Let’s start with a small thought experiment. If you were told you had 12 hours before your home is to be flooded, or to lose its roof, would you have a plan? If a factory ten miles away catches fire and a toxic cloud of chemicals is blown your way, what do you do next?

How we all respond to the unpredictability and magnitude of disasters is a personal matter. We tend to imagine we can cope. As agile sophisticates we are prepared, we react robustly and with cool resilience in these scenarios. Our well-rehearsed playbooks will slip into action and we can take control, just as in a good movie.

In reality experience shows that most of us do not have useful strategies for coping with disasters. Locating our personal documents, our medication and contacts, let alone water, protective clothing and perhaps food is often a major challenge. We tend to be rather ineffective in managing our families, friends, animals and property. Artists ranging from the blues singer Willie Dixon in 1983, to Charles Bradley 40 years later, sing about our tendency to run in the face of natural disasters, particularly hurricanes!

Disasters have always afflicted our species and our habitats, the plants and animals we keep around us. Some types of disaster will become more frequent in future. Climate change is here. However you view the causes of this phenomenon, we can all expect more extreme weather, wherever we live, whether on islands, coastlines, plains or mountains. Some of this will result in significant damage. Whatever your views of the Keeling curve of carbon levels in our planet’s atmosphere, we need to plan carefully futures for ourselves, our families and our colleagues.

As I write the UK government has just declared a state of emergency with respect to climate change. A Swedish teenager, Greta Thunberg, is speaking to European governments about her views on this matter. She is heading for a place in history as she and thousands of British schoolchildren regularly boycott classes to show their concern about climate change. Thunberg has stated “We need to panic!” The World Bank predicted in a report in 2010 that the numbers of people living under threat of earthquakes and cyclones will double by 2050. Environmental degradation, unplanned urbanisation and human-induced earthquakes leading to the growth of megacities will increase these risks. The example of Japan in 2011 shows how an initial earthquake resulted in a multi-modal disaster. The quake caused a tsunami and secondary collateral destruction in an area with a nuclear reactor. 2017 was the year of greatest insurance losses ever from natural catastrophes. Economic entanglement linked to global developments mean that events such as these will affect many more of us in future.

Disasters

There is a spark of good news to brighten these gloomy prospects. Disaster management is developing rapidly. This subject grew from early environmental predictions and has blossomed into a veritable forest of global movements. Alexander von Humbolt was one of the early pioneers. He measured temperature, humidity and altitude at many points on the globe. Employing a cyanometer to estimate the blueness of the sky, Humbolt showed a maximal measure on Mount Chimborazo in the Andes of 46, compared to 39 in the highest Alps in Switzerland. Greater ‘blueness’ indicated distance from the earth’s centre. Because of the equatorial bulge, the summit of Chimborazo is the farthest point from its core. In collaboration with criollo communities he helped develop new perspectives for maps in early nineteenth century South America. Crucially these included observations that atmospheric conditions determined the outcomes for living creatures; changes in these would be linked to widespread environmental damage.

A century later in 1917 research into disasters was picked up in a careful analysis of the circumstances surrounding a maritime collision and the explosion in Halifax. The psychological consequences of disasters were outlined in detail following the second World War. By the early 1960’s a definition of a disaster was agreed internationally and the United Nations (UN) began to develop resolutions specific to disaster situations. In the 1970s UN assistance methods following natural disaster were implemented. The United Nations International Strategy for Disaster Reduction (UNISDR) was established in 2000. Its Hyogo Framework for Action 2005-2015 has been followed by the Sendai framework (2015-2030), both of which delivered beneficial outcomes for international communities. They encourage a ‘disaster without borders’ approach. UNISDR has five regional offices and operates thorough national and local governments, intergovernmental organisations, civil society and the private sector. These procedures have been employed to great benefit in the United States by the Homeland Security, the National Incident Management System and the National Resource Typing Systems.

