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  • Guest Editor collection: 23 Nov 2015 Patrick Rose
    Senior Analyst
    Gryphon Scientific, LLC

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Patrick RoseSenior Analyst Gryphon Scientific, LLC

The cascading effect of disease outbreaks after disasters and the role of public health in disaster response

Throughout disaster operations, one of the more complex issues disaster management professionals have to contend with is implementing crisis standards of care (i.e., treating injured individuals, caring for individuals with functional needs, providing routine medical services) in a resource constrained environment. Regardless of the type of impending disaster scenario, the impact will undoubtedly degrade into a humanitarian crisis. Cascading effects are prone to strain operations much of which involves dealing with the public health impact. Overwhelmed and understaffed, the struggle is to figure out how to leverage existing resources to prevent a second-order impact such as public health disaster.

We Prepare EverydayFederal Emergency Management Agency (FEMA), United States of America – gov, 2015


Whatever the disaster scenario is that we are faced with, the biggest burden is to meet the needs of those displaced and prevent a public health disaster from occurring. The challenges often faced are enormous and can be exacerbated simply by the sheer volume of persons impacted by the disaster. Immediately, healthcare capacities will become strained as casualties require life-saving treatments and worried-well (e.g., individuals psychologically effected, stressed individuals with pre-existing conditions) require support; not to mention healthy individuals will continue to need basic healthcare services. In such a stressful situation survivors will be vulnerable, which demands that the coordination of disaster operations is pre-meditated and expedited.

Public health disasters are a very unique scenario because they do not always directly follow physical destruction. Sometimes the public health disaster is a second-order effect of another disaster. In either case, it will not be immediately evident that a public health disaster is imminent. For this reason, it is even more important to be able to recognize signs that a public health disaster is developing and respond appropriately. They key to being successful is ensuring, a public health disaster is a whole-of-government responsibility; not just the responsibility of healthcare professionals.

Early on, disaster response operations chart a path for how recovery strategies will be most effective. Meanwhile not only does the focus of the response have to be on life-saving, but also life-sustaining operations. As for any type of disaster we already know that it is important to implement a whole-of-government approach to disaster operations. The key to successfully executing such a disaster response operation is in having the situational awareness to be able to reallocate resources as needed. Sometimes resources and assets primarily designated for one type of operation may provide invaluable for another; another time the operations capability of an organization may be able to provide resources and assets where other organizations have a gap. For example, militaries or law enforcement often have the most resources and assets available along with a highly structured response capability. For public health disasters, certain organizations may not immediately see themselves as playing a role in responding to a public health disaster; however, these agencies’ capabilities can provide immensely valuable in a public health disaster. Integration of different response organizations needs to occur as part of preparedness efforts, especially in the case of a public health disaster. It is vital to include all government agencies and educate disaster responders of the operational constraints of public health disaster, so we can build better capacity to respond successfully.

The first rule of disaster response is “Do not make the situation worse.” While immediate disaster response operations are focused on this mantra, oversight or a delayed response in sufficiently considering cascading effects (e.g., health outcomes and issues) can lead to additional long term damage to the affected region and its population.

When disasters occur, emergency response, both local and global, springs into action to save lives, clear the wreckage, and bring in food, water, shelter, and assistance. However, when the dust settles, survivors are often left in overcrowded refugee camps and displacement shelters that lack access to healthcare and sanitation. Combined with the destruction of critical infrastructure and the potential contamination of water, agriculture and livestock, conditions are ideal for disease and health issues to gain the upper hand. This issue, known as a secondary effect, comes from the lack of integration of public health into disaster response and relief planning. The result is that a disaster relief effort mutates into a public health emergency: what starts as an earthquake can cascade into to a cholera outbreak; a flood can cascade into a malaria epidemic.

In order to understand public health’s critical role in disasters, it is important to look back and examine case studies where disasters resulted in public health emergencies. Through these examinations, it will be evident that public health must be a cornerstone of disaster planning, mitigation, response, and relief; disasters are, at their core, human events.


