The U.S. government is also involved in providing aid to international disaster response activities. The U.S. Agency for International Development coordinates the U.S. response to international disasters. A recent example of such help was the U.S. mission to Iran during the Bam earthquake (38).
Humanitarian organizations may act independent of any government or the U.N. These include nongovernmental agencies like the International Committee of the Red Cross and Oxfam, private voluntary organizations, and donor agencies like the U.S. Agency for International Development.
The Future of Disaster Medicine
This is a time of rapid change in our thinking about disaster medicine. We are faced with new scenarios, mostly manmade, unlike any we have faced before. At the same time, the risk of natural disasters is also predicted to increase (24). This has forced us as a nation and as a world community to examine our readiness to respond to disaster. The same principles will continue to apply, but as the variety and scope of disasters escalates, the sophistication of our response will have to keep pace.
As a scientific discipline, disaster medicine is very young but rapidly growing. Collaboration of research across multiple disciplines, including medicine, engineering, sociology, psychology, mathematics, military sciences, and information technology, is required (23). The results of the research conducted should be incorporated and reflected in current and future plans (39). Aspects deserving more attention include public education on these issues and prudent funding of programs as they develop.
It is apparent as we have examined the history of disaster medicine that the focus on our response has been predominantly in the prehospital impact and rescue phases of the disaster cycle. As we understand “the chain of medical response” better, we realize that there are logistic and ethical challenges to be dealt with in the hospital setting as well. The 1988 earthquake in Armenia, which killed 80% of the local medical personnel, as local hospital buildings collapsed, underscored the vulnerability of hospitals themselves to disaster (40). The severe acute respiratory distress syndrome outbreak (41) and flooding of the Houston Medical Center (42) are more recent examples. Development of alternatives that supplement hospital capabilities is needed (43).
Even if hospitals remain undamaged, a small number of causalities may overwhelm a hospital in the absence of “surge capacity” (44). Most regions in the United States are one severe acute respiratory distress syndrome epidemic or industrial accident away from the tipping point and an impossible acute shortage of critical care beds and staff (45). The thinking and development within the various agencies overseeing disaster response will be increasingly focused on the hospital’s ability to rapidly open and staff beds (44, 46). This is particularly true of the critical care capabilities of our hospitals (47).
All efforts toward disaster planning, mitigation, response, and recovery have to be integrated at the community level. Communities with unique risks may need to partner with local governments, private firms, and disaster response agencies to develop disaster management plans (48).
Although disaster medicine as a distinct discipline was in its infancy even 50 yrs ago, significant advances were visible in individual domains as far back as the latter part of the 18th century. In addition to improving our ability to predict some disastrous events (49), we should focus on improving our ability to coordinate the activities of various agencies (50) and incorporate “surge capacity” in our current disaster response capability (51). As physicians, our primary role is to promote proper education and training (44).
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