key: cord- - kghmzf authors: lai, allen yu-hung; tan, seck l. title: impact of disasters and disaster risk management in singapore: a case study of singapore’s experience in fighting the sars epidemic date: - - journal: resilience and recovery in asian disasters doi: . / - - - - _ sha: doc_id: cord_uid: kghmzf singapore is vulnerable to both natural and man-made disasters alongside its remarkable economic growth. one of the most significant disasters in recent history was the severe acute respiratory syndrome (sars) epidemic in . the sars outbreak was eventually contained through a series of risk mitigating measures introduced by the singapore government. this would not be possible without the engagement and responsiveness of the general public. this chapter begins with a description of singapore’s historical disaster profiles, the policy and legal framework in the all-hazard management approach. we use a case study to highlight the disaster impacts and insights drawn from singapore’s risk management experience with specific references to the sars epidemic. the implications from the sars focus on four areas: staying vigilant at the community level, remaining flexible in a national command structure, the demand for surge capacity, and collaborative governance at regional level. this chapter concludes with a presence of the flexible command structure on both the way and the extent it was utilized. situated in southeast asia yet outside the pacific rim of fire, singapore is fortunate enough to have been spared from major natural disasters such as typhoons, floods, volcanic eruptions, and earthquakes. however, this does not imply that singapore is safe, or immune from being affected by disasters. singapore houses a population of . million, a ranking of the third highest population density in the world. about % of singapore's population resides in high-rise buildings (asian disaster reduction center ) . a major disaster of any sort could inflict mass casualties and extensive destruction to properties in singapore. clearly, like its neighboring countries, singapore is also vulnerable to both natural and man-made disasters alongside its remarkable economic growth. the potential risks may result from its dense population, intricate transportation network, or a transnational communicable disease. moreover, singapore can be affected by the situations in surrounding countries. for example, flooding in thailand and vietnam may affect the price of rice sold in singapore. indeed, singapore in her short history of years has experienced a small number of disasters. chief among these, the severe acute respiratory syndrome (sars) epidemic in was the most devastating. the sars outbreak brought about far-reaching public health and economic consequences for the country as a whole. fortunately, the outbreak was eventually contained through a series of risk mitigating measures introduced by the singapore government and the responsiveness of all singaporeans. it is important to point out that these risk mitigating measures, along with the public's compliance, were swiftly adjusted to address the volatile conditions-such as when more epidemiological cases were uncovered. in this chapter, we introduce singapore's all-hazard management framework as well as the insights drawn from singapore's risk management experience with specific references to the sars epidemic. to achieve our research objective, we utilized a triangulation strategy of various research methodologies. to understand the principles and practices of singapore's approach to disaster risk management, we carry out an historical analysis of official documents obtained from the relevant singapore government agencies as well as international organizations, literature reviews, quantitative analysis of economic impacts, qualitative interviews with key informants (e.g. public health professionals and decision-makers), and email communications with frontline managers from the public sector (e.g. the singapore civil defense force, the communicable disease centre) and non-governmental organizations. the authors also employed the 'cultural insider' approach by participating in epidemic control procedures against sars. in particular, we use the method of case study to illuminate singapore's approach to disaster risk management. the rationale of doing a case study of sars along with singapore's all-hazard approach is that the case study can best showcase the contextual differences, those being political, economic, and social. this case study aims to highlight the lessons drawn from past experiences in a specific context and timeframe, through which we are able to focus more on the nature of the risks, and the processes and the impacts of the disaster risk management and policy intervention. we also examined relevant literature on risk mitigating measures against communicable diseases in order to establish our conclusions. we evaluated oral accounts provided by key health policy decision-makers and experts for valuable insights. this chapter offers empirical evidence on the role of the whole-of-government approach to risk mitigation of the sars epidemic. applying the approach to a case study, our research enriches the vocabulary of risk management, adding to the body of knowledge on disaster management specific to the region of southeast asia. indeed, the dominant perspective in this field holds that the state must be able to exercise brute force and impose its will on the population (lai and tan ) . however, as shown in our paper, this dominant perspective is incomplete as the exercise of authority and power from the government is not necessarily sufficient to contain the transmission of transnational communicable diseases. success in fighting epidemics, as most would agree, is also contingent on a concerted effort of partnership between governmental authorities and the population at large. as discussed in the first section of this volume, community and family ties along with government responses can mitigate disasters. this chapter has four main sections. following this introduction, we provide an overview of singapore's historical disaster profiles. second, we introduce the policy and legal framework, and budgetary allocations for risk mitigation in singapore. third, we detail a case study of singapore's experience in fighting sars, as well as the impact of sars on singapore in its economic, healthcare, and psychosocial aspects. in the fourth section, we discuss the implications for practice and future research in disaster risk management, followed by conclusions. singapore has experienced a small number of disasters since it was founded in . in this section, we briefly provide an historical account of singapore's disaster risk profiles including earthquakes, floods, epidemics, civil emergencies, and haze. singapore has a low risk of earthquakes and tsunamis. geographically, singapore is located in a low seismic-hazard region. however, the high-rise buildings that are built on soft-soil in singapore are still vulnerable to earthquakes from far afield (asian disaster reduction center ) . this is because singapore is at a distance (nearest) of km from the sumatran subduction zone and km away from the sumatra fault both of which have the potential of generating large magnitude earthquakes. this geographic vicinity may produce a resonance like situation within high-rise buildings on soft-soil. recent tremors from the september sumatra offshore earthquake were experienced in buildings located mainly in the central, northern and western parts of singapore. on the front of potential tsunamis, singapore has developed a national tsunami response plan which is a multiagency government effort comprising of an early warning system, tsunami mitigation and emergency response plans, and public education. though singapore does not suffer from flood disasters due to the continuous drainage improvement works by the local authorities, the country has a risk of local flooding in some low-lying parts. the floods take place due to heavy rainfall that aggregates over short periods of time. the worst floods in singapore's history took place on december . the floods claimed seven lives, forced more than , people to be evacuated, and the total damages reached sgd million (tan ) . the swift and sudden floods in were caused by a combination of factors including torrential monsoon rains, drainage problems, and high incoming tides. over the following years, singapore saw a series of flash floods hit various parts of the city-state. for example, for example, - southeast asian floods hit singapore on december as a result of mm rainfall in h. from onwards, singapore has experienced a series of flash floods due to the higher-than-average rainfall. one severe episode occurred on june that flooded shopping malls and basement car parks in its most famous shopping area-orchard road. as per the reported historical disaster data from the cred international disaster database, singapore has suffered only two disaster events caused by epidemics. in , singapore experienced its largest known outbreak of hand-foot-mouth disease (hfmd) which affected more than , young children, causing three deaths. later in , sars hit singapore and it was singapore's most devastating disaster to date. the sars virus infected around , people worldwide and caused around deaths. in singapore, sars infected people, of whom died of this contagious communicable disease. in , novel avian influenza h n struck singapore, which affected , people with deaths. civil emergencies are defined as sudden incidents involving the loss of lives or damage to property on a large scale. they include ( ) civil incidents such as bomb explosions, aircraft hijacks, terrorist hostage-taking, chemical, biological, radiological and explosive (cbre) agents and the release of radioactive materials by warships, and ( ) civil emergencies, for example major fires, structural collapses, air crashes outside the airport boundary, and hazardous material incidents. in singapore, the singapore civil defense force (scdf) is responsible for civil emergencies. since , singapore has experienced several episodes of civil emergencies. for example, the greek tanker spyros explosion at the jurong shipyard in was singapore's worst industrial disaster in terms of lives lost (ministry of labor, singapore ) . in , the six-storey hotel new world collapse was singapore's deadliest civil disaster claiming lives. the collapse was due to structural faults. the scdf, together with other rescue forces, spent days on the whole relief operation. after the collapse, the government introduced more stringent regulations on construction building codes, and the scdf went through a series of upgrades in training and equipment (goh ). singapore experienced its first haze in the period of the end of august to the first week of november as a result of prevailing winds. the haze in , called the southeast asian haze, was caused by slash and burn techniques adopted by farmers in indonesia. the smoke haze carried particulate matter that caused an increase of acute health effects including increased hospital visits due to respiratory distress such as asthma, pulmonary infection, as well as eye and skin irritation. the haze also severely affected visibility in addition to increasing health problems. as a result, singapore's health surveillance showed a % increase in outpatient attendance for haze-related conditions (emmanuel ) . apart from healthcare costs, other costs associated with the haze included short-term tourism and production losses. a study by environmental economists of the southeast asian haze indicated a total of usd$ . million in economic losses in singapore alone. singapore is actively involved in various regional meetings to deal with transboundary smoke haze pollution in order to reduce the risk (singapore institute of international affairs ). the singapore government adopts a cross-ministerial policy framework-a wholeof-government integrated risk management (wog-irm), for disaster risk mitigation and disaster management (asia pacific economic cooperation ). this is a framework that aims to improve the risk awareness of all government agencies and the public, and helps to identify the full range of risks systematically. in addition, the framework identifies cross-agency risks that may have fallen through gaps in the system. this framework also includes medical response systems during emergencies, mass casualty management, risk reduction legislation for fire safety and hazardous materials, police operations, information and media management during crises and public-private partnerships in emergency preparedness. the wog-irm policy frame work in singapore functions in peacetime and in times of crisis. it refers to an approach that all relevant agencies work together in an established framework, with seamless communication and coordination to manage the risk (pereira ) . in peacetime, the home team comprises of four core agencies at central government level. these four agencies are the strategic planning office, the home front crisis ministerial committee (hcmc), the national security coordination secretariat, and the ministry of finance at the policy layer. among them, the strategic planning office provides oversight and guidance as the main platform to steer and review the overall progress of the wog-irm framework. during peacetime, the strategic planning office convenes meetings quarterly for the permanent secretaries from the various ministries across government. in a crisis, the home front crisis management system provides a "ministerial committee" responsible for all crisis situations in singapore. in the wog-irm structure, the hcmc is led by the ministry of home affairs (mha). in peacetime, mha is the principal policy-making governmental body for safety and security in singapore. in the event of a national disaster, the mha leads at the strategic level of incident management. the incident management system in singapore is known as the home front crisis management system (hcms). under the hcms, the scdf is appointed as the incident manager, taking charge of managing the consequences of disasters and civil emergencies. reporting to the hcmc is an executive group known as the home front crisis executive group (hceg), which is chaired by the permanent secretary for mha. the hceg is in charge of planning and managing all types of disasters in singapore. within the operation allayer, there are various functional inter-agency crisis management groups with specific responsibilities, integrated by the various governmental crisis-management units. at the tactical layer, there are the crisis and incident managers who supervise service delivery and coordination. the singapore government holds relevant ministries accountable in accordance to the nature and scope of the disaster. among those ministries and government agencies, the scdf is the major player in risk mitigation and management for civil emergencies. now, let us look into the scdf in more detail. for civil security and civil incidents, the singapore civil defense force (scdf) is singapore's leading operational authority-the incident manager for the management of civil emergencies. the scdf is responsible for leading and coordinating the multi-agency response under the home front crisis management committee. the scdf operates a three-tier command structure, with headquarters (hq) scdf at the apex commanding four land divisions. these divisions are supported by a network of fire stations and fire posts strategically located around the island. the scdf also serves the following pivotal functions. the scdf provides effective -h fire fighting, rescue and emergency ambulance services. the scdf developed the operations civil emergency (ops ce) plan-a national contingency plan. when ops ce is activated, the scdf is vested with the authority to direct all response forces under a unified command structure, thus enabling all required resources to be pooled. however, the wog-irm policy framework only came to existence when singapore encountered sars. the sars epidemic in was an institutional watershed for singapore's approach to risk mitigation and disaster management (pereira ) . prior to the sars epidemic, singapore's executive group mainly focused on crises or disasters that were civil defense in nature. these emergencies were merely conceived to be well managed by a solitary incident manager, supported by other relevant agencies. a specific multi-sectoral governance structure was not considered necessary to handle the crisis. the sars epidemic challenged the prevailing home front crisis management structure as the epidemic transcended just managing civil defense incidents. the policymakers realized the necessity to adopt a comprehensive disaster management framework, an all-hazard approach that includes a mechanism for seamless integration at both the strategic and operational levels among various government agencies. to this end, singapore revamped its home front crisis management framework to produce the current inter-agency structure. the main legislation supporting emergency preparedness and disaster management activities in singapore are the civil defense act of , the fire safety act of , and the civil defense shelter act of . the civil defense act provides the legal framework for, amongst other things, the declaration of a state of emergency and the mobilization and deployment of operationally-ready national service rescuers. provides the legal framework to impose fire safety requirements on commercial and industrial premises, as well as the involvement of the management and owners of such premises in emergency preparedness against fires; and the civil defense shelter act provides the legal framework for buildings to be provided with civil defense shelters for use by persons to take refuge during a state of emergency. to tackle disease outbreak, singapore had earlier promulgated the infectious disease act in . this legislation is jointly administered by the moh and the national environment agency (nea). unlike most governments that make regular national budgetary provision for potential disaster relief and early recovery purposes, the government of singapore makes no annual budgetary allocations for disaster response because the risks of a disaster are low (global facility for disaster reduction and recovery , p. ). however, the singapore government can swiftly activate the budgetary mechanisms or funding lines in the event of a disaster and ensure these lines are sufficiently resourced with adequate financial capacity. to illuminate singapore's approach to disaster management, we now use a case study of singapore's fight against sars to highlight policy learning and lessondrawing in a specific context and timeframe. this case study has three sections. we first introduce the epidemiology of sars in singapore. in the second section, we describe the impact caused by sars epidemics on singapore in the economic, healthcare, and psychosocial aspects. in the third section, we demonstrate singapore's risk mitigating management, and detail the government's risk mitigating measures to contain the epidemic. singapore is a small open economy. external shocks can result in high levels of volatility resonating across the domestic economy. these shocks in turn would bring about higher levels of risk and uncertainty in singapore. at the beginning of , singapore's economic outlook was clouded by the iraq war and its impact on oil prices (attorney-general's chambers ). the unexpected outbreak of sars led to greater uncertainty in the singapore economy. singapore's financial markets were severely affected due to the loss of public confidence and reduced floor trading. the impact of sars on the stock market reflected in the straits times index (sti) (see fig. . ). the market did not react well to the sars epidemic. in the first fortnight of the epidemic, the sti closed down points. even though more cases were reported, the sti climbed progressively up points over the next fortnight, eclipsing the earlier falls. this could be attributed to the strict measures which the singapore government introduced. the sti remained relatively stable over the immediate fortnight as new cases were reported. however, it started a downward plunge over the following fortnight as the number of cases peaked once more. the sti plunged points. however, the resilience of the sti was shown when it climbed back up, surpassing the level reported at the beginning of the sars period. the volatility of the sti demonstrates the vulnerability of a small open economy from exogenous forces-in this case, the sars epidemic. sars was the one single activity which contributed to the volatility of singapore's gross domestic product (gdp) in . the ministry of trade and industry (mti) revised the forecast for singapore's annual gdp growth down from to . %. this forecast was later revised upwards to . %. there were a number of channels by which the sars epidemic affected the economy. the economic impacts will be discussed from the positions of demand and supply shocks. the main economic impact of the sars outbreak was on the demand side, as consumption and the demand for services declined (henderson ) . the economic consequence caused fear and anxiety among singaporeans and potential tourists to singapore. the hardest and most directly hit were the tourism, retail, hospitality and transportrelated industries, for example airline, cruise, hotel, restaurant, travel agent, retail and taxi services, and their auxiliary industries (see fig. . and this had a direct impact on hotel occupancy rates, which declined sharply to % in late april . cancellation or postponement of tourism events increased by about - %. revenues of restaurants dropped by % while revenues of the travel agents decreased by %. sars had an uneven impact on various sectors of the economy. a four-tiered framework to assess the impact on the respective sectors showed that tier industries, such as the tourism and travel-related industries were most severely hit. tier industries account for . % of gdp. the tier industries, such as restaurants, retail and land transport industries were significantly hit, which account for . % of gdp. the next two tiers were less directly affected by the sars outbreak. tier industries include real estate and stock broking, which account for close to % of gdp. the remaining % of the domestic economy in tier includes manufacturing, construction and communications. these industries were not directly impacted by the outbreak of sars. all in all, the estimated decline in gdp directly from sars was %, equaling sgd million. singapore experienced a significant drop in tourist arrivals where visitors usually stay for up to days and transit onto their next destination. the trend for visitor inflow is that visitor inflows fall sharply. this is especially true in the case of singapore, when visitor stays tend to be shorter and the high-end visitors stayed away. as a result, tourism and other related industries were nearly crippled due to a significant reduction in both leisure and business travel. visitors from around the world cancelled or postponed their trips to singapore, causing a drastic decrease of total expenditure from visitors. (see table . ) plummeting visitor arrivals directly impacted hotel occupancy rates, which declined sharply to % in late april (see table . ). the hotel occupancy rate plummeted from to %, compared to the normal level of % or above. the annual averages for hotel occupancy rates were . % in , . % in , and . % in . singapore's national carrier, singapore airlines (sia), faced a record-breaking low passenger capacity of % in april and may . sia cancelled approximately % of its weekly schedules (henderson ) . sia laid off employees, of which were ground staff, as a consequence of a usd million loss in june . the hospitality industry had to resort to cutting budgets, which led to a steep plunge in the number of employed in the service sector. out of a total of , made unemployed, hotels and restaurants went through the biggest cut, that being , employees. the breakdown of total job losses showed % in the service sector, % in construction, and % in manufacturing. additionally, transactions in the retail sector were dropped by %. the private property volume transactions for condominiums and private property price index are also good proxies on the impact of the economy from sars. based on quarterly figures between and , the volume transactions dipped to a low in the first quarter of . also, there was a corresponding decline in the price index. transactions recovered steadily by the third quarter boosted by confidence in market sentiments (see fig. . ) . the sti and private property price index seemed to display fairly similar trends, albeit with some observed lag. note also that there is a lagged effect of consumer's deferred purchases after the outbreak of sars in singapore. demand creates its own supply. therefore, a fall in demand of goods and services is likely to bring about a fall in the supply of such goods and services. also, the loss of consumer and business confidence would reduce the level of aggregate demand. these effects were observed as the manufacturing industry experienced supply chain disruptions as the singaporean economy and employment market continued to weaken. singapore was taken off the who's list of sars affected countries on st may -one of the first countries to be removed from the list. with the "fear-factor" managed, normal daily activities slowly resumed. sars affected industries and sectors started to show signs of recovery towards the end of the second quarter in . a more comprehensive analysis of the economic costs of sars will need to consider the direct impact on consumer spending and indirect repercussions of the shock on trade and investment (asian development bank outlook ). the economic costs from a global disease, such as sars, go beyond the immediate impacts incurred in the affected sectors of disease-inflicted countries. this is not just because the disease spreads quickly across countries through networks related to global travel, but also because any economic shocks to one country spread quickly to other countries through the increased trade and financial linkages associated with globalization. however, just calculating the number of cancelled tourist trips, the declines in retail trade, and some of the factors discussed earlier do not provide a complete picture of the impact of sars. this is because there are close linkages within economies, across sectors, and across economies in both international trade and international capital flows. thus, analyzing the tourism sector alone may not be sufficient in analyzing the overall financial impact of sars. sars inflicted a heavy toll on businesses and immediately impacted severely the viability of business. businesses lost employees for long periods of time due to factors such as illness, the need to care for family members and fear of infection at work, or retrenchment. as the workforce shrunk due to absenteeism, business operations, for example supply chain, flow of goods worldwide and provision of services, were all affected both locally and internationally. in terms of retrenchment, the job prospects of employees in affected companies appeared miserable. a survey performed during the sars period showed that the jobless rate increased more than . %, the highest for the last decade in singapore (ministry of manpower, singapore ) . in absolute numbers, overall employment diminished by , in the second quarter of , the largest quarterly decline since the mid- s recession. unlike previous retrenchment that affected mainly blue-collar labor, sars also affected whitecollar employees too. the implementation of workplace sars control measures added to operational and administrative costs. for example, the policy of temperature taking was implemented at workplaces in the private sector. numerous private establishments installed thermal-scanners in their entrances from day one. however, such precautionary measures were necessary to contain the disease. this helped to restore business confidence and investment potential (a lower level of investments will lead to slower capital growth). but the reduction in an economy's capacity may linger on for a few quarters before it is restored to pre-sars levels. the loss of productive working days from quarantine, and implementation costs incurred to monitor movements of employees contributed to the reduction in the aggregate supply front. some of these economic effects may have worsened the public health situation if strategic planning was not in place. sars reduced levels of service and care in singapore's healthcare system as the system mobilized its medical resources to deal with the sars epidemic. the influx of influenza patients to hospitals and clinics crowded out many other patients with less urgent medical problems for treatment. this particularly affected those seeking elective operations that had to be postponed until the epidemic ended in singapore. sars also severely impacted singapore's healthcare manpower. during the peak of sars from mid-march to early april , there was a shortage of medical and nursing professionals because ( ) the demand for care of influenza patients substantially increased, and ( ) the supply of healthcare manpower decreased as some were also affected by the epidemic. like other business sectors, hospitals, clinics and other public health providers also faced a high staff-absenteeism rate and encountered difficulties in maintaining normal operations. this resulted in a further reduction in the level of service capacity. psychosocial impact from sars was mainly caused by limited medical knowledge of sars when it began its insidious spread in singapore. such uncertainty of contracting a highly contagious disease actually deteriorated the fear of security breaches, and the panic of overexposure (tan ) . responding to the uncertainty of disease transmission, the singapore government instituted many draconian public policies, such as social distancing, quarantine and isolation, as risk mitigating measures. all of these control measures created an instinctive withdrawal from society for the general population. this brought about a behavior which resulted in the public avoiding crowds and public places with human interaction. on march , the moh invoked the infectious disease act (ida) to isolate all those who had been exposed to sars patients. after ida was invoked, on march , schools and non-essential public places were closed. public events were cancelled to prevent close contact in crowds. singaporeans with contact history were asked to stay home for a period of time to prevent transmission. harsh penalties, such as hefty fines of more than usd , or imprisonment, were imposed on those who defied quarantine orders. in a drastic move reminiscent of a police state, closedcircuit cameras were installed in the houses of those ordered to stay home to monitor their compliance with the quarantine order (abc news online ). at the height of sars, , suspected cases were ordered to stay home, all of whom were monitored either by cameras or in less severe cases, by telephone calls. quarantine, regardless of its effectiveness, received strong criticism from the general public during the outbreak of sars due to the invasive nature of that measure (duncanson ) . impact of social distancing remains unclear, but who has recommended such control measures depending on the severity of the epidemic, risk groups affected and epidemiology of transmission (world health organization ). singapore's moh advocated the practice of social distancing during the outbreak of sars. the sole intention of social distancing was to limit physical interactions and close contact in public areas to slow the rate of disease transmission. additionally, social distancing measures in particular have a psychological impact. the practice of social distancing led to a social setback in businesses that suffered economic losses as a result (duncanson ) . the psychological impact of sars is longer lasting. the most immediate and tragic impact was the loss of loved ones. in this section, we detail singapore's command structure, legal framework in fighting sars, as well as risk mitigating measures in economic, healthcare, and psychosocial perspectives. one of the most important lessons the singapore government learned from the sars epidemic was the crucial role played by the bureaucracy in disaster management. the bureaucratic structure in place then was severely inadequate in terms of handling a situation that was both fluid and unprecedented; indeed, fighting sars required more than a medical approach because resources had to be drawn from agencies other than the moh. accordingly, a three-tiered national control structure was created in response to sars-these tiers were individually represented by the inter-ministerial committee (imc), the core executive group (ceg) and the inter-ministry sars operations committee (imoc) (tay and mui ) . the nine-member imc was chaired by the minister of home affairs (mha) and it fulfilled three major functions: ( ) to develop strategic decisions, ( ) to approve these major decisions, and ( ) to implement control measures. notably, the imc also played the role of an interagency coordinator overseeing the activities of other ministries and their subsidiaries. on april ( weeks after the first case of sars was reported), the ceg and a ministerial committee was formed. the ceg was chaired by the permanent secretary of home affairs and consisted of elements from three other ministries: the moh, the ministry of defense (mod) and the ministry of foreign affairs (mfa). in particular, the role of the ceg was to manage the sars epidemic by directing valuable resources to key areas. the imoc, meanwhile, was seminal in carrying out health control measures issued by the imc (see fig. . below). the moh, at the operational layer, formed an operations group responsible for the planning and coordination of health services, and operation in peacetime. during sars, it commanded and controlled all medical resources and served as the main operational linkage between the moh and all the healthcare providers. on march , when the epidemiological nature of sars was still unclear, the moh initiated a sars taskforce to look into the mysterious strain. only days later, after more sars cases were reported and a better epidemiological understanding of the strain was developed, the singapore government swiftly declared sars a notifiable disease under the infectious disease act (ida) (ministry of health, singapore a) . in the case of a broad outbreak, ida made it legally permissible to enforce mandatory health examination and treatment, exchange of medical information and cooperation between healthcare providers and the moh, and the quarantine and isolation of sars patients (infectious disease act ). in particular, the government amended the ida on april requiring all those who had come into contact with sars patients to remain indoors or report immediately to designated medical institutions for quarantine (ministry of health, singapore b) . asa legacy of singapore's british colonial past, the singapore legislature is unique and well-known for passing laws in a swift and efficient manner. the uniqueness in singapore's legal framework allows singapore to tan ( ) swiftly amend the ida during health crises to suit volatile conditions, for instance when more epidemiological cases were uncovered and the virus was better understood. all in all, the ida played an adaptive role in terms of facilitating a swift response to the outbreak of this particular epidemic. on march , the ceg designated the restructured public hospital-tan tock seng hospital (ttsh) as the sars hospital (james et al. ; tan ) . that is, once a suspected sars patient was detected at a local clinic or emergency department, he or she would then be transferred to ttsh immediately for further evaluation and monitoring. the national healthcare system prioritized life-saving resources such as medicine and medical equipment to allocate manpower and protective equipment to the ttsh. to ease the flu-like patient influx into the ttsh, the government diverted non-flu patients away from ttsh so that the sudden surge in the number of flu cases at ttsh did not paralyze its service delivery. the full impact of sars on the economy by and large depended on how quickly sars was contained, as well as the course of the sars outbreak in the region and beyond. to mitigate sars impact on singapore's economy, the government took every precaution and spared no effort to contain the sars outbreak in singapore. two aspects of sars warranted government intervention to mitigate economic impact. first, the information that needs to be collected and disseminated to effectively assess sars displays the characteristics of public good. second, there are negative externalities related to contagious diseases in the sense that they affect third parties in market transactions. public good and negative externalities are typical areas where government action is needed (fan ) . there are three major factors which can explain why some economies are more vulnerable and susceptible to the effect of sars than others (asian development bank outlook ) . these factors are structural issues (e.g. shares of tourism in gdp and the composition of consumer spending), initial consumer sentiments, and government responses. as the research shows, the singapore government implemented a usd million (sgd million in ) sars relief package to reduce the costs for tourism operators and its auxiliary services. on the other hand, an economic relief package worth usd m (sgd m) was created to aid businesses hit by sars. in addition, the government incurred usd$ m (sgd m) in direct operating expenditure related to sars, and committed another usd m (sgd m) development expenditure of hospitals for additional isolation rooms and medical facilities to treat sars and other infectious diseases. the government's economic incentives worked when seeking cooperation of other healthcare providers (such as public hospitals and local clinics) so that they would absorb additional cases of non-flu illnesses. to help sars affected firms tide over the plight and minimize job losses, singapore's national wage council widely consulted the private sector, and recommended sars-struck companies adopt temporary cost-cutting measures to save jobs. the measures adopted by the private sector included the implementation of a shorter working-week, temporary lay-offs and the arrangement for workers to take leave or undergo skills training and upgrading provided by the ministry of manpower and associated agencies. when these measures failed to preserve jobs, the last resort was temporary wage cuts. surveillance and reporting is critical in combating pandemics because it serves to provide early warning and even detection of impending outbreaks. the surveillance process involves looking out for possible virulent strains and disease patterns within a country's borders as well as at major border-crossings (jebara ; ansell et al. ; narain and bhatia ) . when sars first surfaced, the nature of this virus was largely unknown. as a consequence, health authorities worldwide were mostly unable to detect and monitor suspected cases. health authorities in singapore encountered this same problem. but with the aid of who technical advisors, singapore managed to establish in a timely manner identification and reporting procedures. furthermore, the moh also expanded the who's definitions for suspected cases of sars (to include any healthcare workers with fever and/or respiratory symptoms) in order to widen the surveillance net (goh et al. ) . as the pace of sars transmission quickened, the singapore parliament amended the ida on april requiring all suspected sars cases to be reported to the moh within h from the time of diagnosis. although these control measures were laudable, sars also exposed the weaknesses of singapore's fragmented epidemiological surveillance and reporting systems (goh et al. ) . as a major part of lesson-drawing in the post-sars era, a number of novel surveillance measures were introduced to integrate epidemiological data and to identify the emergence of a new virulent strain faster. one of the most notable was the establishment of an infectious disease alert and clinical database system to integrate critical clinical, laboratory and contact tracing information. today, the surveillance system has four major operational components that include community surveillance, laboratory surveillance, veterinary surveillance, external surveillance, and hospital surveillance. to limit the risk of transmission in healthcare institutions once the sars epidemic had broken out, the moh implemented a series of stringent infection-control measures that all healthcare workers (hcws) and visitors to hospitals visitors had to adhere to. the use of personal protective equipment (ppe) was made compulsory. visitors to public hospitals were barred from those areas where transmission and contraction were most likely. the movements of hcws in public hospitals were also heavily proscribed. unfortunately, except for ttsh, these critical measures were not enforced in all healthcare sectors until april , and this oversight resulted in a number of intra-hospital infections (goh et al. ). in addition, the policy of restricting the movements of hcws and visitors to hospitals was taken further. more specifically, their movements between hospitals were now restricted. patient movement between hospitals, meanwhile, was strictly restricted to medical transfers. the number of visitors to hospitals was also limited and their particulars recorded during each visit. it is also important to point out that these somewhat draconian control measures required strong public support and cooperation. indeed, their implementation would not have been successful had these two elements been missing. public education and communication are two indispensable components in health crisis management (reynolds and seeger ; reddy et al. ). communication difficulties are prone to complicate the challenge, especially when there is no established, high-status organization that can act as a hub for information collation and dissemination. therefore, it is necessary to disseminate essential information to the targeted population in a transparent manner. during the sars outbreak, the moh practiced a high degree of transparency when it shared information with the public. indeed, the clear and distinct messages from the moh contributed significantly to lowering the risk of public panic. the moh worked closely with the media to provide regular, timely updates and health advisories. this information was communicated to the public through every possible medium. in addition to the media (e.g. tv and radio), information pamphlets were distributed to every household and the moh website provided constant updates and health advisories to the general public. notably, a government information channel dedicated to providing timely updates was created on the same day- march -when the who issued a global alert. a dedicated tv channel called the sars channel was launched to broadcast information on the symptoms and transmission mechanisms of the virus (james et al. ) . the importance of social responsibility and personal hygiene was a frequent message heard throughout the sars epidemic. as an example, when tan tock seng hospital was designated as the sars hospital at the peak of sars epidemics, the government undertook many efforts in public communication and education to seek cooperation and support from other healthcare providers, such as public hospitals and local clinics, so that they would absorb the additional cases of non-flu illnesses. many organizations displayed prominent signs in front of their building entrances that reminded their staff as well as visitors to be socially responsible. school children were instructed to wash their hands and take their body temperature regularly. the public was told to wear masks and postpone non-essential travel to other countries. the moh advocated the practice of social distancing during the outbreak of sars. the sole intention of social distancing was of course to limit physical interactions and close contact in public areas thereby slowing the rate of transmission. as a result, all pre-school centers, after-school centers, primary and secondary schools, and junior colleges were closed from march to april . school children who had stricken siblings were advised to stay home for at least days. moreover, students who showed flu-like symptoms or had travelled to other affected countries were automatically granted a -day leave of absence and home-based learning program were instituted for those affected. extracurricular activities were also scaled down to minimize social contact. meanwhile, the moh also advised businesses to adopt social distancing measures such as allowing staff to work from home and using split-team arrangements. those who were most at higher risk of developing complications if stricken were moved and removed from frontline work to other areas where they were less likely to contract the virus. as mentioned earlier, the practice of social distancing also drew strong criticisms from those businesses that suffered economic losses as a result. apart from providing economic compensation, measures to mitigate psychosocial impacts are also important. the government's measures of public health control, as mentioned above, drew strong criticisms from businesses and the public during the outbreak of sars due to the invasive nature of those actions. besides these, the economic slowdown affected overall employment and personal income. some households required financial assistance. in response to the public complaints, authorities in singapore provided economic assistance to those individuals and businesses who had been affected by home quarantine orders through a "home quarantine order allowance scheme" (tay and mui ; teo et al. ) . at the same time, the moh worked together with various ministerial authorities to provide essential social services to those affected by the quarantine order. for example, housing was offered to those who were unable to stay in their own homes (because of the presence of family members) during their quarantine, ambulance services were freely provided by the singapore civil defense force to those undergoing quarantine at home to visit their doctors, as well as high-tech communication gadgets such as webcams, for those undergoing quarantine to stay in touch with relatives and friends. impacts on social welfare in large part relate to economic outlook, especially in the area of consumption patterns. all these risk mitigating measures were not only effective in containing the epidemic, but also valid for implications in disaster risk management. in this section, we draw on the lesson-learning from singapore's experience in fighting the sars epidemic, and discuss implications for future practice and research in disaster risk management. the implications are explained in four aspects: staying vigilant at the community level, remaining flexible in a national command structure, demand for surge capacity, and collaborative governance at regional level. it remains questionable that singapore's draconian health control measures may not be applicable or replicable in other countries, for example setting a camera to monitor the public's compliance during home quarantine. the evidence suggests that draconian government measures, such as quarantine and travel restrictions, are less effective than voluntary measures (such as good personal hygiene and voluntarily wearing of respiratory masks), especially over the long term. however, reminding the public to maintain a high level of vigilance and advocate individual social responsibility can be a persuasion tactic by an authority to influence and pressure, but not to force individuals or groups into complicity with a policy. therefore, promoting social responsibility is crucial in terms of slowing the pace of infection through good personal hygiene and respiratory etiquette in all settings. to achieve this goal, public education and risk communication are two indispensable components in health crisis management (reddy et al. ; reynolds and seeger ) . the community must be aware of the nature and scope of disasters. they have to be educated on the importance of emergency preparedness and involvement in exercises, training and physical preparations. at the community level, institutions and capacities are developed and strengthened which in turn systematically contribute to vigilance against potential risks. this is best illustrated in the singapore government's communication strategy to manage public fear and panic during the outbreak of sars (menon and goh ) . throughout the epidemic, the singapore government relentlessly raised the level of vigilance of personal hygiene and awareness of social responsibility. this, in large part, has to rely on public education and risk communication. to effectively disseminate the idea of vigilance across the public, political leaders were seen as doing and initiating a series of countermeasures to reassure the public. by showing the people that government leaders practiced what they preached, the examples served to naturalize and legitimize the public discourse of social responsibility for all singaporean citizens (lai ) . the need to stay vigilant is never overemphasized, but being vigilant does not equate to a panacea that ensures all government agencies work together. to be well prepared for the unexpected, we need a clear and swift national command structure that can flexibly respond to, and even more promptly than in the case of disease transmission, the changing situation. all local agencies responding to an emergency must work within a unified national command structure to coordinate multi-agency efforts in emergency response and management of disasters. on top of facilitating close inter-agency coordination, the strength of this flexible structure is in its ability to ensure a swift response to an epidemic outbreak by implementing risk mitigating measures more effectively and efficiently. structural flexibility involves swift deployment of forces to mitigate the incident at the tactical level, and to provide expert advice at the operational level, in order to minimize damage to lives and property. among other things, the flexibility endemic to this command structure facilitates the building of trust between the state and its people (lai ). this in turn ensures that government measures are quickly accepted by the general public. as shown in this chapter, the moh has been entrusted by the singapore government and pre-designated to be the incident manager for public health emergencies. when a sudden incident involves public health or the loss of lives on a large scale, the moh is responsible for planning, coordinating and implementing an assortment of disease control programs and activities. during the outbreak of sars, the singapore government established a national command and control structure that was able to adapt to rapidly changing circumstances that stemmed from the outbreak. specifically, the moh set up a taskforce within that ministry even when the definition of sars remained unclear. as more sars cases were uncovered and better epidemiological information became available, the government quickly created the inter-ministerial committee (imc) and core executive group (ceg)-both of which were instrumental in the design and implementation of all risk mitigating measures-to coordinate the operation to combat the outbreak (pereira ) . while this overarching governance structure is more or less standard worldwide ('t hart et al. ; laporte ) , the case of singapore is unique in that the city-state was able to overcome bureaucratic inertia and adapt this governance structure. from singapore's experiences during the sars crisis, we have learnt that the strength of a national command structure lies in its flexibility to link relevant ministries on the same platform. these linkages ensure a timely, coordinated response and service delivery. having a flexible structure was not the only reason behind the successful defeat of sars. in singapore's case, we also notice the success of containing an uncertain, high-impact disaster has to rely on surge capacity. in the context of this paper, surge capacity refers to the ability to mobilize resources (such as ppes, vaccines and hcws) to combat the outbreak of a pandemic. singapore's response to sars in illustrates the importance of being able to increase surge capacity swiftly to deal with an infectious disease outbreak. in the asia pacific region, this problem continues to hamper many countries' ability to combat infectious diseases (putthasri et al. ). for many public health organizations in asia, it is a matter of fact that they are unable to deal with pandemics because the resources to do so are simply absent (balkhy ; hanvoravongchai et al. ; lai b; oshitani et al. ) . meanwhile, there are evidences which suggest that surge capacity alone is not the full answer. for example, during the sars outbreak, abundant resources contribute an important but not all-encompassing element in the fight against these pandemics. as it turned out, when different stakeholders brought to the task-at-hand their unique skill sets and resources, they actually complicated the fight due to their lack of synergy. in fact, abundant resources without synergy might even undermine collaborative efforts. therefore, it is essential that the ability to link up various stakeholders must be complemented by some type of synergy between them. such ability can be enhanced through close collaboration. this brings us to the third implication for disaster management: collaborative governance at regional level. the trans-boundary nature of the disasters calls for a planned and coordinated approach towards disaster response for efficient rescue and relief operations lai a) . combating epidemics requires multiple states and government agencies to work together in close (webby and webster ) . therefore, it is clear that collaborative capacity of various stakeholders is central to the fight against transboundary communicable diseases (lai ; lai b; leung and nicoll ; voo and capps ) . while member states that are of advanced economic development typically lead such efforts, the inclusion of other developing countries, non-traditional agencies, and organizations (including non-governmental ones) is necessary and ultimately, inevitable. indeed, major countermeasures such as border control and surveillance are often made possible with the aid of regional collaboration. take the association of southeast asian nations (asean) as an example. asean countries take regional, national and sub-national approaches to disaster risk management ). the asean committee on disaster risk management (acdm) was established in and tasked with the coordination and implementation of regional activities on disaster management. the committee has cooperated with united nations bodies such as the united nations international strategy for disaster reduction (unisdr) and the united nations office for the coordination of humanitarian affairs (unocha). the asean agreement on disaster management and emergency response (aadmer) provides a comprehensive regional framework to strengthen preventive, monitoring and mitigation measures to reduce disaster losses in the region. in recent years, singapore has been active in providing training and education for disaster managers from neighboring countries. singapore has an ongoing exchange program with a number of asia pacific nations and europe. for example, to partner with apec to increase emergency preparedness in the asia-pacific region, singapore's scdf provides shortterm courses on disaster management in the civil defense academy (asia pacific economic cooperation ). the world today is far more inter-connected than ever before. international travel, transnational trade, and cross-border migration have drastically increased as a consequence of globalization. no country is spared from being influenced directly or indirectly by disasters. singapore is no exception. singapore is vulnerable to both natural and man-made disasters alongside its remarkable economic growth. in response, the singapore government adopts an approach of whole-of-government integrated risk management, a concerted, coordinated effort based on a total national response. we have witnessed in the case study singapore's all-hazard management framework with specific references to the sars epidemic. in fighting sars, singapore's health authority was responsive enough to swing into action when they realized that the existing bureaucratic structure was inadequate in terms of facilitating close cooperation between various key government agencies to tackle the health crisis on hand. therefore, a command structure was swiftly established. the presence of a flexible command structure, the way and the extent it was utilized, explains how well an epidemic was successfully contained. flexibility actually enhanced organizational capacities by making organizations more efficient under certain conditions. epidemic control measures such as surveillance, social distancing, and quarantine require widespread support from the general public for them to be effective. singapore's experiences with sars strongly suggest that risk mitigating measures can be effective only when a range of partners and stakeholders (such as government ministries, non-profit organizations, and grass-roots communities) become adequately involved. this is also critical to disaster risk management. whether all of these aspects are transferrable elsewhere needs to be assessed in future research. nonetheless, this unique discipline certainly has helped singapore come out of public health crises on a regular basis. singapore's response to the outbreak of sars offers valuable insights into the kinds approaches needed to combat future pandemics, especially in southeast asia. singapore imposes quarantine to stop sars spreading. abc news managing transboundary crises: identifying the building blocks of an effective response system apec partners with singapore on disaster management hfa implementation review for acdr asian development outlook update accessed adrc country report impact of sars on the economy, singapore government avian influenza: the tip of the iceberg severe acute respiratory syndrome -singapore how singapore avoided who advisory, toronto star impact to lung health of haze from forest fires: the singapore experience sars: economic impacts and 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architecture for network centric operations in unconventional crisis: lessons learnt from singapore's sars experience. california: thesis of naval postgraduate school sars in singapore: surveillance strategies in a globalizing city influenza pandemic and the duties of healthcare professionals are we ready for pandemic influenza who guidelines on the use of vaccines and antivirals during influenza pandemics. geneva: word health organization acknowledgement the authors would like to thank the economic research institute for asean and east asia (eria) to initiate this meaningful research project, and four commentators-professor yasuyuki sawada (tokyo university), professor chan ngaiweng (university sains malaysia), dr. sothea oum (eria), mr. zhou yansheng (scdf) and all participants in eria's two workshops, for their insightful comments for an earlier draft of this chapter. key: cord- - hlwwdh authors: quarantelli, e. l.; boin, arjen; lagadec, patrick title: studying future disasters and crises: a heuristic approach date: - - journal: handbook of disaster research doi: . / - - - - _ sha: doc_id: cord_uid: hlwwdh over time, new types of crises and disasters have emerged. we argue that new types of adversity will continue to emerge. in this chapter, we offer a framework to study and interpret new forms of crises and disasters. this framework is informed by historical insights on societal interpretations of crises and disasters. we are particularly focused here on the rise of transboundary crises – those crises that traverse boundaries between countries and policy systems. we identify the characteristics of these