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First, Don't Be a Tourist

2015; Elsevier BV; Volume: 66; Issue: 5 Linguagem: Inglês

10.1016/j.annemergmed.2015.07.020

1097-6760

William B. Millard,

Disaster Response and Management

A familiar narrative comes into play each time a natural disaster strikes somewhere around the world.1Katz J.M. How not to report on an earthquake.New York Times Magazine. April 28, 2015; (Available at:) (Accessed May 9, 2015)http://www.nytimes.com/2015/04/28/magazine/how-not-to-report-on-an-earthquake.htmlGoogle Scholar, 2Brauman R. Global media and the myths of humanitarian relief. MSF/Centre de réflexion sur l’action et les savoirs humanitaires (CRASH), 2006. Available at: http://www.msf-crash.org/drive/4d62-rb-2006-global-medias-and-the-myths-of-humanitarian-relief-_uk-p.8_.pdf. Accessed June 25, 2015.Google Scholar Earthquakes, floods, tsunamis, droughts, or hurricanes overwhelm both the physical infrastructure and the public institutions of a vulnerable site; deaths, injuries, and infectious disease outstrip the local health system's capacities. Whether the calamity demonstrates relative resilience or utter chaos on the part of the affected nation, medical personnel throughout the developed world recognize a professional and humanitarian duty to come to the assistance of the survivors. At great sacrifice, responders fly in from the United States, Europe, and other more fortunate nations, bringing valuable expertise, locally unavailable medicines and technologies, and goodwill. Their charitable presence, as the global media dutifully note, helps make the difference between painstaking recovery and apocalyptic social breakdown (eg, violence, shortages, looting, epidemics, widespread panic). The standard narrative is invariably flattering to the volunteers and the nations, nongovernmental organizations, and donors supporting them. By no means does it misrepresent their honorable intentions, say disaster veterans—few would impugn the sincerity of people who endure privations and risks abroad to benefit the afflicted—but it so consistently gets enough other things wrong that it has become counterproductive. Relief work after disasters or conflict is an increasingly professionalized activity, and those who are most familiar with it emphasize the distinct characteristics of each event, the strengths of the populations directly affected, and the value of rethinking interpretive frameworks centered on heroic rescue. Emergency physicians, say seasoned field workers who make personnel decisions for Médecins Sans Frontières (MSF), are among the most highly prized specialists among potential volunteers. “We recruit quite a few emergency physicians,” said Rogier van Helmond, MA, a New York–based MSF field human resources officer who has served in South Sudan, Pakistan, Nigeria, and Jordan and now recruits for programs in some 70 countries. “It's a nice background to have for MSF because you deal with whatever comes in, and that's actually the type of people we're looking for, being comfortable both with adults and children.” The disaster conditions to which many physicians respond, however, often call for humility over heroics. MSF usually reserves disaster assignments for those who have garnered experience in more general field-based primary health care, van Helmond said, recognizing the “need to be up and running from day one.” MSF's work is driven by standardization and protocols; “that's why disaster response is usually not good for first-missioners.” In addition, he noted that “often we have programs already on the ground when a disaster happens,” and “90% of the work is done by national staff...[and] not only in disasters but everywhere, we always work with local doctors, nurses, drivers, cooks, and cleaners.” These are the people whose immediate contributions often outweigh those of foreign volunteers. Claude de Ville de Goyet, MD, served as the first director of the Research Center on Disaster Epidemiology, located in Belgium; directed the disaster management program of the Pan American Health Organization (a regional office of the World Health Organization [WHO]) from 1977 to 2002; and has led teams evaluating disaster conditions throughout the world. He now works as a freelance risk-management consultant, advising governments and United Nations agencies. His experiences have yielded conclusions that some find contrarian. “The key issue,” Dr. de Ville de Goyet said, is that “most of the medical [emergency] response has to be local because we systematically arrive 2 or 3 days too late for saving life in most of the cases. You have extreme cases like Haiti, where the number of injuries [was] so high that most of the medical teams were