Studies of disasters are nurturing a rich diversity of academic enquiry. This includes disaster medicine, business continuity planning, disaster ethics, disaster diplomacy, disaster security, global insurance and disaster technologies. This suite of powerful engines needs to include disaster architecture, particularly focused on the designs for resilient structures, transport systems and cities. Not to forget the applications of artificial intelligence to all of these. Journals, textbooks and training courses in disaster management are beginning to take places alongside their more placid forebears.

Disaster medicine, to focus on one member of the family, has early links to military operations. Battlefield tourism was commonplace and, in some cases, led to a significant legacy as in the case of Henry Dunant. His makeshift surgery at Solferino in 1859 subsequently led to the establishment of the . An American Board of Disaster Medicine was approved in 2004 and the American Academy of Disaster Medicine in 2006. They evolved systems of training in this field that now has very little to do with battlefields. Uniquely specialists in disaster medicine need to assimilate or embed with a non-medical team in order to perform. They are ideally positioned to manage, for example, medical logistics with victims of many different types of disaster.

Although disasters cannot be prevented, disaster medicine provides optimal advice about preparedness. Prior to disasters it is usually possible to identify vulnerability and develop plans for those who most need them. Capacity-building and relationship development within communities can reduce risks to those exposed. Identifying vulnerability and communicating risks to the most vulnerable is not easy.

Following a disaster pre-planned strategy can limit the range and mitigate the severity of the effects of that disaster. A ‘One Health’ agenda is a valuable perspective in this process. This includes the environment, plants, animals as well as people. Disasters themselves evolve, so that early acute problems may be followed by secondary medical issues relating to mental health and communicable infections such as waterborne and sexually transmitted disease. The World Health Organisation (WHO) has reported that post-disaster psychological distress of a moderate to severe nature may be observed in 30-50% of an affected population. Timely and appropriate care can be efficacious. Given that mental health is a common issue, greater resource needs to be directed at recognising and treating it after a disaster.

Disasters

It is a truism that all disasters are local: initial solutions must be delivered to an area where damage has occurred. Almost inevitably it takes 2-3 days for the arrival of outside assistance. Research shows that it is often just not possible to conduct healthcare evaluations right after a natural disaster. However, localities can spread the burdens of preparation, protection and recovery more effectively by networking. Our world seen in this way changes in many perspectives. One is that human health becomes only one part of any disaster management: that of microbes, plants and animals too becomes relevant. Outbreaks of measles in Venezuela, cholera in Mozambique, tetanus following tsunamis all require joined-up measures from doctors, veterinarians and scientists.

Immediately following a disaster medical facilities typically experience a surge of acute cases. The care of those with long-standing disorders is frequently put to one side. Characteristically there follows a delayed and prolonged secondary surge of morbidity and mortality involving patients with chronic illness such as cardiovascular disease, diabetes and cancer, sometime after the actual disaster. At risk populations in disasters have been better defined by journalists than medics. Those at greatest risk during disasters are those who were at risk before the disaster. That is the poor, those with little access to healthcare and those with chronic disorders, particularly if they live in rural areas with limited infrastructure. Burdens for the management of many aspects of disaster medicine are often carried by those working in primary or family health care. Predictably disasters affect not only humans but animals too -veterinary disaster medicine is a growing component of this discipline

Of the many types of disaster evaluated by agencies such as UNISDR, pandemics are those we are probably least well prepared for. Because of the rapid movement of humans around the globe, we can spread viruses efficiently between ourselves. Increased rates of spread of several groups of pathogens by arthropods such as the Anopheles albopictus mosquito, which now has such wide global reach, makes potential infectious disease threats significant. Mathematical modelling of disease spread shows that human movement is a particular challenge. It takes remarkably few infected individuals to infect large islands such as New Zealand, and even fewer to do the same to smaller communities. Pandemics may develop on slower timeframes than hurricanes or earthquakes, but they often compromise the health of larger communities and exacerbate illness in those with pre-existing diagnoses.