transboundary disruptions, sketch a few scenarios and explore the societal vulnerabilities to this type of threat. we end by discussing some possible implications for planning and preparation practices. disasters and crises are as old as when human beings started to live in groups. through the centuries, new types have emerged. for instance, the development of synthetic chemicals in the th century and nuclear power in the th century created the possibility of toxic chemical disasters and crises from radioactive fallouts. older crisis types did not disappear: ancient types such as floods and earthquakes remain with us. the newer disasters and crises are additions to older forms; they recombine elements of old threats and new vulnerabilities. the literature on crisis and disaster research suggests that we are at another important historical juncture with the emergence of a new distinctive class of disasters and crises not often seen before (ansell, boin, & keller, ; helsloot, boin, jacobs, & comfort, ; tierney, ) . in this chapter, we discuss the rise of transboundary crises and disasters. we seek to offer a heuristic approach to studying these new crises and disasters. we offer a heuristic approach to understanding the disasters and crises of the future. it is presented primarily as an aid or guide to looking further into the matter, hopefully stimulating more investigation on conceptions of disasters and crises in the past, the present, and the future. unlike in some areas of scientific inquiry, where seemingly final conclusions can be reached (e.g., about the speed of light), the basic nature of the phenomenon we are discussing is of a dynamic nature and subject to change through time. the answer to the question of what is a disaster or crisis has evolved and will continue to do so (see perry' s chapter in this handbook). human societies have always been faced with risks and hazards. earthquakes, hostile inter-and intra-group relationships, massive floods, sudden epidemics, threats to take multiple hostages or massacre large number of persons, avalanches, fires and tsunamis have marked human history for centuries if not eons. disasters and crises requiring a group reaction are as old as when human beings started to live in stable communities. the earliest happenings are attested to in legends and myths, oral traditions and folk songs, religious accounts and archeological evidence from many different cultures and subcultures around the world. for example, a "great flood" story has long existed in many places (lang, ) . as human societies evolved, new threats and hazards emerged. to the old there have been added new dangers and perils that increasingly have become potentially dangerous to human groups. risky technological agents have been added to natural hazards. these involve chemical, nuclear and biological threats that can accidentally materialize as disasters. intentional conflict situations have become more damaging at least in the sense of involving more and more victims. the last years have seen two world wars, massive air and missile attacks by the military on civilians distant from battle areas, many terrorist attacks, and widespread ethnic strife. genocide killed one million persons in rwanda; millions have become refugees and tens of thousands have died in darfur in the sudan in africa. while terrorism is not a new phenomenon, its targets have considerably expanded. some scholars and academics have argued that the very attempt to cope with increasing risks, especially of a technological nature, is indirectly generating new hazards. as the human race has increasingly been able to cope with such basic needs as food and shelter, some of the very coping mechanisms involved (such as the double edged consequences of agricultural pesticides), have generated new risks for human societies (beck, ; perrow, ) . for example, in , toxic chemicals were successfully used to eradicate massive locust infestations affecting ten western and northern african countries. those very chemicals had other widespread negative effects on humans, animals and crops (irin, ) . implicit in this line of thinking is the argument that double-edged consequences from new innovations (such as the use of chemicals, nuclear power and genetic engineering) will continue to appear (tenner, ) . we cannot say that the future will bring more disasters, as we have no reliable statistics on prior happenings as a base line to use in counting (quarantelli, ) . at present, it would seem safer to argue that some future events are qualitatively different, and not necessarily that there will be more of them in total (although we would argue the last is a viable hypothesis that requires a good statistical analysis). societies for the most part have not been passive in the face of these dangers to human life and well-being. this is somewhat contrary to what is implicit in much of the social science literature especially about disasters. in fact, some of these writings directly or indirectly state that a fatalistic attitude prevailed in the early stages of societal development (e.g., quarantelli, ) . this was thought because religious beliefs attributed negative societal happenings to punishments or tests this seems to have occurred about five to six thousand years ago (see lenski, lenski, & nolan, ) . however, recent archeological studies suggest that humans started to abandon nomadic wanderings and settled into permanent sites around , years ago (balter, ) so community recognized disasters and crises might have an even longer history. by supernatural entities (the "acts of god" notion, although this particular phrase became a common usage mostly because it served the interests of insurance companies). but prayers, offerings and rituals are widely seen as means to influence the supernatural. so passivity is not an automatic response to disasters and crises even by religious believers, an observation sometimes unnoticed by secular researchers. in fact, historical studies strongly indicate that societal interpretations have been more differentiated than once believed and have shifted through the centuries, at least in the western world. in ancient greece, aristotle categorized disasters as the result of natural phenomena and not manifestations of supernatural interventions (aristotle, ) . the spread of christianity about , years ago helped foster the belief that disasters were "special providences sent directly" from "god to punish sinners" (mulcahy, , p. ) . in the middle ages, even scholars and educated elites "no longer questioned the holy origins of natural disasters" (massard-guilbaud, platt, & schott, , p. ) . starting in the th century, however, explanations started to be replaced by "ones that viewed disasters as accidental or natural events" (mulcahy, , p. ) . this, of course, also reflected a strong secularization trend in western societies. perhaps this reached a climax with the lisbon earthquake which dynes notes can be seen as the "first modern disaster" ( , p. ). so far our discussion has been mostly from the perspective of the educated elites in western societies. little scholarly attention seems to have been given to what developed in non-western social systems. one passing observation about the ottoman empire and fire disasters suggests that the pattern just discussed might not be universal. thus, while fire prevention measures were encouraged in cities, they were not mandated "since calamities were considered" as expressions of the will of god (yerolympos, , p. ) . even as late as an ottoman urban building code stated that according to religious writing "the will of the almighty will be done" and nothing can and should be done about that. at the same time, this code advances the idea that nevertheless there were protective measures that could be taken against fires that are "the will of allah" (quoted in yerolympos, , p. ) . of course, incompatibility between natural and supernatural views about the world are not unique to disaster and crisis phenomena, but that still leaves the distinction important. even recently, an australian disaster researcher asserted that in the southwestern asian tsunami most of the population seemed to believe that the disaster was "sent either as a test of faith or punishment" (mcaneney, , p. ). or as another writer noted, following the tsunami, religiously oriented views surfaced. some were by: "fundamentalist christians" who tend to view all disasters "as a harbinger of the apocalypse". others were by "radical islamists" who are inclined to see any disaster that "washes the beaches clear of half-nude tourists to be divine" (neiman, , p. ) . after hurricane katrina, some leaders of evangelical groups spoke of the disaster as punishment imposed by god for "national sins" (cooperman, ) . in the absence of systematic studies, probably the best hypothesis that should be researched is that at present religious interpretations about disasters and crisis still appear to be widely held, but relative to the past probably have eroded among people in general. the orientation is almost certainly affected by sharp cross-societal difference in the importance attributed to religion as can be noted in the religious belief systems and practices as currently exist in the united states and many islamic countries, compared to japan or a highly secular western europe. apart from the varying interpretations of the phenomena, how have societies behaviorally reacted to existing and ever-changing threats and risks? as a whole, human groups have evolved a for an interesting attempt to deal with these two perspectives see the paper entitled disaster: a reality or a construct? perspective from the east, written by jigyasu ( ) an indian scholar. variety of formal and informal mechanisms to prevent and to deal with crises and disasters. but societies have followed different directions depending on the perceived sources of disasters and crises. responses tend to differ with the perception of the primary origin (the supernatural, the natural or the human sphere). for example, floods were seen long ago as a continuing problem that required a collective response involving engineering measures. stories that a chinese emperor, centuries before christ, deepened the ever-flooding yellow river by massive dredging and the building of diversion canals may be more legend than fact (waterbury, , p. ) . however, there is clear evidence that in egypt in the th century bc, the th dynasty pharaoh, amenemher ii completed southwest of cairo what was probably history's first substantial river control project (an irrigation canal and dam with sluice gates). other documentary evidence indicates that dams for flood control purposes were built as far back as b c in greece (schnitter, , p. , - ) . such mitigatory efforts indicate both the belief that there was a long-term natural risk as well as one that could be coped with by physically altering structural dimensions. later, particular in europe, there were many recurrent efforts to institute mitigation measures. for example, earthquake resistant building techniques were developed in ancient rome, although "they had been forgotten by the middle ages" (massard-guilbaud et al., , p. ) . the threats from floods and fires spurred mitigation efforts in greece. starting in the th century, developing urban areas devised many safeguards against fires, varying from regulations regarding inflammable items to storage of water for firefighting purposes. in many towns in medieval poland, dams, dikes and piles along riverbanks were built (sowina, ) . of course, actions taken were not always successful. but, if nothing else, these examples show that organized mitigation efforts have been undertaken for a long time in human history. there have been two other major behavioral trends of long duration that are really preventive in intent if not always in reality. one has been the routinization of responses by emergency oriented groups so as to prevent emergencies from escalating into disasters or crises. for example, in ancient rome, the first groups informally set up to fight fires were composed of untrained slaves. but when a fire in a.d. burned almost a quarter of rome, a corps of vigiles was created that had full-time personnel and specialized equipment. in more recent times, there are good examples of this routinization in the planning of public utilities that have standardized operating procedures to deal with everyday emergencies so as to prevent them from materializing into disasters. in the conflict area, there are various un and other international organizations, such as the international atomic energy agency and the european union (eu), that also try to head off the development of crises. in short, societies have continually evolved groups and procedures to try to prevent old and new risks and threats from escalating into disasters and crises. a second more recent major trend has been the development of specific organizations to deal first with wartime crises and then with peacetime disasters. societies for about a century have been creating specific organizations to deal first with new risks for civilians created by changes in warfare, and then improving on these new groups as they have been extended to peacetime situations. rooted in civil defense groups created for air raid situations, there has since been the evolvement of civilian emergency management agencies (blanchard, ) . accompanying this has been the start of the professionalization of disaster planners and crisis managers. there has been a notable shift from the involvement of amateurs to educated professionals. human societies adjusted not only to the early risks and hazards, but also to the newer ones that appeared up to the last century. the very existence of the human race is testimony to the social coping mechanisms of humans as they face such threats. here and there a few communities and groups have not been able to cope with the manifestations of contemporary risks and hazards (diamond, ) . but these have been very rare cases. neither disasters nor crises involving conflict have had that much effect on the continuing existence of cities anywhere in the world. throughout history, many cities have been destroyed. they have been: "sacked, shaken, burned, bombed, flooded, starved, irradiated and poisoned", but in almost every case they have phoenix-like been reestablished (vale & campanella, , p. ) . around the world, from the th to the th century, only cities were "permanently abandoned following destruction" (vale & campanella, , p. ) . the same analysis notes that large cities such as baghdad, moscow, aleppo, mexico city, budapest, dresden, tokyo, hiroshima and nagasaki all suffered massive physical destruction and lost huge numbers of their populations due to disasters and wartime attacks. all were rebuilt and rebounded. at the start of the th century, "such resilience became a nearly universal fact" about urban settlements around the world (vale & campanella, , p. ) . looking at these cities today as well as warsaw, berlin, hamburg and new orleans, it seems this recuperative tendency is very strong (see also schneider & susser, ) . in the hiroshima museum that now exists at the exact point where the bomb fell, there is a -degree photograph of the zone around that point, taken a few days after the attack. except for a few piles of ruins, there is nothing but rubble as far as the eye can see in every direction. there were statements made that this would be the scene at that location for decades. but a visitor to the museum today can see in the windows behind the circular photograph, many signs of a bustling city and its population (for a description of the museum see webb, ) . hiroshima did receive much help and aid to rebuild. but the city came back in ways that observers at the time of impact did not foresee. early efforts to understand and to cope with disasters and crises were generally of an ad hoc nature. with the strong development of science in the th century, there was the start of understanding the physical aspects of natural disasters, and these had some influence on structural mitigation measures that were undertaken. however, the systematic social science study of crises and disasters is about a half-century-old (fritz, ; kreps, ; quarantelli, quarantelli, , schorr, ; wright & rossi, ) . in short, there is currently a solid body of research-generated knowledge developed over the last half century of continuing and ever increasing studies around the world in different social science disciplines. to be sure, such accounts and reports are somewhat selective and not complete. there are now case studies and analytical reports on natural and technological disaster (and to some extent on other crises) numbering in the four figures. in addition, there are numerous impressions of specific behavioral dimensions that have been derived from field research (for summaries and inventories see alexander, ; cutter, ; dynes, demarchi, & pelanda, ; dynes & tierney, ; farazmand, ; helsloot, boin, jacobs, & comfort, ; mileti, ; oliver-smith, ; perry, lindell, & prater, ; rosenthal, boin, & comfort, ; rosenthal, charles, & 't hart, ; tierney, lindell, & perry, ; turner, ) . what are the distinctive aspects of the newer disasters and crises that are not seen in traditional ones? to answer this question, we considered what social science studies and reports had found about behavior in disasters and crises up to the present time. we then implicitly compared those observations and findings with the distinctive behavioral aspects of the newer disasters and crises. one issue that has always interested researchers and scholars is how to conceptualize disasters and crises. there is far from full agreement that all disasters and crises can be categorized together as being relatively homogeneous phenomena (quarantelli, ; perry & quarantelli, ) . this is despite the fact that there have been a number of attempts to distinguish between, among and within different kinds of disasters and crises. however, no one overall view has won anywhere near general acceptance among self-designated disaster and crisis researchers. to illustrate we will briefly note some of the major formulations advanced. for example, one attempt has been to distinguish between natural and technological disasters (erikson, ; picou & gill, ) . the basic assumption was that the inherent nature of the agent involved made a difference. implicit was the idea that technological dangers or threats present a different and more varying kind of challenge to human societies than do natural hazards or risks. most researchers have since dropped the distinction as hazards have come to be seen as less important than the social setting in which they appear. in recent major volumes on what is a disaster (quarantelli, ; perry & quarantelli, ) , the distinction was not even mentioned by most of the two dozen scholars who addressed the basic question. other scholars have struggled with the notion that there may be some important differences between what can be called "disasters" and "crises". the assumption here is that different community level social phenomena are involved, depending on the referent. thus, some scholars distinguish between consensus and conflict types of crises (stallings, tries to reconcile the two perspectives). in some research circles, almost all natural and most technological disasters are viewed as consensus types of crises (quarantelli, ) . these are contrasted with crises involving conflict such as are exemplified by riots, terrorist attacks, and ethnic cleansings and intergroup clashes. in the latter type, at least one major party is either trying to make it worse or to extend the duration of the crisis. in natural and technological disasters, no one deliberately wants to make the situation worse or create more damage or fatalities. now, there can be disputes or serious disagreements in natural or technological disasters. it is almost inevitable that there will be some personal, organizational and community conflicts as, for example, in the recovery phase of disasters, where scapegoating is common (bucher, ; drabek & quarantelli, cf. boin, mcconnell, & 't hart, ) . in some crises, the overall intent of major social actors is to deliberately attempt to generate conflict. in contrast to the unfolding sequential process of natural disasters, terrorist groups or protesting rioters not only intentionally seek to disrupt social life, they modify or delay their attacks depending on perceived countermeasures. apart from a simple observable logical distinction between consensus and conflict types of crises, empirical studies have also established behavioral differences. for example, looting behavior is distinctively different in the two types. in the typical disaster in western societies, almost always looting is rare, covert and socially condemned, done by individuals, and involves targets of opportunity. in contrast, in many conflict crises looting is very common, overt and socially supported, undertaken by established groups of relatives or friends, and involves deliberately targeted locations (quarantelli & dynes, ) . likewise, there are major differences in hospital activities in the two kinds of crises, with more variation in conflict situations. there are differences also in the extent to which both organizational and community-level changes occur as a result of consensus and conflict crises, with more changes resulting from conflict occasions (quarantelli, ) . finally, it has been suggested that the mass media system operates differently in terrorism situations and in natural and technological disasters (project for excellence in journalism, journalism, , . both the oklahoma city bombing and the - world trade center attack led to sharp clashes between different groups of initial organizational responders. there were those who saw these happenings primarily as criminal attacks necessitating closure of the location as a crime for a contrary view that sees terrorist occasions as more or less being the same as what behaviorally appears in natural and technological disasters (fischer, ) . scene, and those who saw them primarily as situations where priority ought to be on rescuing survivors. in the - situation, the clash continued later into the issues of the handling of dead bodies and debris clearance. all this goes to show that crises and disasters are socially constructed. whether it is by theorists, researchers, operational personnel, politicians or citizens, any designation comes from the construction process and is not inherent in the phenomena itself. this is well illustrated in an article by cunningham ( ) where he shows that a major cyanide spill into the danube river was differently defined as an incident, an accident, or a catastrophe, depending on how culpability was perceived and who was doing the defining. still other distinctions have been made. some advocate "crisis" as the central concept in description and analysis (see the chapter of boin, kuipers and 't hart in this handbook). in this line of thinking, a crisis involves an urgent threat to the core functions of a social system. a disaster is seen as "a crisis with a bad ending" (boin, ) . this is consistent with the earlier expressed idea that while there are many hazards and risks, only a few actually manifest themselves. but the crisis idea does not differentiate among the manifestations themselves as the consensus and conflict distinction does. this is not the place to try and settle conceptual disagreements and we will not attempt to do so. anyone in these areas of study should acknowledge that there are different views and different proponents should try to make their positions as explicit as possible so people do not continue to talk past one another. it is perhaps not amiss here to note that the very words or terms used to designate the core nature of the phenomena are etymologically very complex with major shifts in meaning through time. we are far from having standardized terms and similar connotations and denotations for them. a conceptual question that has come increasingly to the fore in the last decade or so is the question: have new kinds of crises and disasters began to appear? we think it is fair to say that there are new types of risks and hazards. there are also structural changes in social settings. together, they raise the prospect of new types of disasters and crises. for example, we have seen the breakdown of modern transportation systems (think of the volcanic ash crisis that paralyzed air traffic in ; kuipers & boin, ) . there have been massive information system failures either through sabotage or as a result of technical breakdowns in linked systems. there have been terrorist attacks of a magnitude and scale not seen before. we are living with the prospect of widespread illnesses and health-related difficulties that appear to be qualitatively different from traditional medical problems. we have just lived through financial and economic collapses that cut across different social systems around the world. many of these "new" disruptions have both traditional and non-traditional features: think of the heat waves in paris (lagadec, ) and chicago (klinenberg, ) , the ice storms in canada (scanlon, ) , but also the genocide-like violence in africa and the former yugoslavia. the chernobyl radiation fallout ( ) led some scholars and researchers to start asking if there was not something distinctively new about that disaster. the fallout was first openly measured in sweden. officials were mystified in that they could not locate any possible radiation source in their own country. later radiation effects on vegetation eaten by reindeer past the arctic circle in northern sweden were linked to the nuclear plant accident in the soviet union. the mysterious origins, crossing of national boundaries, and the emergent involvement of see safire ( ) who struggles with past and present etymological meanings of "disaster", "catastrophe", "calamity" and "cataclysm"; also see murria ( ) who looking outside the english language found a bewildering set of words used, many of which had no equivalent meanings in other languages. many european and transnational groups was not something researchers had typically seen together in other prior disasters. looking back, it is clear that certain other disasters also should have alerted all of us to the probability that new forms of adversity were emerging. in november , water used to put out fire in a plant involving agricultural chemicals spilled into the river rhine. the highly polluted river went through switzerland, germany, france, luxembourg and the netherlands. a series of massive fire smog episodes plagued indonesia in and . land speculations led to fire-clearing efforts that, partly because of drought conditions, resulted in forest fires that produced thick smog hazes that spread over much of southeast asia (barber & schweithelm, ) . these disrupted travel, which in turn affected tourism as well as creating respiratory health problems, and led to political criticism of indonesia by other countries as multi-nation efforts to cope with the problem were not very successful. both of these occasions had characteristics that were not typically seen in traditional disasters. in the original version of this chapter, we spoke about "trans-system social ruptures". this term was an extension of the earlier label of "social ruptures" advanced by lagadec ( lagadec ( , . the term "transboundary" has since become the more conventional way to describe crises and disasters that jump across different societal boundaries disrupting the social fabric of different social systems (ansell et al., ) . the two prime and initial examples we used in the original chapter were the severe acute respiratory syndrome (sars) and the sobig computer f virus spread, both of which appeared in . the first involved a "natural" phenomenon, whereas the second was intentionally created. since there is much descriptive literature available on both, we here provide only very brief statements about these phenomena. the new infectious disease sars appeared in the winter of . apparently jumping from animals to humans it originated in southern rural china, near the city of guangzhou. from there it moved through hong kong and southeast asia. it spread quickly around the world because international plane flights were shorter than its incubation period. at least infected persons died. it hit canada with outbreaks in vancouver in the west and toronto far away in the east. in time, persons died of the several hundred that got ill, and thousands of others were quarantined. the city's healthcare system virtually closed down except for the most urgent of cases with countless procedures being delayed or cancelled. the result was that there was widespread anxiety in the area resulting in the closing of schools, the cancellation of many meetings and, because visitors and tourists stayed away, a considerable negative effect on the economy (commission report, , p. ) . the commission report notes a lack of coordination among the multitude of private and public sector organizations involved, a lack of consistent information on what was really happening, and jurisdictional squabbling on who should be doing what. although sars vanished worldwide after june , to this day it is still not clear why it became so virulent in the initial outbreak and why it has disappeared (yardley, ) . the sobig computer f virus spread in august (schwartz, ) . it affected many computer systems and threatened almost all computers connected to the internet. the damage was very costly. a variety of organizations around the world, public and private, attempted to deal with the problem. initially uncoordinated, there eventually emerged in an informal way a degree of informational networking on how to cope with what was happening (koerner, ) . what can we generalize from not only these two cases, but also others that we looked at later in may , the so-called wannacry virus affected millions of computers across the world with ransomware. many hospitals were affected. (ansell et al., ) ? the characteristics we depict are stated in ideal-typical terms; that is, from a social science perspective, what the phenomena would be if they existed in pure or perfect form. first, the threat jumps across many international and national/political governmental boundaries. it crosses functional boundaries, jumping from one sector to another, and crossing from the private into public sectors (and sometimes back). there was, for example, the huge spatial leap of sars from a rural area in china to metropolitan toronto, canada. second, a transboundary threat can spread very fast. cases of sars went around the world in less than hours with a person who had been in china flying to canada quickly infecting persons in toronto. the spread of the sobig f virus was called the fastest ever (thompson, ) . this quick spread is accompanied by a very quick if not almost simultaneous global awareness of the risk because of mass media attention. third, there is no known central or clear point of origin, at least initially, along with the fact that the possible negative effects at first are far from clear. this stood out when sars first appeared in canada. there is much ambiguity as to what might happen. ambiguity is of course a major hallmark of disasters and crises (turner, ) . it is more pervasive in transboundary crises as information about causes, characteristics and consequences is distributed across the system. fourth, there are potentially if not actual large number of victims, directly or indirectly. the sobig computer virus infected % of email users in china, that is about million people and about three fourths of email messages around the world were infected by this virus (koerner, ) . in contrast to the geographic limits of most past disasters, the potential number of victims is often open ended in disruptions that span across boundaries. fifth, traditional "solutions" or approachesembedded in local and/or professional institutions will not always work. this is rather contrary to the current emphasis in emergency management philosophy. the prime and first locus of planning and managing cannot be the local community as it is presently understood. international and transnational organizations must typically be involved very early in the initial response (boin, ekengren, & rhinard, ) . the nation state may not even be a prime actor in the situation. sixth, although responding organizations and groups are major players, there is an exceptional amount of emergent behavior and the development of many informal ephemeral linkages. in some respects, the informal social networks generated, involving much information networking, are not always easily identifiable from the outside, even though they are often the crucial actors at the height of the crisis. in this section, we sketch several future scenarios that most likely would create transboundary disasters. even though some of the scenarios discussed might seem to be science fiction in nature, the possibilities we discuss are well within the realm of realistic scientific possibilities. the most obvious scenario revolves around asteroids or comets hitting planet earth (di justo, ) . this has, of course, happened in the past, but even more recent impacts found no or relatively few human beings around. there are two major possibilities with respect to impact (mcguire, ; wisner, ) . a landing in the ocean would trigger a tsunami-like impact in coastal areas. just the thinking of the possibility of how, when and where ahead of time coastal population evacuations might have to be undertaken, is a daunting thought. statistically less likely is a landing in a heavily populated area. but a terrestrial impact anywhere on land would generate very high quantities of dust in the atmosphere, which will affect food production as well as creating economic disruption. this would be akin to the tambora volcanic eruption in , which led to very cold summers and crop failures (post, ) . the planning and management problems for handling something like this would be enormous. the explosion of space shuttle columbia scattered debris over a large part of the united states. this relatively small disastercompared to a comet or asteroid impactinvolved massive crossing of boundaries, a large number of potential victims, and could not be managed by local community institutions. the response required that an unplanned effort coordinating organizations that had not previously worked with one another and other unfamiliar groups, public and private (ranging from the us forest service to local red cross volunteers to regional medical groups), be informally instituted over a great part of the united states (beck & plowman, ; donahue, ) . a second scenario is the inadvertent or deliberate creation of biotechnological disasters. genetic engineering of humans or food products is currently in its infancy. the possible good outcomes and products from such activity are tremendous (morton, ) and are spreading around the world (pollack, ) . but the double-edged possibilities mentioned earlier are also present. there is dispute over genetically modified crops, with many european countries resisting and preventing their use and spread in their countries. while no major disaster or crisis from this biotechnology has yet occurred, there have been many accidents and incidents that suggest that this will be only a matter of time. for example, in , starlink corn, approved only for animal feed is found in the food supply, such as taco shells and other groceries. the same year farmers in europe learned that that they had unknowingly been growing modified canola using mixed seed from canada. in , modified corn was found in mexico even though it was illegal to plant in that country. that same year, experimental corn that had been engineered to produce a pharmaceutical that was found in soybeans in the state of nebraska. in several places, organic farmers found that it was impossible for them to keep their fields uncontaminated (for further details about all these incidents and other examples, see pollack, ) . noticeable is the leaping of boundaries and uncertainty about the route of spreading. it does not take much imagination to see that a modified gene intended for restricted use, could escape and create a contamination that could wreak ecological and other havoc. perhaps even more disturbing to some is genetic engineering involving human beings. the worldwide dispute over cloning, while currently perhaps more a philosophical and moral issue, does also partly involve the concern over creating flawed human-like creatures. it is possible to visualize not far-fetched worst-case scenarios that could be rather disastrous. it should be noted that even when there is some prior knowledge of a very serious potential threat, what might happen is still likely to be as ambiguous and complex as when sars first surfaced. this can be seen in the continuing major concern expressed in to mid- about the possible pandemic spread of avian influenza, the so called "bird flu" (nuzzo, ; thorson & ekdahl, ) . knowledge of the evolution and spread of new pandemics, their effects and whether presently available protective measures would work, may well be very limited. knowledge that it might occur provides very little guidance on what might actually happen. it is possible to imagine the destruction of all food supplies for human beings either through the inadvertent or deliberate proliferation of very toxic biotechnological innovations for which no known barriers to spreading exists. these potential kinds of global disasters are of relatively recent origins and we may expect more such possibilities in the future. the human race is opening up potentially very catastrophic possibilities by innovations in nanotechnology, genetic engineering and robotics (barrat, ; joy, ; makridakis, ) . a potential is not an actuality. but it would be foolish from both a research as well as a planning and managing viewpoint to simply ignore these and other doomsday possibilities. the question might be asked if there is a built-in professional bias among disaster and crisis researchers and emergency planners to look for and to expect the worst (see mueller, for numerous examples). in the disaster and crisis area, this orientation is reinforced by the strong tendency of social critics and intellectuals to stress the negative. it would pay to look at the past, see what was projected at a particular time, and then to look at what actually happened. the worldwide expectations about what would happen at the turn of the century to computers are now simply remembered as the y k fiasco. it would be a worthy study to take projections by researchers about the future of ongoing crises and disasters, and then to look at what actually happened. in the s, in the united states, scholars made rough analyses about the immediate future course of racial and university riots in the country. their initial appearances had not been forecasted. moreover, there was a dismal record in predicting how such events would unfold (no one seemed to have foreseen that the riots would go from ghetto areas to university campuses), as well as that they rather abruptly stopped. we should be able to do a better job than we have so far in making projections about the future. but perhaps that is asking more of disaster and crisis researchers than is reasonable. after all, social scientists with expertise in certain areas, to take recent examples, failed completely to predict or forecast the non-violent demise of the soviet union, the peaceful transition in south africa, or the development of a market economy in communist china (cf. tetlock, ) . a disaster or crisis always occurs in some kind of social setting. by social setting we mean social systems. these systems can and do differ in social structures and cultural frameworks. there has been a bias in disaster and crisis research towards focusing on specific agents and specific events. thus, there is the inclination of social science researchers to say they studied this or that earthquake, flood, explosion and/or radioactive fallout. at one level that is nonsense. these terms refer to geophysical, climatological or physical happenings, which are hardly the province of social scientists. instead, those focused on the social in the broad sense of the term should be studying social phenomena. our view is that what should be looked at more is not the possible agent that might be involved, but the social setting of the happening. this becomes obvious when researchers have to look at such happenings as the southeast asia tsunami or locust infestations in africa. both of these occasions impacted a variety of social systems as well as involving social actors from outside those systems. this led in the tsunami disaster to sharp cultural clashes regarding on how to handle the dead between western european organizations who came into look mostly for bodies of their tourist citizens, and local groups who had different beliefs and values with respect to dead bodies (scanlon, personal communication with first author). the residents of the andaman islands lived at a level many would consider "primitive". at the time of the tsunami in southeast asia, they had no access to modern warning systems. but prior to the tsunami, members of the tribal communities saw signs of disturbed marine life and heard unusual agitated cries of sea birds. this was interpreted as a sign of impending danger, so that part of the population got off the beaches and retreated inland to the woods and survived intact (icpac report, ) . there is a need to look at both the current social settings as well as certain social trends that influence disasters and crises. in no way are we going to address all aspects of social systems and cultural frameworks or their social evolution, either past or prospective. instead, we will selectively discuss and illustrate a few dimensions that would seem to be particularly important with respect to crises and disasters. what might these be? let us first look at existing social structures around the world. what differences are there in authority relationships, social institutions and social diversity? as examples, we might note that australia and the united states are far more governmentally decentralized than france or japan (bosner, for example, rees ( ) , a cosmologist at cambridge university, gives civilization as we know it only a - chance of surviving the st century. schoff, ) . this affects what might or might not happen at times of disasters (it is often accepted that top-down systems have more problems in responding to crises and disasters). but what does it mean for the management of transboundary disruptions, which require increased cooperation between and across systems? will decentralized systems be able to produce "emergent" transboundary cooperation? as another example, mass media systems operate in rather different ways in china compared with western europe. this is important because to a considerable extent the mass communication system (including social media) is by far the major source of "information" about a disaster or a crisis. they play a major role in the social construction of disasters and crises. for a long time in the former soviet union, even major disasters and overt internal conflicts by way of riots were simply not openly reported (berg, ) . and only late in did chinese authorities announce that henceforth death tolls in natural disasters would be made public, but not for other kinds of crises (kahn, ) . another social structural dimension has to do with the range of social diversity in different systems (bolin & stanford, ) . social groupings and categories can be markedly different in their homogeneity or heterogeneity. the variation, for instance, can be in terms of life styles, class differences or demographic composition. the aging population in western europe and japan is in sharp contrast to the very young populations in most developing countries. this is important because the very young and the very old incur disproportionately the greatest number of fatalities in disasters. human societies also differ in terms of their cultural frameworks. as anthropologists have pointed out, they can have very different patterns of beliefs, norms, and values. as one example, there can be widely held different conceptions of what occasions disasters and crises. the source can be attributed to supernatural, natural, or human factors as indicated earlier. this can markedly affect everything from what mitigation measures might be considered to how recovery and reconstruction will be undertaken. norms indicating what course of action should be followed in different situations can vary tremendously. for example, the norm of helping others outside of one's own immediate group at times of disasters and crises ranges from full help to none. thus, although the kobe earthquake was an exception, any extensive volunteering in disasters was very rare in japan (for a comparison of the us and japan, see hayashi, ) . in societies with extreme cross-cultural ethnic or racial differences, volunteering to help others outside of one's own group at times of disasters or crisis is almost unknown. social structures and cultural frameworks of course are always changing. to understand future disasters and crises, it is necessary to identify and understand trends that may be operative with respect to both social structures and cultural frameworks. in particular, for our purposes, it is important to note trends that might be cutting across structural and cultural boundaries. globalization has been an ongoing force. leaving aside the substantive disputes about the meaning of the term, what is involved is at least the increasing appearance of new social actors at the global level. with respect to disaster relief and recovery, there is the continuing rise of transnational or international organizations such as un entities, the european union, religiously oriented groupings, and the world bank (boin et al., ) . with the decline of the importance of the nation state (guéhenno, ; mann, ) , more and new social actors, especially of an ngo nature, are to be anticipated. the rise of the information society has enabled the development of informal social networks that globally cut across political boundaries. this trend will likely increase in the future. such networks are creating social capital (in the social science sense) that will be increasingly important in dealing with disasters and crises. at the cultural level, we can note the greater insistence of citizens that they ought to be actively protected against disasters and crises (beck, ) . this is part of a democratic ideology that has spread around the world. that same ideology carries an inherent paradox: the global citizen may not appreciate government interference in everyday life, but expects government to show up immediately when acute adversity hits. finally, there has been the impact of the / attacks especially on official thinking not just in the united states but elsewhere also. this happening has clearly been a "focusing event" (as birkland, uses the term) and changed along some lines, certain values, beliefs and norms (smelser, ; tierney, ) . there is a tendency, at least in the us after / , to think that all future crises and disasters will be new forms of terrorism. one can see this in the creation of the us department of homeland security, which repeated errors in approach and thinking that over years of research have shown to be incorrect (e.g., an imposition of a command and control model, assuming that citizens will react inappropriately to warnings, seeing organizational improvisation as bad managing, see dynes, ) . these changes were accompanied by the downgrading of fema and its emphasis on mitigation (cohn, ) . valid or not, such ideas influence thinking about transboundary disasters and crises (and not just in the united states). the ideas expressed above and the examples used were intended to make several simple points. they suggest, for instance, that an earthquake of the same magnitude in france to one in iran will probably be reacted to differently. a riot in sweden will be a different phenomenon than one in myanmar. to understand and analyze such happenings requires taking into account the aspects just discussed. it is hard to believe that countries that currently have no functioning national government, such as somalia and the democratic republic of the congo or marginally operatives ones such as afghanistan, will have the same reaction to disasters and crises as societies with fully functional national governments. different kinds of disasters and crises will occur in rather different social settings. in fact, events that today are considered disasters or crises were not necessarily so viewed in the past. in noting these cross-societal and cross-cultural differences, we are not saying that there are no universal principles of disaster and crisis behavior. there is considerable research evidence supportive of this notion. we would argue, for example, that many aspects of effective warning systems, problems of bureaucracies in responding, the crucial importance of the family/household unit are roughly the same in all societies. to suggest the importance of cross-societal and cross-cultural differences is simply to suggest that good social science research needs to take differences into account while at the same time searching for universal principles about disasters and crises. this is consistent with those disaster researchers and scholars (e.g., oliver-smith, ) who have argued that studies in these areas have badly neglected the historical context of such happenings. of course, this neglect of the larger and particularly historical context has characterized much social science research of any kind (wallerstein, ) ; it is not peculiar to disaster and crisis studies. one trend that affects the character of modern crises and disasters is what we call the social amplifications of crises and disasters. pidgeon, kasperson, and slovic ( ) described a social augmentation process with respect to risk. to them, risk not only depends on the character of the dangerous agent itself but how it was seen in the larger context in which it appeared. the idea that there can be social amplification of risk rests on the assumption that aspects relevant to hazards interact with processes of a psychological, social, institutional, and cultural nature in such a manner that they can increase or decrease perceptions of risk (kasperson & kasperson, ) . it is important to note that the perceived risk could be raised or be diminished depending on the factors in the larger context, which makes it different from the vulnerability paradigm which tends to assume the factors involved will be primarily negative ones. we have taken this idea and extended it to the behaviors that appear in disasters and crises. extreme heat waves and massive blizzards are hardly new weather phenomena (burt, ) . there have recently been two heat waves, however, that have new elements in them. in , a long lasting and very intensive heat wave battered france. nearly , persons died (and perhaps , - , in all of europe). particularly noticeable was that the victims were primarily socially isolated older persons. another characteristic was that officials were very slow in accepting the fact that there was a problem and so there was very little initial response (lagadec, ) . there was a similar earlier happening in chicago not much noticed until reported in a study seven years later (see klinenberg, ) . it exhibited the same features, that is, older isolated victims, bureaucratic indifference, and mass media uncertainty. at the other temperature extreme, in , canada experienced an accumulation of snow and ice that went considerably beyond the typical. the ice storm heavily impacted electric and transport systems, especially around montreal. the critical infrastructures being affected created chain reactions that reached into banks and refineries. at least municipalities declared a state of emergency. such a very large geographic area was involved that many police were baffled that "there was no scene", no "ground zero" that could be the focus of attention (scanlon, ) . there were also many emergent groups and informal network linkages (scanlon, ) . in some ways, this was similar to what happened in august , when the highly interconnected eastern north american power grid started to fail when three transmission lines in the state of ohio came into contact with trees and short circuited (townsend & moss, ) . this created a cascade of power failures that resulted in blackouts in cities from new york to toronto and eventually left around million persons without power, which, in turn, disrupted everyday community and social routines (ballman, ) . it took months of investigation to establish the exact path of failure propagation through a huge, complex network. telecommunication and electrical infrastructures entwined in complex interconnected and network systems spread over a large geographic area with multiple end users. therefore, localized disruptions can cascade into large-scale failures (for more details, see townsend & moss, ) . such power blackouts have occurred among others in auckland, new zealand in (newlove, stern, & svedin, ) ; in buenos aires in (ullberg, ); in stockholm in and in siberian cities in (humphrey, ; in moscow in (arvedlund, ; in brazil in (brooks, ); in bangladesh in (al-mahmood, , and in sri lanka in (lbo, ). all of these cases initially involved accidents or software and hardware failures in complex technical systems that generate severe consequences creating a crisis with major economic and often political effects. these kinds of crises should have been expected. a national research council report ( ) forecast the almost certain probability of these kinds of risks in future network linkages. blackouts can also be deliberately created either for good or malevolent reasons having nothing to with problems in network linkages. employees of the now notorious enron energy company, in order to exploit western energy markets, indirectly but deliberately took off line a perfectly functioning las vegas power plant so that rolling blackouts hit plant-dependent northern and central california with about a million residences and businesses losing power (egan, ) . in the earliest days of electricity in new york city, the mayor ordered the power cut off when poor maintenance of exposed and open wires resulted in a number of electrocutions of citizens and electrical workers (jonnes, ) . one should not think of blackouts as solely the result of mechanical or physical failures creating chain-like cascades. most disasters are still traditional ones. for example, four major hurricanes hit the state of florida in . we saw very little in what we found that required thinking of them in some major new ways, or even in planning for or managing them. the problems, individual or organizational, that surfaced were the usual ones, and how to successfully handle them is fairly well known. more important, emergent difficulties were actually somewhat better handled than in the past, perhaps reflecting that officials may have had exposure to earlier studies and reports. thus, the warnings issued and the evacuations that took place were better than in the past. looting concerns were almost non-existent and less than ten percent indicated possible mental health effects. the pre-impact organizational mobilization and placement of resources beyond the community level was also better. the efficiency and effectiveness of local emergency management offices were markedly higher than in the past. not everything was done well. long known problematical aspects and failures to implement measures that research had suggested a long time ago were found. there were major difficulties in interorganizational coordination. the recovery period was plagued by the usual problems. even the failures that showed up in pre-impact mitigation efforts were known. the majority of contemporary disasters in the united states are still rather similar to most of the earlier ones. what could be seen in the hurricanes in florida was rather similar to what the disaster research center (drc) had studied there in the s and the s. as the electronic age goes beyond its birth and as other social trends continue, new elements may appear creating new problems that will necessitate new planning. if and when that happens, we may have rather new kinds of hurricane disasters, but movement in that direction will be slow. as the famous sociologist herbert blumer used to say in his class lectures a long time ago, it is sometimes useful to check whatever is theoretically proposed against personal experience. in , an extensive snowstorm led to the closing of almost all schools and government offices in the state of delaware. this was accompanied by the widespread cancellations of religious and sport events. there was across the board disruption of air, road and train services. all of this resulted in major economic losses in the millions of dollars. there were scattered interruptions of critical life systems. the governor issued a state of emergency declaration and the state as well as local emergency management offices fully mobilized. to be sure, what happened did not fully rival what surfaced in the canadian blizzard discussed earlier. but it would be difficult to argue that it did not meet criteria often used by many to categorize disasters. what happened was not that different from what others and we had experienced in the past. in short, it was a traditional disaster. finally, at the same time we were thinking about the florida hurricanes and the delaware snowstorm, we also observed other events that many would consider disasters or crises. certainly, a bp texas plant explosion in would qualify. it involved the third largest refinery in the country. more than a hundred were injured and persons died. in addition, there was major physical destruction of refinery equipment and nearby buildings were leveled. there was full mobilization of local emergency management personnel (franks, ) . at about the same time, there were landslides in the state of utah and california; a stampede with hundreds of deaths in a bombay, india temple, train and plane crashes in different places around the world, as well as large bus accidents; a dam rupture which swept away five villages, bridges and roads in pakistan; recurrent coal mine accidents and collapses in china; recurrent false reports in asia about tsunamis that greatly disrupted local routines; sinking of ferries with many deaths, and localized riots and hostage takings. at least based on press reports, it does not seem that there was anything distinctively new about these occasions. they seem to greatly resemble many such prior happenings. unless current social trends change very quickly in hypothetical directions (e.g., marked changes as a result of biotechnological advances), for the foreseeable future there will continue to be many traditional local community disasters and crises (such as localized floods and tornadoes, hostage takings or mass shootings, exploding tanker trucks or overturned trains, circumscribed landslides, disturbances if not riots at local sport venues, large plant fires, sudden discoveries of previously unknown very toxic local waste sites, most airplane crashes, stampedes and panic flights in buildings, etc.). mega-disasters and global crises will be rare in a numerical and relative sense, although they may generate much mass media attention. for example, the terrorist attacks in european cities (madrid in ; london in ; paris in ; brussels, nice, munich berlin in ; stockholm and manchester in ) were certainly major crises and symbolically very important, but numerically there are far more local train wrecks and car collisions everyday in many countries in the world. the more localized crises and disasters will continue to be the most numerous, despite the rise of transboundary crises and disasters. what are some of the implications for planning and managing that result from taking the perspective we have suggested about crises and disasters? if our descriptions and analyses of such happenings are valid, there would seem to be the need for new kinds of planning and preparation for the management of future crises and disasters (ansell et al., ) . non-traditional disasters and crises require some non-conventional processes and social arrangements. they demand innovative thinking "outside of the box" (boin & lagadec, ; lagadec, ) . this does not mean that everything has to be new. as said earlier, all disasters and crises share certain common dimensions or elements. for example, if early warning is possible at all, research has consistently shown that acceptable warnings have to come from a legitimately recognized source, have to be consistent, and have to indicate that the threat or risk is fairly immediate. these principles certainly pertain to the management of transboundary disruptions. actually, if traditional risks and hazards and their occasional manifestations were all we needed to be worried about, we would be in rather good shape. as already said several times, few threats actually manifest themselves in disasters. for example, in the , plus tornadoes appearing in the united states between and , there were casualties in only of them, and of these occasions accounted for almost half of the fatalities (noji, ) . similarly, it was noted in that while about . million people had been killed in earthquakes since , over % of them had died in only occurrences (jones, noji, smith, & wagner, , p. ) . we can say that risks and hazards and their relatively rare manifestations in crises and disasters are being coped with much better than they ever were even just a half-century ago. for example, there has been a remarkable reduction in certain societies of fatalities and even property destruction in some natural disaster occasions associated with hurricanes, floods and earthquakes (see scanlon, for data on north america). in the conflict area, the outcomes have been much more uneven, but even here, for example, the recurrence of world wars seems very unlikely. but transboundary crises and disasters require some type of transboundary cooperation. for example, let us assume that a health risk is involved. if international cooperation is needed, who talks with whom about what? at what time is action initiated? who takes the lead in organizing a response? what legal issues are involved (e.g., if health is the issue, can health authorities close airports?)