In 2010, severe floods across Pakistan affected almost 62,000 square miles and displaced at least 20 million people. The country, much of which was already struggling with poverty, a fragile infrastructure, and limited access to quality healthcare, was quickly overwhelmed not only with the physical damage from the flooding but also the ripples caused by the sudden, increased lack of food, clean water, medical supplies and care, and the spike in need.

Pakistan, and especially the flooded regions, has a long history of farming and raising livestock, much of which was damaged or killed in the flooding. These rural, agricultural communities struggled with healthcare and poverty before the flooding, and the issues were exacerbated once infrastructure was damaged or destroyed.

The reasons for this ranking are demonstrated most clearly with three facts: 1) 45.6 percent of the population are multi-dimensionally poor while an additional 14.9 percent are near multi-dimensional poverty; 2) In 2010 there were only .872 physicians per 1000 people; and 3) for every 100,000 live births, 260 women die of pregnancy related causes. To round out the picture, cholera and malaria had been sporadically recorded in the country for years, mostly tied to the seasonal ebb and flow of mosquitos and outbreaks. Already a resilient people and nation, Pakistan struggled to absorb the impacts of a natural disaster under these circumstances.

The floods destroyed roads, fields, homes, killed crops and livestock, and cut populations off from their resources, healthcare, and their livelihoods. As the displaced population moved into refugee camps, significant spikes were noted in both cholera and malaria, as well as respiratory infections and skin diseases. According to a 2011 study, of the people seeking medical treatment in 17 sites in the Punjab district, there were 314,814 cases of acute diarrhea, 317,450 cases of acute respiratory infections, 421, 198 cases of skin diseases, and 53,707 cases of malaria.

Both malaria and cholera are common outcomes of floods. Mosquitos, which spread malaria, breed in stagnant waters like those found across the country both immediately after a flood and long term as waters recede and pool in low-lying areas. With ample breeding grounds, mosquito populations boom and with them comes the risk of malaria spread. In overcrowded displacement and refugee camps where mosquito nets and repellent are rare, malaria can quickly jump from person to person as the mosquitos freely feed. Cholera, spread through contaminated water, has a similarly easy time gaining a foothold in flooded regions. With the lack of safe latrines, hand washing and sanitation stations, and access to clean drinking water, a single sick person could infect an entire camp.

It is easy to imagine how the quickly assembled, over-crowded, and under-resourced camps and shelters could quickly become hot spots for the spread of infections and diseases.

One of the central factors most likely contributing to the spread of cholera and malaria was that public health and infection control were not included in the response and relief efforts or disaster planning. When disasters strike in vulnerable areas: poor, rural, and with a history of infectious and communicable diseases, surveillance and prevention must be integrated into disaster plans and response. The immediate, major issues like search and rescue, collapsed buildings, and reuniting families easily overshadow public health threats, but a country cannot be expected to recover from a disaster when disease and illness continue to affect and kill the people that the recovery is supposed to benefit.


A critical example of the imbalance between the physical recovery of the infrastructure and the health of the population is Haiti. After the devastating earthquake in January, 2010, Haiti was quickly struck another blow in the form of a major cholera epidemic.

For every 100,000 live births, 350 women die in childbirth. For comparison, Latin America and the Caribbean as a whole see only 74 deaths per 100,000 live births. The most recent data available, from 1998, showed that Haiti had only .25 physicians per 1,000 people. The country was already struggling and was made extremely vulnerable after the earthquake.

The capital, Port-Au-Prince was devastated. 230,000 people were killed and another 300,000 were injured. Two million residents sought temporary shelter as internally displaced populations, while another 600,000 sought refuge in undamaged locations. In the aftermath, relief teams and responders arrived from across the world, and assistance, in the form of money and resources came with them. But so did disease.

Cholera had not been endemic in Haiti for nearly 100 years. But in October, cases began to appear in the state. Improperly placed relief worker camps, and ill workers, contaminated water used downstream by the residents of a displacement camp, and the outbreak can be tracked along the waterways from there.

There have been 698,893 cases and 8,540 deaths reported from October 2010 to date. Despite the efforts of United Nations WASH programs focusing on latrine access, hygiene, and water safety, the outbreak continues and has begun to affect the Dominican Republic, which shares the island of Hispaniola with Haiti.

