Skip to Navigation
University of Pittsburgh
Print This Page Print this pages

October 13, 2005

Relief effort problems will worsen, expert says

In the wake of Katrina and Rita, recent hurricanes that wrought havoc on the U.S. Gulf Coast, disaster preparedness and response has leaped to the forefront of American consciousness.

But according to an international expert on disaster response, the problems exposed by the failings of recent disaster response efforts were not news to public health officials.

What is emerging in the field are multiplying disaster risk factors in an unstable world, providing a new range of challenges and a demand for new skills and knowledge, even for seasoned public health professionals, said Eric K. Noji, senior policy adviser for Health and National Security at the Centers for Disease Control (CDC) and Prevention.

Noji spoke here Sept. 29 at the second annual John C. Cutler Global Health Lecture, sponsored by the Graduate School of Public Health.

“The role of public health is vast and expanding,” Noji said. “When we train our students, it has to be more than biostatistics and epidemiology.”

The title of Noji’s lecture was borrowed from his 1996 book of the same name: “The Public Health Consequences of Disasters.”

After sifting through many definitions of disaster for his book, Noji settled on: “A disaster is a result of a vast ecological breakdown in the relation between humans and their environment, a serious or sudden event on such a scale that the stricken community needs extraordinary efforts to cope with it, often with outside help or international aid.”

“To give you an idea of how much has changed over the years, my book in 1996 did not have one word on terrorism,” Noji said. “So, it’s already out of date. There has been significant change socially, economically and, most importantly, psychologically,” particularly following the terrorist attacks of 2001 and the anthrax scare, he said.

While there was a relatively small loss of life in those two events compared to some natural disasters, such as the tsunami that hit South Asia last winter, the entire philosophy of public health preparedness has changed dramatically, he said.

“Now the government is focused on terrorism, following 9/11 and the anthrax scare,” Noji said. First, there’s been a major increase in the CDC budget. “With anthrax, despite the fact that only five died and 23 got sick, now we have a federal agency (Homeland Security) of 250,000 combining 22 federal agencies, and the biodefense budget is now bigger than the budget directed to fight HIV/AIDS.”

In his 21 years as a public health responder working in the field, Noji has led a wide range of disaster efforts for the CDC and the World Health Organization, including medical and public health response to natural, biological and technological disasters involving complex geopolitical emergencies such as refugee and forced migration situations.

“When I was in medical school, never did I think I’d have to study law,” Noji said. “But I had to learn about international law, human rights, crimes against humanity, disasters born of war and complex human tensions.”

In addition to disease pandemics and natural disasters such as tsunamis, earthquakes, tornadoes, tidal waves, volcano eruptions, landslides, wildfires, floods and hurricanes, now public health responders increasingly must deal with technological disasters (such as the Chernobyl nuclear accident and the Bhopal chemical accident), transportation disasters and potential terrorism.

“And you have to think of these as separate entities, because they require different responses,” Noji said. In addition, where a disaster takes place also requires differing responses. “An event like a transportation accident may be more manageable depending on where it occurs,” he said.

If victims of a bus crash are near an area dense with hospitals and established medical emergency systems, the casualty count likely will not be as high as if the accident occurred in a rural area where getting treatment is difficult, he said. On the other hand, a natural disaster in a heavily populated area obviously has a bigger impact than in less populated areas.

Public health training now requires a multidisciplinary background in sociology, economics, environmental studies, demographics — even public relations, he added.

“I’ve had to work not only with emergency services, but intelligence services and the media for rumor control. You can get the epidemiology right, but bad media relations can make your response a failure.”

Political destabilization in the post-Cold War era has led to increased regional violence and ethnic conflicts where civilians are victims, one of the emerging themes in epidemiology, he said. Moreover, first responders to violent disaster areas often need some governmental or military protection, which, ironically, limits their effectiveness.

In some areas of the world, “the Red Cross means nothing anymore. As a symbol it is no longer respected. People have never heard of the Geneva convention. The feeling of neutrality is compromised when a public health official must rely on a military escort to ensure safety, which makes it difficult to offer assistance. It’s hard to use health as a bridge for peace.”

In the Sudan, for example, which has been crippled by civil war since 1955, entire generations have known nothing but a wartime environment, breeding child-warriors. “I’m trained in gunshot wounds but not for children. There aren’t even any textbooks to refer to.”