? there might be many experts and much technical information around; if so, and they are not consistent, whose voice and ideas should be followed? what should be given priority? how could a forced quarantine be enforced? what of ethical issues? who should get limited vaccines? what should the mass media be told and by who and when? at a more general level of planning and managing, we can briefly indicate, almost in outline form, a half dozen principles that ought to be taken into account by disaster planners and crisis managers. first, a clear connection should be made between local planning and transboundary managing processes. there usually is a low correlation between planning and managing, even for traditional crises and disasters. but in newer kinds of disasters and crises, there are likely to be far more contingencies. planning processes need to be rethought and enhanced to help policymakers work across boundaries. second, the appearance of new emergent social phenomena (including groups and behaviors) needs to be taken into account. there are always new or emergent groups at times of major disasters and crises, but in transboundary events they appear at a much higher rate. networks and network links have to be particularly taken into account. third, there is the need to be imaginative and creative. the response to hurricane katrina suggests how hard it can be to meet transboundary challenges. but improvisation can go a long way. a good example is found in the immediate aftermath of / in new york. in spite the total loss of the new york city office of emergency management and its eoc facility, a completely new eoc was established elsewhere and started to operate very effectively within h after the attack. there had been no planning for such an event, yet around , persons were evacuated by water transportation from lower manhattan (kendra & wachtendorf, ; kendra, wachtendorf, & quarantelli, ) . fourth, exercises and simulations of disasters and crises must take into account transboundary contingencies. most such training and educational efforts along such lines are designed to be like scripts for plays. that is a very poor model to use. realistic contingencies, unknown to most of the players in the scenarios, force the thinking through of unconventional options. even more important, policymakers need to be explicitly trained in the management of transboundary crises and disasters. fifth, planning should be with citizens and their social groups, and not for them. there is no such thing as the "public" in the sense of some homogenous entity (blumer, ) . there are only individual citizens and the groups of which they are members. the perspective from the bottom up is crucial to getting things done. this has nothing to do with democratic ideologies; it has instead to do with getting effective and efficient planning and managing of disasters and crises. related to this is that openness with information rather than secrecy is mandatory. this runs against the norms of most bureaucracies and other organizations. the more information the mass media and citizens have, the better they will be able to react and respond. however, all this is easier said than done. finally, there is a need to start thinking of local communities in ways different than they have been traditionally viewed. up to now, communities have been seen as occupying some geographical space and existing in some chronological time. instead, we should visualize the kinds of communities that exist today are in cyberspace. these newer communities must be thought of as existing in social space and social time. viewed this way, the newer kinds of communities can be seen as very important in planning for and managing disasters and crises that cut across national boundaries. to think this way requires a moving away from the traditional view of communities in the past. this will not be easy given that the traditional community focus is strongly entrenched in most places around the world (see united nations, ) . but "virtual reality communities" will be the social realities in the future. assuming that what we have written has some validity, what new research should be undertaken in the future on the topic of future disasters and crises? in previous pages, we suggested some future studies on specific topics that would be worthwhile doing. however, in this section we want to outline research of a more general nature. for one, practically everything we discussed ought to be looked at in different cultures and societies. as mentioned earlier, there is a bias in our perspective that reflects our greater familiarity with and awareness of examples from the west (and even more narrowly western europe, the united states and canada). in particular, there is a need to undertake research in developing rather than only developed countries. and that includes at least some of these studies being undertaken by researchers and scholars from the very social systems that are being studied. the different cultural perspectives that would be brought to bear might be very enlightening, and enable us to see things that presently we do not see, being somewhat a prisoner of our own culture. second, here and there in this chapter, we have suggested that it is important to study the conditions that generate disasters and crises. but there has to be at least some understanding of the nature of x before there can be a serious turn to ascertaining the conditions that generate x. we have taken this first step in this chapter. future work should focus more on the generating conditions. a general model would involve the following ideas. the first is to look at social systems (societal, community and/or organizational ones), and to analyze how they have become more complex and tightly coupled. the last statement would be treated as a working hypothesis. if that turns out to be true, it could then be hypothesized that systems can break down in more ways than ever before. a secondary research thrust would be to see if systems also have developed ways to deal with or cope with threatening breakdowns. as such, it might be argued that what ensues is an uneven balance between resiliency and vulnerability. in studying contemporary trends, particular attention might be given to demographic ones. it would be difficult to find any country today where the population composition is not changing in some way. the increasing population density in high risk areas seems particularly important. another value in doing research on this topic is that much demographic data are of a quantitative nature. we mentioned financial and economic collapses cutting across different systems. how can financial collapse conceivably be thought of as comparable in any way to natural disasters and crises involving conflict? one simple answer is that for nearly a hundred years, one subfield of sociology has categorized, for example, panic flight in theater fires and financial panics as generic subtypes within the field of collective behavior (blumer, ; smelser, ) . both happenings involve new, emergent behaviors of a non-traditional nature. in this respect, scholars long ago put both types of behavior into the same category. although disaster and crisis researchers have not looked at financial collapses, maybe it is time that they did so. these kinds of happenings seem to occur very quickly, are ambiguous as to their consequences, cut across political and sector boundaries, involve a great deal of emergent behavior and cannot be handled at the community level. in short, what has to be looked for are genotypic characteristics not phenotypic ones (perry, ) . if whales, human beings, and bats can all be usefully categorized as mammals for scientific research purposes, maybe students of disasters should also pay less attention to phenotypic features. if so, should other disruptive phenomena like aids also be approached as disasters? our overall point, is that new research along the lines indicated might lead researchers to seeing phenomena in ways different than they had previously seen. finally, we have said little at all about the research methodologies that might be necessary to study transboundary ruptures. up to now, disaster and crisis researchers have argued that the methods they use in their research are indistinguishable from those used throughout the social sciences. the methods are simply applied under circumstances that are relatively unique (stallings, ) . in general, we agree with that position. but two questions can be raised. first, if social scientists venture into such areas as genetic engineering, cyberspace, robotics and complex infectious diseases, do they need to have knowledge of these phenomena to a degree that they presently do not have? this suggests the need for actual interdisciplinary research. social scientists ought to expand their knowledge base before venturing to study certain disasters and crises, especially the newer ones. there is something here that needs attention. in the sociology of science there have already been studies of how researchers from rather different disciplines studying one research question, interact with one another and what problems they have. researchers in the disaster and crisis area should look at these studies. our view is that the area of disasters and crises is changing. this might seem to be a very pessimistic outlook. that is not the case. there is reason to think, as we tried to document earlier, that human societies in the future will be able to cope with whatever new risks and hazards come into being. to be sure, given hazards and risks, there are bound to be disasters and crises. a risk free society has never existed and will never exist. but while this general principle is undoubtedly true, it is not so with reference to any particular or specific case. in fact, the great majority of potential 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q authors: sargiacomo, massimo; morales, jérémy; moerman, lee; andrew, jane title: special issue on accounting, disasters and the government of biosecurity date: - - journal: nan doi: . /j.cpa. . sha: doc_id: cord_uid: pyehjw q nan special issue on accounting, disasters and the government of biosecurity for several decades, ''disasters" have punctuated the rhythm of our lives. while ''disasters" are not new, the way we give them meaning through discourse and social practices has changed continuously. while disasters are accompanied by undeniable material events, what constitutes a disaster is bound by temporal, cultural and political contexts, and these have a profound effect on the way we prepare for and respond to crises. given this, researchers have begun to explore the relationship between accounting, accountability and disasters. in terms of ''natural" disasters, accounting researchers have considered earthquakes (sargiacomo et al, ; sargiacomo, ) , hurricanes (baker, ; perkiss & moerman, ) , drought (walker, ) , floods (lai, leoni, & stacchezzini, ) and bushfires (taylor, tharapos, khan, & sidaway, ) . others have investigated technological/industrial disasters (cooper, coulson, & taylor, ; matilal & hopfl, ; matilal & adhikari, ; sinkovics et al. ) ; disasters at events (cooper & lapsley, ) ; and post-war scenarios (cooper & catchpowle, ) . a number of studies have highlighted accountability issues that surface in crisis scenarios (everett & friesen, ) and the kinds of social purpose alliances that might emerge to respond to crises such as global pandemics (rahaman, neu, & everett, ) . despite these early studies, there is still much to learn about the role of accounting before, during and after ''disasters" (flyvbjerg, ; cooper & morgan, ) . the current ongoing coronavirus pandemic provides the stimulus for this special issue. internationally, responses to the challenges presented by covid- have been hugely uneven, as have its effects (oecd, ) . in some countries, government programs have sought to limit the amount of healthcare assistance available to citizens, while in others, sustained effort has been channeled towards the fortification of health care services so they could meet the needs of citizens. in situations of scarce resources, accounting may influence life-prolonging decisions and have implications for how citizens are triaged more generally (le theule, lambert, & morales, ). for a short while, the pandemic shed light on practices surrounding triage, but there has been little public debate about their implications for citizens and resource allocation. so questions remain: if healthcare capacities do not meet the population's needs, how should lifesaving equipment be allocated? who will make such decisions? the twin challenges of sustaining lives and livelihoods have meant that in some countries, life-prolonging decisions have only been possible for certain patients, whereas in others, the public health response has treated all citizens equally. in some countries, the government has provided extraordinary resources to protect the vulnerable, the homeless and those in precarious work; in others, the government has tried to stimulate businesses presuming this will drive public welfare whereas in other settings, governments have been unable or unwilling to respond. this unevenness has been mirrored elsewhere and at other times in response to disasters and crises (klein, ) and, as such, this particular unfolding disaster reminds us that there is still much to learn about the use of accounting and calculative practices in response to all kinds of crises. there is no doubt that covid- and prior high risk bio-security threats such as ebola or sars/mers are crises of extraordinary significance, but it is also true that our lives have and will be punctuated by a variety of ''disasters"-some that are natural, some that are a result of technical or engineering failures, and others that materialize from inequalities and injustices which can be exacerbated by the sudden arrival of disasters. given this, in making this call for papers, it is our intention to create space for research that considers the role accounting plays, or might play, in both the local and international efforts of governments, corporations, and non-governmental organizations as they respond to a wide range of disasters and risks (power, ) . as such, contributors are invited to consider accounting within the context of disasters across a variety of events, scales, locations and time. amongst other things, we are interested in the construction, representation and calculation of security risks through maps, tables, accounting and calculations (collier, ; lentzos & rose, ; miller, ) , the shape of these practices once a ''national state of emergency" has been declared (agamben, ) , and the ''technologies of government" (miller critical perspectives on accounting j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / c p a & rose, ; rose & miller, ) before, during and after the emergence of a disaster. indeed, the ethical/bioethical implications of programs and calculative practices undertaken by governments and organizations, sometimes in tandem with or through hybrid organizations (johanson & vakkuri, ; kurunmäki & miller, ; grossi et al., ) , in the aftermath of disasters requires analysis. it is also important to consider the implications of these responses on the shaping of possible futures. these unique circumstances invite novel investigations. submissions examining the roles of accounting practices, accountability mechanisms and auditing are all welcome. we encourage submissions from a wide range of theoretical, methodological and empirical approaches -as long as they are consistent with the spirit of critical accounting research (e.g., dillard & vinnari, ; gendron, ) . topics may include, but are not limited to: the use of accounting to construct a discourse of ''disaster". the use of accounting by national governments to organize the ''preparedness" and the government of national risks and biosecurity. the links between the calculative practices of costing the disaster and the fund-raising activities of the organizations involved, either at the levels of local and national government, as well as at level of supranational entities, such as the european union. the interrelations between the ''cost" calculations of the disaster and the politics and ''strategic gaming" involved in such calculations. the use of accounting practices to ''guide" interventions during an emergency and/or the recovery stages, as well as the use of accountability and control mechanisms in these processes. the use of calculative practices, such as morbidity figures, as performance measurements in responses to disasters. the intersection of disaster governance, hybrid organizations and accounting. the relationship between accounting, and other professional expertise and organizations working in the aftermath of disasters. conceptualizations of accounting, accountability and corporate social responsibility before and after disasters. the use of accounting and accountability practices in governmental and non-governmental organizations before, during and after the disasters. the politics and practices surrounding the auditing of such interventions. the intersection of accounting, integrated reporting, and disaster governance and communication, at a macro, meso, or micro level. the effects of accounting on all forms of inequality during the emergency and recovery stages of disasters. in particular, the implications these have in terms of race, gender, and class. potential contributors are encouraged to interpret the above themes broadly, yet critically, using diverse theoretical and methodological perspectives in a wide array of country and regional settings. a workshop will be organized by the special issue editors to be hosted virtually through a webinar in late february . due to the global reach of the journal and the multiple time zones inhabited by the participants, it is likely that some of the webinar sessions will be held outside of normal work hours. authors wishing to present at the workshop should contact massimo sargiacomo (msargiacomo@unich.it) by december , . all workshop participants will be required to provide a draft paper to be shared at least four weeks prior to the date scheduled for the workshop. authors of selected papers from the workshop will be invited to submit revised papers for this special issue. these submissions will then be subject to the journal's normal review processes. attendance and/or presentation at the workshop is not a pre-requisite for submission to the special issue. the closing date for submissions to this special issue is may , . manuscripts should be submitted electronically via https://www.journals.elsevier.com/critical-perspectives-onaccounting. the guest editors welcome enquiries from those who are interested in submitting. all papers will be reviewed in accordance with the normal processes of critical perspectives on accounting. it is anticipated that this special issue will be published in early . any queries or enquiries about the special issue should be directed to massimo sargiacomo (msargiacomo@unich.it) . state of exception breakdown of accountability in the face of natural disasters: the case of hurricane katrina enacting catastrophe: preparedness, insurance, budgetary rationalization us imperialism in action: an audit-based appraisal of the coalition provisional authority in iraq accounting for human rights: doxic health & safety practices -the accounting lessons from icl hillsborough: the fight for accountability case study research in accounting. accounting horizons a case study of critique: critical perspectives on critical accounting humanitarian accountability and performance in the théâtre de l'absurde making social science matter: why social inquiry fails and how it can succeed again on the elusive nature of critical (accounting) research accounting, performance management systems, and accountability changes in knowledgeintensive public organizations a literature review and research agenda governing hybrid organizations the shock doctrine: the rise of disaster capitalism modernising government: the calculating self, hybridisation and performance measurement the socializing effects of accounting in flood recovery governing insecurity: contingency planning, protection, resilience governing death: organizing end-of-life situations accounting in bhopal: making catastrophe accounting for the bhopal disaster: footnotes and photographs the margins of accounting governing economic life interim economic assessment hurricane katrina: exploring justice and fairness as a sociology of common good(s). critical perspectives on accounting riskwork: essays on the organizational life of risk management accounting for social purpose alliances: confronting the hiv/aids pandemic in africa political power beyond the state: problematics of government earthquakes, exceptional government and extraordinary accounting. accounting accounting for suffering: calculative practices in the field of disaster relief rana plaza collapse aftermath: are csr compliance and auditing pressures effective? accounting downward accountability for victoria's 'black saturday' bushfire recovery: evidence from reports of government and ngos drought, resettlement and accounting key: cord- -t ydu l authors: shi, peijun title: hazards, disasters, and risks date: - - journal: disaster risk science doi: . / - - - - _ sha: doc_id: cord_uid: t ydu l in this chapter, we will elaborate on three basic terms in the field of disaster risk science: hazards, disasters, and risks. we will also discuss the classification, indexes, temporal and spatial patterns, and some other fundamental scientific problems that are related to these three terms. atmospheric hazard: tropical cyclone, tornado, hail, snow, lightning and thunderstorm, long-term climatic change, and short-term climatic change. biophysical hazard: wildfire. space hazard: geomagnetic storm and extra impact events. the hazard groups proposed by joel c. gill et al. are almost equivalent to the hazard families of icsu-irdr classification except for two differences. one difference is that the meteorological and climatological families of icsu-irdr were combined into a single atmospheric group in gill's classification. the other difference is that the hazard group of shallow earth processes was added in gill's classification in order to emphasize the hazardous impacts of shallow earth changes (table . ). gill and malamud ( ) hazard group code definition component hazards (where applicable) geophysical earthquake eq the sudden release of stored elastic energy in the earth's lithosphere, caused by its abrupt movement or fracturing along zones of preexisting geological weakness and resulting in the generation of seismic waves ground shaking, ground rupture, and liquefaction tsunami ts the displacement of a significant volume of water, generating a series of waves with large wavelengths and low amplitudes. as the waves approach the shallow water, their amplitude increases through wave shoaling volcanic eruption vo the subterranean movement of magma and its eruption and ejection from volcanic systems together with associated tephra, ashes, and gases, under the influence of the confining pressure and superheated steam and gases gas and aerosol emission, ash and tephra ejection, pyroclastic and lava flows in the book regions of risk by hewitt ( ) , hazards were divided into the following categories: natural hazards include four types (meteorological, hydrological, geological and geomorphological, biological and disease hazards) technological hazards include hazardous materials, destructive processes, and hazardous designs. social violence hazards include weapons, crime, and organized violence. compound hazards include fog, dam failure, and gas explosion. complex disasters include famine, refugees, poisonous flood, nuclear wastes and explosion of nuclear power plants (table . ). famine (drought + poor harvest + food hoarding + poverty) refugee crisis (famine + war) toxic floods (tailings dams + toxic waste + flood) harmful nuclear tests and power plant explosions (nuclear explosion and pollution + atmospheric circulation + rain and atomic dust + migration) another way to categorize hazards is based on the environment where hazards occur (also called disaster-formative environment). the classification based on causes emphasizes the origin of hazards, that is, whether the hazards are caused by natural factors, human factors, or the interaction between natural and human factors. in contrast, the classification based on disaster-formative environment lays stress on the environmental basis of hazards, especially the distinctions among different spheres of the earth, and relatively ignores the causes. actually, different kinds of hazards nowadays contain effects from both the natural and human factors to different degrees. and this is one of the important reasons why un changed the goal of the global disaster reduction activities from natural disaster reduction to disaster risk reduction. ( ) classification of hazards by peijun shi in shi's paper ( ) published on the journal of nanjing university (natural sciences, special issue on natural hazards), hazards were divided into four levels: systems, groups, types, and kinds. this classification highlights not only the occurrence environment but also the causes of hazards (shi ) . the first level of this classification is focused on the causes, the second level the environments, the third level the types, and the fourth level the detailed hazards. the hazard system is composed of three systems: nature, human, and environment. the natural hazard system is then divided into four groups: atmosphere, lithosphere, hydrosphere, and biosphere. the hazards are mainly caused by natural environmental factors. the human hazard system includes three groups: technology, conflicts, and wars. the hazards are mainly caused by human environmental factors. the environmental hazard system is made up of five groups: global change, environmental pollution, desertification, vegetation degradation, and environmental diseases. the hazards are due to integrated natural and human factors. ( ) classification of hazards in zhang lansheng and liu enzhen the atlas of natural hazards in china edited by zhang and liu, as a result of the cooperation between beijing normal university and the people's insurance company of china, was published by china science press (beijing) in . based on the atlas, the paper a research on regional distribution of major natural hazards in china by wang et al. ( ) was published, and the classification system of major natural hazards in china consisting of types and subtypes (table . ) was built. the major natural hazards in china can be divided into environments, types, and subtypes based on the differences in disaster-formative environments. atmosphere including nine natural hazards-drought, typhoon, rainstorm, hailstorm, extreme low temperatures, frost, ice and snow, sandstorm, and dry-hot wind. hydrosphere including five natural hazards-flood, waterlogging, storm surge, sea wave, and tsunami. lithosphere including five natural hazards-earthquake, landslide, debris flow, subsidence, and wind-drift sand. biosphere including six natural hazards-crop diseases, crop pests, forest diseases and pests, rodents, poisonous weeds, and red tide. geosphere including six natural hazards-soil erosion, desertification, soil salinization, frozen soil, endemic disease, and environmental pollution. ( ) intensity classification of single hazard the intensity classification of single hazard is based on the measurement specifications and standards of hazards. hazards of different origins and in different environments are measured by different indicators. for example, earthquakes are measured in magnitude, rainstorms in rainfall intensity, typhoons in maximum sustained wind, and floods in flood stage. those hazard measurement specifications and classification standards can be found on the web sites of international or national departments of measurement standards. generally speaking, meteorological departments set up the measurement specifications and classification standards for atmospheric hazards; hydrological or water resources, and oceanic administrations for hydrosphere hazards; geological and a large number of observations show that there is a negative correlation between hazard intensity and frequency. in other words, the higher the intensity is, the lower the occurring frequency is and the longer the repeating period is. there is a power function relationship between the hazard intensity and the occurring frequency (chen and shi ) . refer to textbooks or monographs on geoscience, life science and resources and environmental science for the intensity classification of single hazard. ( ) intensity classification of multi-hazards the regional and integrated disaster risk research requires scientists to understand the diversity of hazards of different spatial and temporal scales and classify the intensities of multi-hazards. because the measurement indicators vary among different hazards and there is no universal indicator, the intensity classification method for single hazard mentioned in the previous section will not be able to meet the needs of the regional and comprehensive studies of the diversity of hazards. based on current data, it is very difficult to synthesize various hazard intensities measured in different indicators. one way to get around this problem is to divide each kind of hazard intensity into relative levels and then calculate the average of levels weighted by the area that respective type of hazard covers during a certain period of time. this method can approximately reflect the regional overall hazard intensities in a certain space and a certain period of time. but there is one problem with this method; that is, different hazards with the same level of relative intensity might have different impacts on hazard-affected bodies. therefore, in order to eliminate this effect, another term is added-the weighted average of the loss rate of each hazard in a certain space and time period. referring to the quadrat method in the vegetation investigation, we proposed to use multiple degree to describe the abundance of hazards in a region. another way to do this is similar to the multiple cropping index calculation in land-use research. based on wang et al.'s paper ( ) , in this book, we propose to use multiple degree and covering index of hazards to express the clustering degree and influence of multiple hazards in a region. multiple degree (h d ): the clustering degree of hazards in a certain region. as a relative value changing with the compared region, it can be expressed as where h d is the multiple degree of hazards in a region (%), n is the number of hazards in the region, and n is the number of hazards in a higher level of region (e.g., world, asia, china). the value of n is set to be (table . ) for the calculation of county-level multiple degree of natural hazards in china. relative intensity (h i ): the relative destructive or damaging ability of hazards. relative intensity is a relative value and only a quantity of the hazard per se. it is not an obvious positive correlation with the disaster loss or damage but is the basic reason (condition) for the regional loss. it can be calculated as follows: where h i is the relative intensity (level) of hazards in a region, p i is the relative intensity of hazard i, and s i is the area ratio of hazard i, ranging from . to . , i.e., - % and i is the number of hazard types. covering index of hazards (h c ): the percentage of covering area of hazards in a region. it can be expressed as where s i is the percentage of covering area of a type of hazard in a region and i is the number of hazard types. composite index (h): the sum of the three indexes mentioned above divided by the respective maximum values. the formula is where h d is the hazard multiple degree, h i is the relative intensity, h c is the covering index of a hazard in a region, and max () is the maximum value of the respective index. we will use the calculated results in wang et al.'s paper ( ) to demonstrate the practical application of the four indexes-multiple degree, relative intensity, covering index, and composite index of hazards. multiple degree of natural hazards. in fig. . , the maximum value of the natural hazard multiple degree is about eight times as large as the minimum value in china. the value ranges from below . to above . . this large variation shows that there is an obvious spatial clustering feature of natural hazards in china. generally speaking, the high values are centered in north china and decrease toward northeast, northwest, and southeast. ninety percent of the districts and counties with h d value greater than % are located in the middle latitude belt ( °- °n). in southwest china where the h d values are relatively low, the h d value increases in some topography-transition areas. thus, it can be seen that natural hazards relatively cluster in natural environment transition zones, such as the middle latitude belt, sea-land transition zones, topography-transition areas, and semiarid farming-pastoral ecotone. in the transition regions of several natural environments, there exist continuous areas with high h d values. north china is right in such location and thus becomes the most concentrated area of natural hazards in china, also an important part of the pacific rim and mid-latitude multiple hazard belt. therefore, regional natural hazards' factors are of important value to the degree of regional natural environmental change. covering index of natural hazards. figure . shows that there is a large variation in covering index of natural hazards in china, ranging from less than . to more than . and indicating obvious regional differences. on the whole, the trapezoid region with qiqihar, harbin, tianshui, and hangzhou as four vertexes has the highest h c values (> . ) in the country. in this high-value region, the northeast china plain and the north china plain have values usually greater than . . the regions with h c values greater than display a lambda-shaped layout; that is, one line is qiqihar-tongliao-beijing-taiyuan-baoji-tianshui, and the other line stretches from southern hebei province to hangzhou along the grand canal. the low-value regions are centered in the northern tibetan plateau, from which h c value increases outwards. in regions south of the yangtze river, there are two high-value belts: southeast coastal belt and southwestern provinces including yunnan, guizhou, and sichuan. there is a positive correlation between the h c value and the h d value. it can be seen from figs. . and . that h c values and h d relative intensity of natural hazards. figure . shows that h i values are within the range of . - . . regions with a h i value greater than . are sparsely distributed. one high-intensity area (h i > . ) stretches from the northeast to the southwest, and another one is in the southeastern side of the first one-hunan and jiangxi provinces. the relative intensities in the vast north-central tibetan plateau and northwest china are relatively low. the regional differentiation of relative intensity is tightly associated with the regional distribution of several major hazards. first of all, the seismically active belts of china, i.e., the pacific rim belt and himalayan seismic belt, have the correspondingly high intensities. seismic regions, once having an earthquake with a magnitude greater than , usually become small high-intensity centers, such as west china, tangshan. secondly, the high-intensity regions are overlapped with the regions concentrated with cloudbursts. for example, the coastal typhoon belt, the northern hebei mountains-taihang mountains-dabie mountains cloudburst belt, and the cloudburst belts in western sichuan and (shi ) western hunan. thirdly, the frequently flooded areas also correspond to high relative intensity areas. these areas include liaohe plain, north china plain, northern jiangsu plain, and hubei and hunan plains. finally, areas with frequent debris flows and landslides, mainly in the "second step" east to tibetan plateau, have high values of relative intensity. therefore, the overall relative intensity of natural hazards is controlled by several major natural hazards. however, these major natural hazards may also interact in the same region, which makes the regional differentiation of relative intensity of china's natural hazards more complicated and also expands the high-intensity regions. in every high relative intensity area, there is at least one dominant natural hazard. relationships among multiple degree, relative intensity, and covering index. the interaction of the three indexes varies among regions. figure . shows the regional distribution of the composite index of natural hazards in china. north china has the highest values of all three indexes and thus is affected by frequent and catastrophic hazards. coastal areas have the second highest values of three indexes and are subject to frequent and severe hazards. the third highest value regions include the farming-pastoral ecotone in northern and western sichuan, yunnan, western guizhou, and southeastern tibetan plateau in the southwest. whereas, the northern tibet is a low-value region. the above outlines the basic regional differentiation of natural hazards in mainland china. (shi ) there are differences in natural hazards between eastern and western china and between southern and northern china. as for east-west differentiation, the values of multiple degree, relative intensity, and covering index are higher in the east and lower in the west. the high values in the east are centered in north china while the low values in the west are centered in northern tibet. as for north-south differentiation, the vast area within °to °n in the east has values of all three indexes higher than areas to its south and north. among this vast area, the highest values exist in range of °to °n. however, the north-south differentiation in the west is not obvious, since there are incomplete data records, especially in the border area among tibet, qinghai, and xinjiang, or the hoh xil region. due to inadequate data, this region has the lowest values of all three indexes nationwide. the regional differentiation of natural hazards is closely associated with the environments where hazards develop. the environmental evolution-sensitive zones usually have high multiple degree, high relative intensity, and high covering index, suffering frequent or severe hazards. however, a small number of ecologically vulnerable areas have low values of multiple degree and intensity. one outstanding example is eastern guizhou. in areas with harsh environment, such as the vast west china, the multiple degree and relative intensity are not necessarily high. therefore, there is no direct relationship between environmental conditions and the impacts of natural hazards. disasters are direct or indirect results of hazards. disaster impacts include human losses, property losses, resources and environmental destruction, ecological damages, disruption of social order, and threats to the normal functioning of lifelines and production lines. the classification of disasters is closely associated with hazards and disaster-affected bodies. in chinese literatures, "zaihai" is used to refer to both hazards and disasters. however, in western literatures, hazard and disaster are two terms used separately. most researches in the west are focused on the classification of hazards, rarely on the classification of disasters. whereas, in chinese literatures, the classification of disasters takes the place of the classifications of both hazards and disasters. this confusion of hazards with disasters, or the confusion of hazard science with disaster science (e.g., seismology substitutes for earthquake catastrophology, and rainstorm meteorology for rainstorm catastrophology), negatively affects the development of disaster risk science. with the development of human society, the types of disaster-affected bodies (exposure) have increased and the distribution of disaster-affected bodies has expanded. at the same time, human's ability of disaster prevention has also been improved. therefore, even the same hazard could induce varying degrees of disasters. when analyzing the disasters, people stress on the disaster-affected bodies; namely, focus on human's disaster prevention level, which is referred as the vulnerability, resilience, and adaptation of human beings to hazards in the western literatures. as mentioned above, in western research there is more of an emphasis on the classification of hazards than that of disasters. in chinese official documents or research literatures, the majority is the classification of disasters based on the causes and scales of disasters. the genetic classification of disasters according to the causes in chinese literatures is basically the same as that of hazards in western literatures. ( in the book introduction to catastrophology by ma ( ) , according to the causes, disasters can be divided into natural disasters and man-made disasters. natural disasters can be further categorized into natural disasters and man-made natural disasters, while man-made disasters are composed of man-made disasters and natural man-made disasters. when the management of disasters is taken into account at the same time, disasters can be divided into classes and further types. in the book, the author also clearly pointed out the administration departments in charge of each type of disaster (table . ) . this classification is different from others in the classification of the disaster-formative environments, with an inclusion of ocean sphere instead of hydrosphere. another difference is that sources of flood and drought are attributed to the atmosphere in ma's classification (ma ) . besides, this classification is basically in accordance with the classifications in prc disaster reduction report ( ) and major natural disasters and disaster reduction in china ( ) (table . ). similar to the classification of introduction to catastrophology, in the book natural disasters by chen ( ) , based on the differences between the internal, external, and gravitational energy of the earth, natural disasters were divided into seven major categories: earthquakes, tsunamis, volcanos, meteorological disasters, floods, landslide and debris flow, and spatial disasters. this classification does not only reflect the holistic view of disasters but also emphasizes the timescales of disasters and environmental processes of the earth system. ( ) classification of disasters in chinese state standards for the dual purposes of comprehensive prevention, reduction and relief of disasters and counting the losses and damages caused by natural disasters, experts organized by state disaster reduction center of ministry of civil affairs drew up the classification standards of natural disasters in china, in which the definition and code of each disaster are also given. in this classification, natural disasters in china are divided into groups and specific types, including specific meteorological and hydrological disasters, seismic and geological disasters, ocean disasters, biological disasters, and eco-environmental disasters (table . ). natural disasters resulting from the abnormal or anomalous quantity, intensity, temporal and spatial distribution, and combination of meteorological and hydrological elements, causing adverse impacts on people's lives and properties, industrial and agricultural production, and ecological environment drought a deficiency in precipitation and/or a shortage in river runoff or other kinds of water resources, causing adverse impacts on people's life, industrial and agricultural production, and ecological environment flood an overflow of water from rivers or other water bodies onto land which is usually dry, caused by excessive rainfall, melting snow and ice, levee breach and storm surge, resulting in life losses, property losses, and disruption in social functioning typhoon a tropical cyclone that develops in a wide area over tropical or subtropical oceans, accompanied with heavy winds, rainstorm, storm surge and huge waves, bringing out damages to human lives and properties rainstorm rainstorm happens when the precipitation rate is more than mm per hour, or more than mm for h or mm for h, causing damages to human lives and properties (continued) hail hail is a type of solid precipitation formed in thunderstorm clouds and controlled by strong convective weather, causing damages to human lives and properties and to crops and animals thunder disaster thunder disaster is an electric discharge, directly or indirectly striking human and animals, resulting in damages to human lives and properties low-temperature disaster intrusion of strong cold front or constant low temperatures, causing freezing injury and damages to crops, animals, human beings, and infrastructures, disrupting normal life and production snow and ice disaster due to snowfall, a wide area is covered with snow or affected by snowstorm, avalanche, frozen road, and other infrastructures. it severely disturbs the lives of human beings and animals and causes damages to traffic, power, and communication systems high-temperature disaster high temperatures cause harms to the health of animals, plants and human beings and damages to production and environment sandstorm a strong wind blows loose sand and dirt that later mix with air from a dry surface, causing damages to human lives and properties. horizontal visibility is usually less than km fog a visible mass composed of cloud water droplets and ice crystals suspended in the air or near the earth's surface, causing damages to human lives and properties and especially harms to the traffic safety. horizontal visibility is usually less than km other m&h disasters meteorological and hydrological disasters that are not mentioned above seismic and geological disasters natural disasters resulting from the sudden energy release or violent mass transport in the lithosphere of the earth or long-term accumulative geological changes, causing damages to human lives and properties and ecological environment earthquake the strong shaking of the earth's surface and the accompanying ground rupture, resulting from the sudden release of energy in the earth's crust. it causes damages to human lives, buildings and infrastructures, social functioning, and eco-environment (continued) the sudden occurrence of a violent discharge of the interior materials of the earth, causing direct damages to human lives and properties. the erupted material is referred to as lava. other impacts include pyroclastic flow, lava flow, volcanic gases and ashes, and eruption-induced debris flow, landslide, earthquake, and tsunami collapse the sudden fall of unstable materials occurring at the edge of a steep cliff, causing damages to human lives and properties landslide a slide of a large mass of dirt and rock down a slope under the action of gravity, causing damages to human lives and properties debris flow a special water flow, entraining objects such as fragmented rocks, muds, branches in the path, rapidly rushes down mountain valleys or slopes. it results from heavy rains, reservoir or pond breach, or a sudden melting of snow and ice, causing damages to human lives and properties surface collapse a surface depression due to abandoned mines or karst processes, causing damages to human lives and properties ground subsidence a large-area land subsidence due to excessive extraction of groundwater or gas and oil, causing damages to human lives and properties. it occurs in unconsolidated or semi-consolidated soil areas ground fracture a linear fissure on the ground surface cracking through the rocks or soils, causing damages to human lives and properties other geological disasters geological disasters that are not mentioned above ocean disasters disasters resulting from the abnormal or drastic change of the ocean environment and occurring on the sea or coast strom surge a coastal flood caused by non-periodic abnormal rising of water over part of the sea that results from tropical cyclone, extratropical cyclone or cold front, causing damages to human lives and properties along the coast sea wave sea waves with wave height of more than meters, causing damages to ships, offshore oil drilling facilities, fishery, aquaculture, harbors and ports, seawalls, or other ocean and coastal engineering sea ice it blocks channels and causes damages to ships, offshore facilities and coastal engineering (continued) tsunami sea waves with wavelength up to hundreds of kilometers, induced by seafloor earthquakes, volcanic eruptions, underwater landslide, and subsidence, producing a sudden upward displacement of seawater and forming a "water wall" on the coast, devouring farmlands and villages, causing damages to human lives and properties red tide a sudden increase or high concentration of aquatic planktons and microorganisms changing the water body color to red or brown. it disrupts the normal aquatic ecology and causes damages to human lives and properties and eco-environment. see also the red tide disaster in the biological disasters other ocean disasters ocean disasters that are not mentioned above biological disasters natural disasters in the forest or grassland resulting from activities of living being, lightning, or spontaneous combustion, causing damages to crops, woods, cultivated animals and related facilities plant diseases and pests an outbreak of pathogenic microorganisms and pests, harming the farming and forestry pandemic disease an epidemic of infectious disease caused by microorganisms or parasites that rapidly spreads through human or animal populations, usually resulting in a high morbidity or mortality. it causes great damages to animal husbandry and harms to human health and life safety rodents an outbreak of rodent-related disasters, causing damages to plantation, animal husbandry, forestry and properties weeds weeds cause severe damages to plantation, animal husbandry, forestry, and human health red tide a sudden increase or high concentration of aquatic planktons and microorganisms changing the water body color to red or brown. it disrupts the normal aquatic ecology and causes damages to human lives and properties and eco-environment forest/grassland fire a fire in a forest or grassland caused by lightning, spontaneous combustion or human beings under combustible conditions. it causes damages to human lives and properties and eco-environment other biological disasters biological disasters that are not mentioned above natural disasters induced by the damage to ecosystem or ecological imbalance, bringing out negative impacts on the harmony between human beings and nature and on the living environment of human beings (continued) from the comparison between the classification of the twelfth five-year special plan and that of the state standards, it can be seen that they share the same five big groups of natural disasters, but the latter one has more specific types than the former one. besides, an emergency incident is defined as "a natural disaster, accidental disaster, public health incident or social safety incident, which takes place by accident, has caused or might cause serious social damage and needs the adoption of emergency response measures" in emergency response law of the people's republic of china ( ). there is no universal standard for the classification of disaster scale. although there are different standards in different fields, the major factor considered is the scale of the hazardous event-induced disasters. generally, the classification indicators include the number of casualties, the amount of property loss, disaster-affected area, and hazard intensity. ( ) indicator system of unisdr in the sendai framework for disaster risk reduction - , there are seven disaster reduction indicators, four of which are related to the measuring of disasters, namely disaster mortality, disaster-affected people, direct disaster mortality. number of people killed or missing from a hazardous event. the death toll refers to the number of death population during or after the event, while the missing toll only refers to the total number of missing people during the event. besides counting the total number of dead and missing people, it is also important to calculate the percentage of killed and missing people per , people. thus, the effect of population base can be eliminated in temporal and spatial comparison of mortality. affected people. it refers to the total population that are affected directly or indirectly by disasters. directly affected people are those whose health was affected, such as injured and sick people, and those evacuated, displaced or relocated, and those who suffered from the disaster-induced direct damages to livelihoods, infrastructure, social culture, environment, and properties. at the same time, disaster statistics also need to include people whose houses were destroyed or collapsed and people who receive food aid. indirectly affected population are those suffered from the additive effects of disasters, namely people affected by disaster-induced disruption or modification of economy, critical facilities, basic services, business, work, society, and health. in practice, due to the difficulty in counting indirectly affected population, only directly affected population are included in the disaster statistics. likewise, it is also worth calculating the percentage of affected people per , people. in addition to counting the killed and missing people and affected people, it is also common to specify their ages, genders, residence addresses, and disabilities. direct economic loss. direct economic loss refers to disaster-induced loss of materials or properties, such as houses, factories, and infrastructures. usually after the occurrence of a disaster, it is advised to assess the property loss as soon as possible to facilitate the cost estimation for disaster recovery and insurance claims processing. it is also recommended to calculate the percentage of direct economic loss accounting for the global or national gross domestic product (gdp). direct economic loss can be further divided into agriculture loss, loss of industrial and commercial facilities, houses, critical infrastructure damaged or destroyed by disasters. direct agriculture loss: it refers to crop and livestock losses and also includes the losses of poultry, fishery, and forestry. industrial facilities damaged or destroyed: it refers to the loss of manufacturing and industrial facilities damaged or destroyed by hazardous events. commercial facilities damaged or destroyed: it refers to the loss of commercial facilities (including storage, warehouse, cargo terminal, etc.) that are damaged or destroyed by hazardous events. houses damaged: it refers to the loss of houses slightly affected by hazardous events and subject to no structural or architectural damages. after repair or cleanup, these damaged houses can still be habitable. houses destroyed: it refers to the loss of houses that collapsed or were burnt, washed away, and severely damaged and are no longer suitable for long-term habitation. critical infrastructure damaged or destroyed: it refers to the loss of educational and health facilities, and roads damaged or destroyed by hazardous events. educational facilities damaged or destroyed: it refers to the number of educational facilities damaged or destroyed by hazardous events. educational facilities include children's playroom, kindergarten, elementary school, high school (junior and senior), vocational school, college, university, training center, adult education school, military school, and prison school. health facilities damaged or destroyed: it refers to the number of health facilities damaged or destroyed by hazardous events. health facilities include health centers, clinics, local or regional hospitals, outpatient centers, and facilities that provide basic health services. roads damaged or destroyed: it refers to the length of road networks in kilometers that are damaged or destroyed by hazardous events. infrastructure damaged or destroyed: it refers to the loss of infrastructures other than the critical infrastructures, such as railways, ports, airports. railways damaged or destroyed: it refers to the length of railway networks in kilometers that are damaged or destroyed by hazardous events. ports damaged or destroyed: it refers to the number of ports that are damaged or destroyed by hazardous events. airports damaged or destroyed: it refers to the number of airports that are damaged or destroyed by hazardous events. basic services. basic services refers to the disruption of public services or time loss due to low-quality services, which are caused by hazardous events. basic services include health facilities, educational facilities, transportation system (including train and bus terminals), ict system, water supply, solid waste management, power supply system, emergency responses, etc. the health facilities, educational facilities, transportation system are mentioned above in the critical infrastructure loss and infrastructure loss sections. ict system refers to communications and the associated equipment network, including radio and tv stations, post offices, public information offices, internet, landline and mobile telephones. water supply includes drinking water supply and sewerage systems. drinking water supply system includes drainage system, water processing facilities, water transporting channels (channels and aqueducts) and canals, water tank, or tower. sewerage system includes public sanitary facilities, sewerage treatment system, collection and treatment of solid wastes from public sanitation. solid waste management refers to collection and treatment of solid wastes that are not from public sanitation. power/energy system includes power facilities, electrical substations, power control centers, and other power services. emergency response includes disaster management offices, fire departments, police stations, military, and emergency control centers. ( ) indicator system of statistical system of damages and