This disaster is an example of how public health concerns should not only be focused on the affected population, but also on those responding to the disaster. Programs, policies, and checks must be put in place to ensure that responders are not in danger of either being infected or infecting others.

There are current programs working to provide and ensure vaccinations for first responders entering areas with endemic diseases or risks of infection, but very few policies exist to prevent ill aid workers from responding to a disaster, which ultimately led to the cholera epidemic in Haiti. For the safety and health of the affected populations, public health must be incorporated into the response plans as well as the policies surrounding aid workers.

Avoiding outbreaks

Why do some disasters precipitate outbreaks and some do not? What are the key actions and policies that prevent outbreaks in disaster situations? Two examples might provide some insight:

Example 1. In March of 2011 a major earthquake struck off the coast of Japan and triggered a tsunami wave up to 16 meters high in some places and devastated the Eastern coast of the nation. Hundreds of thousands of people were displaced, injured, or killed while camps lacked sufficient power and supplies. Electric, water, and sanitation services were disrupted and made response and health activities harder.

Example 2. On Boxing Day, 2004, the Asian Tsunami reverberated around the Indian Ocean killing hundreds of thousands and displacing millions. Many islands, both the densely and sparsely populated, struggled to track populations or provide services in areas that already lacked sufficient access and resources. The tsunami changed the landscape of the area and made movement between islands dangerous and difficult.

In each case, major disease outbreaks were avoided due to concerted efforts focusing on public health and surveillance. In Japan, as early as April 13th, surveillance teams with electronic computer tablets were on site tracking disease symptoms and infections. With 2.29 physicians per 1,000 people, Japan has over 9 times the physicians of Haiti and 2.5 times that of Pakistan. Thanks to the available modern technology and a robust public health infrastructure in Japan, mobile networks and computers were used to aid in disease surveillance. The task force included a mobile team that collected data from a mean of 13.2 centres per day. This constant and far-reaching surveillance prevented significant outbreaks of common post-tsunamis illnesses like water-borne diseases like acute diarrhea and forms of pneumonia and acute respiratory illnesses.

In the case of the Asian Ocean tsunami, disease surveillance and outbreak tracking was performed by international organizations and especially the United States Government and Department of Defense. The well-established support structure from organizations such as the United States Government and other organizations allowed appropriated authority and funding to quickly assist in the overall response. The result was that public health implications of the disaster were quickly recognized and addressed. The coordinated effort allowed other humanitarian organizations to focus on their missions while avoiding duplication of operations addressing disease surveillance, tracking, and public health follow-up. There were upticks of prominent diseases in some locations; however, major outbreaks were avoided. While many of the nations affected by the Asian Ocean tsunami did not have the technology or industrialization of Japan, these nations benefited hugely from the existing preparedness planning and coordination of efforts of partner organizations who make public health security a principle tenant of their response operations.

Avoiding outbreaks requires that the response be holistic (i.e., include public health security plans) and coordinated. Efforts must include extensive surveillance and immediate mitigation of public health threats. These efforts must utilize available skills and abilities of responding organizations and individuals, although these skills and abilities do not require advanced technology to achieve. For Japan, as an industrialized nation, it was possible to rely on the existing and undamaged infrastructure as well as the culture of organization and communication. For Indian Ocean nations like Sri Lanka and Indonesia, the existing partnerships with organizations, who are cognizant of public health security threats, provided the expertise, resources, and coordination required to avoid significant outbreaks.


It may not always be possible to rely on technology or a constant presence of disaster response organizations, but, moving forward, including public health priorities and disease surveillance activities in disaster planning will help to reduce risk and ensure that disaster planning addresses all aspects of disasters.

Many nations, like Haiti or Pakistan, will require assistance and significant effort to incorporate public health into their own disaster planning, but even if it is not possible for them to provide the planning and preparedness for themselves, major multi-national organizations like the United Nations, Red Cross, or World Health Organization can work to ensure that surveillance and infection prevention, as well as responder health, are thoroughly incorporated into their response and relief plans.

Contributing editor

Mary Wakefield
MPH Pandemic and Catastrophic Preparedness Intern
National Association for County and City Health Officials

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Patrick RoseSenior Analyst Gryphon Scientific, LLC

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