able to do good work. That is [the] exception.” Because “it is almost impossible for a medical team to be there before 36 hours,” he observed, local medical resources have repeatedly proven more important than foreign teams. A study of foreign medical teams' performance in sudden-onset disasters (distinguished from military conflict), being prepared by Dr. de Ville de Goyet and colleagues for WHO, analyzes a decade's worth of direct experiences, peer-reviewed publications, and expert or official interviews about situations ranging from Iran's Bam earthquake (2003) to the Haitian postearthquake cholera outbreak (2010 to 2013).3de Ville de Goyet C, Perez Calderon LJ, Sarmento JP, et al. The management of foreign medical teams in the aftermath of sudden onset natural disasters. 2014-2015: in preparation.Google Scholar The deployment of foreign teams, always a politically sensitive measure complicated by nonmedical considerations, has not always been an unalloyed benefit to the host nations. “In the Philippines, in Pakistan, in Indonesia,” he continued, “you had such a huge background of medical facilities, of volunteers from the sophisticated trauma centers in the countries, and the number of injuries compared to the number of medical personnel made a lot of people [who] were not prepared totally useless or counterproductive.” This description does not invalidate the lifesaving work done by volunteers, particularly those working through well-established nongovernmental organizations like MSF, the International Medical Corps, or Partners in Health. The argument Dr. de Ville de Goyet has been making for years,4Booth J. WHO slams “crisis junkies.”.Telegraph. September 3, 2000; (Available at:) (Accessed June 25, 2015)http://www.telegraph.co.uk/news/worldnews/europe/1353962/WHO-slams-crisis-junkies.htmlGoogle Scholar however, is that foreign volunteers accomplish the most good by dropping preconceptions about the superiority of developed countries' medical personnel, the helplessness of residents in developing countries, the corruption of their officials, or the benefits of apparently selfless gestures from abroad. Disaster sites present both unprecedented challenges and underappreciated local resources; the most effective responses involve attention to nuances and attentiveness toward the persons directly affected. Disasters display unique characteristics, and sites differ widely in complex variables: physical accessibility, infrastructure for transportation and communication, population demographics, local medical systems, degree of social organization and preparedness, political openness to outsiders, and economic resilience. Instead of a large influx of volunteers from overseas—who may burden the already strapped local resources if they arrive without prearranged housing, transportation, translators, or other essentials—Dr. de Ville de Goyet believes a response should focus specifically on the distinct features of the site and the event, making the most of local expertise and matching volunteers with local needs, not with their own expectations. “The disaster response has been around for a long time,” noted Paul Auerbach, MD, chief of emergency medicine at Stanford School of Medicine and cofounder of the Stanford Emergency Medicine Program for Emergency Response. “Disaster medicine has been here for a shorter period of time, and evidence-based disaster medicine is really just beginning to emerge.” Dr. Auerbach's extensive fieldwork includes trips to the earthquake sites in Haiti and Nepal, where he recently worked under the International Medical Corps's auspices. He cited the accuracy and timeliness of situation reports as a critical variable in helping responders identify medical and nonmedical needs, risks of additional earthquakes, and other factors such as civic unrest. Whether foreign responders have reliable or unreliable information, the key factor is local preparation. “If it wasn't already an austere setting, [an earthquake] creates an austere setting,” Dr. Auerbach said. “People are displaced. It can be chaotic. Normal surveillance systems for diseases and infectious diseases and all sorts of medical situations may not be as robust as they normally are, and so there can be events and situations that aren't spotted as soon as they would normally be.” Contingency planning needs to account for the likeliest local risks (eg, tornadoes in the central United States, earthquakes near fault lines, cyclones and tsunamis at coastal sites) and for how patterns of medical need evolve: “We spend a tremendous number of resources bringing in search and rescue, and I think it's fairly well accepted that everyone who's saved is certainly grateful,” Dr. Auerbach said. “But a large amount