losses of large-scale natural disasters in china the ministry of civil affairs and national bureau of statistics of china jointly introduced the regulation statistical system of damages and losses of large-scale natural disasters in , which brought the comprehensive assessment of natural disaster loss into the regulation system (shi and yuan ) . this statistical system explains the purpose and meaning of statistics of large-scale disasters and defines the statistical scope and major indicators. other contents described in this regulation include the submission procedure, forms of organization and data collection, loss statistical report forms ( of which is the loss summary table), basic report, and indicators. some examples of these indicators are affected people, houses damaged and destroyed, household property loss, agriculture loss, industry loss, service loss, infrastructure loss, loss of public service system, resources and environmental loss, and so on (table . ) . figure . shows the changes in the percentage of direct economic loss accounting for gdp and human mortality caused by disasters in china ( china ( - which wenchuan earthquake data are not included). the overall decreasing trends of the two items demonstrate a good result of comprehensive disaster reduction. compared to the disaster indicators in sendai framework for disaster risk reduction - that incorporates both the human-made and natural disasters, the statistical system can only be applied to natural disasters. in contrast to the emphasis of the latter one on the comprehensiveness, the former one only highlights the key points. another difference between these two is that the latter one includes report of rural residential houses damaged and destroyed b report of urban residential houses damaged and destroyed b report of non-residential houses damaged and destroyed c report of household property loss d report of agriculture loss e report of industry loss f report of service loss g report of infrastructure (transportation) loss g report of infrastructure (communications) loss g report of infrastructure (energy) loss g report of infrastructure (water conservancy) loss amount of materials damaged and destroyed g report of infrastructure (municipal service) loss economic loss g report of infrastructure (living facilities in rural area) loss g report of infrastructure (geological hazard prevention) loss h report of public service (educational system) loss h report of public service (technology system) loss h report of public service (health system) loss h report of public service (culture system) loss h report of public service (media system) loss h report of public service (sports system) loss h report of public service (social security and service system) loss h report of public service (social management system) loss h report of public service (cultural heritage system) loss report of resources and environmental loss amount of materials damaged and destroyed j report of basic indicators the resources and environmental damages caused by natural disasters, while the former one stresses on the effectiveness and quality losses of infrastructure and services caused by disasters. therefore, there are similarities in the disaster indicators of these two regulations, and there are also differences due to social and cultural differences. even though some indicators share the same name in two systems, the actual meanings might be different. in practice, people need to be cautious in choosing the right indicator(s). at present, the classification of disaster grade mainly adopts the standardized division method of disaster risk factors of each disaster, while there is no standard division for multi-hazard classification. the qualitative approach is usually used to classify disaster intensity levels, that is, the use of continuous quantitative or semiquantitative indicators, such as applied multi-risk mapping of natural hazards for impact assessment (armonia) that categorizes a disaster into high, medium, or low level according to its intensity. another example is hazard score proposed by odeh engineers inc. ( ) that takes into account the level, frequency, and percentage of the affected area in the total research area. a higher score means the hazard has a higher intensity. the world natural disaster hotspots identified by the world bank are based on . °Â . °grid cells for risk assessment. in each grid cell, the hazard indexes of all types of hazards occurred are summed to give a score for the determination of hotspots. the hazard index of each type of hazard is established according to the corresponding data. the term very large-scale disaster emerged in the beginning of the twenty-first century. at the end of the twentieth century, a series of disasters happened worldwide and caused great impacts on the human society and economy. for example, hurricane andrew occurred in usa in claimed lives and caused -billion-dollar definition of very large-scale disaster. the chinese word "juzai" appeared in in china for the first time and was used to mistranslate the word "catastrophic disaster" in the western literatures. the appearance of "juzai" in chinese media and academia is closely related to the founding and explanation of the catastrophic disaster insurance funds. according to the statistical data from cnki.com.cn, as of the end of december , there were up to literatures that include "juzai" in the titles. and the number of papers increased annually with the peak of publications in the year . more than half of these papers are related to the catastrophic disaster insurance. due to the frequent occurrences of very large-scale disasters in recent years, the new words such as "juzai prevention," "juzai relief," and "juzai assessment" are becoming more and more widely used in scientific publications. in the chinese academic literatures, it is the author of this book that first introduced the word "dazai" for "large-scale disaster" and "juzai" for "very large-scale disaster" in the western literatures after attending the high level advisory board seminar of financial management of large-scale catastrophes held by oecd in paris in the july (shi et al. (shi et al. , . although a lot of work has been done in the definition and classification of very large-scale disasters, there are no well-recognized definition and classification standards of very large-scale disasters in the fields of academia or finance. different scholars have their own angles. in western literatures, the following definitions have great influences. in the book large-scale disasters-lessons learned published by oecd in , the terms large-scale disasters (or megadisasters) and very large-scale disasters were used, but the specific quantitative criterion was not provided. in oecd's opinion, very large-scale disasters can cause a great number of casualties, property losses, and widespread infrastructure damage. the impacts are so great that governments of the affected area and neighboring regions become unable to cope with; even public panic occurs. oecd also emphasizes the importance of cooperation and assistance among the member countries in response to the very large-scale disasters (oecd ) . in the book large-scale disaster-prediction, control, reduction by mohamed gad-el-hak ( ), disasters are divided into large-scale and very large-scale disasters based upon the disaster scope and death toll ( fig. . ) . a very large-scale disaster is defined as a disaster with the death toll more than , or the affected area over km . the definition of catastrophic disaster is usually based on the scale of the insured property losses by experts on insurance and financial management and development. the insurance services office (iso) of usa defines a catastrophic disaster as an event that causes insured property losses of million dollars or more and affects a significant number of property/casualty policyholders and insurers. swiss re uses losses more than . million us dollars as a standard. from the amount of property losses, it can be seen that the scale of a catastrophic disaster cannot reach that of a large-scale disaster or megadisaster, let alone a very large-scale disaster. this also shows that the term "juzai" mentioned in the chinese literatures in the late s has a scale of the catastrophic disaster and was only paid attention to by experts on insurance and financial management and development. therefore, before the use of large-scale disasters or megadisasters and very large-scale disasters in the western literatures in the early twenty-first century, the term "juzai" in the chinese literatures only refers to a catastrophic disaster. from the angle of geoscientists, very large-scale disasters are usually defined according to the hazard intensity, casualties, property losses, and affected scope. a very large-scale disaster in ma's opinion must reach two of the following criteria: over , deaths, direct economic losses of more than billion chinese yuan of , economic losses of more than the average annual fiscal revenue of the previous three years of a chinese province, drought disaster rate more than %, or flood disaster rate more than %, crop losses of more than % of the average annual crop production of the previous three years of a chinese province, more than , houses collapsed, and livestock death toll of more than million (ma et al. ). shi et al. defines a very large-scale disaster as a great disaster caused by a -year hazard (e.g., a . -magnitude or stronger earthquake) and resulting in a great number of casualties and large and widespread property losses (shi et al. ) . also in shi's definition, the impacts of a very large-scale disaster are so great that the affected area is unable to respond by itself and has to resort to outside help (table . ). according to the classification standard in table . , the very large-scale disasters caused by natural hazards worldwide between and are listed in table . . from table . , we can see that one of the characteristics of the very large-scale disasters is the big hazard intensity. a very large-scale disaster can be a disaster chain composed of a very large hazard and its induced secondary disasters. it can also be a superposition of multiple types of disasters that are triggered by multiple hazards in a specific region and during a specific period of time. besides, very large-scale disasters usually cause a great number of deaths and injuries, a huge amount of property losses, severe impacts on economy, society and natural large-scale . - . (earthquake) or / a- / a - . - . , - , medium-scale . - . (earthquake) or / a- / a - . - . - small-scale below . (earthquake) or below / a . note ( ) for each disaster level, at least two of the four criteria must be met. ( ) death toll includes both the people dead and people missing over month. ( ) direct economic loss is the value of actual disaster-caused property loss of the year. ( ) the affected area is the area where there are casualties, property losses, or damages to ecosystems approx. environment, and a large disaster area. the emergency aids and reconstruction when or after the occurrence of the very large-scale disasters usually need help from a larger region or the whole country. in some cases, even international aids are indispensable. all the very large-scale disasters mentioned so far are caused by sudden hazards. the indicators and classification standards for disasters caused by the accumulation of gradual hazards should be different (zhang et al. ) . however, there are few discussions about the classification standards of gradually generated very large-scale disasters. drought is one of the major natural disasters in both china and the world. since , a number of severe droughts causing great number of casualties and huge property losses have happened in china. for example, more than tens of thousands of people were killed due to the three-year great drought from to . based on the case of drought, we will discuss the classification standard of gradual very large-scale disasters below. we cannot use hazard intensity to measure or to classify very large-scale droughts. this is because the forming process of a drought is very complicated. a drought hazard could be meteorological, or hydrological. it can also be soil drought or socioeconomic drought. the indicators and measurement criteria vary among different types of droughts. the data and studying methods are also different. what's more, there is no linear relationship between the drought intensity and drought losses. and there is no definite relationship between the drought hazards and the formation of drought disasters neither. the impacts of a very large-scale drought disaster can be represented in crop losses and population in need of aids. drought could result in a bad harvest or total crop failure and water shortage for both human beings and livestock. industrial production, urban water supply, and ecological environment could also be affected to varying degrees if a drought lasts for a long time. in the statistical system of damages and losses of natural disasters by prc ministry of civil affairs ( ), the following items are included in the statistics of droughts: affected population, population affected by water shortage, number of livestock affected by water shortage, affected crop area, crop disaster area, total crop failure area, affected grassland area, and population in need of food and water aids. the inclusion of population affected by water shortage and population in need of aids in this statistical system demonstrates the "people-oriented" disaster relief philosophy. in the state-level contingency plan for natural disaster relief by general office of the state council of prc, it is mentioned that when the number of people in need of food and water aids from governments accounts for a certain percentage of the agricultural population or reaches a designated magnitude, the state will initiate emergency response of the corresponding level (table . ). based on the severe droughts in china in table . , five criteria are used to define very large-scale drought disaster, crop disaster ratio, crop disaster area, disaster population, population in need of aids ratio, and direct economic loss (table . ). ( ) indicator explanation. affected crop area is the crop area that has a reduction of more than % of production. crop disaster area is the crop area that has a reduction of more than % of production. crop disaster ratio is the ratio of crop disaster area over affected crop area. population affected is the number of people who suffer from losses caused by natural disasters (including non-permanent residents). disaster population is the population that are affected by the crop disaster. in this table, it is estimated from the crop disaster area and the cultivated area per capita in the disaster province. population in need of aids is the number of people who are directly affected by natural disasters and are in need of food and water supply or medical treatment from the government (including non-permanent residents). population in need of aids ratio is the ratio of population in need of aids to the population affected. direct economic loss is the value of depreciated of the disaster-bearing bodies or the value of the disaster-bearing bodies forfeited. in this table, it is the value of actual property damages of the year when the disaster happened. ( ) the disaster population in events - was estimated from the crop disaster area and the cultivated area per capita in the disaster province. forum are fiscal crises in key economies, structurally high unemployment/ underemployment, water crises, severe income disparity, failure of climate change mitigation and adaptation, greater incidence of extreme weather events (e.g., floods, storms, fires), global governance failure, food crises, failure of a major financial mechanism/institution, and profound political and social instability. it can be seen from the above that, besides the continuing focus on the traditional risks, we need to accelerate the study of response to a series of non-traditional risks. the five categories of risks were not changed in the global risk report , but the number of specific risks was decreased from to (global risk ). in this report, a global risk is an uncertain event or condition, if occurring, which can cause significant negative impact for several countries or industries within the next years. a global trend is a long-term pattern that is currently taking place and that could contribute to amplifying global risks and/or altering the relationship between them (table . ). the global risks landscape was proposed in the global risk report . from the landscape, it can be seen that the risks with the highest impact and likelihood are failure of climate change mitigation and adaptation, water crises, large-scale involuntary migration, fiscal crises, interstate conflict, profound social instability, cyber attacks, and unemployment or underemployment (global risk ). in the global risks interconnections map , the most strongly connected risks are failure of climate change mitigation and adaptation, profound social instability, large-scale involuntary migration, and unemployment or underemployment (global risk ). the davos world economic forum reports involve a wide range of global risks covering the fields of economy, politics, culture, society, and ecology and could be corresponding to the economic development, political development, cultural development, social development, and ecological development proposed by the chinese government, respectively. thus, it can be seen that the risk classification of the world economic forum emphasizes the combination with practice. the risk taxonomy of irgc is from the perspective of hazards, similar to the disaster classification in sect. . . this classification stresses on the causes of risks and thus lacks in combination with practice. however, it pays attention to emerging risks and slow-developing catastrophic risks, including the governance of very large-scale disaster risks. at the same time, it provides the framework for systematic risk assessment and governance. in china, the classification of risks is tightly associated with the security and disaster classifications. for example, the overall national security concept proposed by the chinese government is in a one-to-one correspondence with the global risks in the world economic forum report. in detail, the political security, homeland security, and military security correspond to geopolitical risks; economic and resource security to economic risks; cultural and societal security to societal risks; technology, information, and nuclear security to technological risks; ecological security to environmental risks (xi ) . another example is the four public securities proposed by the chinese government corresponding to five of the six risk categories of irgc, that is, natural disaster of the former corresponds to the natural forces of the latter, accidental disasters to physical risks, public health accidents to chemical and biological risks, and social security incidents to social-communicative hazards. the complex hazards are usually related to the four public securities proposed by the chinese government, and also to the integrated disasters. the classification system of risks is built upon the hazard and disaster classifications in china. for example, if hazards are divided into natural, man-made, and environmental ones, risks can be classified into the corresponding three types. in the same way, risks can also be divided into four categories of natural, accidental, public health, and social security ones based on the four-type classification of hazards. the natural disaster risk level is usually expressed in exceedance probability or return period, the same way as the intensity level of natural hazards. for example, the meteorological, hydrological, and ocean disaster risks can be divided into -year level (small-scale disaster), -year level (medium-scale disaster), -year level (large-scale disaster), and -year level (very large-scale disaster). the earthquake disaster risk level is usually expressed in earthquake magnitude. for example, a magnitude . or above earthquake poses a very large-scale disaster risk, . - . large-scale, . - . medium-scale, and . or below small-scale disaster risks. the natural disaster risk level does not only depend on the natural hazard intensity but also count on the vulnerability and exposure of the hazard-bearing bodies. in practice, the classification of natural disaster risk levels is even more complicated and thus usually resorts to the relative levels such as the first-level risk, the second-level risk, the third-level risk, the fourth-level risk, and the fifth-level risk. the larger the number is, the higher the risk level is. in the atlas of natural disaster risk of china by peijun shi (chinese-english bilingual version, shi ) and the world atlas of natural disaster risk by peijun shi and roger kasperson . risks (shi et al. ) , the temporal and spatial patterns of natural disaster risks of china and the world are displayed by using indicators including risks, risk grades, and risk levels (qin et al. ; shi shi , . it is more difficult to classify man-made and environmental risk levels by using quantitative criteria. a common way is to use relative level, or using the trends and changes of man-made and environmental risks to describe their levels. the global risk trends in the davos world economic forum risk report is an example of this kind of way of reflecting global risk levels. in detail, increasing global risk levels at are aging population, changing landscape of international governance, climate change, environmental degradation, growing middle class in emerging economies, increasing national sentiment, increasing polarization of societies, rise of chronic diseases, rise of cyber dependency, rising geographic mobility, rising incoming and wealth disparity, shifts in power, and urbanization (wef ) . the top three most likely global risks in in each region are reported in the global risk report of wef (wef ) . in north america, the top three are cyber attacks, extreme weather events, and data fraud or theft. in latin america and the caribbean, the top three are failure of national governance, profound social instability, and unemployment/underemployment. in europe, the three are large-scale involuntary migration, unemployment/underemployment, and fiscal crisis. in the middle east and north africa, they are water crises, unemployment/ underemployment, failure of national governance, and profound social instability. in sub-saharan africa, they are failure of national governance, unemployment/ underemployment, and failure of critical infrastructure. in central asia (including russia), they are energy price shock, interstate conflict, and failure of national governance. in east asia and the pacific, they are natural catastrophes, extreme weather events, and failure of national governance. in south asia, the top three are water crises, unemployment/underemployment, and extreme weather events. the exceedance probability mentioned previously, a concept usually used in the study of natural disaster risks, refers to the likelihood of the intensity or motion parameters of an earthquake, or the flood level, or the maximum wind speed at the center of a typhoon exceeding a designated value or values in a specific location and during a certain period of time. in other words, it is the probability of the required value exceeding the given value and can be mathematically expressed as where p exceed is the likelihood of the required value (u) of a data series exceeding the limit value (u limit ). for example, a set of data x (x , x ,…x n ) have n raw data points that are arranged from the lowest to the highest. the exceedance probability of data point x i is p ¼ n À i þ n  % ð : Þ the following takes the earthquake as an example for the calculation of exceedance probability. within t years, the probability of earthquake occurrence for n times p(n) in a region is p n ð Þ ¼ f n ð Þ ð : Þ in the same way, within t years, the likelihood of no earthquake happening in this region is then, the likelihood of at least one earthquake within t years, or the exceedance probability, is the probability density is poisson distribution is widely used in earthquake studies. within t years, the probability p(n) of n earthquakes occurring in a region can be expressed in the poisson distribution form as below: p n ð Þ ¼ e Àu  vt n n! ð : Þ then, within t years, the likelihood of no earthquake happening in this region is p ð Þ ¼ e Àvt  vt ! ¼ e Àvt ð : Þ so the likelihood of at least one earthquake happening or the exceedance probability within t years is f t ð Þ ¼ À p ð Þ ¼ À e Àvt ð : Þ the corresponding probability density is : Þ the variable v mentioned above is the annually averaged occurrence probability of earthquake in a region, which has an inverse relationship with the return period t : from here, we can see that the relationship between the return period t and the exceedance probability f(t) can be expressed as based on the equation above, we can calculate the return periods of different exceedance probabilities for a period of time. for example, the exceedance probability of % for years is equivalent to a -year disaster, % means a -year disaster, and - % means a - -year disaster. in summary, hazards are negative factors to human beings, and the temporal and spatial patterns of hazards can be studied by comparing with historical observed data. disasters are the impacts of hazards on human beings and can be measured in terms of losses and damages. risks are future hazard-induced disasters in a specific location. in short, disaster risk science is a discipline studying the mechanics, processes, and dynamics of the interactions among hazards, disasters, and risks, as well as disaster risk prevention and reduction. the relationships among hazards, disasters, and risks are shown in fig. . . greater incidence of man-made environmental catastrophes (e.g., oil spills failure of climate change mitigation and adaptation geopolitical . global governance failure . political collapse of a nation of geopolitical importance . increasing corruption . major escalation in organized crime and illicit trade . large-scale terrorist attacks . deployment of weapons of mass destruction . violent interstate conflict with regional consequences . escalation of economic and resource nationalization (continued) and sabotage • human violence (criminal activities) • humiliation, mobbing consumer products (chemical, physical, etc • technologies (physical, chemical • large constructions, like buildings, dams, highways, and bridges • critical infrastructures, in terms of physical, economic, social-organizational and communicative severe acute respiratory syndrome (sars) china international decadal commission for disaster reduction china's extreme weather events and disaster risk management and adaptation assessment report gb/t . . natural disaster classification and code notice on the emergency plan for the issuance of natural disaster relief in china beijing: ministry of civil affairs, people's republic of china reviewing and visualizing the interactions of natural hazards regions of risk: a geographical introduction to disasters risk governance: towards an integrative approach. white paper no. , author o. renn with an annex by a research on regional distribution of major natural hazards in china remarks on national security the atlas of natural hazards in china large-scale disaster prediction, control, and mitigation notice on statistical regulations of natural disasters. ministry of civil affairs, people's republic of china notice of "twelfth five-year" special plan on disaster prevention and reduction large-scale disasters -lessons learned theory and practices on disaster science world atlas of natural disaster risk on integrated disaster risk governance: seeking for adaptive strategies for global change on the classification standards of catastrophe and catastrophe insurance: the perspective from wenchuan earthquake and southern freezing rain and snowstorm disaster, china [c]. international integrated disaster prevention and mitigation and sustainable development forum integrated governance of natural disaster risk integrated assessment of large scale natural disasters in china theory on disaster science and disaster dynamics china atlas of natural disaster risk integrated risk governance: ihdp comprehensive risk prevention science program and comprehensive catastrophe risk prevention research integrated risk governance: ihdp integrated scientific plan and integrated catastrophe risk governance research death toll exceeded in europe during the summer of the law on response to emergencies. bulletin of the standing committee of the national people's congress of the people's republic of china terminology on disaster risk reduction disaster risk reduction for sustainable development. guidelines for mainstreaming disaster risk assessment in development. a publication of the united nations' international for disaster reduction integrated research on disaster risk. peril classification and hazard glossary united nations office for disaster risk reduction study on definition and division criteria of a large-scale disaster: analysis of typical disasters in the world in recent years global risks report global risks china's major natural disasters and mitigation measures (overview introduction to natural disasters hunan people's press (in chinese) risk is the probability of disaster loss in a future period of time in a region, or the future disaster. essentially, risk is the probability of occurrence of a future hazardous event and its impacts (loss and/or damage). unisdr ( ) defines risk as the probability of harmful consequences resulting from interactions between natural or human-induced hazards and vulnerable conditions. two aspects that need special attention are the influence of social factors on risk and the estimation of hazard intensity and distribution.disaster risk usually refers to natural disaster or environmental risk that is associated with natural factors. the wide attention which disaster risk receives is related to the disaster (especially catastrophic disaster) insurance and the risk governance of emerging risks and very large-scale disasters.the international risk governance council, founded in in geneva, switzerland, paid high attention to the governance of emerging risk and slow-developing catastrophic risks and also established the transition from risk management to risk governance.in , chinese national committee for the international human dimensions program on global environmental change (cnc-ihdp) proposed to ihdp to undertake the integrated risk governance (irg) research under the background of global environmental change. this international scientific program proposal was approved by the scientific committee of ihdp and launched in (shi et al. key: cord- - pp ra authors: woolard, robert h.; borron, stephen w.; mackay, john m. title: emergency department design date: - - journal: ciottone's disaster medicine doi: . /b - - - - . - sha: doc_id: cord_uid: pp ra nan in the aftermath of terror events and natural disasters with subsequent disaster response planning, hospital architects have begun to design eds to better meet the needs anticipated from a terror attack, flood, or epidemic. some ed design lessons have been learned from disaster events. from the tokyo sarin event, recent natural disasters and epidemic illnesses, and other routine "disasters," such as influenza outbreaks, hospitals know they need to plan for surge capacity. methods of alerting and preparing ed staff early and protecting emergency care providers from contamination and infection are needed, a lesson integrated into current ed staff vaccination requirements and made painfully clear by the tokyo sarin event, in which many emergency providers were contaminated. the boston marathon bombing event illustrated the need to provide emergency and surgical care to mass casualties, requiring coordination of response between hospitals and enhanced field rescue efforts to meet high volume demands over a short time period. in new york after / , the cleanup phase after the event led to prolonged increased prehospital and ed volume. most care was provided by emergency personnel working close to ground zero. from the anthrax mailings in the wake of the world trade center event, planners learned to anticipate the need for accurate public information and increased ed patient volume. from the flooding and evacuation of hospitals and eds, with the needs for medical capacity met at new sites on high ground during katrina, planners relearned the importance of providing care throughout a larger health care system, with each hospital and ed participating uniquely, some evacuating and relocating, and others providing care to surges of relocated and new patients. the ed remains the most available point of access to immediate health care in the united states. ed designers are now anticipating increased volumes of patients that might be generated by a disaster, epidemic, or a terror event. although a stressed public needs information and health screenings that perhaps can be met by providers outside the ed, the ed will be accessed for counseling and screening when other services are overwhelmed, critical information is misunderstood, or delay to access is anticipated or encountered. in most disaster scenarios, shelter needs are provided outside the ed. however, loss of facilities or needs for quarantine of exposed and ill patients during bioterror events and epidemics may create shelter needs proximate to eds. ed design and response capability after / became a larger concern for public disaster planners, the federal government, and hospital architects. two federally funded projects coordinated by emergency physicians, one at washington hospital center (er one) and another at the rhode island disaster initiative (ridi), have developed and released recommendations. er one suggests designs for a new ed that meets any and all anticipated needs of a disaster event. ridi has developed new disaster response paradigms, training scenarios, and response simulations that also can be used in ed design. threat mitigation • self-decontamination surfaces • offset parking away from building footprint • single-room and single-zone modular compartmentalized ventilation systems • % air filtration • assured water supply with internal purification capabilities • blast-protection walls and blast-deflection strategies • elimination or encapsulation of building materials that can shatter during an event • built-in radiation protection • advanced security and intrusion detection technologies an ed design using er one concepts has been constructed at tampa general hospital in florida. after considering highly likely disaster scenarios, specific recommendations were developed and integrated into the tampa ed design. to address surge capacity, the state of florida, the project architects, and hospital administration agreed on an ed that could expand from treatment spaces to within the ed. a parking area beneath the ed was designed to convert to a mass decontamination zone, feeding directly into the ed. the ed observation area was designed to convert into a quarantine unit, with direct access from outside the ed during epidemics. adding these elements to create an ed that is more disaster ready increased the cost of the project by less than %. ed design would be tremendously enhanced if a prototype "disaster-ready" ed demonstrating all the elements of er one could be built. to date no full prototype has been constructed, and it has yet to be shown that ed designers are able to create an "all-hazards-ready" ed, given financial constraints. however, incorporating some disasterready suggestions when eds are built or renovated will improve our readiness and may be more financially feasible. new building materials, technologies, and concepts will continue to inform the effort to prepare eds for terror attack. urban ed trauma centers are attempting to develop the capacity to serve as regional disaster resource centers and the capability for site response to disaster events. these eds are designed to incorporate larger waiting and entrance areas, adjacent units, or nearby parking spaces in their plans to ramp-up treatment capacity. more decontamination and isolation capacity is being built to help control the spread of toxic or infectious agents. information systems are being made available to provide real-time point-of-service information and any needed "just-in-time" training for potential terror threats. an example of better organized disaster information is the co-s-tr model, a tool for hospital incident command that prioritizes action to address key components of surge capacity. there are three major elements in the tool, each with four subelements. "co" stands for command, control, communications, and coordination and ensures that an incident management structure is implemented. "s" considers the logistical requirements for staff, stuff, space, and special (event-specific) considerations. "tr" comprises tracking, triage, treatment, and transportation. having an information system with robust capability to gather and display the detailed information needed in a preformatted and rehearsed mode such as co-s-tr, with easy access by multiple electronic means, including wireless and handheld devices, is an important facility design feature. the technology needed to respond to a terrorist event, such as personal protective equipment (ppe), is becoming more widely available and is stored where it is easily available in eds. although mass decontamination can and in general should occur close to the disaster scene, eds are gearing up to better decontaminate, isolate, and treat individuals or groups contaminated with biologic or chemical materials upon arrival. the tokyo sarin episode demonstrated clearly that contaminated patients will make their way to the ed without waiting for first responders. four elements of ed design are being addressed to prepare eds for terror events: scalability, security, information systems, and decontamination. eds are generally designed with sufficient, but not excess, space. the number of treatment spaces needed in an ed is usually matched to the anticipated ed patient volume; roughly treatment space per annual ed visits or treatment space per annual ed hospital admissions is recommended. according to disaster planners, a major urban trauma center ed built for , to , visits per year should have surge capacity up to patients per hour for hours and patients per day for days. one disaster-ready design challenge is to provide surge capacity to meet anticipated patient needs. hospitals are woefully overcrowded, and eds are routinely housing admitted patients. [ ] [ ] [ ] to maintain surge capacity, efforts to address hospital overcrowding and eliminate the boarding of admissions in the ed must be successful. eds are now being designed to allow growth into adjacent space: a ground level or upper level, a garage, or a parking lot. garage and parking lot space has been used in many disaster drills and mass exposures. garages and parking lots can be designed with separate access to streets, allowing separation of disaster traffic and routine ed traffic. more often, needed terror-response supplies (e.g., antidotes, respirators, personal protective gear) are stored near or within the ed. the cost of ventilation, heat, air conditioning, communication, and security features often prohibits renovation of garages. more often, tents are erected over parking lots or loading areas. modular "second eds," tents or structures with collapsible walls (fold and stack), have been deployed by disaster responders. these can be used near the main ed, preserving the ed for critical cases during a disaster surge. some hospitals are building capacity for beds in halls and double capacity patient rooms, and converting other nontreatment spaces to wards to increase their ability to meet patient surges during disaster. hallways can provide usable space if constructed wider and equipped with medical gases and adequate power and lighting. often only minimal modifications are necessary to make existing halls and lobbies dual-use spaces. some hospitals have increased space by installing retractable awnings on the exterior over ambulance bays or loading docks. tents are often used outside eds as decontamination and treatment areas in disaster drills. tents with inflatable air walls have the added benefit of being insulated for allweather use. in the military, the need to provide treatment in limited space has resulted in the practice of stacking patients vertically to save space and to reduce the distances that personnel walk. u.s. air force air evacuation flights have stacked critical patients three high, and some naval vessels may bunk patients vertically in mass-casualty scenarios. similar bed units could be deployed for a mass event. portable modular units are also available to help eds meet additional space needs. unfortunately, many eds plan to rely on other facilities in the regional system and do not build in surge capacity. during a terror event occurring on a hospital campus, the ed function may need to be moved to a remote area within the hospital in response to a flood, fire, building collapse, bomb or bomb threat, active shooter, or other event. many disaster plans designate a preexisting structure on campus as the "backup" ed. the area is stockpiled with equipment and has a viable plan for access. patient and staff movement are planned and developed during drills. in addition to increasing ed surge capacity, significant off-loading of ed volume can be accomplished by "reverse triage" of inpatients. through such measures as delaying elective admissions and surgeries, early discharge, or interhospital transfer of stable patients, significant improvements in bed capacity can be accomplished within hours. , although the capacity to handle patient surges is being addressed regionally and nationally, large events with high critical care volumes will overtax the system regionally, as was the case during hurricane katrina. the national disaster medical system (ndms) can be mobilized to move excess victims and establish field hospitals during events involving hundreds or thousands of victims. however, there are barriers to a prompt response time in the deployment of ndms resources. the ed plan to provide treatment during disaster must include evacuation, since the event may produce an environmental hazard that contaminates, floods, or renders the ed inaccessible. evacuation of ed patients has been addressed by ed designers. some eds have the capacity to more easily evacuate. in well-planned eds, stairwells have floor lights to assist in darkness. stairways are sufficient in size to allow backboarded and chair-bound patients to be evacuated. ground level eds should have access to surface streets, interior pathways, and exterior sidewalks. the communication and tracking system includes sensors in corridors and stairways. patient records are regularly backed up and stored for web access and hence available during and after evacuation. specially designed ambulance buses allow for the safe transfer of multiple patients of variable acuity to other facilities. securing the function of an ed includes securing essential resources: water, gases, power, ventilation, communication, and information. ed security involves surveillance, control of access and egress, threat mitigation, and "lockdown" capacity. surveillance exists in almost all eds. many ed parking and decontamination areas are monitored by cameras. the wireless tracking system can also be part of the surveillance system. a tracking system can create a virtual geospatial and temporal map of staff and patient movement. tracking systems have been used in disaster drills to identify threat patterns. most eds have identification/access cards and readers. chemical and biologic sensors for explosives, organic solvents, and biologic agents are becoming available, but have not been used in eds. many eds have metal detectors and security checkpoints prior to access by ambulatory patients and visitors. when selecting a sensor, designers consider sensitivity, selectivity, speed of response, and robustness. [ ] [ ] [ ] [ ] [ ] sensor technology is an area of active research that continues to yield new solutions that could be incorporated into ed security. in concept, all entrances could be designed to identify persons using scanning to detect unwanted chemicals, biologic agents, or explosives, allowing detention and decontamination when needed. given the wide array of physicochemical properties of hazardous materials in commerce, developing sensors with sufficient sensitivity to detect threats while avoiding an excess of false positives will remain a challenge. most eds have multiple entry portals for ingress of patients, visitors, staff, vendors, law enforcement personnel, and others. eds are using screening and identification technologies at all entrances in combination with closed-circuit video monitoring. personnel must be dedicated for prompt response when needed. automation of identification can efficiently allow safe flow of patients, staff, and supplies. vehicle access has been managed by bar-coding staff and visitor vehicles. at some road access points, automated scanners could monitor and control vehicle access. modern eds limit the number of entrances and channel pedestrian and vehicular traffic through identification control points. for the most part, points of entrance into the ed can be managed with locking doors, identification badge control points, and surveillance to allow desired access for staff and supplies. thoughtful planning should facilitate rapid access between the functional areas, such as the ed, operating rooms, catheterization suites, and critical care units. movement within and between buildings needs to be controlled and must allow a total lockdown when necessary. direct threats to the ed include blasts; chemical, biologic, and environmental contamination; and active shooting. there are several strategies to mitigate blasts. twelve-inch-thick conventional concrete walls, using commercially available aggregates ( lb per cubic foot), afford reasonable blast protection. , on some campuses, the space between the ed and the entrance is designed largely to prevent direct attack. however, atriums are terror targets. although atriums are useful as overflow areas, their windows and glass can create hazardous flying debris. in general, use of unreinforced glass windows, which help create a more pleasant ed environment, must be balanced against threat of injury from broken glass shards. given the threat of blast attack, communication, gas, electric, water, and other critical services should be remote from vulnerable areas and shielded when they traverse roads and walkways. protection against release of chemical and biologic agents inside or outside the ed requires a protective envelope, controlled air filtration in and out, an air distribution system providing clean pressurized air, a water purification system providing potable water, and a detection system. better hvac systems can pressurize their envelope, keeping contaminants out, and also purge contaminated areas. anticipated computing needs for ed operations during disaster events are immense. in most eds, large amounts of complex and diverse information are routinely available electronically. overflow patients in hallways and adjacent spaces can be managed with mobile computing, which is available in many eds. wireless handheld devices can facilitate preparation for disasters and allow immediate access to information by providers in hallways and decontamination spaces. multiple desktop and mobile workstations are available throughout most eds. during disaster, displays of information that will aid decision making include bed status, the types of rooms available, the number of persons waiting, and ambulances coming in. monitors now display patient vital signs, telemetry, and test results. significant improvements in efficiency and decision making can be achieved when more real-time information is available to decision makers. having available multiple computer screens with preformatted disaster information screens that are regularly used should enhance ed readiness. clinical decision tools and references, such as uptodate, make information readily available to providers. these and other just-in-time resources will be needed when practitioners treat unusual or rare diseases not encountered in routine practice. the wide variety of potential disaster scenarios argues for the availability of just-in-time information. information specific to a disaster event should be broadcast widely on multiple screens in many areas. cellular links and wireless portable devices should also be designed to receive and display disaster information. access to information has been enhanced in most eds through cell phone, texting, and other social media use. developing apps to make local disaster information available through as many media as possible and to guide each staff member should be part of the information system disaster plan. diagnostic decision support systems have been demonstrated to help practitioners recognize symptom complexes that are uncommon or unfamiliar. information systems should be capable of communicating potential terror event information regularly. many eds have log-on systems that require staff to read new information. in a disaster-ready ed, a list of potential threats could be posted daily. however, the utility of computer references or on-call experts is limited by the practitioner's ability to recognize a situation that requires the resource. computer-based patient tracking systems are available for routinely tracking patients in most eds. some computer-based tracking systems have a disaster mode that quickly adapts to a large influx of patients allowing for collation of symptoms, laboratory values, and other pertinent syndromic data. in many regions, eds provide real-time data that serve as a disaster alert surveillance network. routine data obtained on entry are passively collected and transferred to a central point for analysis (usually a health department). in the event of a significant spike in targeted patient symptom complexes, these data can trigger an appropriate disaster response. the capacity for this entry point surveillance should be anticipated and built in to any disaster-ready ed information system. [ ] [ ] [ ] for example, data terminals allowing patients to input data at registration similar to electronic ticketing at airports could passively provide information during a surge, rather than requiring chief complaint and registration data input by staff. this self-service system could add to ed surge capacity. similarly, real-time bed identification, availability, and reservation systems used to assist patient management in some eds could aid ed function during disaster. movement to an inpatient bed is a well-documented choke point recognized nationally during normal hospital operations, and implementing a plan to open access to admissions becomes an issue during disaster. lobby screens can facilitate family access to information during a disaster, displaying information about the event and patient status using coded names to preserve confidentiality. during disasters, family members can be given their family member's coded name and access to screens to query for medical information. computers with internet access that could display public event information are available in patient rooms in some eds. during anthrax mailings, public hysteria taxed the health care system. posttraumatic stress, anxiety, and public concern over possible exposure to a biologic or chemical agent may generate a surge of minor patients at eds. within some eds, lecture halls or media centers are available; they are generally used for teaching conferences but could provide venues for health information and media briefings during disaster. the media are an important source of public information and must be considered when planning disaster response. an adjacent conference area can serve as a media center, where information could be released to the internet and closed-circuit screens could provide more accurate information to allay public concerns and direct the public to appropriate resources and access points for evaluation of potential exposures. poison control centers provide an immediate source of valuable information for hazard communication and risk assessment. notwithstanding the tremendous potential value of computer systems in disaster management, it is important to anticipate and plan for information systems and communications failure. failure of hospital generators, such as occurred in hurricane sandy, will rapidly render computers and landline telephones inoperable. cellular telephone services are often overwhelmed during disasters. the internet appears to be less likely to crash during disasters, due to its redundancy, but hospitals should plan for alternative methods of communication and documentation. many eds have patient decontamination (decon) areas. adequate environmental protection for patients undergoing decon is necessary and includes visual barriers from onlookers, segregation of the sexes, and attention to personal belongings. , in many eds, decon areas are being added to accommodate mass exposures. eds have added or augmented decon facilities. decon areas should have a separate, self-contained drainage system, controlled water temperature, and shielding from environmental hazards. exhaust fans are used to prevent the buildup of toxic off-gassing in these decontamination areas. most importantly, decon facilities should be deployable within minutes of an incident, to avoid secondary contamination of the ed. for most eds, mass decon has been accomplished by using an uncovered parking lot and deploying heated and vented modular tent units. uncovered parking areas adjacent and accessible to the ed have been enabled for disaster response. other eds use high-volume, lowpressure showers mounted on the side of a building. serial showers allow multiple patients to enter at the same entrance and time. however, serial showers do not provide privacy, can be difficult for an ill patient to access, and can lead to contaminated water runoff. also, persons requiring more time may impede flow and reduce the number of patients decontaminated. parallel showers built in advance or set up temporarily in tenting offer greater privacy but require wider space and depth. combined serial and parallel design allows the advantages of each, separating ill patients and increasing the number of simultaneous decontaminations. often built into the ed is another decon room for one or two patients with the following features: outside access; negative pressure exhaust air exchange; water drainage; water recess; seamless floor; impervious, slip-resistant, washable floor, walls, and ceiling; gas appliances; supplied air wall outlets for ppe use; high-input air; intercom; overhead paging; and an anteroom for decon of isolated cases. ppe is routinely used by military and fire departments during events involving hazardous materials. hospitals likewise must be trained for and plan to use these devices and store a reasonable number of protective ensembles (i.e., gloves, suits, and respiratory equipment), usually near the ed decon area. decon areas are built with multiple supplied air outlets for ppe use to optimize safety and maximize work flexibility. powered air purifying respirators (paprs) are used by many hospitals in lieu of air supplied respirators. while providing increased mobility and convenience, their utility is somewhat limited by the requirement for battery power and the need to select an appropriate filtration cartridge. voice-controlled two-way radios facilitate communication among decon staff with receivers in the ed. a nearby changing area is available in some eds. the changing area is laid out to optimize medical monitoring and to ease access to the decon area. [ ] [ ] [ ] [ ] [ ] the need for easily accessible ppe and adequate training and practice in the use of ppe cannot be overemphasized. some capability to isolate and prevent propagation of a potential biologic agent has been designed into most eds. patients who present with undetermined respiratory illnesses are routinely sent to an isolation area. a direct entrance from the exterior to an isolation room is not usually available but has been a recent renovation in some eds. creation of isolation areas poses special design requirements for hvac, cleaning, and security to ensure that infections and infected persons are contained. an isolation area should have compartmentalized air handling with high-efficiency filters providing clean air. [ ] [ ] [ ] [ ] biohazard contamination is particularly difficult to mitigate. keeping the facility "clean" and safe for other patients is an extreme challenge. biologic agents of terrorism or epidemics may resist decontamination attempts. infected patients present a risk to staff. during the severe acute respiratory syndrome (sars) epidemic, singapore built outdoor tent hospitals to supplement their existing decontamination facility. patients were evaluated outside the ed and those with fever were isolated and not allowed to enter the main hospital. this, among other measures, allowed singapore to achieve relatively rapid control over the epidemic. few triage areas and ed rooms have been designed for decontamination. surfaces must be able to withstand repeated decontamination. sealed inlets for gases and plumbing have also been considered. patients who are isolated can be observed with monitoring cameras. some isolation areas include a restroom within their space, which helps restrict patient egress. all ed areas could have more infection control capabilities built in. floor drains have been included in some ed rooms for easier decontamination. infection control is improved using polymer surface coatings that are smooth, nonporous, and tolerant to repeated cleaning, creating a virtually seamless surface that is easy to clean. these coatings can be impregnated with antimicrobial properties, enhancing their biosafe capability. silver-impregnated metal surfaces in sinks, drains, door handles, and other locations can reduce high bacterial content. silverimpregnated metal has demonstrated antimicrobial effects. conventional ventilation systems use % to % outside air during normal operation, thus purging indoor contaminants. air cleaning depends on filtration, ultraviolet irradiation, and purging. hvac design should model demand for adequately clean air and also for isolation of potential contaminants. the disaster-ready ed requires protection from external contaminations as well as contagious patients. a compartmentalized central venting system without recirculation has the ability to remove or contain toxic agents in and around the ed. compartmentalized hvac systems allow for the sealing of zones from each other. more desirable hvac systems electronically shut down sections, use effective filtration, and can clean contaminated air. a compartmentalized system can fail, but it only fails in the zone it is servicing; smaller zones mean smaller areas lost to contamination. these systems are less vulnerable to global failure or spread of contamination. modular mobile hvac units developed for field military applications have been added to existing ed isolation areas for use when needed to create safe air compartments. cost may prohibit addressing issues like building more space or better ventilation, decontamination, and isolation facilities. if added space and facilities are not made more available, many lives may be lost during a disaster event. when funds are scarce, less money is spent for disaster readiness, since all available money is spent to support eds' continuous function day to day. eds in the united states are challenged to provide efficient routine care and board excess admitted patients. however, they must also be designed to handle the consequences of a terror event, epidemic, or natural disaster. these competing functions could result in eds with less financial support to handle routine care. these design efforts could also lead to unnecessary