Noji also dispelled a number of commonly held myths related to disaster relief efforts, including:

• Myth: Foreign medical volunteers with any kind of medical background are needed.

“The reality,” Noji said, “is that local populations almost always are able to cover immediate life-saving needs. In some cases, doctors would be a liability. Few survivors owe their lives to outside teams. What are needed are skills not available at the affected site.”

For example, the biggest problem in hurricane relief are people with chronic diseases, the infirm or disabled, people on dialysis or in chemotherapy treatment. “The stereotype in a hurricane is the need for blood and surgeons, but it’s not true. Surgeons would be bored,” Noji said.

Last year’s devastation of Florida during the hurricane season caused millions in damages, but only an estimated 10 people died, he noted.

The mass descent of volunteers, including trained medical personnel, does more harm than good, he said. “It’s almost a second disaster.”

• Myth: Any kind of assistance is needed and it’s needed as soon as possible.

“A hasty response not based on evaluation only contributes to the chaos of a situation,” Noji maintained. Un-requested goods are inappropriate — such as sending furs to victims of famine in tropical Bangladesh — and burdensome because they divert resources and more often are destroyed rather than separated and inventoried or returned.

“Used clothing, over-the-counter or prescription drugs or blood products are seldom needed,” he said. Ditto for medical teams and field hospitals, he added.

• Myth: Epidemics and plagues are inevitable following a disaster.

“The reality is epidemics rarely ever occur after a disaster. Dead bodies will not lead to outbreaks of exotic diseases. The proper resumption of public health services — immunizations, sanitation, waste disposal, water quality and food safety — will ensure the public’s safety,” Noji said.

“I have to offer one caveat: Criminal or terror-intent disasters require special consideration,” because the public services (such as the water supply) themselves might be the target, he said.

• Myth: Disasters bring out the worst in human behavior.

In reality just the opposite is true, Noji said. “While isolated cases of antisocial behavior exist, the majority of people respond spontaneously and generously.”

• Myth: The community directly affected by a disaster is too shocked and helpless to respond effectively.

Reality: “Many find new strengths during a disaster,” Noji said. “We’ve seen this time and time again [around the world]. A cross-cultural dedication to the common good is the most common response to natural disasters.”

Most rescue efforts, first aid and transport of victims are provided by fellow victims and bystanders, he said.

What does the future hold?

First, things will get worse, Noji said. There is an upward spiraling of at-risk victims due to increasing population density and settlement in high-risk areas; growing technology hazards; rising incidents of terrorism — including potential biological, chemical and nuclear attacks; meager global security and awareness; emerging infectious diseases such as SARS, and an upsurge in international travel — all of which create the potential for simultaneous creation by one event of a huge number of casualties, he said.

“The influence of population growth, especially among the poor, is very scary,” Noji said. In 1920, there were about 100 million people worldwide living in urban areas. By 1980 that increased to 1 billion and now stands at 2 billion, with 20 cities of 10 million or more people, many of which are built on sites of previous known natural disasters such as Mexico City, which was hit with an earthquake as recently as 1985.

Potential disaster severity also is exacerbated by human vulnerability due to poverty and social equality and by environmental degradation, Noji said. “For example, following large-scale deforestation in the Philippines, in June 1990, 6,000 people died from [resultant] flooding,” he said.

What is most needed for future disaster preparation is better planning beforehand, Noji said. That includes hazard analyses, vulnerability measures, training, education, better planning for evacuations and contingency planning. “Knowing the threat agent is very important and understanding its potential is a tool crucial to public health preparedness and response,” he said.

Also crucial is better epidemiologic data collecting in the aftermath of disasters, Noji said. Data are needed to determine appropriate relief supplies, equipment and personnel needed to respond effectively to disaster situations.

The overall objective of disaster epidemiology is to measure scientifically the health effects of disasters and contributing factors to these effects, to assess properly the needs of disaster-affected populations, to match resources to needs efficiently and to prevent additional adverse health effects.

“I hope I’ve given you a flavor of some of the problems public health professionals face,” Noji said. “My final thought is nothing replaces well-trained, competent and motivated people. People are the most important asset.”


The Cutler lecture was coordinated through the Global Health Network Supercourse project at the World Health Organization Collaborating Centre housed at Pitt. The lecture was web cast live to a global audience, reaching more than 150 countries and potentially making it the largest audience for an academic lecture ever.

—Peter Hart

Filed under: Feature,Volume 38 Issue 4

Leave a Reply