of that is accomplished by people who are local, who can get to the victims quickly, as opposed to the teams that are flown in that come days later, because there are diminishing returns.” Despite the chaos surrounding a disaster, panic is uncommon, disaster experts comment. “In Katmandu there was no civil disobedience,” Dr. Auerbach observed. “It was very orderly, and the people were phenomenal, given what they had been through—which was quite a different situation from Haiti, where the victims were also good, but the state of civil affairs in Port-au-Prince is quite different.... Having not responded to an earthquake scenario since Haiti, I was envisioning going into Armageddon.” Communities differ widely in planning mechanisms and degrees of resilience—with Haiti's weak to nonexistent public sector perhaps representing an extreme condition, earning the nation the nickname “an NGO [nongovernmental organization] republic”5Klarreich K. Polman L. The NGO Republic of Haiti.Nation. November 19, 2012; (Available at:) (Accessed July 1, 2015)http://www.thenation.com/article/170929/ngo-republic-haitiGoogle Scholar—and the public image of extreme dependence that arose after the Port-au-Prince earthquake does not extend elsewhere. “I don't think we project the wrong images of those people,” Dr. de Ville de Goyet said, referring to residents of the developing world generally. “We try to project the wrong image of ourself [sic] as being so much better: of being organized and going and saving life.” When the United States Agency for International Development, the Canadian International Development Agency, or other equivalents from developed countries send physicians or mobile army surgical hospital teams overseas, he contends, it projects an impressive political image, but the areas in which developed nations can make better contributions are less glamorous. “They are not good in organization. But in terms of providing appropriate care more rapidly than we are, which they are capable to do [sic], they are better than we are.” Fear, Dr. de Ville de Goyet said, underlies some forms of overreaction. The assumption that rapid mass burials are required to prevent communicable-disease outbreaks often flies in the face of biology and is unnecessarily disruptive, as well as often culturally antagonistic. “Dead bodies [are] literally incapable to transmit [sic] the most endemic diseases: cholera, typhoid, or anything,” he noted. “If you are a cholera carrier, I prefer you dead than alive because from a public-health point of view...the process becomes anaerobic in different terms, and you don't produce any more vibrion.” Hasty disposition of bodies, seized by soldiers and buried in trenches or burned, deprives survivors of a normal respectful grieving process. “There's a cost of not being allowed to bury your relatives, or even to identify your relatives,” Dr. de Ville de Goyet cautioned. Volunteers in some cases, he has found, have priorities other than medical assistance. “In [the] Philippines and Pakistan,” he said, “you have people [who] were not very concerned with medical care but were using this as an opening door, a key to do proselytism...so you have a mixture of motivations, some of which are very good, very [solid], very naive, and sometimes, some which are very sordid. “You have in Haiti stories of doctors, surgeons, ‘heroically' amputating, guillotining a leg in front of the camera, and then dropping the patient to wherever they wanted to take [him] and go back once the shot has been made.” In the Philippines he saw “a team from the US which came much earlier than any other team, did some very rough surgery in front of the cameras, criticized the system, and left after 3 days.... I don't have the data to see whether they were competent enough to have done some good for 36 hours. Of course, they left after 3 or 4 days because they had a PR [public relations] objective being achieved.” The cholera outbreak after the Haitian earthquake was actually an artifact of foreign intervention, not involving the work of medical teams, Dr. de Ville de Goyet said, but “imported by peacekeeping troops from Nepal” shortly after an outbreak in that nation6Piarroux R. Barrais R. Faucher B. et al.Understanding the cholera epidemic, Haiti.Emerg Infect Dis. 2011; 17: 1161-1168Crossref PubMed Scopus (218) Google Scholar and spread through fecal contamination of drinking water. Cases appeared months after the earthquake and in an area unaffected by the quake, Artibonite, some 100 km north of the epicenter at Port-au-Prince. Although United Nations spokespersons and the official report7Cravioto A, Lanata CF, Lantagne DS, et al. Final report of the independent panel of experts on the cholera outbreak in Haiti. United Nations, 2011. Available at: http://www.un.org/News/dh/infocus/haiti/UN-cholera-report-final.pdf. Accessed June 30, 2015.Google Scholar hedged on the question of responsibility for the outbreak strain's appearance, a molecular sequencing study implicated variants isolated in South Asia8Chin C.