increases in expenditures in anticipation of terror events that never materialize. to the extent that efforts to provide disaster care can be translated into solutions that address other more immediate hospital and ed problems, they will gain support. more access to information systems providing just-in-time training could inform staff not only of terror events but of mundane policy changes and unique patient needs such as bloodless therapy for jehovah's witnesses, etc. better information access could also improve routine ed efficiency and communication with patients and families. hopefully, these rationales will prevail when funds are made available for disaster readiness. decontamination equipment and areas may be used for commercial hazardous materials spills. isolation areas could be more routinely used in an effort to contain suspected contagions, such as influenza. lack of bed capacity in hospitals leads to ed overcrowding. scalable eds may offer temporary solutions in times of overburdened hospital inpatient services. however, when reserve spaces are used to solve other overcapacity problems, those spaces are no longer available for disaster operations. thus, a new facility could "build" the capability of handling large surges of patients into adjacent spaces, only to lose it by filling these spaces with excess patients whenever the hospital is over census, which is a recurrent problem at many medical centers. finally, the next disaster event may be different from those for which responders prepare. the rarity of terror events creates a need for testing and practicing disaster plans, skills, and capacities in drills to maintain current competence. drills may uncover design problems that can then be addressed, but such drills can only prepare emergency personnel for anticipated threats. why pour such resources into building capacity that may never be used or undertake other costly initiatives in anticipation of disaster events? among the lessons learned from past disaster events is the need to develop disaster skills and build a disaster response system from components that are in daily use. systems that are used routinely are more familiar and more likely to be used successfully during disaster events. certainly the surge capacity of a disaster-ready ed could be used for natural disaster response and in disaster drills. the surge space could also be used for over-census times, public health events, immunizations, and health screenings. newly built or renovated eds should have excess capacity by design to serve as a community disaster resource. these capacities could be utilized routinely in response to hospital overcrowding or public service events (such as mass immunization campaigns) and should be deployed and tested regularly in disaster drills to maintain readiness in a post- / world. australian college for emergency medicine functional and space programming designing for emergencies rhode island disaster initiative. improving disaster medicine through research integrating disaster preparedness and surge capacity in emergency facility planning surge capacity concepts for health care facilities: the co-s-tr model for initial incident assessment the tokyo subway sarin attacklessons learned emergency departments and crowding in us teaching hospitals trends in emergency department utilization do admitted patients held in the emergency department impact the throughput of treat-andrelease patients? using 'reverse triage' to create hospital surge capacity: royal darwin hospital's response to the ashmore reef disaster creation of surge capacity by early discharge of hospitalized patients at low risk for untoward events inglesby systemic collapse: medical care in the aftermath of hurricane katrina physical security equipment action group (pseag) interior/exterior intrusion and chemical/biological detection systems/sensors computational methods for the analysis of chemical sensor array data from volatile analytes electrochemical detection in bioanalysis array-based vapor sensing using chemically sensitive, carbon black-polymer resistors nadel ba. designing for security putting clinical information into practice emergency department and walk-in center surveillance for bioterrorism: utility for influenza surveillance iceid syndromic surveillance for bioterrorism policewomen win settlement. seattle times fire department response to biological threat at b'nai b'rith headquarters chemically contaminated patient annex (ccpa): hospital emergency operations planning guide emergency department hazardous materials protocol for contaminated patients centers for disease control and prevention. cdc recommendations for civilian communities near chemical weapons depots. occupational safety and health administration. hospitals and community emergency response: what you need to know weapons of mass destruction events with contaminated casualties: effective planning for health care facilities outline of hospital organization for a chemical warfare attack guidelines for design and construction of hospitals and healthcare facilities. philadelphia: the american institute of architects academy of architecture for health emergency response guidebook: a guidebook for first responders during the initial phase of a dangerous goods-hazardous materials incident department of health and human services. metropolitan medical response system's field operation guide volume i-emergency medical services: a planning guide for the management of contaminated patients. agency for toxic substances and disease registry infectious diseases epidemiology and surveillance. australia: victoria guidelines for design and construction of hospital and health care facilities sars: experience from the emergency department, tan tock seng hospital chemically contaminated patient annex: hospital emergency operations planning guide silver-nylon: a new antimicrobial agent filtration of airborne microorganisms: modeling and prediction. available at: ashrae transactions key: cord- -ysyz grd authors: kim, soo jin; kim, chu hyun; shin, sang do; lee, seung chul; park, ju ok; sung, joohon title: incidence and mortality rates of disasters and mass casualty incidents in korea: a population-based cross-sectional study, - date: - - journal: j korean med sci doi: . /jkms. . . . sha: doc_id: cord_uid: ysyz grd the objective of study was to evaluate the incidence and mortality rates of disasters and mass casualty incidents (mcis) over the past yr in the administrative system of korea administrative system and to examine their relationship with population characteristics. this was a population-based cross-sectional study. we calculated the nationwide incidence, as well as the crude mortality and injury incidence rates, of disasters and mcis. the data were collected from the administrative database of the national emergency management agency (nema) and from provincial fire departments from january to december . a total of , events were collected from the nema administrative database. of these events, and , cases were defined as disasters and mcis that occurred in korea, respectively. the incidence of technical disasters/mcis was approximately . times greater than that of natural disasters/mcis. over the past yr, the crude mortality rates for disasters and mcis were . deaths per , persons and . deaths per , persons, respectively. the crude injury incidence rates for disasters and mcis were . injuries per , persons and injuries per , persons, respectively. the incidence and mortality of disasters/mcis in korea seem to be low compared to that of trend around the world. disasters can be defined as rapid or emerging incidents that require excessive resources, or more resources than are available in a local area when natural or technical dangers are present ( ) ( ) ( ) ( ) . the term mass casualty incident (mci) refers to disasters that involve many people ( , ) . mcis occur in many different contexts, including car crashes, chemical leaks, building collapses, fires, terrorism events, and mass gatherings ( , ) . the frequency of disasters and mcis is increasing, and calamities always involve mass casualties because they are unpredictable. from to , according to a un report, the world witnessed over , deaths and million people wounded each year due to disasters ( ) . an estimated loss of u$ billion occurred due to natural disasters in the s ( , ) . disasters and mcis consume local resources in the short and long term, and therefore, appropriate preparation is required to avoid high death and failure rates in such cases ( , ) . disaster and mci-related research in korea has mostly focused on the establishment of a national disaster management system ( ) , the role of disaster management agencies ( ) , database (db) building for disaster prevention ( ) , and descriptive studies on post-disaster stress management ( ) , post-traumatic stress disorder (ptsd) ( ) , hospital disaster ( ) , incidents at mass gatherings and sporting events and building collapses ( , ) . according to statistics report over the 's ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , natural disasters/mcis such as storms and floods have caused an annual average of people dead or missing, , refugees and property losses of over billion won (krw) ( ) . in the same period technical disasters/mcis such as train derailments, plane crashes, bridge collapses, fires aboard liners, city gas explosions and building collapses cause tens to http://dx.doi.org/ . /jkms. . . . hundreds of victims. in the s, mcis such as the daegu subway fire and the mt hebei spirit oil spill raised issues of the physical health of local residents and volunteers ( ) . however, it is difficult to compare and evaluate korean cases with those from other parts of world because there is no research that presents an epidemiologic indicator for annual disaster-and mci-related events; thus, we lack the basis for practical evaluation. the aim of this study was to calculate the incidence, mortality and overall rates of disasters and mcis and to examine their relationship with population characteristics, using health-related indicators to facilitate future comparison of disasters and mcis between domestic and foreign cases. south korea covers an area of approximately , km and has a population of just over million people. korea, based on act no. (march . ) the framework act on the management of disaster and safety, adopts mixed model between civil defence model and emergency medical treatment priority system as disaster policy, in which administration security department carries out a key role ( ). disaster management system of korea consists of the central safety management committee, headed by the prime minister and subcommittees headed by the ministers of various government ministries. the central safety management committee supervises and coordinates overall policy related to disaster and safety, and also promotes negotiations and coordination among the relevant ministries. the subcommittees help ensure the seamless operation of the central committee, especially, the coordination committee under the minister of public administration and security, is in charge of the overall process of negotiations and coordination with regard to tasks delegated by the central committee. the national emergency management agency (nema) provides emergency medical service (ems) to korea and plays a key role in the response to disasters and mcis in most communities. a single-tiered fire-based ems handles disasters and mcis occurring throughout the entire korean region and includes regional headquarters of the fire department with a total of , advanced ambulances and , ems providers. in addition, headed by the administrator of the nema, operates the central emergency rescue control team to supervise and control matters related to emergency rescue, command, and control at the disaster site. we aimed to calculate the incidence, mortality and overall rates of disasters and mcis and to examine their relationship with population characteristics, using health-related indicators based on disaster/mci database of nema to facilitate future compari-son of disasters and mcis between domestic and foreign cases. this study was a population-based cross-sectional study based on nema administrative data from to . the centre for research on the epidemiology of disasters (cr-ed), which is an international epidemiological disaster research institution, has defined a disaster as a case in which more than deaths are reported, more than people are affected, a national emergency has been declared, or international assistance has been requested ( ). the centers for disease control (cdc) in the united states (us) has defined an mci as a case in which more than casualties have occurred ( ) . thirty papers were reviewed by searching medline and the cochrane library prior to conducting expert interviews to create a definition for both disasters and mcis that would fit the situation of korea. a number of the aforementioned survey papers and classroom presentations on various definitions of disasters and mcis were introduced in further expert interviews with instructors who had finished the national disaster life support (ndls) course, a disaster emergency medical expert training program. the classic delphi method was used to conduct the first survey via e-mail with experts who are instructors of the ndls course, and the policy delphi survey ( ) was undertaken as a secondary survey after presenting the results of the first survey to interview subjects so that they could collect ideas and suggestions. on the basis of these discussions, a disaster has been defined for korea as an incident that affects more than one municipal local governing district, involves the death of more than people, or involves more than casualties. an mci has been defined as an incident that involves more than casualties, regardless of the affected area or number of deaths. with regard to the credibility of the representative data, the study employed data for to taken from the nema administrative database to analyze the major disaster and mci types in korea. this database includes all official records of disasters that have occurred in korea information from the statistics korea website (http://kosis.kr/feature/feature_ list.jsp?me-nuid = all&mode = listall) was used to present other social statistics, such as population and size of korea. people who were killed or injured in korean disasters or mcis who were registered in the nema administrative database for the period from to were selected as study subjects. we collected study data in two steps: first, we collected the 'daily accidental management situation report' , which inhttp://dx.doi.org/ . /jkms. . . . cludes daily incidents, and is sorted by severity. the 'daily accidental management situation report' can be downloaded from the home page of nema (www.nema.go.kr) and is prepared by the nema disaster status control center. next, we collected and analyzed internal nema reports, referred to as 'accidental status reports' , which notify the relevant teams within nema (e.g., fire investigation, rescue and ems) about major incidents (appendix - ). these reports were made available for this study through the cooperation of nema. using the daily accidental management situation reports, all nema disaster reports from the korean provinces were coded and entered into an electronic database. using the accidental status reports, more detailed information was coded and added to this database. finally, the cases that met the defined category of disasters and mcis for this study were extracted to establish the final dataset. the final dataset for this study is the result of the reconstructed database of reports from regional fire department headquarters within nema from january to december . the extracted variables were the dates of the disaster, the address, the disaster type, the number of casualties, the estimated financial loss, the mobilized manpower, the victims' gender, age and major symptoms, the location of the fire (if the event was a fire), the type of collision (if the event was a car crash), and the number of mobilized ambulances (table ) . statistical analysis sas version . was used as the statistical analysis tool. the primary outcome was analyzed using a descriptive analysis to calculate the incidence, crude mortality rates and crude injury incidence rates of disasters and mcis for each year, using central populations from the ministry of statistics. the secondary outcome was the assessment of the incidence trends of disasters/ mcis by time-series and by type and calculation of the number of deaths and casualties by disaster/mci type, the number of deaths and crude death rates by province, and the number of injuries and crude injury incidence rates by province. we collected , events from the nema administrative database, covering the period from january to december . of these, and , were defined, respectively, as disasters and mcis that occurred in korea. there were , ( . %) cases of disasters and mcis in rural areas, which is approximately . times greater than the ( . %) cases that occurred in urban areas. the incidence of technical disasters/mcis was approximately . times greater than that of natural disasters/ mcis ( , cases vs cases). with regard to both disasters and mcis, transportation crashes were the most common cases. in an analysis of the seasonal factors, both disasters and mcis occurred more frequently in the summer (june-august) and the winter (november-february). with respect to the provincial factor, the gyeonggi province showed the highest frequency of disasters ( cases, . %) and mcis ( cases, . %), followed by seoul with cases ( . %) of disasters and cases of mcis ( . %) and gyeongnam with cases ( . %) of disasters and cases of mcis ( . %) ( table ) . from to , both disasters and mcis showed a tendency to increase in number over time, but there is no significant time trend, although the frequency of incidents and the number of casualties were directly proportional in mcis (fig. , ) . as for natural factors, general floods were the most common type of disaster and mci with cases ( . %), followed by flash floods with cases ( . %) and tropical cyclones with cases ( . %). the number and the frequency of injuries and deaths were on the same order. for disasters only, general floods were the most common type ( cases, . %), followed by tropical cyclones ( cases, . %) and flash floods ( cases, . %). the number and frequency of injuries and deaths were on the same order. for mcis, the number and frequency of occurrence and the number of injuries and deaths were the same as those of the total ( table ) . as for technical factors, road crashes were the most common type of disaster and mci with , cases ( . %), followed by fire with cases ( . %) and others incidents such as isolations of closed space, escalator incident, rippling incident, leisure place incident with cases ( . %). the number and the frequency of affected and deaths were on the different order for disaster and mci. for affected victims of disaster only, road crashes were the most common type ( , persons, . %), followed by mass gatherings ( , persons, . %), fires ( persons, . %). for dead victims of disaster, fires were most common type ( persons, . %), followed by road crashes table ) . the crude mortality rates for disasters and mcis nationwide were . per , people and . per , people, respectively. the crude injury incidence rates per , people for disasters and mcis nationwide were . and , respec-tively (table ) . for disasters by province, ulsan showed the highest injury incidence rate ( . per , ), followed by jeonnam ( . ) and gangwon ( . ). for mcis, the rate for gangwon was . per , people, followed by jeju ( . ) and jeonnam ( . ) . most research undertaken in the early and mid- th century focused on the definition of disaster, epidemiologic studies and research methodology. subsequent research by the world health organization (who) and cred was mostly focused on natural disasters, such as earthquakes, floods, high winds, tornados, and heat waves, comparing the causes of disasters between countries and continents and measuring the economic losses, mortality, injuries and suffering incurred by these events ( , , , , ) . previous research carried out in the us, britain, and spain dealt only with natural disasters, mcis, and major incidents ( , , ) . spain showed a linear increase in the incidence of disasters over a -yr period , % of which were natural and % technical ( ) . most disasters showed a mixed pattern. for disaster types, flood was the most common ( . %), followed by air crashes ( . %). with regard to the effects of technical disasters, transit crashes showed the highest death rates ( . %). for transit crashes, land-based events were the most common ( . %), followed by air ( . %) and sea ( . %), results that were significantly different from those of korea. in britain, major incidents documented in research papers over a -yr period were analyzed to calculate the incidence rate; the results indicated a rate of to incidents per year with a total of incidents (range - ) ( , ) . there were cases ( . %) of public transportation crashes, cases of civil disturbance ( . %), and cases of industrial incidents ( . %). these results were similar to those for mcis in our study. in our study, disasters and mcis were analyzed to calculate the national and regional statistics for the incidence, crude mortality, crude injury, and characteristics of each disaster type using the nema database, which includes all major incidents and accidentals, to increase the credibility and sensitivity of the study and decrease the selection bias. we reconstructed our database from nema reports to verify the special characteristics of disasters and mcis in korea. furthermore, in our study, both disasters and mcis were analyzed to show the incidence frequency, the number of incidents for each incident type, and the number of injuries and deaths by time-series. in previous research, traffic crashes, residential fires and violence were reported as the leading causes of mci ( ) . however, the leading causes for disasters in korea were road crashes, general floods, incidents at mass gatherings, and fires. the leading causes for mcis were road crashes, fires, and general floods. nema has two separate lines of work, fire-based tasks and mitigation-based tasks, and it focuses only on prevention, rapid response and mitigation to minimize disaster damage with a minimum expenditure of resources. thus, there is no efficient connection and cooperation with the ministry of health and welfare, which handles the public health sector. a disaster management plan for public health is warranted to properly analyze and present the characteristics of disasters/mcis, thus enabling preparations for each region, mitigating damages, and monitoring trends in disasters/mcis. nema and the ministry of health and welfare need to establish a system for cooperation on disaster management and epidemiologic investigation of the disasters/mcis using a predetermined standard. in this regard, this study may have significant value if it is used to compare domestic cases with those in foreign countries. furthermore, a set of standards needs to be established for epidemiologic research on disasters/mcis, along with a web-based registry system to maintain and update research results and a monitoring system for measuring the impact of disasters/mcis. there are certain limitations to this study due to the nature of the information available in the administrative database. first, the nema administrative data were not fully computerized, and they may not contain sufficiently meaningful variables for an epidemiologic survey. therefore, many of the variables that could have been used in the discussion of disasters and mcis were not included in the study, and only some of the extracted variables were used to calculate the indicators for epidemiologic assessment using a descriptive method. second, even though this study was a retrospective observational study, the environmental exposure at the time of each incident could not be found due to the characteristics of the administrative data. the cause-effect relationship between disasters/mcis and exposure of the disasters/mcis related environment to risks could not be determined, and thus, this result could not be analyzed. third, some of the administrative data were duplicated or may have been overlooked because when the incident occurred on the boundary of two provinces, such data were excluded from the study. fourth, the data source used in this study was the administrative data prepared for immediate incident reports, and these data may not be suitable for monitoring or for the establishment of a long-term database. finally, administrative data from all provinces were used in our analysis, but the number of incidents and casualties may have been underestimated. in addition, the data reported to nema for early and mid- did not contain data on mcis and biological disasters such as severe acute respiratory syndrome (sars) and avian influenza, which may have contributed to an underestimation of the number of incidents. in conclusion, from january to december , disasters and , mcis occurred in korea. technical disasters/ mcis occurred more frequently than natural disasters/mcis. there was no significant trend in the time-series regarding the numbers of disasters and mcis. with regard to the type of disaster, the most common types were road crashes, general http://dx.doi.org/ . /jkms. . . . floods, and mass gathering incidents. for mcis, the most common types were road crashes, fires, and general floods. floods and transportation crashes were the main causes of natural and technical disasters/mcis, respectively. the crude death rates per , people for disasters and mcis were . and . , respectively. the crude injury incidence rates per , people for disasters and mcis were . and , respectively. we established a nation-wide administrative ems-reported disaster and mci database that includes yr of data. the incidence and mortality of disasters/mcis in korea seem to be lower compared to that of trend around the world. these data can be used to determine the optimal response plan for disaster and mcis in korea. further study will be needed for disaster and mci data base computerization to monitor incidents and to establish preparedness and early warning systems. three decades of disasters: a review of disaster-specific literature from - trends in disasters in spain and their impact on public health disaster epidemiology: prudent public health practice in the pacific islands methodological challenges and contributions in disaster epidemiology definition and classification of disasters: introduction of a disaster severity scale the definition and classification of disasters analysis of multiple casualty incidents -a prospective cohort study major incidents in britain over the past years: the case for the centralised reporting of major incidents world disaster report: international federation of the red cross and the red crescent societies centre for research on the epidemiology of disasters. annual statistical review: numbers and trends cred: brussels order in chaos: modelling medical management in disasters an information fusion-based disaster information system framework building the governance system for the effective disaster management of local government: focusing buchon city a study of the extraction algorithm of the disaster sign data from web posttraumatic stress responses of taean residents: focused on a regional comparison at two and eight months after the disaster crisis intervention models: a comparison of six models for improving mental health of disaster victims analysis of hospital disaster in south korea from to a survey of human injury and crowd packing in mass gathering insjury type in sampung collapse an annual report of disaster biomarker responses in pelagic and benthic fish over year following the hebei spirit oil spill emergency preparedness and response building consensus using the policy delphi method disaster epidemiology: or why most international disaster relief is ineffective task force on quality control of disaster management; world association for disaster and emergency medicine; nordic society for disaster medicine. health disaster management: guidelines for evaluation and research in the utstein style: volume i. conceptual framework of disasters overview of deaths associated with natural events mortality from flash floods: a review of national weather service reports appendix . incident report criteria of nema* (article in fire basic act no. ) fire which belongs to one of the following criteria a. fire with more than deaths or casualties b. fire with more than people affected c. fire with financial loss of more than billion won fire at government buildings, schools, rice-polishing mill, cultural assets, subways, or underground tunnel e. fire at tourist hotel, building with more than stories, underground shopping street, market, department store, manufacturer/storage/station of dangerous materials which are more than , times of standard, accommodations with more than stories or guest rooms, hospital with more than stories or patient rooms, mental institution, oriental-medicine hospital, nursing home fire at train, ship heavier than , tons, aircraft, power plant, or power transforming station disaster which is otherwise selected by administrator of nema (amended on appendix . nema* directive for fire investigation and incident report emergency incident report) fire chief or fire commissioner shall report to the administrator of nema for the following incidents during investigation ) . major fire a. fire at public buildings and facilities such as government buildings, schools, rice-polishing mill, cultural assets, subways, or underground tunnel b. fire at tourist hotel, high-rise building, underground shopping street, market, department store, manufacturer/storage/station of dangerous materials, fire-vulnerable subjects, and fire in fire alert area fires a. fire at train, ship stationed at seaport, aircraft, power plant, or power transforming station b. special incident, fire with special cause (e.g. arson) c. fire at foreign embassy and residence d fires and incidents involving other important national establishments or special fire which may draw public attention and broadcasting by media is expected * seriously wounded people can be considered as death and used to decide whether to report we are grateful to the national emergency management agency for their cooperation in providing the data. any opinions, findings, conclusions, and recommendations are those of the authors and do not represent the official views of nema in korea. the authors have no conflicts of interest to disclose. appendix . incident report criteria of nema* dispatch center a. incident report criteria for the administrator of nema* a. human damage or damage is expected -incident with more than deaths or casualties -incident with affected people and more # incident which requires rescue operation/ems service b. fires -vulnerable subjects: large-scale fire at bazaar market or other places -publicly used establishments: deaths or more / casualties or more • general fire - deaths or more ( casualties = death) -financial loss of more than million won (krw) / when the second damage is expected c. security accidental: explosion, collapse, large-scale car crashes -damage at major establishments, theater, auditorium -when rapid rescue/ems are required # deaths or more / casualties or more d. earthquake (tsunami) -over . (inland)/over . (coast) -when warning or alert for tsunami is issued e. mountain fire, others -in case of mountain fire: when fire spread is expected / when residential or human damage are expected -opening of water gate at dam near border, mountain fires, etc. key: cord- -ie xisg authors: zhong, shuang; clark, michele; hou, xiang-yu; zang, yuli; fitzgerald, gerard title: progress and challenges of disaster health management in china: a scoping review date: - - journal: glob health action doi: . /gha.v . sha: doc_id: cord_uid: ie xisg background: despite the importance of an effective health system response to various disasters, relevant research is still in its infancy, especially in middle- and low-income countries. objective: this paper provides an overview of the status of disaster health management in china, with its aim to promote the effectiveness of the health response for reducing disaster-related mortality and morbidity. design: a scoping review method was used to address the recent progress of and challenges to disaster health management in china. major health electronic databases were searched to identify english and chinese literature that were relevant to the research aims. results: the review found that since considerable progress has been achieved in the health disaster response system in china. however, there remain challenges that hinder effective health disaster responses, including low standards of disaster-resistant infrastructure safety, the lack of specific disaster plans, poor emergency coordination between hospitals, lack of portable diagnostic equipment and underdeveloped triage skills, surge capacity, and psychological interventions. additional challenges include the fragmentation of the emergency health service system, a lack of specific legislation for emergencies, disparities in the distribution of funding, and inadequate cost-effective considerations for disaster rescue. conclusions: one solution identified to address these challenges appears to be through corresponding policy strategies at multiple levels (e.g. community, hospital, and healthcare system level). d isaster health management is fast becoming a unique specialty around the world, with its governing theories and principles ( ) . essential phases of disaster management to improve the effectiveness of the disaster health response have made use of the 'pprr' continuum of prevention and mitigation (p), preparation and planning (p), response and relief (r), and recovery (r) ( , ) . the ultimate goal of disaster health management is to reduce the impact of disasters on human health and wellbeing by providing urgent health interventions and ongoing health care during and after disasters ( , ) . during a disaster, the healthcare system becomes a high profile element, critical to the immediate health response and recovery phase. the system itself can be impacted directly by the consequences of the disaster while at the same time being expected to have the capacity to respond to the sudden increase in the demand associated with the disasters ( , ) . the system, because it provides continuous health care, can be viewed as community infrastructure essential to the life-preserving front-line response ( ) . most of the extant research has occurred in high-income countries, such as the united states of america and has focused on the health system's disaster management (disaster health management), or the capability to supply medical services during disasters ( , , , ) . however, there is little available information from low-and middle-income countries ( ) . china, one such country, has been severely affected by multiple kinds of disasters including natural and manmade disasters and pandemics of infectious diseases ( , ) . to date, disaster management research into the health system in mainland china is in its infancy. while many studies in the chinese language have been published in national medical journals, they often lack scientific rigor (e.g. inappropriate study design, and the lack of empirical data). only a small number of investigators have published their studies in peer-reviewed international journals. moreover, few studies have evaluated the effectiveness of the current disaster arrangements. thus, there is an opportunity for researchers to share china's experience with international communities about the impact that disasters have on the health response systems. hence, it is essential to identify the full extent of the challenges that confront china in order to gain an understanding of those areas that require policy improvement and to assist in identifying strategies into the future. these challenges can also be used to benchmark with some high-income countries (e.g. the united states) to identify any gaps and priorities for improving disaster health management strategies. this paper aims to provide an overview of the status of disaster health management in china. it has several objectives: ) to identify the progress or current status of disaster management of the healthcare system in china; ) to identify current challenges; ) to discuss future strategies to overcome these challenges; and ) to identify future research directions. the 'pprr' disaster management continuum can be used to identify the progress and the challenges within each management phase. then corresponding strategies are proposed to promote the overall effectiveness of the health system response during and after major disasters and to reduce disaster-related mortality and morbidity by providing continuous healthcare. the aim of this review was to provide an overview of the extent of the challenges of disaster management rather than to undertake an in-depth assessment of individual studies. for this reason, we conducted a scoping review rather than a systematic review. the aim of the scoping review was to rapidly map the key concepts underpinning the research area using the main sources and types of evidence available ( ) . a scoping review can be used to address topics that are too broad for a systematic review, or have not been previously reviewed comprehensively ( ) . although we did not use meta-analysis (an approach commonly used for systematic reviews), systematic review methods were used where possible to minimize bias in the identification and inclusion of the studies ( ) . the 'pprr' continuum offered a preliminary framework which was used as a guide to identify the progress and challenges of disaster health management. the major health electronic databases including pro-quest, pubmed, ebsco, sciencedirect, web of science, and the chinese biomedical literature database were searched to identify publications such as public reports and peer-reviewed journal articles, which were relevant to the research aims. the search terms and their logical relation (e.g. and) were: 'disaster or emergency' and 'medical or health or hospital' and 'management or preparedness or response'. additional references were identified through an examination of the references from recent pertinent publications (snowballing) and through scrutiny of the contents pages of highly relevant journals for the previous years. the research inclusion criteria were: ) journal articles, governmental and institutional reports written in english or chinese in the past two decades; ) studies comprising relevant evaluations of the status or description of the progress and challenges of disaster management (i.e. disaster prevention, preparedness, responsiveness, and recovery) of the healthcare system in china; and ) other jurisdictions that had direct relevance to disaster health management in china (e.g. disaster healthcare management, disaster medical responses, emergency medical care, and emergency healthcare systems). the research exclusion criteria were: ) studies that only focused on disaster management of specific healthcare systems of other countries, without any implications to china; and ) studies with no detailed evaluations or descriptions that could assist in informing the identification or description of the progress and challenges of disaster health management in china. the article titles were scanned by two reviewers independently for relevance to the research aims; then the abstracts were appraised for relevance, significance, and utility. next, the full text format was retrieved for the remaining publications and analyzed in relation to their contributions to two areas: the identification of the main progress and challenges of disaster health management in china and the description of such progress and challenges. initially, a total of potentially eligible publications were retrieved. of these, were excluded through the screening of their titles and abstracts. after scanning the full text of the remaining publications, relevant publications were identified as potentially relevant to the current study; they included governmental and institutional reports and journal articles written in english or chinese. after an analysis of these publications, all were assessed as relevant to the study's aims, and thus were included in the review. over the past decade, china has witnessed a series of major disasters. as a consequence the ability of the health shuang zhong et al. system to respond to disasters has improved significantly. many of the resultant changes that have occurred stem from the lessons learned from these disasters and were implemented in an attempt to better respond to disasters in the future. first, in response to the sars crisis, the government acted to improve the prevention and management of infectious diseases. these initiatives included the establishment of a national infectious disease surveillance system and independent infectious disease hospitals; improved isolation facilities in emergency departments (ed); the upgrading of the isolation wards; improved training and monitoring of hospital staff in infection-control procedures; and improved compliance with the use of personal protection equipment ( Á ). a national integrated emergency response system has also been developed and promoted. china's national committee for disaster reduction (ncdr) was established in as the state inter-agency coordination body. it comprises ministries and departments, as well as military agencies and social groups ( ). the integrated system seeks to ensure the effective management of resources and rescue personnel from different facilities throughout china ( ) . in addition, there has been an integration of military medical resources into the disaster management system. the army hospitals have advantages that include: intrinsic infrastructure, well-trained staff, modern equipment, and communications and transportation systems ( , ) . in , china began establishing medical emergency teams across the country to respond to different disasters ( ) . many of these teams can be deployed from military hospitals. army hospitals are fully equipped with portable medical equipment and independent living supplies, so that they do not need to use local supplies ( , ) . they provide healthcare services by establishing temporary field hospitals, accepting and transferring patients, or providing expert rescue teams onsite ( , ) . despite this progress, there remain challenges that hinder efficient disaster health management in china. such challenges have been caused mainly because china is still in the early stages of health disaster management development ( ) . these challenges were identified and extracted from the literature and described in detail below. health infrastructure safety the world conference on disaster reduction endorsed a number of policies to ensure that 'all new hospitals are built with a level of resilience that strengthens their capacity to remain functional in disaster situations' ( , ) . disaster-resilient infrastructure is a primary guarantee for health care organizations to maintain their functions during disasters; they achieve this outcome through their ability to resist and absorb disaster impacts on physical facilities. resilient infrastructure includes not only physical strength but also back-up for the systems. however, no standard has been endorsed or enforced to ensure that healthcare facilities can resist natural disasters. in addition, back-up systems (e.g. electricity, water, and communication) were not fully considered when many hospitals were being built. for example the health facilities in the earthquake-prone areas of western and rural china rarely comply with the standards of construction, nor are their back-up systems required to resist natural disasters ( ) . the sichuan earthquake caused the collapse of . % of healthcare buildings in the worst affected areas ( ) . as a consequence, a large proportion of the county hospitals were destroyed or lost their critical systems. it is also noted that a number of the township hospitals and village clinics required temporary facilities to support their ongoing roles ( ) . thus, in china, the low standard of disaster-resilient infrastructure is the first challenge to efficient disaster response ( ) . an effective disaster response can be achieved only through sufficient preparedness before the occurrence of any disaster ( ) . however, several studies based on hospital evaluation surveys have revealed that china is still in the early stages of developing hospital emergency preparedness ( , , ) . in many provinces, hospitals were found not to have specific disaster plans for natural disasters that have a low frequency of occurrence (e.g. earthquakes and floods), novel infectious diseases, or terrorism attacks (particularly biological, nuclear, and radiation attacks) ( , , ) . moreover, the health facilities in many regions have a low level of essential preparedness in relation to disaster vulnerability analysis, disaster stockpiles, coordination with other institutions, emergency training in disaster first-aid, rescue, and the use of specialized supplies ( , , , ) . western and rural area hospitals are even less prepared, having lower proportions of these essential preparedness aspects ( , , ) . the availability of medical devices and equipment, especially the miniaturization and portability of medical devices, are crucial for the initial disaster medical response, as well as for onsite rescue ( ) . for instance, portable kidney doppler ultrasonography devices are effective for initial diagnoses and triage during mass casualty disasters ( ) . however, there are still inadequate portable medical devices in china. as happened during the wenchuan earthquake, an enormous amount of hospital equipment was unavailable in the hardest hit areas, with the larger equipment not being appropriate for onsite triage and treatment. further, during this event, most of the rescue teams were not prepared; they did not have portable radiography machines or ultrasonography facilities ( ) . such inadequacy may impede the ability of the rescue teams to provide first-line medical treatment during future natural disasters ( ) . emergency supplies are also an essential component of hospital disaster preparedness ( ) . while one study recently found that more than % of tertiary hospitals in the shandong province had stockpiles of emergency supplies (e.g. medicine, food, water, stretcher, and tourniquet), only a small number ( . %) of hospitals had signed a memorandum of understanding with other regional hospitals to share these supplies during disasters ( ) . disaster medical response capability a rapid and effective medical response by the local health services can be seen as the front-line of rescue efforts. this response is critical for facilitating the process of field triage, transport, and transfer ( ) . consideration of these factors assists the rational allocation of healthcare resources during disasters. currently, several crucial aspects for an effective health response are inadequate. the establishment of the triage criteria, based on the severity of the disaster and the availability of the health resources, is central to improving healthcare capacity during disasters ( , ) . a simple triage and rapid treatment (start) method was established after the wenchuan earthquake to facilitate site triage and injury classification ( ) . however, no standard triage procedure or guidelines have been fully adopted in china. instead, most hospitals have adopted disaster triage procedures from the general procedures used in ed ( , ) . the skills of the emergency staff in disaster management such as disaster triage skills were also found to be wanting, mainly due to the lack of targeted and appropriate disaster education and training programs. for example, the literature revealed that a large proportion of doctors had not received any formal training in triage, effectively relying on their own judgment which might cause bias, a delay in treatment or even waste scarce resources ( , ) . in addition, medical students also failed to receive appropriate disaster training. they acquire their training and skills in the inpatient wards of large tertiary care hospitals in urban areas where the emphasis is on making the right diagnosis rather than on the principles of triage and emergency management ( ) . to be effective, it is essential that hospitals surge their patient-care capacity in a short period of time after a disaster (e.g. within Á hours) ( Á ). however, chinese disaster surge capacity still lags behind other countries such as the united states ( ) . as revealed by previous research, most secondary and tertiary hospitals in beijing acknowledge they have insufficient surge (extra) beds to meet the demands during disasters, such as an infectious disease epidemic. the surge beds accounted for only . % of all the fixed beds after the sars crisis in ( ) . in , only . % of the tertiary hospitals in shandong province were able to surge patient-care beds, with the total surge capacity being . %, within hours ( ) . two reasons were identified for this low surge capacity. first, there was a lack of a hospital surging plan that used flexible surging strategies during disasters ( , , Á ) . for instance, in , only . % of the tertiary hospitals in the shandong province had surging plans; only . % of the hospitals adopted a variety of flexible procedures for surging their beds (e.g. through the early discharge of patients, the cancellation of elective admissions, or the transfer of patients). second, the health system was already under increased pressure from the growing daily demand ( , , ) . this human resource shortage compounded the limited surge capacity of the hospitals during disasters. as noted earlier, during the earthquake, the local healthcare workers were overwhelmed by the large number and the severity of casualties ( ) . when the acute phase of a disaster ends, the challenge moves to sustaining the long-term rehabilitation of the population, particularly those with disabilities and chronic diseases ( , ) . the psychological intervention guidelines for public emergencies were sued by the ministry of health. the guidelines stipulated two phases for psychological interventions. the first phase, the acute phase, occurs when general psychological counselling is used to reduce the incidence of posttraumatic stress disorder. the second phase, the chronic phase, occurs when psychological interventions are focused on issues associated with depression ( ) . however, to date, few programs exist for the evaluation and identification of psychological problems (especially during the chronic phase) of the population in the disaster areas. as a result, the targeted interventions remain inadequate for the treatment of large numbers of victims with psychological problems (e.g. postinjury stress disease), or for victims with the potential for psychological problems that arise during disasters ( ) . two factors underpin this inadequacy. first, psychological problems have become common especially during natural disasters and infectious disease outbreaks and these affect both the victims and the rescuers ( ). however, psychological problems have not received the same emphasis that physical illnesses and injuries receive. second, the local medical staff have not been welltrained in managing severe psychological effects, even in disaster prone areas ( , ) . further, there has been a nationwide shortage of senior experienced doctors and mental health professionals, which contributes to the lack of sensitivity to patients' psychological needs and impedes the supply of post disaster psychosocial interventions ( , ) . this workforce shortage became apparent during the wenchuan earthquake. in essence, there were insufficient professionals in the local area and they could not be dispatched at short notice to respond to the psychosocial problems ( ) . shuang zhong et al. several supporting systems were found to be wanting in terms of aiding the delivery of disaster relief emergency services, namely: the fragmentation of emergency health service systems, the lack of specific emergency legislation, the disparities in funding distribution, and inadequate cost-effective considerations. these systems are discussed below. fragmentation of emergency health service system. the prehospital emergency service is arguably the least developed aspect of the emergency medical service system. there are large variations in the structure of the pre-hospital emergency service across china ( ) . some large cities have independent pre-hospital emergency services, while others rely on hospitals ( ) . hence, the roles of hospital eds and emergency service centers overlap in some large cities such as beijing and shenyang ( ) . moreover, there is no official guideline, protocol, or legal standard for patient management and transfer between these two sectors. during disasters, the independence of these two sectors can lead to inefficiencies and the waste of valuable resources ( , ) . in most regions, pre-hospital emergency services lack effective cooperation with the fire and police departments. a lack of cooperation may result in the loss of precious rescue time for advanced pre-hospital medical care. lack of specific emergency legislation. in china, the legal foundation for disaster management has been established through the 'act on tackling emergency affairs ( )' ( , ) . however the document is not specific enough to be implemented in the local area. in addition, there are numerous legal obstacles that hinder appropriate disaster health management. first, there is a lack of a guaranteed reimbursement to the disaster healthcare services; this lack of reimbursement may encourage perverse financial disincentives. this situation may effectively discourage hospitals from becoming involved in disaster preparedness ( ) . without legal guarantees, few insurance companies will accept insurance for health staff working in the disaster areas ( ) . in addition, there is the need to have similar hospital command and control systems across hospitals in all responding sites, to ensure the maximum efficiency of mutual aid. however, to date, there is no such overarching command and control guideline to assist the different areas of china. this lack of legal clarification may impede the formulation of an integrated response system for disaster command, control and cooperation ( ) . also, the responsibility and authority of the different levels of government, the army facilities, and the non-governmental organizations are not clearly defined within the law. for non-profit organizations this vagueness may cause chaos during disasters ( ) . for example, the lushan earthquake highlighted the difficulties that can arise in the absence of a legal system to recruit and coordinate the volunteers. in that instance, the individual volunteers and unauthorized organizations entering the disaster area created road congestion and inadvertently, unnecessary casualties ( ) . further, without the legal enforcement to release details to the public about the use of donations, embezzlement of some of the donations for the wenchuan earthquake occurred. this event caused a credibility crisis for the public in regard to the donations given to the government-organized ngos (non-governmental organizations) ( ) . disparities in funding distribution. the funding gaps and the disparities in the distribution of funds present major challenges for healthcare organizations providing medical care during a disaster response ( ) . the first disparity occurs between the funding of urban and rural areas. for example, healthcare resources, modern healthcare facilities, and physicians are concentrated mainly in the urban areas while the rural areas are less well resourced ( , ) . there is also a tension between the allocation of resources for the immediate day-to-day needs and for disaster preparedness. in addition, investments that are put toward the improvement of emergency preparedness may compromise other more urgent programs such as primary healthcare in rural and western areas ( ). in addition, most funding was used for the reimbursement of actual expenses after a disaster. the government finance report indicates that most government funding was used for the wenchuan earthquake rescue (the central government invested . billion rmb, about us$ . billion), while the earthquake relief and preparedness funding amounted to . billion rmb (about us$ . billion). finally, since the health system reforms were introduced in the s, healthcare organizations have turned their attention to revenue-generating services ( ) . as a result, hospitals and professionals can be paid significantly more for their clinical services than their disaster-related work ( ) . thus, without sufficient financial allocations the motivation of hospitals to improve their disaster preparedness is likely to remain low. inadequate cost-effective considerations. the cost-effectiveness of disaster management is easily neglected especially during catastrophic disasters. when the disaster occurs the decisions about who and what to send to the disaster zone might be determined by dogma, rather than by scientific analysis ( ) . for instance, during natural disasters, a large number of search and rescue teams are dispatched to the disaster zones and part of the purpose of their role is moral inspiration ( ) . however, if there is an oversupply of search and rescue teams, the influx of too many teams may become a burden on the limited supplies for the victims, such as food, shelter, sanitation, and healthcare services ( ) . occasionally, outside aid agencies have been known to rush manpower, equipment, and supplies to a disaster area regardless of the local requirements, and without coordination with the other local organizations' plans and resources; this situation may lead to the waste of resources and result in low efficiency ( , ) . for instance, during a disaster, supplies are delivered from the outside (such as clothes and foods); these donations can be useless as they are inappropriate for the current situation. moreover, receiving these donations may cause a waste of valuable warehouse space and manpower. also, because the source is unknown, the donated items may need to be sterilized properly, which uses even more resources ( ) . several contributions have been made by this review to the broader body of knowledge. first, the review identified comprehensively the progress and challenges of disaster health management in china; this outcome was achieved through the extraction of relevant information from the literature, in both the english and chinese languages. indeed, the topic was found to be poorly covered. importantly, the review offered the opportunity to assess and evaluate the current status of disaster health management. it also provided a foundation for further in-depth analysis of the individual challenges and the progress achieved. second, some challenges involved the internal aspects of the health system while others arose from the external environment. the 'pprr' disaster management continuum integrates the internal challenges; it also offers a preliminary framework which can be used to highlight the progress and the weaknesses of each management phase. further, this continuum can be used to develop a proposed multi-strategic approach to address corresponding challenges with a view to enhancing disaster management in the future. most of the information that informed this scoping review of disaster health management in china was in the format of qualitative descriptions and analyses. because the topic has been poorly researched, few quantitative studies with empirical data were available for appraisal. further, these quantitative studies had limitations including the short length of the study period and the examination of samples of hospitals in a small number of locations or regions, for example, beijing, sichuan, and shandong. because of the limited amount of research in the literature, and in particular empirical research, the current study used scoping review methods to locate research materials that could then be used for a systematic review. despite the aforementioned limitations, the methods were appropriate for a policy analysis topic such as the current study which sought to identify the current status of and challenges to health disaster management in china. the limitations identified in the literature in terms of need for more rigorous research designs and information on health services in more areas of china provide considerable potential for future research. the current study revealed that the healthcare facilities' preparedness for disasters was under challenge by the vulnerability of the physical infrastructure, inadequate disaster plans, and disaster resourcing, and funding considerations. to enhance local disaster preparedness, multiple strategies need to be adopted. first, the local prioritized hazards need to be evaluated, while strict structural standards need to be enforced; these aspects are essential for reducing casualties from disasters ( , ) . for example, in the hardest hit area of the lushan earthquake, . % of the public buildings built after the wenchuan earthquake were still functional and able to be used. as a result, the new structural standards reduced the impact of the disaster on human health and wellbeing ( ) . second, operational disaster plans for healthcare facilities need to be devised, in advance. in addition, they need to take into consideration the communities' resources, hazards and other unique factors ( , ) . third, healthcare organizations need to have the capacity to be self-sufficient for the first to hours; this disaster coping capacity is essential as it may take this long for supplies to be delivered from the outside ( ) . fourth, non-governmental mutual assistance, as well as a social insurance mechanism, needs to be strengthened to decrease the gap between the governmental funding and the actual costs of the disaster relevant work ( , ) . finally, funds need to be allocated to local primary healthcare centers and hospitals to assist their roles in providing adequate capability as the first disaster responders ( ) . the scoping review revealed that research on surge capacity exists in developed countries, such as the united states; however, its concept and strategies are not fully adopted in the chinese context. nevertheless, some international surge strategies would appear to have the potential to be adapted into the chinese disaster-planning environment. these surge strategies would include: providing staff with onsite accommodation, and the training of non-clinical staff to support the fully trained staff ( , ) , cancelling elective surgery in order to focus on critical care ( ) , triaging the resources, and providing patients with adjusted standards of healthcare during the period of the disaster ( , ). other strategies would include converting non-clinical areas for surging clinical space (prepared in advance, with available power, water, oxygen, equipment and telecommunication) ( , , ) ; early discharge of stable inpatients or referring them to ancillary healthcare services (e.g. nursing homes and primary healthcare centers) ( , , ) ; and obtaining cooperative agreements with other facilities and off-site hospitals ( , ) . such considerations have the potential to assist the country to surge its capacity during times of disaster. in china, psychological interventions, triage skills, and other disaster management skills are limited by inadequate education in disaster management. thus, appropriate education or training curricula need to be developed and implemented to address these issues in the long term ( ) . such courses need to be available for hospital professionals as part of their ongoing professional development. systematic and ongoing training of staff in disaster skills and equipment usage should be conducted in highrisk communities. for example, staff should be trained in how to triage a large number of patients and with limited resources. the training programs used in other countries could be implemented but with appropriate modification to fit the chinese environment, as necessary. the american medical association has developed two courses that have this potential, but which are largely directed to the initial triage and management in the field and in the ed, namely the basic disaster life support course, and the advanced disaster life support course ( ) . currently, the fragmentation or lack of coordination of the emergency systems in china hinders efficient disaster management. the close coordination of the medical rescue services (e.g. government and non-government, domestic and international) is essential to overcoming this challenge ( ) . such cooperative channels should include strengthening effective cooperation from pre-hospital centers, hospital ed, and fire and police departments ( ) ; establishing a unified command and information platform for governmental agencies, national delegations, and ngos ( , ) ; and, finally, strengthening ngos, particularly with respect to their management of volunteers. a system similar to the us national verification system that would enable or facilitate the quick identification, recruitment and coordination of the medical volunteers is worthy of consideration ( ). based on this review, a number of research questions have been proposed with the aim of providing scientific evidence as the basis for disaster health management in china and facilitating policy-making that would overcome future challenges. these questions are listed below: q : how can the new concept of 'disaster preparedness' and 'surge capacity' be best implemented to prepare the local health system as the first disaster responder and integrate the health system into the local planning network? q : can user-friendly and validated tools be developed to evaluate hospital capability to cope with disasters? in order to evaluate the hospitals' actual ability to cope with disasters, the relevant validated evaluation tools will need to be tested during disaster simulations to identify the beneficial factors. hence, the tools can be used to monitor and analyze hospital response performance through the disaster drills. q : how can the research-to-policy interface be bridged? for example, can context-specific domestic disaster guidelines or plans be formulated to encourage vulnerable healthcare organizations to take adequate actions before or during disasters? can a minimum number of items be identified that should be stored in ed and which take into account specific regional and geographic needs and resources. q : how can evidence-based research be used to determine and specify whether the levels of ability are linked to a desirable outcome, and is the outcome regarded as adequate? for example, in terms of surge capacity, the thresholds for the extent of, and rapidity for, surge capacity should be investigated with considerations being given to different regional conditions. effective disaster management of the health system is essential for disaster response. this paper has identified the progress of and challenges to the chinese health system in providing continuous health care services during disasters. these challenges emanate from both the internal components of the health organizations and the external environment, which can directly or indirectly impede effective disaster health management. solutions that were identified to address these challenges require corresponding policy strategies at community, hospital and healthcare system levels. disaster medicine: advances in local catastrophic disaster response crisis management for executives: the definitive handbook to corporate rescue in crisis situations. 