In September 2017 a powerful Cape Verde hurricane, Irma, struck St Martin, the first category 5 hurricane recorded to have done so. Irma was the second most costly hurricane after hurricane Maria which followed two weeks later. St Martin is an island of some 35 square miles with a population of approximately 41 000 people. It is the home of the American University of the Caribbean Medical School (AUC). In response to the damage caused by both Irma and Maria and with the aim of improving future preparation and responses to natural disasters, the AUC made links with a weather bureau, developed a playbook and began a collaboration with physicians from Boston. These activities combined in the establishment of a Caribbean Centre for Disaster Medicine (CCDM) on its campus. At the inaugural meeting in March of this year local and regional authorities gathered with experts in extereme weather, pandemics and terrorist events. Issues as varied as developing better linked communications, identifying sources of intravenous fluids, blood transfusions and tetanus vaccines; pet transport and the impacts of the hurricane on traditional medicine use were discussed. Revealing observations were collected from those residents during the storm and from those living on neighbouring islands.

What were the headline messages from this collaboration? The most obvious we know all too well – human beings and their agencies are not particularly efficient at preparation. It has been 22 years since the previous severe hurricane damaged St Martin. This time period was sufficiently long to have dampened enthusiasm for collaborations between pharmacies and Hospitals, building authorities and construction engineers, authorities on the Dutch and the French sides of the island. Individuals and agencies responded with prodigious energy and enthusiasm in the days following Irma. However, these activities were unscripted, overlapping and inefficient. In the medical school, for instance, great time was expended in establishing who was on the island at the time and whether they were safe. Lists of individuals, their families and pets were revised constantly as there was no preassigned system. The School was particularly fortunate as there were no Irma-related deaths or serious injuries on campus; there was no subsequent infectious disease. A crucial message from the inaugural CCDM meeting was that this type of engaged academia, like any preparedness plan, requires repetition and development.

The delivery of training in disaster management based on sound science, requires evangelical zeal. Society is often slow to change. However, it is only through this type of work that communities can become better prepared against disasters and potential catastrophe. Connecting and convincing, allows this discipline to work with both towers and squares. That is, with both hierarchies and networks, irrespective of our backgrounds. We may be separated by water, but after all history is clear that dealing with disaster is already part of Creole culture. Disaster medicine and its many siblings in disaster management will change our worlds, reducing some uncertainties and risks, scientifically.

Disasters

Sources of useful information for disaster preparation and management

  • Until Help Arrives: https://community.fema.gov/until-help-arrives
  • American College of Emergency Physicians: https://acep.org/
  • Core Competencies for Disaster Medicine and Public Health: https://www.usuhs.edu/sites/default/files/media/ncdmph/pdf/core-competencies.pdf
  • Emergency Preparedness and Response Resources: Disaster Medicine: https://guides.himmelfarb.gwu.edu/c.php?g=27789&p=170423
  • Disaster Medicine Literature: https://disasterinfo.nlm.nih.gov/
  • Disaster Medicine, an overview: https://www.sciencedirect.com/topics/medicine-and-dentistry/disaster-medicine
  • United Nations INernational Strategy for Disaster Reduction: https://www.unisdr.org/who-we-are
  • Climate Risk and Early Warning Systems (CREWS): https://public.wmo.int/en/media/news/climate-risk-and-early-warning-systems-initiative-expands-its-coverage
  • Global Facility for Disaster Reduction and Recovery: https://www.gfdrr.org/en
  • Ciottone’s Disaster Medicine 2nd Edition: https://www.us.elsevierhealth.com/ciottones-disaster-medicine-9780323286657.html
  • American Academy of Science: Science and Diplomacy: http://www.sciencediplomacy.org/article/2018/disaster-related-science-diplomacy-advancing-global-resilience-through-international
  • Pan-American Health Organisation Natural Disaster Monitoring: https://www.paho.org/disasters/index.php?lang=en
  • Office of the Assistant Secretary for Preparedness and Response, ASPR TRACIE Information Gateway: https://asprtracie.hhs.gov/
  • Human Induced Earthquake database: http://inducedearthquakes.org/