-S. Sorenson J. Harris J.B. et al.The origin of the Haitian cholera outbreak.N Engl J Med. 2011; 364: 33-42Crossref PubMed Scopus (559) Google Scholar; the correlation, Dr. de Ville de Goyet said, is “not for criminal or liability purpose, but scientifically it is totally proven.” (Considering the arguments about other possible sources, he asked a commonsense question: “You wonder for 20 years how come Haiti was spared the cholera outbreak going through the Americas, because that is a normal place to have a major cholera outbreak. You have everything in Haiti but cholera. That has been ‘corrected.'”) He added that “the ratio of nurses [to] doctors is very bad in disasters in most of the teams,” putting a premium on senior nurses—but they are precisely the personnel whom hospital directors are reluctant to let go. “It is much easier to send your chief surgeon than to send your chief nurse. That, I'm not going to give you!” For physicians who do go abroad—“You will never stop do-gooders,” he commented—Dr. de Ville de Goyet has strong recommendations. “First, they have to get some exposures with developing countries…. And if they are not integrated within a team which has an exposure, the adaptations to local conditions will be much, much too difficult.” “Emergency physicians are particularly well suited to disaster settings because they have a diverse set of skills,” Dr. Auerbach said. “They're comfortable with the acute phase; they can be effective for much of the medical care that they provide. It's not disaster related in terms of it being trauma, or a medical problem that was created by the disaster, but backfilling for the health care system.” Less helpful, he has found, are the “‘disaster tourists,' who come in and really don't do much, and may take up places to stay and food and resources.” Echoing recent calls for stern soul-searching about one's own skill set and discomfort tolerance before volunteering,9Hein IG. Should you volunteer in a disaster? advice for physicians. Medscape Public Health, June 4, 2015. Available at: http://www.medscape.com/viewarticle/845698_print. Accessed June 9, 2015.Google Scholar he commented, “You have to have the good judgment and the grace to help when you can and to depart when you don't have anything to contribute.” Emergency physicians need no reminding that disasters occur everywhere, although not with equal frequency. Disasters in the United States have recently evoked responses that are both encouraging and bracing; those who have endured these situations observe that conditions, even in the nation's chief metropolis, can rapidly resemble those seen in developing nations, and that the learning curve can be just as steep. Christopher McStay, MD, now associate professor of emergency medicine and chief of clinical operations at the University of Colorado in Denver, was serving as medical director and director of services for the Bellevue Hospital emergency department (ED) when Superstorm Sandy struck New York City on October 29, 2012. Having survived the milder Hurricane Irene the previous year and strengthened precautions accordingly, Bellevue officials “knew that we had plenty of diesel fuel and plenty of oxygen and all the things that we're supposed to have...and things were OK. And then things quickly took a major turn once the basement flooded.” Power-related consequences from locating key electrical equipment at a flood-vulnerable altitude produced a cascade of trouble throughout the Bellevue complex's distribution grid. “We lost the ability to move electrical power around the campus,” Dr. McStay reported. (Although generators were on the 13th floor, a fuel pump delivering diesel to them from underground tanks “was a known vulnerability and had been hardened behind submarine doors”; it failed anyway.) After the ED lost generator power, hospital officials made a series of decision on the fly, first to divert power to the area including ICUs. With 736 inpatients, whose charts were maintained in an electronic medical records system, the hospital had an ED without lights (except for small battery-powered emergency lights that lasted about half an hour) or electricity. Battery-operated computers on wheels allowed enough connection to the records to transfer critical information to paper and revert to pre–electronic medical records procedures. “I think we had a pretty stable situation; ER folks are pretty used to dealing with