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mechanism of public finance in earthquake disaster emergency management mental health and the psychosocial consequences of natural disasters in asia emergency law in china: its formation, present state and future frequent emergency calls for crisis consciousness Á building effective emergency prevention system the necessity of building the huge disaster insurance legal system in china (page number not for citation purpose) citation: glob health action china's public health-care system: facing the challenges earthquake disaster prevention and mitigation and emergency status in japan disaster reduction report of the people's republic of china study of enhancing financial mechanism to guarantee public emergency management in china hospital disaster preparedness in los angeles county wise ra. the creation of emergency health care standards for catastrophic events clinical review: mass casualty triageÁpandemic influenza and critical care recommendations for intensive care unit and hospital preparations for an influenza epidemic or mass disaster: summary report of the european society of intensive care medicine's task force for intensive care unit triage during an influenza epidemic or mass disaster expanding icu facilities in an epidemic: recommendations based on experience from the sars epidemic in hong kong and singapore the authors declare that they have no competing interests. authors' contributions sz and gf conceptualized this review. sz and xh reviewed and selected the relevant articles for inclusion. sz drafted the manuscript. all authors participated in the writing, revision, and approval of the final manuscript. key: cord- - lx rd authors: ismail-zadeh, alik title: science for earthquake risk reduction date: - - journal: j geol soc india doi: . /s - - -y sha: doc_id: cord_uid: lx rd nan components in studies of earthquake-prone regions. these studies provide information on the localization of stresses and their changes, which can be used then in hazard assessment. earthquake simulations can complement the knowledge on tectonic stress release at the faults, which have not been ruptured in the past or if the information on historical earthquakes have not been recorded. because historical data on seismicity are usually incomplete and instrumental observations cover a short time interval compared to the duration of the tectonic processes responsible for earthquakes, studies of seismic hazard based only on historical and instrumental observations are lacking the information on large earthquake occurrences. numerical modelling of seismic processes allows to generate synthetic earthquake catalogues covering long time intervals and provides a basis for reliable estimates of the parameters of the earthquake occurrences (e.g. soloviev and ismail-zadeh, ; rundle et al., ; ismail-zadeh et al., ) . results of the modelling can then be used in assessments of seismic hazard (e.g., ismail-zadeh, , ) . seismic hazard assessments provide an information on strong ground motions due to potential earthquakes combining the knowledge on seismological, tectonic, geomorphological, and geological features and modelling results. although a seismic hazard assessment identifies a spatial distribution of strong ground motions and predicts the exceedance of a certain level of ground motions for a certain period of time with a prescribed probability, it does not answer an important questions required for disaster risk management: when does a big earthquake occur? earthquake forecasting tries to answer the question, although opinions on the possibilities of forecasts range from the statement that earthquake prediction is intrinsically impossible (geller et al., ) to the statement that prediction is possible, but difficult (e.g., knopoff, ; keilis-borok et al., ) . earthquake forecasting based on monitoring of precursors (e.g. a ground elevation, water level in boreholes, radon emission, electromagnetic field issues, and animal behaviour) issues an alarm at the time of the abnormal behaviour of the precursors. alarm-based earthquake prediction methods have been developed for the last several decades. for example, the intermediate-term earthquake prediction method (m algorithm; keilis-borok and kossobokov, ; ismail-zadeh and kossobokov, ) aims to forecast large (magnitude and greater) earthquakes by monitoring and analysis of several parameters of the seismic activity in a region. another type of earthquake prediction is based on calculating the probabilities of target events within future space-time domains, e.g., the shortterm earthquake probability (step) method that uses aftershock statistics to make hourly revisions of the probabilities of strong ground motion (gerstenberger et al., ) . although earthquake prediction methods are improving along with geophysical, seismological, and geodetic data analysis and assimilation, the current quality and accuracy of earthquake forecasting are significantly low compared to those of weather forecasting (bauer et al., ) . our knowledge of earthquake physics and earthquake dynamics is still limited to predict large earthquakes with a relatively high accuracy. meanwhile, even current level of earthquake prediction capacity can be useful for seismic risk assessment and disaster preparedness (davis, ) . disaster risk is associated with a potential loss of life, injury, damaged assets, which could occur to a community/ society in a specific period of time, determined probabilistically as a function of four indicators: hazard, exposure, vulnerability, and capacity (unga, ). when an earthquake happens, exposure, vulnerability, and capacity are the key determinants of disaster risk, whereas vulnerability and exposure are the main drivers of disaster losses. enhancing the capacity (that is, resources, infrastructure, human knowledge and skills, social relationships, leadership, and management) available within a community/society will contribute to significant reduction of risks and strengthen resilience. changes in any of these indicators alter the risk calculus by increasing or reducing the impacts of disaster risk on affected communities, regions, or countries. capacity, exposure, and vulnerability patterns vary in space and time, and the geographic patterns of the indicators are unevenly distributed leading to the disproportionate impacts of disasters, especially in disadvantaged regions or countries (ismail-zadeh and cutter, ; ismail-zadeh, ) . as geohazards cannot be significantly reduced and exposure increases with economic development, major elements in disaster risk management are the reduction of vulnerability and strengthening capacity. many parts of the world are still vulnerable to earthquakes despite the progress made in earthquake research and engineering for the past several decades. for example, seismic risk assessments show that the risk is normally associated with a building resistance to damage due to ground shaking and/or with socio-economic vulnerability rather than with ground motion due to earthquakes (e.g., babayev et al., ; baker, ) . with economic and technological development more structural elements become exposed to risks due to geohazards. risk assessment allows elaborating strategic countermeasure plans for the disaster risk mitigation. an estimation of risks may facilitate a proper choice in a wide variety of safety measures, ranging, in the case of earthquakes, from building codes and insurance to establishment of rescue-and-relief resources. our societies should be prepared to extreme geohazard events and subsequent environmental, economic, and financial events associated with them and hence to recover easily from a disaster. stronger efforts are needed to develop societies resilient to geohazards and related disasters. the ongoing global covid- crisis caused by a coronavirus sars-cov- is a tragic example of how a (biological) hazard event can turn to become a disaster, mainly due to unpreparedness and ignorance of many states, and unawareness of the population about the severity of the hazard and reproductivity of the virus. although scientific knowledge about coronaviruses and their consequences has been available for years, no preventive measures have been implemented and no strategy to confine the biological hazard and then to mitigate its consequences has been developed (ismail-zadeh, ). similarly, earthquakes or other geohazard events turn into a disaster. preparedness and awareness are important factors in preventive measures to reduce disaster risks. for example, the level of preparedness for the indian ocean tsunami disaster in many countries was extremely low. even though an early warning had been sent to the appropriate local authorities of the countries, it is unlikely that it would have been delivered to the public in a timely manner. it is also unlikely that people would have responded to it in appropriate manner, since most of them did not believe that such a disaster could affect them (ismail-zadeh and takeuchi, ) . in japan, where the preparedness and awareness of people regarding earthquakes and tsunamis are the highest in the world, the initial data on the earthquake of march sent to the tohoku coastal region underestimated the height of tsunami waves. in a response, some people did not evacuate their building and did not move to safer places, because they considered that available sea walls would protect their houses and lives. unfortunately, the tsunami waves were much higher than expected, and the sea walls were incapable to prevent the great inundation. a strong earthquake in the plate interior may lead to a disaster if it strikes near a town. and this earthquake will turn to become a disaster in the case of high physical and social vulnerability and low capacity of the town to withstand the earthquake. for example, the energy released by the chile m . earthquake was by a factor of about higher than that by the haiti m . earthquake. however, the damage and the death toll showed the inverse proportionality: several hundred people lost their lives in the case of the chile earthquake versus several hundred thousand lives in the case of the haiti earthquake resulting in a humanitarian catastrophe (ismail-zadeh, ) . earthquake disasters happen mainly because of the unwillingness of some local authorities to invest in resistant construction due to various reasons including irresponsibility, ignorance, corruption, the perceived requirement to balance the need for costs versus the increased costs of implementation, local politics, funding availability and other urgent and more politically competitive needs (ismail-zadeh et al., ) . multi-hazard concatenated events play a significant role in transformation of hazards into disasters. the tohoku m . earthquake, which generated great tsunami waves and flooding, was the largest and most costly disaster in the known history of japan caused by concatenated hazards events. although scientists knew about past earthquake and tsunami disasters occurred in the region, e.g., the jogan earthquake, which produced unusually large tsunamis and took up people in the sendai plain or tsunamis generated by the sanriku earthquake causing , casualties, the historical experience was not fully utilized to reduce risks. the lessons learned from the great east japan earthquake and tsunami disaster include an importance of geophysical observations, improvement of long-term forecast of earthquakes, effective tsunami warning, assessment for future tsunami hazard, and preparedness and education for infrequent hazards (satake, ) . the khait (tajikistan) m . earthquake triggered hundreds of rockslides, which took a heavy toll (more than ten thousand casualties; evans et al., ) . the lake sarez in pamir mountain (also in tajikistan), which formed as a big natural dam due to the earthquake-triggered rockslides, is one of the most vulnerable objects in the region. in the case of dam failure, e.g., due to an earthquake or other events, over a million of people downstream along the amu daria river would be exposed to severe flooding (stone, ) . scientists knew about historical devastating earthquakes and associated geohazard events, and in many cases, they tried to deliver scientific evidences and relevant information to the decision makers. just a few examples. geoscientists alerted about a potential strong earthquake near the capital city of haiti: "… the enriquillo fault in haiti is currently capable of a mw . earthquake if the entire elastic strain accumulated since the last major earthquake was released in a single event today" (manaker et al., ) . it seems that the available information was submerged under other matters like political, financial, and social affairs. it is a challenging task to convince governments to invest in preparedness against disasters, especially it is a difficult task in economically less developed countries. "if about to % of the funds, necessary for recovery and rehabilitation after a disaster, would be spent to mitigate an anticipated earthquake, it could in effect save lives, constructions, and other resources" (ismail-zadeh and takeuchi, ) . the sendai framework for disaster risk reduction - highlights the importance of investments and broader preventive approaches as mentioned in its priority "investing in disaster risk reduction for resilience" and priority "enhancing disaster preparedness for effective response" (sendai framework, ) . disaster risk reduction should be based on firm scientific knowledge, vast information/data, and the systematic development and application of policies, strategies, and practices to minimize vulnerabilities, enhance capacities, and reduce disaster risks throughout a community/society. this will result in avoiding (prevention) or in limiting (mitigation and preparedness) adverse impact of geohazards, within the broad context of sustainable development. interdisciplinary, coengaged, and co-produced scientific knowledge will provide the basis for better understanding and communicating disaster risks to ensure maximum benefits towards the sendai framework's implementation. science-based disaster risk reduction efforts through integrated research and risk assessments (cutter et al., ) and informed decision-making through disaster science diplomacy efforts (kontar et al., ) would allow for greater actions towards an effective reduction of disaster risks due to geohazards as well as other natural and technological hazards, and would help the governments and societies in mitigating disasters. buoyancydriven deformation and contemporary tectonic stress in the lithosphere beneath central italy scenariobased earthquake hazard and risk assessment for baku (azerbaijan) seismology: quake catcher the quiet revolution of numerical weather prediction tectonic development of the new madrid rift complex topo-europe -ilp's program on coupled deep earth 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integrated analysis of seismic, heat flow, and gravity observations numerical modeling of crustal block-andfault dynamics, earthquakes and slip rates in the tibet-himalayan region three-dimensional numerical modeling of contemporary mantle flow and tectonic stress beneath the central mediterranean geodynamic and intermediate-depth seismicity in vrancea (the south-eastern carpathians): current state-of-the-art extreme natural hazards, disaster risks and societal implications forging a paradigm shift in disaster science. natural hazards quantitative modeling of the lithosphere dynamics, earthquakes and seismic hazard geodynamics, seismicity, and seismic hazards of the caucasus premonitory activation of earthquake flow: algorithm m non-linear dynamics of the lithosphere and intermediateterm earthquake prediction static stress changes and the triggering of earthquakes earthquake prediction is difficult but not impossible disaster-related science diplomacy: advancing global resilience through international scientific collaborations interseismic plate coupling and strain partitioning in the northeastern caribbean virtual california: fault model, frictional parameters, application extreme natural hazards, disaster risks and societal implications united nations officer for disaster risk reduction seismic hazard from instrumentally recorded, historical and simulated earthquakes: application to the tibet-himalayan region on the use of multiple-site estimations in probabilistic seismic hazard assessment models of dynamics of block-and-fault systems subduction zones peril in the pamirs report of the open-ended intergovernmental expert working group on indicators and terminology relating to disaster risk reduction acknowledgements: this editorial paper is based on the dedicated research efforts of interdisciplinary group of scientists involved in natural hazards and disaster science. special thanks go to tom beer, susan cutter, john eichelberger, harsh gupta, katia kontar, vladimir kossobokov, birgit mueller, giuliano panza, frank schilling, vladimir sokolov, alexander soloviev, kuni takeuchi, and inessa vorobieva for their valuable contributions and discussions. the german science foundation (dfg), the russian science foundation (rsf), the international union of geodesy and geophysics (iugg), and the international science council (isc) are thanked for support of the research related to disaster risk reduction. key: cord- -gia eu authors: argent, a. c.; kissoon, n. “tex” title: the needs of children in natural or manmade disasters date: - - journal: intensive and critical care medicine doi: . / - - - - _ sha: doc_id: cord_uid: gia eu disasters have been described as “events of sufficient scale, asset depletion, or numbers of victims to overwhelm medical resources” [ ] or as “a serious disruption of the functioning of a community or a society causing widespread human, material, economic or environmental losses that exceed the ability of the affected community or society to cope using its own resources” [ ]. importantly, that definition goes on to state: “a disaster is a function of the risk process. it results from the combination of hazards, conditions of vulnerability and insufficient capacity or measures to reduce the potential negative consequences of risk.” disasters have been described as "events of sufficient scale, asset depletion, or numbers of victims to overwhelm medical resources" [ ] or as "a serious disruption of the functioning of a community or a society causing widespread human, material, economic or environmental losses that exceed the ability of the affected community or society to cope using its own resources" [ ] . importantly, that definition goes on to state: "a disaster is a function of the risk process. it results from the combination of hazards, conditions of vulnerability and insufficient capacity or measures to reduce the potential negative consequences of risk." disasters may occur in many forms (table . ); in different settings and levels of complexity; with variable amounts of warning and very different consequences for people. the number of natural disasters have increased in the last century and doubled within the last years, with many more people affected. during the same period the proportion of disasters that are manmade has increased from . % in the s to % in the s (not including "complex emergencies") [ ] . as the density of population across the world increases (related both to population growth and increasing urbanization) it is likely that the frequency and impact of disasters will continue to increase. climate change (with associated extreme weather conditions; change in regional weather and associated change in distribution of pathogens and vectors) is likely to exacerbate this trend. increasingly, plans are being put in place to cope with disasters [ ] . sadly, many of the most devastating disasters in recent times have taken place in poorer countries not only are children caught up in general disasters, but they are sometimes specifically involved in tragedies that affected institutions where large numbers of children were grouped together in schools (as happened in china in ). some mass casualty events have even been specifically targeted at children. as reviewed by rassin et al. [ ] there have been a number of attacks that have specifically targeted schools and nursery schools across the world, resulting in significant mortality and morbidity among children at those institutions. although many disaster plans make provision for the care of vulnerable sectors of the population, relatively few plans are specifically geared for the needs of children and particularly for children across the full range of developmental stages. unless those needs are specifically addressed in the planning for and organization of disaster relief, it is inevitable that children will suffer unnecessary harm. some of the reasons for the vulnerability of children in disasters are outlined in table . . children are vulnerable at virtually all phases of disasters, and it is important to highlight both their specific needs and the skills and resources that are required to fulfill those needs at various stages [ ] . in the acute phase of physical disasters such as tsunamis and earthquakes, children have been particularly vulnerable to death and injury. with limited strength and capacity to flee and/or find shelter from danger, mortality has been particularly high in young children in these events [ ] . in a survey of mortality in the aceh province of indonesia following the tsunami, the age-specific mortality in the age-group of children - years was . %, which was higher than all other age groups other than > -year-olds. [ ] . in eastern coastal areas of sri lanka, the mortality among children (during the same tsunami) aged less than years was . %, vs. . % for children aged - years and . % for adults aged - years (p< . ) [ ] . at a red cross field hospital in kashmir in , ( . %) of patients attending for emergency care were under the age of [ ] . in the gas explosion disaster in bhopal children were particularly affected by gas inhalation, aggravated by the tendency of many toxic gases to gravitate to ground level. children were also less able to use clothes or other methods to limit their inhalation of toxic gases [ ] . the pattern of injury suffered by children in physical disasters has also differed from those of adults. commenting on their experience in pakistan, laverick et al. [ ] noted that children often presented with scalp injuries and le fort facial fractures as if they had been looking up when the masonry began to fall on them, instead of protecting themselves by lying face down (as the adults did). the care of children in acute disasters may be considerably complicated when parents have been killed or injured, or when children have been separated from their parents. apart from the psychological trauma of separation, consent for procedures and ongoing care is also problematic [ ] . even after the acute phase of a disaster children remain more at risk for injury in the "damaged environment." following hurricane katrina one team commented on the higher rates of injury for children saying: "the most common injuries in children were lacerations and punctures caused by debris. several children were bitten by animals, many of which were stray pets with unknown rabies status. many of the wounds were infected, likely because clean water and antibacterial ointment were unavailable. cellulitis resulting from insect bites was also particularly common in children." [ ] . children may be particularly susceptible to injury from disasters involving chemical or radioactive contamination (table . ). while rapid decontamination is ideal, decontamination of small children may pose challenges both to healthcare workers and to the children [ ] and there are no existing tested and proven guidelines [ ] . children are also at higher risk of hypothermia (table . ) and small children will require considerable assistance in the process of decontamination. as children may be accompanied by their parents, pediatric facilities should ideally have the resources to decontaminate accompanying parents [ ] . guidelines for chemical and radioactive material decontamination are available in many centers [ , ] ; although some protocols have been suggested [ ] , there is a need for altered protocols that reflect pediatric needs [ ] . unfortunately, few centers are adequately equipped to decontaminate large groups of children in terms of facilities; appropriate washing environments to ensure adequate privacy, temperature control for small children, and adequate numbers of trained and equipped staff to decontaminate large numbers of small children [ ] . this is particularly true in the developing world where industrial chemical accidents are probably more likely. in general, children and especially infants are more susceptible to infection than adults. thus children may be afflicted as part of a widespread infective process (possible influenza epidemic) but they may also develop infections in the environment that develops subsequent to a disaster. ligon [ ] and watson have recently reviewed the infectious diseases that may be problematic following disasters. often the environment following a disaster may be highly contaminated (toxins, sewerage, dead bodies, etc.) with limited access to clean water and frequent overcrowding of survivors. in that context infections spread via hands are particularly frequent unless particular attention is paid to hand washing. many survivors may have wounds, which again have risk of being contaminated, either during the incident or soon thereafter. meticulous cleaning of wounds and debridement of devitalized and infected tissue is particularly important. this may be difficult to achieve with limited pediatric services. respiratory infections may be more frequent in conditions following disasters. children may be particularly vulnerable to viral infections, and also to infections such as tuberculosis when crowding exists. every effort must be made to ensure that patients with known tuberculosis receive ongoing therapy, and if possible are kept away from children. gastrointestinal infections (including hepatitis) are a particular problem in the context of limited water and sewerage disposal facilities. children are particularly vulnerable to gastro-enteritis and attention must be paid to prevention and arranging oral rehydration facilities to resuscitate and treat children. outbreaks of infections such as cholera [ ] , rotavirus [ , ] , tetanus [ , ] , malaria [ ] [ ] [ ] , typhoid [ ] , shigellosis, novovirus, leptospirosis, and others have all been documented following natural disasters [ ] . other pathogens that have been involved in outbreaks of disease include viruses including dengue [ ] , and malaria [ ] [ ] [ ] . rabies may be a problem in some parts of the world. it is important to note that when people are grouped together into a high population density, a much higher level of immunization is required to prevent the development of epidemics [ ] . following the tsunami, spread of measles was documented in a population that had had dose of vaccine following the tsunami [ ] . clearly early involvement of public health experts in the management of disaster aftermath is vitally important. a manual has been produced by the who to provide guidance for health care workers who may be called on to provide care for children in humanitarian disasters. one of the issues that is often seen as a priority following disasters is the disposal of dead bodies. in fact these are not a major infection hazard, and it is likely that it would be better to try and allow families every opportunity to mourn and bury their dead, rather than to use mass graves [ ] . urgent and rapid epidemiological assessments by teams with pediatric expertise may be useful in disease prevention and treatment following disasters. there is limited data available on the effect of respiratory viral pandemics on children [ ] . however, experience from the sars outbreak in toronto in highlighted the need for extensive planning for infection control measures before the outbreak of an epidemic and management of epidemics involving children using a family-based approach [ ] . children are particularly vulnerable to adverse effects of isolation, and this may be a significant problem in management of other outbreaks [ ] . in the case of sars there seemed to be limited spread of the infection from children to adults [ ] but that may not be so in other pandemics. schools and institutions for children may be also an important source of cross-infection in communities exposed to pandemic infections. following disasters there may be an increased exposure to many toxins. carbon monoxide poisoning has occurred on many occasions because of the means used to provide power and warmth [ ] . following hurricane katrina in the usa > , people were rendered homeless and many were given temporary accommodation in mobile homes. many of those homes were found to be contaminated with formaldehyde, and the management of related symptoms was complicated by the fact that the healthcare structure surrounding those in displaced housing was inadequate [ ] . in many settings the post-disaster environment may have many dangers such as unstable masonry, exposed power and gas lines, contaminated soils and environments, etc. children with their capacity for exploration and limited knowledge of potential dangers may be at substantial risk, particularly if adult supervision is compromised (as will usually be the case post disaster). there is relatively little data available that compares the rates of mortality following conflicts with baseline data. guha-sapir and gijsbert reviewed data from available datasets, and showed that there were considerable differences in mortality rates for children following conflicts [ ] . in most cases the rates or death increased sharply, although there were other situations in which mortality rates dropped, largely related to populations who were displaced as a result of the conflicts. in mass displacements (usually as a consequence of war or civil strife) children under have often had the highest mortality. in these situations "complex emergencies" defined as "relatively acute situations affecting large civilian populations, usually involving a combination of war or civil strife, food shortages and population displacement, resulting in significant excess mortality" [ ] may occur. essentially these disasters combine many of the individual components of issues described above. during the s the mortality of children aged - in areas such as northern ethiopia (in ) and southern sudan ( ) were extremely high [ ] . in the s crude death rates in refugees in some parts of africa were - times higher than the crude death rates of the nondisplaced (with rates of up to times described [ ] , and the rates were highest in children under years of age [ ] ) leading toole et al. to state that "children under the age of regularly bear the brunt of the death toll associated with complex emergencies" [ ] . likewise in , % of all the deaths among refugees from rwanda and burundi who fled to eastern zaire were under the age of [ ] . a recent publication [ , ] has reviewed much of the data. one of the problems quoted is that much data is in "gray data" which is not readily available to the greater audience. children are also affected by the patterns of adult mortality. in many settings such as the indonesia tsunami three women died for each man [ ] , and as most child care is provided by women, their children would have been adversely affected. fortunately much has been learned about the management of complex disasters [ ] , and there is hope that future events will provide better care for children. the issues of relief work in complex disasters are extremely complex and challenging to all concerned. there is a large body of evidence documenting the psychological problems of children who have been exposed to disaster situations [ ] [ ] [ ] which has been recently reviewed [ ] [ ] [ ] [ ] . specific and focused care is required from the time of the disaster onwards to ameliorate the long-term psychological problems for children affected by disasters [ ] . particular attention needs to be focused on the family [ ] . penrose et al. have recently highlighted the importance of involving children in the process of planning for disaster, as well in the recovery phases following events. children can offer useful knowledge and information, and it is deeply in their interests to feel part of the processes that surround actual and potential disasters. "the children consulted have clear ideas about the information, knowledge, and skills that they and their communities need to be better prepared for future disasters; all we have to do is listen." [ ] . the same authors have raised many issues surrounding children's rights in disasters and ways in which they can be addressed [ ] . it is also important to bear in mind that dealing with child victims of disasters or mass casualty events can be extremely demanding and emotionally devastating for healthcare and rescue workers [ , ] . specific steps must be taken to provide support to these people both during and after the events. in any disaster, there may be direct (e.g., injury related to the earthquake), or indirect consequences (e.g., subsequent epidemics) which may be physical or psychosocial in nature [ ] (or both). not only are children more likely to suffer injury in physical disasters, the facil-ities available for their care are likely to be more limited than would be the case for adults. the special needs of injured children include: a range of equipment sizes; personnel with special expertise in dealing with children; increased nursing requirements post intervention, etc. particular insight into the needs of children and the availability of specific pediatric resources will be required by any team coordinating both planning for and response to any disaster in which significant numbers of children are involved [ , , , ] . even within well-resourced areas children's services in general have extremely limited capacity to deal with a surge and there are limited alternatives [ ] . recent reviews considered options for surge management for adult patients, but did not include children [ ] [ ] [ ] . although up to % of the population in developing countries may be pediatric, there are usually far fewer pediatric services than there are adult services. in the usa about % of hospitals have both emergency departments and separate hospital wards with specific facilities for children, while % do not admit children [ , ] . only . % had all the equipment recommended for emergency care for children, while about % had % of the equipment suggested in the guidelines [ ] . thus capacity to accommodate a large surge of pediatric patients may be limited, even in countries as well-resourced as the usa. kanter and moran [ ] have reviewed the adequacy of pediatric beds in new york city for mass casualty purposes. the current bed numbers could accommodate approximately children per million population assuming no surge in current demand and that all beds were available. even if there were reductions in the intensity of care to allow % more admissions, it would not be possible to accommodate more than children per million population and more than children per million in picu even if the standards of care were altered to allow quadruple the usual throughput. disaster situations involving children per million and with % requiring intensive care would almost always exceed picu capacity. to further compound the situation % of all picu capacity was located in four hospitals. the who has recently launched a campaign aimed at ensuring that health facilities remain safe during and after disasters "health facilities are only truly safe from disasters when they are accessible and functioning, at maximum capacity, immediately after a hazard strikes." (http://www.who.int/hac/techguidance/safehospitals/en/ index.html ) (safe hospitals document) and this is of particular relevance to pediatric facilities. there is frequently a "surge" in demand for injury care shortly after the onset of the disaster. at a teaching hospital in sri lanka for instance there was a % increase in admissions on the day of the tsunami (with % injuries). the rate of admissions for injury remained high for the next week [ ] . however, the ongoing need for additional care may be high, particularly in the setting of burns (or other injuries requiring multiple surgical procedures or investigations) or children requiring intensive care. thus the surge may be sustained, and is always superimposed on existing service requirements. fortunately, there are few reports of disasters overwhelming the capacity of children's hospitals. however during the hurricane katrina disaster in new orleans, it was necessary to move significant numbers of critically ill children and neonates away from affected areas to other hospitals. patients requiring transportation included those affected directly by the hurricane, but also those who were in neonatal and pediatric wards and critical care areas at the time of the event [ ] . this may be much more challenging or even impossible in other contexts. it may be necessary to provide accommodation for parents and caretakers at the health facility where the children are being cared for. this may be particularly important when the surrounding environment is significantly affected by the disaster [ ] . following the early phase of a disaster shortage of healthcare facilities for children (if facilities have been damaged during the acute incident) may remain a significant problem for a long period unless there is focused rehabilitation of pediatric services. even provision of accommodation and health care for relatively well (but displaced) children may be a problem [ ] . the equipment required for the care of children (and particularly small children and infants) is different from that required for adults. in a study of preparedness of pediatric disaster assistance teams, mace and bern reviewed the availability of pediatric resources. pediatric equipment was missing as follows: airway, %; intravenous lines, %; cervical collars, %; medicines, %; broselow tape, %; backboards, %. pediatric patients were included in disaster drills % of the time [ ] . a review of emergency departments in the usa again showed significant deficiencies in availability of pediatric equipment [ ] . recommendations to ensure the availability of pediatric equipment include appropriate stocking of pediatric emergency departments [ ] , some stockpiling in pediatric practice offices [ ] , or the collection of pediatric equipment in international relief equipment collections. the majority of injuries requiring early treatment will be orthopedic and hence there is a major need for orthopedic devices which may be short supply, particularly in the countries affected [ ] . this was also expressed by laverick et al. with regard to their experience following the pakistani earthquake [ ] . experience has shown that there may be many spinal cord injuries [ , ] after earthquakes. children have different food and pharmaceutical requirements than adults. for small infants, breast feeding remains the most important source of nutrition and should be a. c. argent, n."tex" kissoon encouraged if at all possible. a study from pondicherry following the tsunami showed that breastfed infants who were given formula feeds had a threefold higher incidence of diarrhea [ ] . noji et al. [ ] have commented on the challenges of providing appropriate medication, immunization resources, and nutritional support for children following disasters. extensive recommendations relating to these problems are available from the who [ ] . pediatric expertise is required at many stages of the management of a disaster involving significant numbers of children [ , ] . this ranges from triage systems at the point of first contact with the injured children, through emergency and intensive care services, to ongoing medical and rehabilitative care. expertise is also required at different levels in the organization of relief efforts from management of the casualties, management of evacuation and transportation, allocation of resources, and management of overall relief organization. the number of people within rescue and health care services who are trained and experienced in the care of children may be extremely limited. mace and bern [ ] reviewed the capacity of disaster medical assistance teams in the usa to respond to pediatric emergencies and found major deficiencies in the training curriculum with pediatric topics such as trauma, disaster triage, burns, pain management, and mental health missing in , , , , and % of the time, respectively. data from emergency units in israel showed that the staff were significantly less well prepared to cope with pediatric mass casualties than with adults [ ] . there is a need to involve pediatric trained personnel in the disaster management process [ ] at all levels. however, those personnel are unlikely to be of significant assistance unless they have gone through some training [ ] as the skills required in an acute disaster are very different to normal pediatric practice. management of large groups of patients requires multiple levels and command structures. at the point of first patient contact, and subsequently in the hospital services, there is a need for triage systems. triage systems used for adults may overestimate the severity of injury of children [ ] , and not be a problem when small numbers of children are involved. however, when large numbers of children are affected it is important that pediatric triage systems be used. a number of systems have been devised including the pediatric triage tape, simple triage and rapid treatment (start), jumpstart, and careflight systems. jumpstart was the only system available to % of disaster medical assistance teams in the usa [ ] . however, when application of the systems was assessed in a south african emergency department the careflight system had the highest specificity and sensitivity with similar performance from the pediatric triage tape. the jumpstart and start systems did not function well [ ] . weiner et al. [ ] , within the context of disaster relief for hurricane katrina, have clearly described the role that pediatric subspecialty teams within the national disaster management system can play. the teams that were deployed had been trained specifically prior to that event, and had prepared for the possibility of a hurricane affecting new orleans. a recent survey of emergency medical systems in the usa showed that although . % of agencies had mass casualty plans in place, only . % reported having specific pediatric mass casualty plans [ ] . planning for the needs of children is complicated by a number of factors. children are not a homogeneous group of people. children of different ages and developmental stages have very different needs (infant foods vs. adult nutrition), capacity to respond to situations (adolescents vs. infants), vulnerability to infection (infants vs. adolescents), needs for parental care, etc. there are also children with specific needs, and in the richer parts of the world there is an ever-growing population of children who are dependant on technology such as home ventilators. some disasters are completely unexpected, and detailed planning to deal with such events is impossible. however, many disasters are predictable and with increasing access to geological, meteorological, and other data across the world, many regions will have increased capacity to consider and plan for disasters. while it may be impossible to make adequate plans for events such as the kashmir earthquake in in which some , people were killed and , injured [ , ] , there are many other disasters for which appropriate planning can and should be made. in many cases children are included under the category of "vulnerable people," and specific plans are not made to deal with the needs of children. improving pediatric emergency care needs should be at the forefront of every disaster planner's agenda [ ] . appropriate disaster planning should include: measures to reduce the injury during possible disasters, organization of emergency and pre-hospital services to deal with emergencies, plans for utilization of health services and utilities such as hospitals and intensive care units, and contingency plans to provide accommodation and resources to support both the rescue efforts and the ongoing needs of displaced people in the sichuan earthquake, which is reported to have killed some , people, the chinese government has reported that , children died when school buildings collapsed on them (http://www.timesonline.co.uk/tol/news/world/asia/arti-cle .ece accessed nd june ). appropriate building standards for institu-a. c. argent, n."tex" kissoon tions in areas at risk for seismic events could reduce death toll, even though it could be argued that the devastation was related to the force of that particular earthquake. in rassin et al. [ ] found that in israel, despite well-developed plans for mass casualty events, there were "no epidemiologic data concerning children affected by mces in israel and no unique recommendations to enable the ministry of health to prepare for coping with such pediatric casualties." shirm et al. [ ] have completed a recent survey of emergency departments across the usa showing that about % have not met with schools or child care agencies to discuss the care of children in the event of a mass casualty. the role of adults who are in charge of children such as teachers, nurses, and caregivers should be defined. particular responsibilities of organizations that care for large groups of children whose needs will differ depending on the age group and the particular characteristics of the children at that institution -e.g., special schools and hospitals -should beaddressed. in addition, plans should be developed to deal with children whose caregivers are missing. a crucial part of pediatric planning for disasters is comprehensive involvement of the communities that may be affected [ ] . disaster planning can take place at many different levels within the community, both national and international. to some extent the level of planning is also affected by the relative size of the likely disaster. planning of disaster management processes and structures should incorporate schools and educational facilities. incorporation of pediatric health services in planning may include the utilization of both public and private resources and the designation of some adult hospitals as alternative centers for pediatric care. planning is constrained by the resources available, and if health care resources are already inadequate or are functioning at the limits of capacity, then it may not be possible to plan for large disasters in any meaningful way. it is in this scenario that the international community may have a role in developing resources with which to assist in the amelioration of disasters across the world. with regard to organization of responses to emergencies, a common theme is that there needs to be centralized control centers that monitor and keep processes in action. a deep concern is that the people and systems that are put in this position are fully competent to deal with children's issues. these concerns arise from the recognition of the following: . it is often relatively easy to get resources (often the wrong ones) in the short term, but much more difficult over a longer period of time. . the need to get the correct resources, and not what the people in other countries want to give. . the need to work out how to deal with "excess resources" and make sure that these are not actually sources of development of ongoing crime and corruption. olness et al. [ ] have described their experience of establishing and running training courses for health professionals in management of children's needs in disasters and emergencies. the training course is based on the extensive experience of faculty who have worked in emergencies across the world on many occasions. some of the topics to be covered in the course include: definition and overview of disasters; the international humanitarian disaster response system; rapid epidemiological assessment; triage; malnutrition; renal emergencies for children in disasters; water, shelter, and sanitation; logistics and resource management; personal preparedness; infectious diseases and immunization; and the psychosocial issues for children who suffer disasters. however there is considerable evidence of major deficiencies in the training programs for staff who may be required to care for pediatric mass casualties [ ] . the aap (all the websites related to disasters) the who (website-based materials), and other organizations have put significant emphasis on involvement of families in preparation for disasters [ ] . a number of authors have considered the principles of resource allocation in the context of mass disasters [ ] [ ] [ ] . one of the underlying problems from a critical care perspective is that many intensive care systems are currently operating at % of capacity [ ] . there is also data suggesting that the capacity to upscale intensive care facilities for adults (even with a gradual onset disaster) would be maximum at %. it is likely that the potential to increase pediatric intensive care beds to cope with mass casualties may be substantially less that that. essentially it is likely that in most countries of the world there would be limited capacity within the health systems to deal with a significant surge in demand for acute services for children. in most developing countries there is simply no capacity at present to deal with the current demand, and in both situations we will have to work out how to provide the best possible care to the affected children. while some general principles appear to be recognized for the triage of adult patients [ , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , there is very little published material on the allocation of scarce resources for children in the context of mass casualties or disasters [ , ] . the tenets of the accountability for reasonableness [ ] [ ] [ ] [ ] may be useful in working through this process. as it is simply not tenable for clinicians involved in disaster care to make these decisions on their own, there is an urgent need for communities across the world to consider and discuss the possible approaches to allocation of scarce clinical resources in disasters in their region. this may be relatively straightforward within countries, but becomes extremely problematic in the context of disasters in countries where foreign healthcare workers are brought in as part of the response to the emergency. the long-term consequences of disasters may affect every level of society; however, there is a specific need to address the health care needs of people who have either been displaced or severely affected by the disaster. in many cases healthcare services will be curtailed in the disaster and these need to be rebuilt and redeveloped in a configuration that is appropriate to the new context. in addition, development of those services must take into the account the health consequences of the disaster which may operate over a range of time scales. particular attention may need to be paid to the ongoing development of mental health services. in the bhopal gas tragedy in , it was estimated that the death toll week after the event was approximately , , by the end of the mortality was estimated to be , , and by the end of the numbers were approximately , . by it was estimated that disaster-related deaths may have been between , and , [ ] . thus the systems required for health effects may need long-term commitment. in summary, planning must address the unique needs of children (immediate and long-term) the context of the likely disaster, and the resources available. planning should involve clinicians, health planners, the public, and children. protocols and processes should be devised a priori and should be transparent, taking into consideration the ethical principles of fairness and equitable care. pediatric disaster preparedness: best planning for the worstcase scenario risk reduction and emergency preparedness: who sixyear strategy for the health sector and community capacity development. world health organization mass casualty management systems. strategies and guidelines for building health sector capacity. world health organization global assessment of national health sector preparedness and response. world health organization critical concepts for children in disasters identified by handson professionals: summary of issues demanding solutions before the next one emergency department staff preparedness for mass casualty events involving children abc of conflict and disaster. the special needs of children and women tsunami mortality in aceh province who died as a result of the tsunami? risk factors of mortality among internally displaced persons in sri lanka: a retrospective cohort analysis characterisation of patients treated at the red cross field hospital in kashmir during the first three weeks of operation the union carbide disaster in bhopal: a review of health effects asian earthquake: report from the first volunteer british hospital team in pakistan overcoming legal obstacles involving the voluntary care of children who are separated from their legal guardians during a disaster fema's organized response with a pediatric subspecialty team: the national disaster medical system response: a pediatric perspective a mass casualty incident involving children and chemical decontamination disaster preparedness: hospital decontamination and the pediatric patient-guidelines for hospitals and emergency planners decontamination of multiple casualties who are chemically contaminated: a challenge for acute hospitals health care facility-based decontamination of victims exposed to chemical, biological, and radiological materials principles of disaster planning for the pediatric population infectious diseases that pose specific challenges after natural disasters: a review cholera in disasters: do vaccines prompt new hopes? the post-tsunami outbreak of diarrhoeal diseases in car nicobar island, india, was caused by human group a rotavirus g strains outbreak of rotaviral diarrhoea in a relief camp for tsunami victims at car nicobar island, india a tsunami related tetanus epidemic in aceh, indonesia outbreak of tetanus cases following the tsunami in aceh province selective ambulatory management of plasmodium falciparum malaria in paediatric refugees malaria and dengue infection after tsunami in southern thailand deficiencies in disaster funding: malaria epidemics are predicted in tsunami regions from el nino conditions disasters in health. typhoid epidemic in jamaica public health in crisis affected populations. a practical guide for decision makers. humanitarian practice network at the overseas development institute measles transmission following the tsunami in a population with a high one-dose vaccination coverage pandemic influenza planning for children and youth: who's looking out for our kids? pediatric epidemic crisis: lessons for policy and practice development severe acute respiratory syndrome in children carbon monoxide poisonings after two major hurricanes-alabama and texas building integrated mental health and medical programs for vulnerable populations post-disaster: connecting children and families to a medical home conflict-related mortality: an analysis of datasets prevention of excess mortality in refugee and displaced populations in developing countries the public health aspects of complex emergencies and refugee situations refugees and displaced persons. war, hunger, and public health mass population displacement. a global public health challenge health situation of refugees in eastern zaire child health in complex emergencies caring for children amidst chaos: guidelines to maintain health among the most vulnerable: women and children in global disasters lessons learned from complex emergencies over past decade psychological symptoms of turkish children and adolescents after the earthquake: exposure, gender, location, and time duration the psychosocial consequences for children of mass violence, terrorism and disasters caring for children and adolescents in the aftermath of natural disasters american academy of pediatrics committee on psychosocial aspects of child and family health, task force on terrorism. psychosocial implications of disaster or terrorism on children: a guide for the pediatrician psychological impact of disasters on children: review of assessment and interventions post-disaster victimization: how survivors of disasters can continue to suffer after the event is over research with children exposed to disasters recommendations to reduce psychological harm from traumatic events among children and adolescents family context and young children's responses to earthquake children's rights in emergencies and disasters reactions and needs of tristate-area pediatricians after the events of september th: implications for children's mental health services a critical concern: pediatrician self-care after disasters caring for evacuated children housed in the astrodome: creation and implementation of a mobile pediatric emergency response team: regionalized caring for displaced children after a disaster delphi study into planning for care of children in major incidents creating a regional pediatric medical disaster preparedness network: imperative and issues definitive care for the critically ill during a disaster: medical resources for surge capacity: from a task force for mass critical care summit meeting definitive care for the critically ill during a disaster: a framework for optimizing critical care surge capacity: from a task force for mass critical care summit meeting augmentation of hospital critical care capacity after bioterrorist attacks or epidemics: recommendations of the working group on emergency mass critical care availability of pediatric services and equipment in emergency departments: united states, - factors associated with ability to treat pediatric emergencies in us hospitals committee on pediatric emergency medicine and american college of emergency physicians, and pediatric committee ( ) care of children in the emergency department: guidelines for preparedness pediatric hospital and intensive care unit capacity in regional disasters: expanding capacity by altering standards of care the impact of the tsunami on hospitalizations at the tertiary care hospital in the southern province of sri lanka getting kids from the big easy hospitals to our place (not easy): preparing, improvising, and caring for children during mass transport after a disaster american academy of pediatrics committee on medical liability, task force on terrorism ( ) the pediatrician and disaster preparedness needs assessment: are disaster medical assistance teams up for the challenge of a pediatric disaster? treating natural disaster victims is dealing with shortages: an orthopaedics perspective epidemiology of spinal cord injuries in the pakistan earthquake spinal cord injury management and rehabilitation: highlights and shortcomings from the earthquake in pakistan feeding of infants and young children in tsunami affected villages in pondicherry the historical development of public health responses to disaster planning for major incidents involving children by implementing a delphi study training needs of pediatricians facing the environmental health and bioterrorism consequences of september th comparison of paediatric major incident primary triage tools prehospital preparedness for pediatric masscasualty events profile of injuries arising from the kashmir earthquake: the first h earthquake injuries and the use of ketamine for surgical procedures: the kashmir experience children and megadisasters: lessons learned in the new millennium training of health care professionals on the special needs of children in the management of disasters: experience in asia, africa, and latin america ethical triage and scarce resource allocation during public health emergencies: tenets and procedures clinical review: allocating ventilators during large-scale disasters-problems, planning, and process clinical review: mass casualty triage-pandemic influenza and critical care disaster triage systems for large-scale catastrophic events earthquakes and trauma: review of triage and injury-specific, immediate care mass-casualty triage: time for an evidencebased approach evolving need for alternative triage management in public health emergencies: a hurricane katrina case study ethical issues in resource triage triage in mass casualty incidents: challenges and controversies creating order from chaos: part i: triage, initial care, and tactical considerations in mass casualty and disaster response simple triage scoring system predicting death and the need for critical care resources for use during epidemics disaster preparedness, triage, and surge capacity for hospital definitive care areas: optimizing outcomes when demands exceed resources a procedure based alternative to the injury severity score for major incident triage of children: results of a delphi consensus process priority setting in a hospital critical care unit: qualitative case study bedside rationing by health practitioners: a case study in a ugandan hospital combining evidence and values in priority setting: testing the balance sheet method in a low-income country fairness and accountability for reasonableness. do the views of priority setting decision makers differ across health systems and levels of decision-making? federal emergency management agency website for children the youngest victims: disaster preparedness to meet children's needs tex" kissoon key: cord- -ddau fu authors: ciottone, gregory r. title: introduction to disaster medicine date: - - journal: ciottone's disaster medicine doi: . /b - - - - . - sha: doc_id: cord_uid: ddau fu nan c h a p t e r introduction to disaster medicine what exactly is disaster medicine? if you have decided to purchase and read this book, it is likely a question you have wrestled with. disaster itself is not an easily defined entity, thus the new medical specialty evolving around it is continuously undergoing metamorphosis. because a disaster is a local event, throughout history, the local medical responders have cared for the victims of disaster. the same medical personnel who provide health care on a daily basis also assume the responsibility of providing care to patients with illness or injury resulting from a disaster. unlike other areas of medicine, however, the care of casualties from a disaster requires the health care provider to integrate into the larger, predominantly nonmedical multidisciplinary response. this demands a knowledge base far greater than medicine alone. to operate safely as part of a coordinated disaster response, either in a hospital or in the field, an understanding of the basic principles of emergency management is necessary. now we begin to see the evolution of the specialty of disaster medicine. to respond properly and efficiently to disasters, all health care personnel should have a fundamental understanding of the principles of disaster medicine (which incorporates emergency management in its practice) and what their particular role would be in the response to the many different types of disasters. in the mid- s, disaster medicine began to evolve from the union of disaster management (now called emergency management) and emergency medicine. although disaster medicine is not yet an accredited medical subspecialty, those who practice it have been involved in some of the most catastrophic events in human history. practitioners of presentday disaster medicine have responded to the aftermaths of the tsunami in southeast asia, hurricane andrew, the haiti earthquake, the madrid train bombings, and the world trade center attacks, to name a few. during the past several decades, we have seen the first applications of basic disaster medicine principles in real-time events, and as demonstrated by the devastation caused by hurricane sandy in and the devastating ebola outbreak of - , there is sure to be continued need for such applications. the impetus for this text grew from a realization that as the specialty of emergency medicine grows, emergency physicians must take ownership of this new field of disaster medicine and ensure that it meets the rigorous demands put upon it by the very nature of human disaster. if we are to call ourselves disaster medicine specialists and are to be entrusted by society to respond to the most catastrophic human events, it is imperative that we pursue the highest level of scholarly knowledge and moral conduct in this very dynamic area. until there is oversight from a certifying board, it is our responsibility to the public to maintain this high level of excellence. as in medical ethics, where patients rely on the virtue of their physicians to compel them to abide by moral standards, so must we exercise virtue in how we conduct the medical response to disaster. because disasters strike without warning, in areas often unprepared for such events, it is essential for all emergency services personnel to have a foundation in the practical aspects of disaster preparedness and response. the first step is to understand that disaster can strike here at home. i can assure you the people of haiti minutes before the earthquake of and the people of japan minutes before the earthquake and tsunami of all were going about their normal daily routine, not expecting disaster to strike. then it did. as is discussed in other chapters throughout this text, emergency responders have an integrated role in disaster management. all disasters follow a cyclical pattern known as the disaster cycle ( figure - ) , which describes four reactionary stages: preparedness, response, recovery, and mitigation or prevention. emergency medicine specialists have a role in each part of this cycle. as active members of their community, emergency specialists should take part in mitigation and preparedness on the hospital, local, and regional levels. once disaster strikes, their role continues in the response and recovery phases. by participating in the varied areas of disaster preparation and response, including hazard vulnerability analyses, resource allocation, and creation of disaster legislation, the emergency medicine specialist integrates into the disaster cycle as an active participant. possessing a thorough understanding of the disaster medicine needs of the community allows one to contribute to the overall preparedness and response mission. over the course of recorded history, natural disasters have predominated in frequency and magnitude over human-made ones. some of the earliest disasters have caused enormous numbers of casualties, with resultant disruption of the underlying community infrastructure. yersinia pestis caused the death of countless millions in several epidemics over hundreds of years. the etiologic agent of bubonic plague, y. pestis, devastated europe by killing large numbers of people and leaving societal ruin in its wake. during the writing of this chapter, an ebola outbreak raged in west africa, along with concern that a worldwide pandemic might ensue. the and ebola and middle east respiratory syndrome (mers) outbreaks have proven that, despite the passage of time and the great advances in medicine, the world continues to be affected by disease outbreaks. in addition, diseases that have been eradicated have the potential of being reintroduced into society, either accidentally from the few remaining sources in existence around the world, as in the measles outbreak in the united states, or by intentional release. such events have the potential of devastating results, as the baseline intrinsic immunity the world population developed during the natural presence of the disease has faded over time, putting much larger numbers of people at risk. finally, with the advent of air travel allowing people to be on the opposite side of the world in a matter of hours, the bloom effect of an outbreak is much harder to predict and control. disease outbreaks that were previously controlled by natural borders, such as oceans, no longer have those barriers, making the likelihood of worldwide outbreak much greater now than it was hundreds of years ago. we saw evidence of this in , with ebola-infected patients arriving in spain and the united states from west africa. during that outbreak, naysayers to intrusive actions such as quarantine and travel restrictions cited following the "science" learned since the disease emerged in central africa in the s. the problem with such logic was that ebola had never before been seen in urban settings such as nigeria, new york city, and dallas, texas. transmission parameters in such settings were truly uncharted waters for the medical community. in addition to epidemics, with each passing year, natural disasters in the form of earthquakes, floods, and deadly storms batter populations. one need only to remember the destruction in terms of both human life and community resources caused by the indian ocean earthquake and tsunami of , the haiti earthquake in , or the earthquake, tsunami, and radiation disaster in japan in to understand the need for preparedness and response to such natural events. considering that the earthquakes that caused these tsunamis occurred hours before the devastation, it is difficult to understand how today's advanced society, able to travel far into space among other great achievements, was unable to mitigate against some of the most deadly natural events in recent history. the realization that disaster can strike without warning and inflict casualties on the order of the , , and earthquakes and tsunamis, despite our many technological advances, serves as a warning that mitigation, preparedness, response, and recovery to natural disaster must continue to be studied and practiced vigorously. today, the possibility of terrorist attack threatens populations across the globe. both industrialized and developing countries have witnessed some of the most callous and senseless taking of life, for reasons not easily fathomed by civilized people. it is unusual to read an internet news article or watch a television newscast without learning of a terrorist attack in some part of the world. with the advent of more organized groups such as the islamic state of iraq and syria (isis), boko haram, the revolutionary armed forces of colombia (farc), and the epanastatikos agonas (ea), these attacks are more frequent and deadly, often using horrifying means of execution. the commonplace nature of a terrorist attack in modern society ensures it is unquestionably something that will continue long into the future, and will very likely escalate in scale and frequency. the multilayered foundation on which ideological belief evolves into violent attack is beyond the scope of analysis that this book ventures to undertake. these ongoing events do demonstrate, however, that the principles studied in the field of disaster medicine must include those that are designed to prepare for and respond to a terrorist attack. because there are very intelligent minds at work designing systems to bring disaster on others, equally there must be as robust an effort to prepare for and respond to those disasters. such response involves the deployment of law enforcement, evidence collection, and military personnel and equipment, which are typically not seen in the response to a natural disaster. the integration of these unique assets into the overall response is essential for the success of the mission. the disaster medicine specialist must have a thorough understanding of the role of each. a thorough discussion of disaster preparedness and response must be predicated on a clear definition of what, in fact, constitutes a disaster. used commonly to describe many different events, the word disaster is not easily defined. the indian ocean tsunami in and the haiti earthquake in , each killing significantly more than , people, would certainly meet the criteria for disaster. however, the flood in peru that killed people and tropical storm in madagascar that killed have also been called disasters. likewise, the explosion of the space shuttle columbia on reentry into earth's atmosphere that killed the crew of seven astronauts onboard has often been referred to as the columbia disaster in the lay press. how can an event resulting in the loss of seven people be placed in the same category as one that kills hundreds of thousands? herein lies the paradox of disaster. what is it? who defines it, and by what criteria? it is difficult to dispute that an event causing thousands of casualties should be considered a disaster, but let us analyze why that is the case. what is it about the sheer number of dead and injured that allows the event to be called a disaster? in terms of medical needs, it is simply because there is no health care system on earth that can handle that number of casualties. therefore an event of such magnitude is a disaster because it has overwhelmed the infrastructure of the community in which it occurred. following this logic, we can then also make the statement that any event that overwhelms existing societal systems is a disaster. this definition is close to the definition of disaster given by the united nations international strategy for disaster reduction (unisdr) : a serious disruption of the functioning of a community or a society involving widespread human, material, economic, or environmental losses and impacts, which exceeds the ability of the affected community or society to cope using its own resources. a similar definition is used by the world health organization (who). by applying these definitions, one can understand how an event in a rural area with to casualties may also be considered a disaster because the limited resources in that area may prevent an adequate response without outside assistance. the widely accepted unisdr and who definitions of disaster justify describing both the haiti earthquake and the flood in peru as disasters. however, what about the destruction of the space shuttle columbia on reentry? clearly, this definition does not allow one to justify the use of disaster in describing that horrific accident, which brings to light a discrepancy in how disaster specialists and the public term events. the columbia accident, as an example, does not meet any accepted criteria of disaster. it was, however, an exceedingly tragic event, seen by millions on television, as it was unfolding. it was tragic by the word's very definition in the cambridge dictionary: "a very sad event, especially one involving death or suffering." public perception of such events may cause this misnomer, with a tragic incident being termed a disaster. much like disaster, tragedy can also have a profound and lasting effect on society, especially a tragedy that is widely viewed through modern media outlets. this text, however, will follow the unisdr and who definitions when discussing disaster. disaster medicine is a discipline resulting from the marriage of emergency medicine and disaster management. the role of medicine and emergency medical services in disaster response has abundant historical precedence. responsibility for the care of the injured from a disaster has been borne by the emergency specialist or its equivalent throughout history. therefore disaster medical response, in its many forms, has been around for thousands of years. whenever a disaster has struck, there has been some degree of a medical response to care for the casualties. in the united states, much of the disaster medical response has followed a military model, with lessons learned through battlefield scenarios during the last two centuries. the military experience has demonstrated how to orchestrate efficient care to mass casualties in austere environments. however, it does not translate directly into civilian practice. for instance, scenarios encountered on the battlefield with young, fit soldiers injured by trauma are vastly different from those encountered in a rural setting, where an earthquake may inflict casualties on a population with baseline malnutrition or advanced age. with this realization came the need to create disaster medicine as an evolution from the military practice. this recent organization of the medical role in disasters into a more formalized specialty of disaster medicine has enabled practitioners to define further their role in the overall disaster preparedness and response system. disaster medicine is truly a systems-oriented specialty, and disaster specialists are required to be familiar and interact with multiple responding agencies. the reality is there is no "disaster clinic." no practitioners leave home in the morning intent on seeing disaster patients. disaster medical care is often thrust upon the practitioner and is not necessarily something that is sought out. the exception to this is the medical specialist who becomes part of an organized (usually federal) disaster team, such as a disaster medical assistance team (dmat). in this case, one may be transported to a disaster site with the intention of treating the victims of a catastrophic event. in all other circumstances, however, the disaster falls on an unsuspecting emergency responder who is forced to abandon his or her normal duties and adopt a role in the overall disaster response. unlike the organized disaster team member, if an emergency provider treats casualties from a disaster, it will most likely be because of an event that has occurred in his or her immediate area. because of the random nature of disaster, it is not possible to predict who will be put into that role next. therefore it is imperative for all who practice in emergency health services to have a working knowledge of the basics of disaster medicine and disaster management. in addition, especially with natural disease outbreaks and the escalation in perceived and real terrorist threats of - , there are several possible natural or attack scenarios that may involve dangerous chemical, biological, or nuclear agents and modalities. a response to these events may also require a robust public health system and knowledgeable health care practitioners spanning all specialties. most clinicians will have a very limited knowledge of many of these agents, so it is therefore important to educate our potential disaster responders on their specifics. the field of disaster medicine involves the study of subject matter from multiple medical disciplines. disasters may result in varying injury and disease patterns, depending on the type of event that has occurred. earthquakes can cause entrapment and resultant crush syndrome; tornados may cause penetrating trauma from flying debris; and infectious disease outbreak, either natural or intentional, can result from many different bacteria, viruses, and fungi. because of the potential variability in casualty scenarios, the disaster medicine specialist must have training in the many injury and illness patterns seen in disaster victims. even though the expanse of knowledge required is vast, the focus on areas specifically related to disaster medicine allows the science to be manageable. the study of disaster medicine should not be undertaken without prerequisite medical training. a disaster medicine specialist is always a practicing clinician from another field of medicine first and a disaster specialist second. by integrating these many disciplines, one is better prepared for the variety of injury and illness patterns that may be faced. finally, disaster medicine presents unique ethical situations not seen in other areas of medicine. disaster medicine is predicated on the principle of providing care to the most victims possible, as dictated by the resources available and by patient condition and likelihood of survival. this amounts to a balance of needs versus assets, an equation that can change over time as more resources are pulled into the response. thus the triage of patients in disasters is fluid and should be repeated regularly. disaster triage involves assigning patients into treatment categories based on their predicted survivability. this triage process may dictate that the most severely injured patient is not given medical care but rather, it is given to a less critically injured patient. to the best of his or her ability, the triage officer must make a determination as to whether, in the environment of the specific disaster and the availability of resources, a given patient has a significant probability of survival or does not. if it is the latter, disaster triage principles mandate that care be given to the patient with a higher likelihood of survival. this basic disaster triage principle can have a profound psychological effect on the care provider. as a physician, one is trained to render care to the sick and not to leave the side of a needy patient. to deny care to a critically ill or injured patient can be one of the most emotionally stressful tasks a disaster medicine specialist performs. the unique and ever-changing circumstances under which disaster medicine specialists operate mandate the continued evolution and vigorous pursuit of academic excellence in this new specialty. a comprehensive approach that unifies medical principles with a sound understanding of disaster management procedures will yield a wellrounded and better-prepared disaster responder. if emergency medicine providers around the world can develop a basic understanding of the fundamental principles of this specialty, great advances in the systems included in the disaster cycle will surely follow. the more widely dispersed this knowledge becomes, the better prepared we are as a society to respond to the next catastrophic event. tsunami in thailanddisaster management in a district hospital a comparison of patient needs following two hurricanes analysis of the international and us response to the haiti earthquake: recommendations for change casualties treated at the closest hospital in the madrid the world trade center attack: lessons for disaster management identifying sources of human exposure to plague the ebola crisis: perspectives from european public health united nations international strategy for disaster reduction worldwide disaster medical response: an historical perspective key: cord- - yo rfml authors: bortolin, michelangelo; ciottone, gregory r. title: disaster medicine date: - - journal: trauma team dynamics doi: . / - - - - _ sha: doc_id: cord_uid: yo rfml millions of people every day face disasters, for example, typhoons, terrorist attacks, earthquakes, famine, civil wars, explosions, and tornadoes. disaster is defined as every event that causes serious disruption which exceeds the ability of the affected community or society to cope using its own resources. disasters are usually categorized as natural or man-made and are described using a series of steps called the disaster cycle, defined in four phases: mitigation and prevention, preparedness and planning, response, and recovery. disaster medicine is an emerging specialty that integrates the medical response to disaster with the systems of disaster management. devastating events such as natural disasters like the typhoon in the philippines ( ) and the earthquake in haiti ( ), intentional events like the terrorist attack in new york ( ) , and the sarin attack in tokyo's subways ( ) demonstrate that disasters are both unpredictable and ubiquitous. disaster is defi ned as any event that causes "a serious disruption of the functioning of a community or a society involving widespread human, material, economic or environmental losses and impacts, which exceeds the ability of the affected community or society to cope using its own resources" [ ] . considering that any number of different events could hit a population at any time, there is no place on earth completely immune to disasters. therefore, disaster medicine was created as a broad specialty grounded in emergency medicine, but utilizing the skill sets of other surgical and medical specialties, and only able to become operational in combination with the systems supported by disaster management. for example, during an earthquake, several specialties are involved in the response and immediate care of the victims: emergency physicians, surgeons, anesthesiologists, and orthopedics; however, other subspecialties are also required in the ongoing care of victims. these include nephrologists to treat acute renal failure related to crush syndrome, both during and following the event, and psychosocial and rehabilitation specialties for continued care. these medical and surgical specialists are only able to perform their roles under the umbrella of disaster management. without being enabled by the logistics and operations capabilities seen in a large-scale disaster response, these specialists would not be functional. outbreaks and human immunodefi ciency virus (hiv) are just two examples of natural disasters that for several reasons can spread quickly, ravaging entire communities. the spanish fl u in the early s caused more than million deaths, and severe acute respiratory syndrome, (sars) that arose from china in , resulted in thousands of death in that part of the world and concern for a global pandemic. another virus that affl icts and kills millions of people, particularly in the poor areas of africa and developing countries, is hiv. it is estimated that from the s, hiv has caused more that million deaths around the world. an estimated % of natural disaster-related deaths occur in developing countries (world bank, - [ ] . man-made disaster is defi ned as any event that is caused by the activity of human beings. explosions, building collapse, civil wars, and nuclear accidents are some examples. the collapse of the hyatt regency hotel in kansas city in is one such example. investigations found that the cause of the collapse was due to an engineering problem. there were more than deaths and more than casualties from that disaster. the transportation industry is commonly involved in incidents that cause large numbers of injured and dead. in in eschede, germany, a high-speed train derailed causing fatalities. other industrial sectors, such as the chemical industry, have also been involved in man-made catastrophes. in december in bhopal, india, more than half a million people were exposed to methyl isocyanate. in the immediate phase after the leak, almost , people died. the indian government has calculated that this event has caused over the years almost , casualties due to lingering effects of the chemical exposures [ , ]. the / terrorist attack in new york and the oklahoma city bombing ( ) are also man-made disasters. it is important to recognize and underline that disasters also result from war, the conduct of repressive regimes, the use of sanctions, as well as economic and social policies, particularly in developing countries [ ] . the syrian civil war arose in the and has caused more than , deaths and more than . million refugees since [ ] . disasters and the response to them follow a pattern called the disaster cycle, which is defi ned in four phases: mitigation and prevention, preparedness and planning, response and recovery. mitigation and prevention involve measures designed either to prevent hazards from occurring or to lessen the effects of the disasters [ ] . these measures involve multiple different agencies and commissions, for example, policymakers introducing regulations regarding the storage, transportation, and disposal of chemical substances. another example of mitigation is to empower a public health system to monitor and conduct surveillance for infection diseases and at the same time introduce rules regarding health screening at the borders. the importance of the mitigation phase is to avoid disaster or to reduce the impact on the population. it is clear if we compare the earthquake in haiti, with a magnitude of . , and similar earthquakes in japan where despite the same magnitude the number of dead and injured were more limited, that we see the effect of a disaster is often dependent on the underlying condition of the area affected. for decades, japan has introduced strict building codes that follow seismic regulations. nevertheless, it is not possible to fully mitigate against all disaster events. for instance, the earthquake in the pacifi c ocean produced a tsunami that hit the east coast of japan and caused severe damage, in particular a failure of the nuclear plant in fukushima, with release of radiation that affected the local community. the preparedness and planning phase includes all activities conducted on an ongoing basis, in advance of any potential incident. preparedness involves an integrated combination of assessment; planning; procedures and protocols; training and exercises; personnel qualifi cations, licensure, and certifi cation; equipment certifi cation; and evaluation and revision [ ] . the fi rst step of preparedness is defi ning what events are more likely to hit a community. the hazard and vulnerabilities assessment (hva) is a way to objectively risk-stratify those hazards that are more likely to strike a given community. the hva takes into account different events: natural, man-made, and cbrn (chemical, biologic, radiological, and nuclear). the output from an hva prioritizes the risks to which a population is most susceptible and should therefore be prepared for. after the hva, it is possible to then establish standard operating procedures (sop) and the emergency operations plan (eop) for the community or hospital. it is a good rule that the eop adopts an allhazards approach to preparedness, with annexes and appendices specifi c for every type of probable event [ ] . an important part of the preparedness phase is training. in particular, every healthcare professional must be trained when to activate a disaster response and their own specifi c roles and responsibilities within the framework of the response. the typical drills commonly used are tabletop and full-scale exercises. they are important also to identify shortfalls, bottlenecks, and gaps in the eop. the staff should take part in the training, and the eop should be tested, reviewed, and updated at least once per year. response is the phase in which agencies and sections with responsibility to deploy to disasters activate their emergency response plan as a result of specifi c threats or situations and can incorporate local, regional, and federal response agencies [ ] . the response is conducted through the intervention of several agencies and must be fl exible and adaptable for any type of event. it is important to immediately establish a response framework with a unifi ed command structure that establishes a chain of command, control, and coordinate the resources, in terms of staff, stuff, and structure. the incident command system (ics) provides a structure to enable agencies with different legal, jurisdictional, and functional responsibilities to coordinate, plan, and interact effectively on scene [ ] . the medical response is provided at the scene by the emergency medical services (ems), with triage, treatment, and transport to the hospitals. ems plays a crucial role in the immediate phase of the response to disaster. the response must be quick and effective on the scene as well as in the determination of hospital destinations for every patient, to guarantee an appropriate standard of care and to avoid bottlenecks and congestion at hospitals. rarely, ems is able to triage, treat, and transport every single patient from the scene. often some casualties reach the closest hospital on their own, giving rise to disruption in the chain of triage and to the hospital. the ability of a healthcare system to suddenly expand its capacity beyond normal services to meet the increased demand for qualifi ed medical staff and services during a large-scale event is defi ned as "surge capacity" [ ] . the surge capacity depends on the features of the healthcare system, but also by an effective eop and training of the staff. the post-impact period revolves around disaster recovery in which the goal is to eliminate impairment caused by a disaster and rebuild communities and infrastructures [ ] . also this phase involves several agencies and may be long lasting, ranging from weeks to years. people affected by a tremendous disaster must face a long recovery phase. survivors from the september , , terrorist attacks on the twin towers not only had immediate treatment in the fi eld and in the hospitals that day, but their treatment has continued for years. the majority of people exposed to disasters do well; however, some individuals develop psychiatric disorders, distress, or risky behaviors such as an increase in alcohol or tobacco use [ ] . the department of health and human services spent months and years following the / attacks and has gone on to provide health care, both physical and mental, to those who were, and continue to be, affected and in need [ ] . the recovery phase often also involves rescue workers as their exposure to the traumatic event has a severe impact on their mental health. studies confi rm that rescue workers are prone to have diseases or documented behavioral health disturbances following events. for example, several articles describe how the acute and prolonged exposures were both associated with a large burden of asthma and posttraumatic stress (pts) symptoms years after the / attack. during an incident, the response must be effective and efficient. to achieve this, and thereby ensure that the best care possible is rendered to victims, it is fundamental to have a well-prepared and organized system. the incident command system (ics) is a standardized, on-scene, all-hazards incident management concept and allows its users to adopt an integrated organizational structure to match the complexities and demands of single or multiple incidents without being hindered by jurisdictional boundaries [ ] . the ics was developed in the s in california to manage, command, and control fi re brigades during their operations to extinguish wild fi res. shortly after that, it was adopted by ems and other agencies, as well as endorsed by the u.s. department homeland security as a fundamental element of incident management. the ics is used for all events and is modifi ed depending on the size of the incident. its goal is to manage and to resolve the incident with an effi cient use of resources while protecting all persons involved. the ics is a modular and fl exible organizational system that can be standardized for multiple uses. the ics is modifi ed according to the size and complexity of the incident, specifi cs of the hazard, environment effected by the incident, the incident planning process and incident objectives (ics expansion and contraction) [ ] . the ics establishes an incident commander (ic), who is in charge of all the activities regarding the incident, a chain of command, and unifi ed command between the agencies. the priorities of the ic are three: the safety of the casualties and the rescue team, incident stabilization, and property preservation. every incident must have an incident action plan (iap) that establishes incident goals, operational period objectives, set activities, and the response strategy defi ned by the ic during response planning [ ] . the ic manages and carries out his responsibilities with three features of command that are important for every role within the framework of the ics: the chain of command, the unity of command, and the span of control. the chain of command is a key part of the ics and is defi ned as a structure with a clear line of authority. the unity of command infers that every responder knows without question who his/her supervisor is. span of control describes the typically - people a supervisor directly leads. during a disaster, it is extremely important to establish a unifi ed command, because it enables all responsible agencies to manage and coordinate an incident together by establishing a common approach and a single iap. it permits the integration of staffi ng and shared facilities, with everyone having the same objectives and not replicating efforts [ ] . the iap describes activities, responsibilities, and the communication procedures. this system is fundamental to avoid confusion and lack of communications. adequate and redundant communication systems are very important during the response to disaster. it is essential that the ics use common terminology and integrated communications among agencies and establish precise ways of communications. the communication systems should be: interoperable between agencies; reliable to function in the context of any kind of emergency; portable, built on standardized radio technologies, protocols, and frequencies; scalable as the needs of the incident dictate; resilient to perform despite damaged or lost infrastructure; and redundant to enable the use of alternate communications methods when primary systems go out [ ] . the ics is supported by a command staff that includes a safety manager, a liaison offi cer, and a public information offi cer. it is organized into four sections, the general staff, which supports the ics: operation, planning, logistics, and fi nance/administration. the operation section is in charge of managing all the tactical operations on the scene; tactical operations include fi re brigades, ems, and every agency required for the incident. the planning section is responsible to draft the iap; to get, receive, elaborate, and share information; and to track all the resources. the logistic section provides the supplies, needs, and the facilities and supports the personnel with food, water, and fi rst aid. the fi nance/administration section is in charge of tracking all the costs and to negotiate and supervise contracts. these sections, like the ics, are modular organizations and can be further expanded into: units (the organizational element with functional responsibility for a specifi c incident planning, logistics, or fi nance/administration activity), divisions (only for operation section, used to divide an incident geographically), groups (only for operation section, established to divide the incident management structure into functional areas), and branches (used when the number of divisions or groups exceeds the span of control and can be either geographical or functional for major aspects of incident operations) [ ] . triage in a disaster event places casualties in four classes: black (or expectant), red (or immediate, priority ), yellow (or delayed, priority ), or green (or minor, priority ) in agreement with the severity of the injuries. when sorting casualties, it is important to give immediate medical care to critical patients that have a chance of survival with prompt, advanced treatment. in minor patients and patients who are so severely injured that they have very little chance of survival treatment is delayed. the goal is to provide the greatest good for the greatest number of patients, forcing the triage offi cer to decide whether the chance of a patient surviving is so low in comparison to the burden such care would place on the medical system that the patient must be consigned to the "expectant" category (dying; little or no treatment) [ ] . the concept of triage must be seen in a wider context and is composed of the following elements: rapid evaluation of all disaster victims, assessment of the nature and severity of the injuries and its consequences on the vital functions of the casualties, and categorization of the casualties, resuscitation, stabilization, and conditioning for transport, distribution, and evacuation of the casualties [ ] . triage is a quick and dynamic process. this means that it must be repeated often and at every moment in which a new healthcare professional takes control of a patient, for example, during transport, at arrival at the hospital, or if there is the suspicion that the state of the patient has changed. triage will be discussed further in the chap. . the "second hit" is a classic tactic and pattern seen in terrorist attacks. it is defi ned as second incident caused by the terrorists, following the fi rst event, with the goal of striking the fi rst responders that are on scene. typically, it is a second explosion close to the scene and often more powerful than the fi rst detonation. this is because the intention is to create casualties during the fi rst blast and to attract people to the scene and then striking them with a larger detonation. this achieves the goal of a terrorist attack: to cause additional chaos thereby delaying the response and causing great physical and psychological impact on the populations and on the rescuers. an example of this was the terrorist attack in in bali. two bombs detonated within a short period of time. the fi rst was concealed in a vest worn by a suicide bomber. the second charge was in a minivan about m away when the fi rst explosion happened. the force of the car bomb was enormous [ ] . terrorist attacks are very challenging and diffi cult to manage, because they are designed to create loss of life and property damage, disruption of the agencies involved in the response, and fear and harm to the population. the israel response system is very seasoned to terrorist attack and has specifi c guidelines and protocols in case of attacks to avoid damage from a "second hit." traditionally, medical teams do not enter the scene of the explosion until it is deemed safe by police or army personnel. with many of the terrorist attacks in israel, a secondary explosion or bomb is set off timed to cause additional injuries to the emergency personnel and bystanders responding to the primary event. however, because time is critical, often ems does not wait for such security clearance and attempts to rapidly remove the casualties from the immediate vicinity of the initial event. the only medical care given before this initial evacuation is external hemorrhage control [ ] . they apply the "scoop and run" approach on the scene (minimal resuscitation on the scene and immediate transportation to the trauma center) to clear the casualties from the area of the event but in the meantime minimize the risk for the rescuers. therefore, in case of a terrorist attack, it is imperative to maintain the role of the incident commander, the coordination between the agencies, and training of the rescuers to guarantee the safety of all the workers involved in the response. the united nations offi ce for disaster risk reduction, terminology world bank seminar on the role of local governments in reducing the risk of disasters man-made disaster and development-the case of iraq united nations high commissioner for refugees, stories from syrian refugees community emergency preparedness: a manual for managers and policy-makers guide for allhazard emergency operations planning public health and disasters, chapter department of homeland security national response. national response framework (nrf) das konzept von "surge capacity" im katastrophenfall notfall rettungsmed koenig and schultz's disaster medicine: comprehensive principles and practices individual and community responses to disasters testimony before the committee on oversight and government subcommittee on government management, organization and procurement united states house of representatives, on / health effects: hhs's monitoring and treatment of responders federal emergency management agency "ics- . a: introduction to ics emi course number: is ". student manual version ics- : single resources and initial action incidents" emi course number: is instructor guide version offi ce of the assitant secretary for preparedness and response. what is an incident action plan? ics- intermediate ics for expanding" student manual is- .a: national incident management system, an introduction federal emergency management agency. introduction to the incident command system (ics ) student manual mostly dead: can science help with disaster triage? triage unit for emergency preparedness, committee for disaster medicine studies. the terror attack on bali medical lessons from terror attacks in israel • disaster is defi ned as any event that causes serious disruption of society which exceeds the ability of the affected community to cope using its own resources. • disasters are usually categorized as natural or manmade, and response to them follows the same pattern, called the disaster cycle, defi ned in four phases: mitigation and prevention, preparedness and planning, response, and recovery. • the incident command system (ics) is a standardized and modular organization, on-scene, and allhazards incident management concept and allows its users to adopt an integrated organizational structure to match the complexities and demands of single or multiple incidents. • the word triage means "to categorize, to sort." the purpose of triage in a disaster event is to catalogue the casualties in agreement with the severity of injuries. sorting casualties is important to give immediate medical care among critical patients that have a chance of survival. the goal is to provide the greatest good for the greatest number of patients. • the "second hit" phenomenon is a classic tactic and pattern of terrorist attacks. it is defi ned as a second incident caused by the terrorists, a little bit later than the fi rst event that is geared to injure the fi rst responders that are on the scene. key: cord- -yan q r authors: woolard, robert h. title: emergency department design date: - - journal: disaster medicine doi: . /b - - - - . - sha: doc_id: cord_uid: yan q r nan in the aftermath of recent terror events and subsequent disaster planning, hospital architects have begun to design eds to better meet the needs anticipated from a terror attack. some ed design lessons have been learned from terror events. from the tokyo sarin gas event and other natural disasters, such as earthquakes, hospitals know they will need to plan for surge capacity. methods of alerting ed staff early and protecting emergency care providers from contamination are needed, another lesson made clear by the tokyo sarin gas event in which many emergency providers were contaminated. the new york city world trade center event illustrated the need to respond to a disaster scene and continue to treat a sustained increase in ed volume over prolonged periods. in new york, the clean-up phase after the event led to prolonged increased prehospital and ed volume. most care was provided by emergency personnel working close to ground zero. from the anthrax mailings in the wake of the world trade center event, we can learn to anticipate the need for accurate public information. the ed remains the most available point of access to immediate healthcare in the united states. ed designers are now anticipating increased volumes of patients that might be generated by disaster or a terror event. although a stressed public needs information and health screenings that perhaps can be met by providers outside the ed, the ed will be accessed for counseling and screening when other services are overwhelmed or delay to access is encountered. in past disasters, shelter needs were met outside the ed. however, needs for quarantine during bioterror events may create shelter needs in eds. ed design and response capability after sept. has become a larger concern for public disaster planners, the federal government, and hospital architects. two federally funded projects coordinated by emergency physicians, one at washington hospital center (er ) and another at rhode island hospital (ridi), have developed and released recommendations. er suggests designs for a new ed that meets any and all anticipated needs of a disaster event. ridi has developed new disasterresponse paradigms, training scenarios, and response simulations that also can be used in ed design. ed design would be tremendously enhanced if a prototype "disaster-ready" ed such as er could be built. ed designers may not be able to create an "all-risks-ready"ed given financial constraints. however, incorporating disaster-ready suggestions when eds are renovated or built new will improve our readiness and may be more financially feasible. new building materials, technologies, and concepts will continue to inform the effort to prepare eds for terror attack. urban ed trauma centers are attempting to develop capacity to serve as regional disaster resource centers and respond out to a terror event. these eds are designed to incorporate larger waiting and entrance areas, adjacent units, or nearby parking spaces in their plans to ramp up treatment capacity. more decontamination and isolation capacity is being built to help control the spread of toxic or infectious agents. information systems are being made available to provide real-time point-of-service information and any needed "just in time" training for potential terror threats. the technology needed to respond to a terrorist event, such as personal protective equipment (ppe), is becoming more widely available and is stored where easily available in eds. although mass decontamination can occur close to the disaster scene, eds are gearing up to decontaminate, isolate, and treat individuals or groups contaminated with biologic or chemical materials. four elements of ed design are being addressed to prepare eds for terror events: scalability, security, information systems, and decontamination. eds are generally designed with sufficient, but not excess, space. the number of treatment spaces needed in an ed is usually matched to the anticipated ed patient volume; roughly treatment space per annual ed visits or treatment space per annual ed hospital admissions is recommended. according to disaster planners, a major urban trauma center ed built for , to , visits per year should have surge capacity up to patients per hour for hours and patients per day for days. one sept. challenge is to provide "surge capacity" to meet anticipated patient needs. hospitals are woefully overcrowded, and eds are routinely housing admitted patients. [ ] [ ] [ ] eds are now being designed to allow "growth" into adjacent space: a ground level or upper level, a garage, or a parking lot. garage and parking lot space has been used in many disaster drills and mass exposures. garages and parking lots are more purposely designed with separate access to streets, allowing separation of disaster traffic and routine ed traffic. needed terror-response supplies (e.g., antidotes, respirators, personal protective gear) are being stored near or within the ed. the cost of ventilation, heat, air conditioning, communication, and security features often prohibits renovation of garages. more often, tents are erected over parking lots or loading areas. modular "second eds," tents or structures with collapsible walls (fold and stack), have been deployed by disaster responders. these can be used near the main ed, preserving the ed for critical cases. some hospitals are considering beds in halls, patient rooms, and other spaces to increase their ability to generate surge capacity. hallways can provide usable space if constructed wider and equipped with medical gases and adequate power and lighting. often only minimal modifications are necessary to make existing halls and lobbies "dual-use" spaces. some hospitals have increased space by installing retractable awnings on the exterior over ambulance bays or loading docks. tents are often used outside eds as decontamination and treatment areas in disaster drills. tents with inflatable air walls have the added benefit of being insulated for all-weather use. in the military, the need to provide treatment in limited space has resulted in the practice of stacking patients vertically to save space and to reduce the distances that personnel walk. u.s. air force air evacuation flights have stacked critical patients three high. these bed units could be deployed for a mass event. portable modular units are also available to help eds address the space needs. unfortunately, many eds rely on other facilities in the regional system. in a terror event on a hospital campus, the ed function may need to be moved to a remote area within the hospital. many disaster plans designate a preexisting structure on campus as the "backup" ed. the area is stockpiled with equipment, and plans for access and patient and staff movement are developed. although the capacity to handle patient surges is being addressed regionally and nationally, large events with high critical care volumes may overtax the system of the trauma centers regionally. the national medical disaster system can be mobilized to move excess victims and establish field hospitals during events involving hundreds or thousands of victims. the ed plan to provide treatment during disaster must consider evacuation, since the event may produce an environmental hazard that contaminates the ed. evacuation of ed patients has been addressed by ed designers. some eds have the capacity to more easily evacuate. in better planned eds, stairwells have floor lights to assist in darkness. stairways are