disaster and circumstance,” Dr. McStay recalled. Batteries in waterproof Pelican cases were distributed throughout the ED; Dr. McStay and several other colleagues brought in headlamps. Sometime around 1 am, he made “a leadership decision” to go to bed and conserve his own energy while a colleague, medical director Rajneesh Gulati, MD, worked through the night. At one point, Dr. McStay said, once physician leaders recognized that the fuel pump had failed and the generators were down to minutes' worth of fuel, they instituted a bucket brigade to pass fuel manually up 13 flights of stairwells in 5-gallon buckets to an auxiliary tank. Photographs exist of the chief of medicine and other senior personnel manning brigade positions; “[E]verybody pitched in, and it was recognized that was the most important thing to do at the time.” The basement flood also caused outages of elevators, telecommunications, and heating/ventilation/air conditioning systems. Bellevue includes a forensic prison unit for the city's Department of Corrections on the 19th floor, psychiatric units on higher levels, and a methadone clinic. Having begun to discharge some patients and transfer others who had been admitted to stay in the ED or whose evaluations indicated they needed admission, Dr. McStay and colleagues realized, as methadone-dependent outpatients began appearing in the morning, that “we're not prepared here to take care of anybody in these circumstances”; he and the chief operating officer decided to close the ED entirely, retaining just a handful of physicians for the next few days as a campus-wide ad hoc employee health service. The broader decision to close and evacuate the entire hospital took place on October 31, with 269 patients discharged, 464 transferred to other institutions, and a massive task by clinical departments to inform patients of the closure (the hospital has about 300,000 to 400,000 annual outpatient visits, with 100,000 visits to the ED, serving a population of whom many are “homeless or at the margins of society”). Almost half of those evacuated were psychiatric inpatients; with no elevator service, the challenge of moving patients with behavioral risks, ambulatory or otherwise, involved the aid of Army National Guard volunteers and an improvised technique of wrapping a patient in a sheet and sliding him or her downstairs on a plastic MedSled. Units began reopening in stages, Dr. McStay said, in a First Avenue building new enough to be less severely affected by flooding: first nonemergency primary care on November 19, then the ED starting a continuously staffed urgent care clinic, then a freestanding ED accepting ambulances (a model that has subsequently been replicated at St. Vincent's) on December 24, and finally the full-service hospital reopening on February 7, 2013. Hospital workers, he pointed out, had been uncertain whether the institution would ever reopen, or whether their jobs would vanish: “They were thinking about Charity Hospital.” Unlike that New Orleans institution, in which “the decisions...I think, were highly political, in terms of basically never reopening it…. I never heard a leader say, ‘We might not be able to reopen the hospital.'” “For me, one of the big [lessons] was, I showed up to the hospital prepared to be sustaining myself,” Dr. McStay said. “So when I came in that night, I brought a sleeping bag, I brought a camping stove, I brought coffee, I brought enough food to take care of myself, and I had lamps and those kinds of things. I'm sort of a back-country-camper kind of guy.” This preparedness extended from the individual level to the collegial, he noted: “Emergency medicine folks are all kind of like that: we work elbow to elbow all the time with our techs and our nurses and registration people.... Taking care of each other and taking care of yourself is really, really important. If you can't do that, you can't take care of patients. I think that a place like Bellevue is far stronger now because of what happened, because of the bond that the leadership team and the folks that were involved in all the events created with each other.” Dr. McStay hails neighboring institutions, particularly Beth Israel, New York Presbyterian, Metropolitan Hospital, and the rest of the city's Health and Hospitals Corporation, for absorbing the massive overflow of patients from Bellevue (and its sister institution NYU Langone, also evacuated). The city's Healthcare Facility Evacuation Center, he added, first activated in preparation for Hurricane Irene in 2011, coordinates hospitals' maneuvers during crises; its trial run involving NYU Langone and Mount Sinai the previous year, he said, helped establish relationships that strengthened institutions and saved lives.