sufficient in size to allow backboarded patients to be evacuated. the communication and tracking system includes sensors in corridors and stairways. patient records are regularly backed up to portable disk and available for evacuation. securing the function of an ed includes securing essential resources: water, gases, power, ventilation, communication, and information. ed security involves surveillance, control of access and egress, threat mitigation, and "lockdown" capacity. surveillance exists in almost all eds. many ed parking and decontamination areas are monitored by cameras. the wireless tracking system can also be part of the surveillance system. a tracking system can create a virtual geospatial and temporal map of staff and patient movement. tracking systems have been used in disaster drills to identify threat patterns. most eds have identification/access cards and readers. chemical and biologic sensors for explosives, organic solvents, and biologic agents are becoming available. when selecting a sensor, designers consider sensitivity, selectivity, speed of response, and robustness. [ ] [ ] [ ] [ ] [ ] sensor technology is an area of active research that continues to yield new solutions that are being incorporated into eds. in concept, all entrances could be designed to identify persons using scanning to detect unwanted chemicals,biologic agents,or explosives and to detain and decontaminate as needed. most eds have multiple entry portals for ingress of patients, visitors, staff, vendors, law enforcement personnel,and others. eds are using screening and identification technologies at all entrances in combination with closed circuit video monitoring. personnel must be dedicated for prompt response when needed. automation of identification can efficiently allow safe flow of patients, staff, and supplies. vehicle access has been managed by barcoding staff and visitor vehicles. at some road access points, automated scanners could monitor and control vehicle access. modern eds limit the number of entrances and channel pedestrian and vehicular traffic through identification control points. for the most part, points of entrance into the ed can be managed with locking doors, id badge control points, and surveillance to allow desired access for staff and supplies. thoughtful planning should facilitate rapid access between the functional areas such as the ed, operating rooms, and critical care units. movement within and between buildings needs to be controlled and must allow a total lockdown when necessary. direct threats to the ed include blasts and chemical, biologic, and environmental contamination. there are several strategies to mitigate blast. twelve-inch-thick conventional concrete walls, using commercially available aggregates ( lb per cubic foot) affords reasonable blast protection. , on some campuses, the space between the ed and the entrance is designed largely to prevent direct attack. however, atriums are terror targets. although atriums are useful as overflow areas, their windows and glass create hazardous flying debris. given the threat of blast attack, communication, gas, electric, water, and other critical services should be remote from vulnerable areas and shielded when they traverse roads and walkways. protection against release of chemical and biologic agents inside or outside the ed requires a protective envelope, controlled air filtration in and out, an air distribution system providing clean pressurized air, a water purification system providing potable water, and a detection system. better hvac systems can pressurize the envelope and purge contaminated areas. anticipated computing needs for ed operations during disaster events are immense. in most eds, large amounts of complex and diverse information are routinely available electronically. overflow patients in hallways and adjacent spaces can be managed with mobile computing, which is available in many eds. wireless handheld devices can facilitate preparation for disasters and allow immediate access to information by providers in hallways and decontamination spaces. multiple desktop workstations are available throughout most eds. during disaster, displays of information that will aid decisionmaking include bed status, the types of rooms available, the number of persons waiting, and ambulances coming in. monitors now display patient vital signs, telemetry, and test results. significant improvements in efficiency and decision-making can be achieved when more realtime information is available to decision-makers. multiple computer screens enhance ed readiness. clinical decision tools, such as uptodate, make information readily available to providers. these and other "just-in-time" resources will be needed when practitioners treat unusual or rare diseases not encountered in routine practice. the wide variety of potential disaster scenarios argues for the availability of just-in-time information. information specific to a disaster event should be broadcast widely on multiple screens in many areas. cellular links and wireless portable devices should also receive information. access to information has been enhanced in most eds through cell phone use, etc. this facilitates making information available to guide each staff member. diagnostic decision support systems have been demonstrated to help practitioners recognize symptom complexes that are uncommon or unfamiliar. information systems should be capable of communicating potential terror event information regularly. many eds have log-on systems that require staff to read new information. in a disaster-ready ed, a list of potential threats could be posted daily. however, the utility of computer references or on-call experts is limited by the practitioner's ability to recognize a situation that requires the resource. computer-based patient-tracking systems are available for routinely tracking patients in most eds. some computer-based tracking systems have a disaster mode that quickly adapts to a large influx of patients allowing for collation of symptoms, laboratory values, and other pertinent syndromic data. in many regions, eds serve as a terror surveillance network. routine data obtained on entry are passively collected and transferred to a central point for analysis. in the event of a significant spike in targeted patient symptom complexes, these data can trigger an appropriate disaster response. the capacity for this entry point surveillance should be anticipated and built into any disaster-ready ed information system. [ ] [ ] [ ] for example, data terminals allowing patient input data at registration similar to electronic ticketing at airports could passively provide information. this selfservice system could add to ed surge capacity. similarly, real-time bed identification, availability, and reservation systems used to assist patient management in some eds could aid ed function during disaster. movement to an inpatient bed is a well-documented choke point recognized nationally during normal hospital operations and becomes an issue during disaster. lobby screens can facilitate family access to information during a disaster, displaying information about the event and patient status. during disasters, family members can be given access to screens to query for missing persons. computers with internet access that could display event information are available in patient rooms in some eds. during the anthrax mailings, public hysteria taxed the healthcare system. posttraumatic stress, anxiety, and public concern over possible exposure to a biologic or chemical agent may generate a surge of minor patients at eds. within some eds, lecture halls or media centers are available (generally used for teaching conferences) but could provide health information and media briefings during disaster. the media are an important source of public information and must be considered when planning disaster response. information from a media center in the ed could be released to the internet and closedcircuit screens. accurate information can allay public concerns and direct the public to appropriate resources and access points. many eds have patient decontamination (decon) areas. adequate environmental protection for patients undergoing decon is necessary and includes visual barriers from onlookers, segregation of the sexes, and attention to per-sonal belongings. , in many eds, decon areas are being added to accommodate mass exposures. eds have added or augmented decon facilities. decon areas should have a separate, self-contained drainage system, controlled water temperature, and shielding from environmental hazards. exhaust fans are used to prevent the buildup of toxic fumes in these decontamination areas. for most eds, mass decon has been accomplished by using an uncovered parking lot and deploying heated and vented modular tent units. uncovered parking areas adjacent and accessible to the ed have been enabled for disaster response. other eds use high-volume, lowpressured showers mounted on the side of a building. serial showers allow multiple patients to enter at the same entrance and time. however, serial showers do not provide privacy, can be difficult for an ill patient to access, and can lead to recontaminated water runoff. also, persons requiring more time may impede flow and reduce the number of patients decontaminated. parallel showers built in advance or set up temporarily in tenting offer greater privacy but require wider space and depth. combined serial and parallel design allows the advantages of each, separating ill patients and increasing the number of simultaneous decontaminations. often built into the ed is another decon room for one or two patients with the following features: outside access; negative-pressure exhaust air exchange; water drainage; water recess; seamless floor; non-pervious, slipresistant, washable floor, walls, and ceiling; gas appliances; supplied air wall outlets for ppe use; high-input air; intercom; overhead paging; and an anteroom for decon of isolated cases. ppe is recommended for use by military and fire departments during events involving hazardous materials. hospitals use these devices and store a reasonable number of protective ensembles (i.e., gloves, suits, and respiratory equipment) usually near the ed decon area. decon areas are built with multiple supplied air outlets for ppe use to optimize safety and maximize work flexibility. a nearby changing area is available in some eds. the changing area is laid out to optimize medical monitoring and to ease access to the decon area. [ ] [ ] [ ] [ ] [ ] some capability to isolate and prevent propagation of a potential biologic agent has been designed into most eds. patients who present with undetermined respiratory illnesses are routinely sent to isolation. a direct entrance from the exterior to an isolation room is not usually available but has been a recent renovation in some eds. creation of isolation areas poses special design requirements for hvac, cleaning, and security to ensure that infections and infected persons are contained. an isolation area should have compartmentalized air handling with high-efficiency filters providing clean air. [ ] [ ] [ ] [ ] biohazard contamination is particularly difficult to mitigate. keeping the facility "clean"and safe for other patients is an extreme challenge. biologic agents of terrorism may resist decontamination attempts. infected patients present a risk to staff. few triage areas and ed rooms have been designed for decontamination. surfaces must be able to withstand repeated decontamination. sealed inlets for gases and plumbing have also been considered. [ ] [ ] [ ] patients who are isolated can be observed with monitoring cameras. some isolation areas include a restroom within their space, which helps restrict patient egress. general ed areas could have decon capabilities built in. floor drains have been included in some ed rooms for easier decontamination. infection control is improved using polymer surface coatings that are smooth, nonporous, and tolerant to repeated cleaning, creating a virtually seamless surface that is easy to clean. these coatings can be impregnated with antimicrobial properties enhancing their biosafe capability. silverimpregnated metal surfaces in sinks, drains, door handles, and other locations can reduce high bacterial content. silver-impregnated metal has demonstrated antimicrobial effects. conventional ventilation systems use % to % outside air during normal operation, thus purging indoor contaminants. air cleaning depends on filtration, ultraviolet irradiation, and purging. hvac design should model demand for adequately clean air and also for isolation of potential contaminants. the disaster-ready ed requires protection from external contaminations as well as contagious patients. a compartmentalized central venting system without recirculation has the ability to remove or contain toxic agents in and around the ed. compartmentalized hvac systems allow for the "sealing" of zones from each other. more desirable hvac systems electronically shut down sections, use effective filtration, and can "clean" contaminated air. a compartmentalized system can fail, but it only fails in the zone it is servicing; smaller zones mean smaller areas lost to contamination. these systems are less vulnerable to global failure or spread of contamination. modular hvac units developed for field military applications have been added to existing ed isolation areas for use when needed to create safe air compartments. cost may prohibit addressing issues like building more space or better ventilation, decontamination, and isolation facilities. if added space and facilities are not made more available, many lives may be lost during a disaster event. when monies are spent for terror readiness, eds must continue to function day to day. eds will be challenged to provide efficient routine care and also handle the consequences of a terror event or natural disaster. these competing functions could result in eds that cannot handle routine care. these design efforts could also lead to unnecessary increases in expenditures in anticipation of terror events that never materialize. to the extent that efforts to provide disaster care can be translated into solutions that address other more immediate hospital and ed problems, they will gain support. more access to information systems providing just-in-time training could inform staff not only of terror events but of mundane policy changes and unique patient needs such as bloodless therapy for jehovah's witnesses, etc. better information access could also improve routine ed efficiency and communication with patients and families. however, these rationales may not prevail to fund disaster readiness. decontamination equipment and areas may be used for commercial hazardous materials spills. isolation areas could be more routinely used in an effort to contain suspected contagions, such as severe acute respiratory syndrome (sars). lack of bed capacity in hospitals leads to ed overcrowding. scalable eds may offer temporary solutions in times of over-burdened hospital inpatient services. however, once reserve spaces are used to solve other over-capacity problems, those spaces may no longer be available for disaster operations. thus, a new facility could "build" the capability of handling large surges of patients into adjacent spaces, only to lose it by filling these spaces with excess patients whenever the hospital is over census. finally, a terror event may be different from those for which we prepare. the rarity of terror events creates a need for us to test our disaster plans, skills, and capacities in drills. drills may uncover design problems that can then be addressed but may only prepare us for anticipated threats. why pour such resources into building capacity that we hope never to use? among the lessons learned from past disaster events is the need to develop disaster skills and build a disaster-response system from components that are in daily use. systems that are used routinely are more familiar and more likely to be used successfully during terror events. certainly the surge capacity of a "terror-ready" ed would be used for natural disaster response and in disaster drills. the surge space could also be used for over-census times, public health events, immunizations, and health screenings. a modern ed should serve as a community resource, deploy and test capacities regularly in disaster drills, and maintain "readiness" in a post-sept. world. australian college for emergency medicine functional and space programming. dallas, tex: american college of emergency physicians rhode island disaster initiative. improving disaster medicine through research emergency departments and crowding in us teaching hospitals trends in emergency department utilization do admitted patients held in the emergency department impact the throughput of treat-and-release patients? physical security equipment action group (pseag) interior/exterior intrusion and chemical/biological detection systems/sensors computational methods for the analysis of chemical sensor array data from volatile analytes electrochemical detection in bioanalysis array-based vapor sensing using chemically sensitive, carbon black-polymer resistors code of federal regulations nuclear shielding supplies and service, inc,web site heavy concrete web site designing for security. architectural record putting clinical information into practice emergency department and walk-in center surveillance for bioterrorism: utility for influenza surveillance boston ae warning early surveillance system for bioterrorism syndromic surveillance for bioterrorism new york city policewomen win settlement. seattle times fire department response to biological threat at b'nai b'rith headquarters chemically contaminated patient annex (ccpa): hospital emergency operations planning guide. united states public health service emergency department hazardous materials protocol for contaminated patients cdc recommendations for civilian communities near chemical weapons depots. federal register occupational safety and health administration. hospitals and community emergency response: what you need to know weapons of mass destruction events with contaminated casualties: effective planning for health care facilities guidelines for design and construction of hospitals and healthcare facilities. philadelphia: the american institute of architects academy of architecture for health emergency response guidebook: a guidebook for first responders during the initial phase of a dangerous goods-hazardous materials incident department of transportation, and secretary of transport and communications of mexico department of health and human services. metropolitan medical response system's field operation guide. washington dc: department of health and human services volume i -emergency medical services:a planning guide for the management of contaminated patients, agency for toxic substances and disease registry infectious diseases epidemiology and surveillance american institute of architects. guidelines for design and construction of hospital and health care facilities chemically contaminated patient annex: hospital emergency operations planning guide silver-nylon: a new antimicrobial agent filtration of airborne microorganisms: modeling and prediction key: cord- - l twbc authors: winans, melissa title: nicu disaster preparedness: were we ready for covid- ? date: - - journal: nurse lead doi: . /j.mnl. . . sha: doc_id: cord_uid: l twbc the terrorist attacks of september , , along with natural disasters such as hurricane katrina, have led to decades of disaster preparedness planning. despite the attention and focus on planning, many studies have found that hospitals are ill prepared to appropriately manage extended disasters. the author completed her doctoral program capstone project on nicu disaster preparedness. this article will discuss lessons learned during the covid- pandemic and what future disaster preparedness plans must consider. nicu disaster preparedness: were we ready for covid- ? disaster can strike at any time, and in any place. when disaster strikes a hospital, especially one with a neonatal intensive care unit (nicu), the stakes are high. a recent systematic review of the literature demonstrated that nurses are not prepared for and do not know what their role is in a disaster. the american academy of pediatrics (aap) supports the findings of labrague et al. and identifies that technology-dependent individuals, such as our most vulnerable nicu patients, are disproportionately affected by disasters. hospitals must be prepared for disaster and as a part of the preparation must consider a specific plan for their nicus, nicu families, and staff. four months into a worldwide pandemic, the question shifted from preparedness to sustainability. while we may have been prepared for disaster, we were not prepared for a pandemic of this magnitude. as covid- continues to play out before us our response and lessons learned will reshape future disaster preparedness planning. in september , the world as america knew it changed. in the years to follow the terrorist attacks of / , public policy and healthcare organizations have implemented changes to improve disaster response. a report from the department of homeland security published in september reported that disaster preparedness is a shared responsibility and highlighted the planning and preparation needed at an individual, regional, and national level. changes to date, however, have not prepared healthcare organizations to appropriately manage large scale or extended disasters. ten years from now we will be talking about how the pandemic of changed healthcare as we knew it, but for now we are living that change. j o u r n a l p r e -p r o o f much like we can remember other key dates, we will remember march when covid- became a reality for healthcare providers in the united states. for a mid-sized community hospital in north texas the reality hit on march th after just days of system planning. by march th the hospital had a manned incident command center that ran / through june rd , the manned incident command center re-opened on july th and transitioned to a hybrid manned/virtual command center on august th . previous disaster planning included plans for evacuation if operations could not be sustained, especially for the nicu. this pandemic has required sustained operations through conflicting reports and a multitude of changes. the early focus for texas health resources the author was asked to participate in system planning for nicu and women's response plans to covid- . this planning involved the creation of a subcommittee that consisted of frontline providers, infection prevention experts, and system leaders. the goal was to create a clinical guideline for the care and treatment of covid positive moms and babies. as organizations such as the aap and centers for disease control and prevention (cdc) continue to release updated recommendations, the committee and guideline had to be fluid. over time the j o u r n a l p r e -p r o o f frequency and intensity of the meetings reduced, but at the writing of this article the subcommittee continues to meet bi-weekly on an as needed basis. disaster can be defined as any event that significantly impacts the functioning of a group of individuals and exceeds the group's ability to sustain with their available resource. the joint commission (tjc) and the hospital preparedness program (hpp) provide input into the guidelines and hold hospitals and providers accountable for implementation and compliance. the end goal of disaster preparedness is for everyone to be responsible for his or her part in the process to mitigate risk and to implement procedures to alleviate human suffering resulting from a disaster. in her doctoral program the author developed a disaster preparedness plan for the nicu. the author used a pre-existing standard language for disaster preparedness to develop the nicu guidelines. interventions identified included risk assessment that addressed geographical natural disaster potential, consideration and action plans for internal and external disasters, and j o u r n a l p r e -p r o o f instructions for individual and family preparedness in the event of a disaster. unfortunately, the plan and roadmap created did not count on a novel coronavirus that would create an unprecedented pandemic response. some might wonder why a separate focus on nicu. nicu patients pose a unique challenge regardless of the type of disaster. missing from many hospitals is a disaster preparedness plan specific to the nicu. nicu patients are technology-dependent and fragile. disasters that affect the hospital are also likely to affect the nicu patients' families. if an evacuation is necessary, there is a risk for family separation. with covid- a new type of separation exists, separation of symptomatic or asymptomatic covid positive parents from their neonate in the nicu. hospitals and healthcare teams are faced with a new dilemma, whose guidelines to follow and how to mitigate risk of covid exposure/spread, while allowing for the bonding needed between parent and child. what if the parent(s) are too sick, how do we identify an alternate caregiver and who will make decisions for the baby? these considerations, and more, will need to be included in future disaster preparedness planning. nicus are a microsystem of the hospital and pose unique challenges during a disaster. nicu babies are technology-dependent making them at risk for an adverse outcome in a catastrophe. a critical component of disaster preparedness planning for a nicu is family separation risk mitigation and reuniting families if separation occurs. during orientation to the nicu, families should be encouraged to create their own family disaster preparedness plan which includes a communication strategy for their family. the strategy might consist of alternative contacts for hospital staff, as well as directions on who will contact whom and where the family will meet if they cannot return to their homes. nicu staff should also be encouraged to develop family disaster plans so that when disaster strikes, they can focus on caring for their patients and not worrying about home. with covid- there is an added concern for exposing family to the virus. many nurses and healthcare workers identified strategies to reduce risk of transmission that may become best practices to be included in future disaster preparedness plans. these strategies included showering/changing clothes before leaving work or immediately upon arriving at home and before interacting with family, staying at hotels when several shifts in a row were worked and avoiding situations in which close contact with others would be required. throughout the pandemic to date the recommendations for face coverings, social distancing, community gathering, and essential work have changed frequently causing confusion, frustration, and caregiver fatigue. a key consideration of many hospital disaster plans is surge capacity. surge capacity allows for local and regional preparedness, especially for a mass-casualty event (mce). a vital component of the nicu disaster preparedness plan considers surge capacity as well as a plan for where the nicu will evacuate to if the disaster at hand requires it. disasters can be internal or j o u r n a l p r e -p r o o f external to hospital operations and preparedness planning must include risk-assessment and geographical considerations. as nicus plan for disaster, the response must consist of more than just the physical restoration. the planning and preparedness must address mental, emotional and psychological factors that nurses and others will face in the aftermath of the disaster. disasters such as hurricane sandy, have highlighted the inadequacies that exist, and provided an opportunity to refine and revise plans so that individuals and communities can have trust in the identified plan. disaster preparedness is everyone's responsibility and as such, community disaster plans need to consider and account for vulnerable populations. nurses and other health care workers are held to a higher moral standard than the general public with regards to disaster preparedness and response. ; in a disaster, resources may become scarce and the scope of care able to be delivered reduced. pre-planning will facilitate difficult decisions during an actual disaster. the nicu disaster preparedness plan should include what changes to standards of care may be necessary during a disaster or evacuation, and a framework for decision making that can be used in an actual disaster. the inclusion of ethical situations in a simulation, may assist caregivers in mental exercises that will help with the out of box thinking required during an actual disaster or evacuation situation. finally, the consideration of the potential need for ethical decision making before a disaster, may alleviate additional stress when these in-the-moment decisions need to be made. in the post-covid- era, health care workers must review and reflect on the ethical dilemmas encountered during the pandemic. these dilemmas will guide future planning and help leaders prepare the next generation of health care workers for disaster. the ethical, policy and political challenges during covid- will guide future decision making at local, regional and j o u r n a l p r e -p r o o f national levels. health care leaders will need to be advocates and contributors as future disaster planning guidance is developed. an awareness of potential risk is a necessary component of disaster preparedness. during a disaster staff may be asked to work outside of their comfort zone, with less than optimal supplies and conditions, and with different individuals or teams adding to their stress and emotions. necessary components of the disaster preparedness plan include staff preparedness for their home and family, training, awareness of risk and participation in disaster drills ; ; . nurses and healthcare workers must take responsibility for their preparedness which includes family care and communication strategies to ensure they can focus on implementing their hospital disaster plan without the added burden of worrying about their family's safety. an additional component of preparedness is to consider the capability and capacity of ems during a disaster. a realistic plan can be developed and implemented if resource limitations are known ahead of time. likewise, including identification of potential alternative locations which the nicu can be moved will save precious time in the event of an actual disaster requiring nicu evacuation. the author was able to use this component of preparedness when planning her hospital's nicu covid- response. the team was able to create a covid unit for babies born to moms under suspicion of covid and/or who were covid positive. as covid- became a reality in the united states many were faced with conflicting information, changing guidance and an outpouring of public opinion. the response to covid- quickly became political with strong opinions on both sides. hospitals, health care leaders and health care workers faced a novel coronavirus with rapid change to guidance that was not always j o u r n a l p r e -p r o o f based in science or evidence. hospital and health care leaders were faced with a constant challenge of keeping their staff, patients, providers and visitors safe, while balancing the guidance with available personal protective equipment (ppe) and supplies. nurses and other healthcare workers have always had to be concerned with infection prevention and control. covid- has taken this concern to a new level. community spread, early estimates of inadequate hospital resources and concerns for lack of ppe added to an already stressed team. as hospital administrators, infection prevention specialists and nurse leaders worked tirelessly to keep up with the changing reality, nicu teams had to identify strategies for caring for patients with covid- or with exposure to covid- . these strategies were often developed after much discussion and input, and rarely met without question and resolve from frontline staff! the covid- pandemic of has tested the disaster preparedness of healthcare in the united states and beyond. we have always known that disaster can strike at any time and in any hospital, the previous disaster planning allowed hospitals and healthcare systems to mobilize their incident command, while allowing them to focus on learning everything that they could about the novel coronavirus known as covid- . hospitals need to have disaster plans and specific plans for specialty populations such as the nicu are critical for successful disaster response. in terms of the covid- pandemic of , time will tell how it will alter the way hospitals and nicus plan for disaster in the future. j o u r n a l p r e -p r o o f preparedness for natural disasters among older us adults: a nationwide survey opportunities for general practitioners to enhance disaster preparedness among vulnerable patients disaster preparedness and families of children with special needs: a geographic comparison disaster preparedness in neonatal intensive care units ready for our children? results from a survey of upstate new york hospitals' utilization of pediatric emergency preparedness toolkit guidance promoting community preparedness and resilience: a latino immigrant community-driven project following hurricane sandy evacuation of a neonatal intensive care unit in a disaster: lessons from hurricane sandy prepared for what? addressing the disaster readiness gap beyond preparedness for survival disaster preparedness among health professionals and support staff: what is effective? an integrative literature review responding to a fire at a pediatric hospital disaster preparedness among nurses: a systematic review of literature ethical guidance for disaster response, specifically around crisis standards of care: a systematic review frontline nurses: ethical and legal considerations of disaster preparedness patient-driven resource planning of a health care facility evacuation disaster preparedness: emergency planning in the nicu hurricane sandy, disaster preparedness, and the recovery model key: cord- - qfdqlpw authors: rinnert, k. j.; wigginton, j. g.; pepe, p. e. title: catastrophic anachronisms: the past, present and future of disaster medicine date: journal: yearbook of intensive care and emergency medicine doi: . / - - - _ sha: doc_id: cord_uid: qfdqlpw there is a worldwide spiraling risk for more frequent catastrophic events involving multiple casualties, not only in terms of acute injury and illness, but also subsequent psychological and public health concerns. today, such events will likely be multinational in nature, even when localized to a particular venue and this require international cooperation in terms of prevention, mitigation and relief. the best approach to preparing for disasters is to expand, modify and enhance current local ∖jobname: s batch number: infrastructures and capabilities for managing the multiple types of disaster scenarios and create a number of inter-facility cooperative agreements in advance. aside from safer internal locations for icus and surgical theaters, certain structural changes will need to be installed such as modified ventilation systems, protected water supplies, decontamination mechanisms and security renovations. a key strategy will be to proliferate interoperable, multi-disciplinary, all-hazards training initiatives such as the ama national disaster life support courses. purchases of cadres of antidotes, antibiotics and hemoglobin-based oxygen carriers should be coordinated regionally, stored in secure locations and made readily-available for the applicable disaster scenario. pointed out the concepts of modern vulnerability. not only were the victims highly concentrated in one building making it easier to target and cause many casualties, but modern technology facilitated the incident. a large modern transportation device laden with explosive fuel made such a dramatic disaster possible, one that would not have occurred to such an extent before . while such technology makes a local disaster global in nature, the same technology can bring a global disaster to each locality. the threat of worldwide spread of contagious disease, both naturally-occurring and malicious (bioterrorist) promulgation [ , ] is accelerated not only by exponential population growths, but the air ship as well. again, with more people on the planet who have the potential to become an infected vector and with more global concentrations of highly-mobile populations moving around in jet aircraft (and thus more opportunities for exposure), the risk for pandemics has clearly become greater than ever before. although the overt threats of cold war nuclear holocaust have seemingly dissipated, the underlying devices of mass destruction still exist, particularly in a world where terrorists are further spurred on by another form of technology, the mass media and internet. such threats are unimaginable, even for those who must anticipate how to deal with the aftermath [ , ] . as inferred previously, we are no longer a self-sufficient agrarian culture. major populations are now fully dependent on day-to-day energy and water supplies, sewage, garbage removal, and food products from others. therefore, in addition, to the initial impact of injury and illness are the subsequent public health sequelae such as insufficient food supplies, contaminated water, lack of shelter and the subsequent threat of associated diseases. likewise, the psychological impact of disasters on populations is only just now beginning to be better appreciated, not just for those directly affected, but for the population as a whole [ ] . for example, the economic downturns in the united states, europe and elsewhere after the events of fall are often considered one of the casualties of the terrorist attacks. it emphasizes the under-recognized widespread affects that disasters can have on the international public psyche. even when loss of life and infrastructure are relatively minimal in the grand scheme of the particular nation involved, disasters can have significant and farreaching psychological impact (e.g., the usa anthrax postal system attacks). the mass media, internet and other modern technology not only race information to all of us worldwide, but often do so in a graphic and emotionally-stimulating manner. even though the death and long-term morbidity toll was not as high as the staggering consequences of the indian ocean tsunamis, the public health risk management issues associated with the usa anthrax attacks and other identified potential threats were still enormous [ , , ] . facilitated by obsessive mass media mania, the potential threat of other public health crises (involving large populations) as a result of either terrorism or natural disease (e.g., small pox and avian flu pandemic scenarios) became more of a reality in terms of public perception. as a result, tremendous political pressure has developed for clinicians and public health officers alike to become better prepared to protect the public from all disasters, let alone doomsday scenarios. such psychological affects on the public play out in political venues as evidenced in the usa with the development of the department of homeland security and improved worldwide intelligence-gathering cooperation both domestically and internationally. nevertheless, while some improvements in surveillance and pharmacological resource allocations have evolved, the medical aspects of homeland security and catastrophic anachronisms: the past, present and future of disaster medicine public health emergency preparedness remain worrisome and clearly fall short of public expectations, appropriate expectations or not. sociologically, it is logical that wealthier countries might stand a better chance of mitigating mortality and morbidity with their robust health care systems, solid public infrastructures, substantial community resources and early detection-warning systems. this would occur not only through forewarned prevention of injury and illness, but also through rapid access to sustenance, medical and rescue assets. it could be emphasized that much of the loss of life and morbidity from the indian ocean tsunamis and their subsequent sequelae actually resulted from relative limitations in terms of such characteristics. nevertheless, the events of the fall of in the usa, the subsequent toronto experience with severe acute respiratory syndrome (sars) and the recent aftermath of hurricane katrina in the gulf coast, also exposed the vulnerability of even relatively healthy and well-resourced nations. in fact, these recent events emphasized our vulnerability in surge capacity. regardless of disaster events, on a daily basis, the great majority of healthcare facilities and emergency medical services (ems) systems, even in prosperous western nations, are overwhelmed in terms of emergency care capacity, be they government-based or private entities. many of the world's key trauma centers and ems crews are deluged on a day-to-day basis, with in-patient facilities brimming with fully-occupied beds, sub-optimal nurse and ancillary personnel staffing, despite increasing demands for service and a higher acuity of illness and injury. one could argue that these existing health care services, including ambulances, emergency centers, operating rooms, and intensive care units (icus) are facing a disaster each day as available medical resources outstrip the daily demands for urgent and critical care. this tenuous situation causes the looming threat of additional surges from disasters, be they technological or natural, to become truly deep concerns for the future of disaster medicine. table . some key reasons for increases in the frequency, magnitude and impact of disasters (natural, unintentional and intentional) since the mid- th century z exponential growth of human populations, concentrated in high-risk venues (e.g., shorelines, earthquake zones and prior uninhabited regions), particularly those externally dependent upon on others for sustenance (food supply chains), power resources and public health hygiene, making human populations increasingly vulnerable when infrastructures disrupted. z increasing exposures to zoonoses; more mutations of microbes (more human vectors); potential effects of global warming on storm formation; more sites (e.g., large buildings, subways) that are larger destructive traps. z technology that facilitate disasters (e.g., jet aircraft allowing more rapid spread of disease globally or terrorist use as a massive explosive device). z growth of hazardous industries and transportational systems (e.g., chemicals in plants, trucks, boats); genetic engineering/technology that facilitates bio-terrorism and weapons of mass effect across populations. z mass media (television, internet) that provide instantaneous imagery and disaster threat concerns, affecting populations psychologically worldwide, and, in turn, affecting markets/economies (also a stimulus for terrorists). z the global, multinational, multi-jurisdictional nature of disasters because of international-global industries, businesses, and tourist activities, and the associated global vulnerability through computer/internet disruption in essence, there is a spiraling risk for catastrophic events involving multiple casualties and population-based medical morbidity, including proximal injury and illness and subsequent psychological and public health concerns (table ) . such events will likely be multinational in nature with global ramifications, even when localized to a particular venue. therefore, this will require international cooperation in terms of prevention, mitigation and relief. however, the medical care infrastructure, even in wealthy countries already seems to operate at capacity, making a major multiple injury event or even an influenza pandemic a true challenge. z key problems in disaster medicine today just as the threats of disasters have increased and become multi-faceted, so have the medical sequelae and complications [ , , ] . explosions carry the triple threat of thermal, penetrating and blunt trauma [ , ] . associated building collapses not only cause crush injury syndromes, but a higher risk of being trapped, and modern fires induce chemical inhalation injuries as well as carbon monoxide poisoning and traditional respiratory tract impairment [ , ] . earthquakes cause all of the above, but killer tsunamis as well because of concentrated population centers. hurricanes, floods and tidal waves result in drowning, snake bites, and contaminated water supplies and subsequent mosquito-borne/zoonotic illnesses [ ] . chemical releases can result in pulmonary injury, burns, nerve system dysfunction, liver damage and cellular dissolution [ , ] . severe radiation exposure causes burns, immunological suppression, and diffuse epithelial damage, internally and externally. biological agents result in a myriad of physiological insults. from pneumonia, coagulopathies, and central nervous system compromise to cardiac suppression and liver failure, the viral and bacterial agents provide often-insidious challenges to clinicians and public health officers alike, regardless whether the root source is a natural epidemic or a malicious dissemination. while using existing medical personnel would be best, developing coordinated plans to incorporate them into a disaster plan (and provide them with timely respite and staggered shifts) is the challenge. while additional personnel theoretically could be imported from nearby (unaffected) medical facilities or from other regions or countries, the local personnel work best in their own environments and still would need to provide coordinating leadership roles. this even plays out politically as was seen in the aftermath of hurricane katrina where local medical personnel still wanted control despite the loss of resources (hospitals, supplies), both out of sense of loyalty to`their' patients, and their own sense of duty. in some respects, using the local personnel is in keeping with the number one rule of multiple casualty incident management, namely to follow day-to-day routines as closely as possible or modify day-to-day routines as much as possible to meet the unique demands of a disaster [ ± ]. the logic here is that unfamiliar activities or settings result in logistical and procedural learning curves for clinicians and that such medical care obstacles can be amplified in a strange venue with overwhelming patient care demands. learning how the laboratory or pharmacy works or how to operate less familiar equipment or communications systems, can delay and impair the true focus of patient care. in the hurricane katrina scenario or the pakistani earthquake circumstance, however, much of that infrastructure was wiped out, diluting such arguments. if, then, outside teams are to be brought in, one solution is to bring in a team that al-catastrophic anachronisms: the past, present and future of disaster medicine ready works together well. in the aforementioned dallas field hospital built to handle the surge from katrina evacuees, the medical team was used to working together. likewise, the arrival into new orleans of the uss comfort, a floating naval hospital replete with extensive operative capacity, neurosurgeons, multiple icus and airlift capacity, worked well because the team had been in place and worked well together. the question remains, however, how long could such`borrowed teams' last in the disaster zone. what is an appropriate tour of service? therefore, if they are still standing and operational, the utilization of highly-experienced trauma centers and icus would optimize the medical care skills needed and the efficiency of the delivery of care assuming that they could be off-loaded from some of their day-to-day activities. for example, a busy emergency department could off-load sore throats, urinary tract infections, and broken arms to clinics and field infirmaries (places where surge and delays in care would have less concerning consequences). through prospective, government-moderated agreements, icus at major receiving centers for disaster victims could transfer certain critical care patients to other community hospitals if necessary. this kind of arrangement has been worked out to significant degree in venues like miami, usa, a frequent target for major hurricanes in which certain hospitals themselves are at risk of damage. in any case, there will be a need for external surge capacities outside the day-to-day facilities. contrary to popular perception, most disastrous events do not create an immediate influx of critical patients [ ± ] . victims are either killed outright or they have generally survivable injuries. in most traditional situations, experience has shown that less than % of patients (those not killed outright) will require critical care or critical care monitoring [ ± ] . the main threat is actually displaced persons who need their day-to-day medical care, prescription, optometrist, dentist, and, in some cases, their dialysis or chemotherapy. in the aftermath of hurricane katrina, hundreds of thousands needed to be evacuated for extended periods of time. even if most were healthy, some of these healthy evacuees were bound to have their unanticipated appendicitis or their typical sore throats. more to the point, tens of thousands, especially the elderly nursing home patients, needed so much more. and how does one address the situation of a woman who says she is due for her chemotherapy when she has no medical records or physician contact? this becomes the real challenge, not necessarily the threat from the actual disaster event. most conventional disasters can be handled by existing resources when those resources are not involved or currently overwhelmed [ ] . if the major problem becomes the destruction of the local facilities and these concerns become further confounded by legal issues such as licensure and credentialing of medical professionals coming to volunteer at other alternative hospitals or the disaster zone itself. a physician coming to provide aid at another locale or hospital may not be authorized to do so if they are not licensed to practice medicine in that jurisdiction (i.e., country, state, province). moreover, even if licensed, hospital accreditation, in most venues, requires prospective scrutiny of physicians with relevant background checks and certain administrative requirements. all of these procedures take time and are, therefore, essentially impossible to provide at the time of a catastrophic event. while some communities have set up mechanisms to cross-credential physicians for a disaster, only a few have done so and this does not account for the issues of familiarity and skills utilization. furthermore, the key practitioners that might be needed to provide assistance at alternative locations in a disaster are skilled nurses, respiratory therapists, dialysis technicians, pharmacists and the like. while all of these practitioners could also bè cross-credentialed', it still does not account for motivators to have any of those persons participate. motivators are not just the dedication of a zealous volunteer or the lure of a financial incentive, but they also include care for those practitioners' families in the midst of a disaster during which time the families may be vulnerable as well (no food or water, loss of electricity, trapped by flooding, possible exposure to contagious disease, etc.). many of the persons trapped in the flooded new orleans hospitals were actually family members of the health care workers. finally, there could be concerns about liability coverage and protection from malpractice lawsuits when providing services outside of one's routine location [ ] . all of these concerns strengthen the argument that existing facilities, particularly major trauma centers and critical care hospitals, should all be fortified and better prepared for surge capacity. not only are there issues of skills, experience, familiarity, learning curves, licensure, credentialing, motivation and liability protection with which to be concerned, but, again, this paradigm follows the basic disaster tenet to follow one's day-to-day routines as closely as possible [ ± ] . it relies on the premise that one should prepare for such events by modifying day-to-day activities to accommodate requirements for a multi-casualty event. one of the major reasons why disaster scenarios, be they drills or actual events, often go awry is that they are encumbered by plans or procedures that fall outside normal routines. therefore, working in environments that facilitate familiar clinical and procedural behaviors in a disaster is the most advisable strategy. while local, reinforced facilities might be best suited for the more traditional st century disasters, a major nuclear or biological event can pose a more regional-national threat, if not a global risk [ ± ] . for example, even if only a fifth of a population becomes infected with a highly contagious disease over a several week period and only % of such patients require critical care, this can mean , critical care patients in a city of a million residents. assuming a week's stay for each patient whether they live or die, it still translates into the need for thousands of icu beds at any given time. also, under such circumstances, patients more than likely would not be transferred out to other communities because those other venues also may be experiencing similar, or even worse, surges in patient demands in such scenarios. similarly, certain catastrophes may involve those`routine facilities' and transport services themselves such as that seen in the hurricane katrina aftermath. they may be destroyed or inaccessible due to flood, earthquake, terrorist bombing or contamination. this scenario also entreats a plan for working outside one's normal routine or enormous surge at other facilities, either local or at a distance, established or makeshift. nevertheless, if current, day-to-day facilities are to be fortified (as they should), then these modifications will have significant fiscal impact. already strapped with budgetary challenges, such infrastructure changes would be unreasonable without full public support (government assistance) and commitment that all other facilities would share in similar burdens. in fact, far beyond the costs of constructing better ventilation mechanisms, improved water supply systems, well-placed generators and circumferential barricades (e.g., mitigating the effectiveness of car-bombs) as well as better control of hospital entrances, are the sociological conflicts. such security measures defeat the purpose and current philosophy of hospitals, clinics and medical facilities which should strive to provide even easier, patient-friendly access to medical care, particularly for the elderly, sick and chronically ill who need comfortable entrance. even with infrastructure changes, they will be of little avail without standardized training of the healthcare providers. during the last quarter of the th century, standardized, multi-disciplinary courses had been developed for the management of other major threats to life, namely cardiac arrest and trauma (e.g., the american heart association's advanced cardiac life support and the american college of surgeons' advanced trauma life support). such standardized training has even been demonstrated to be effective in increasing life-saving. however, unlike cardiac arrest and trauma cases that can present in certain facilities on a daily basis, disaster events are uncommon and infrequent events, even worldwide, making additional training and practice even more critical. even if the infrastructure is addressed and personnel trained, the complexity of nuclear explosion or`simply' a pandemic may be overwhelming. it is feared that with the typical current processes for producing vaccines, an entirely new influenza virus could sweep through even healthy worldwide populations in a matter of months, long before a vaccine could be developed, processed, and distributed, not to mention the time it takes for inoculated persons, particularly children, to develop adequate protective antibodies. a similar genetic jump from animal populations (e.g.,`avian flu') could proliferate with the same scenarios. in both cases, with more people to infect, more ways of rapidly transmitting the virus around the globe, and more persons with immunological suppression alive today, the risk for pandemic will become even more of a threat, not only for the population as a whole, but also for the ambulance crews, emergency department staff and icu practitioners. if they become ill as well, there will be even fewer healthcare providers available to care for the throngs of ill persons, making the disaster scenario even worse. such as seen in the sars situation, the medical facilities and healthcare workers may become a main vector themselves. more worrisome is the unknown. the concept of sars was unknown three years ago. with tremendous advances in genetic engineering, it is feared that both malicious and unintentional contagion threats will become new realities. and while threats for disaster are increasing, medical care resources are being spread thinner and thinner, from sociological factors (nursing shortages) to financial constraints (decreasing reimbursements for medical care). ironically, with increased demands for protection from terrorism and other public health threats, financial resources have been diverted from healthcare to national defense and homeland security efforts. unfortunately, most security efforts are overhead costs and not at all revenue-generating. even within hospitals, dealing with disaster management is generally administrative in nature (training, equipment, procedures, personnel) and consumes and diverts medical care professionals' time and efforts from their day-to-day patient care activities. these concerns are likely to become worse and resources further drained. moreover, the actual costs of the disasters are accelerating and public expectation for assistance stronger than ever before. z some potential solutions and improved preparations many lessons have been learned in our era of expanding and more frequent disasters. in a cyclone, tornado or hurricane belt, reinforced hospitals should have their icus and operating rooms secured within the center of the edifice, well above the level of potential storm surges and flood levels and far below the roof-top levels where spin-off tornadoes can rip off the top floors and blow out exterior windows. secondary and back-up generators should be protected in a similar fashion. all hospitals, particularly those in recognized earthquake zones, should have`earthquake-proof' designs with applicable structural integrity. when a hospital is a potential terrorist target such as any main receiving facility, trauma center, burn center, or children's hospital, security measures will dictate the need for barricades to bombs and specialized ventilation systems that detect and can control the spread of aerosolized poisons or biologicals. these hospitals should have a disproportionate number of negative pressure rooms and well-established decontamination zones around the potential entrance and receiving personnel (e.g., trained triage nurses and security personnel will be staged further out into the periphery and prepared with universal precautions and easy access to decon (decontamination) suits, including high level personal protective equipment (ppe). within the next ten years, spurred on by additional major terrorist events and further recognition of the vulnerability of the medical safety net, governmental resources will likely begin to make these changes and architects for new facilities will incorporate them into future design. but, economically intensive, this aspect of preparation will lag behind other efforts. this first consideration to enhance the structural aspects of disaster management would be of most value to handle the more likely conventional disasters. however, one might then return to entertaining the concept of a specialized facility or facilities to manage pandemics and disseminated bioterrorism incidents such as a mutated smallpox organism. in this case, to overcome the concepts of lack of familiarity with equipment and resources, credentialing, liability and medical skills utilization, a mitigating solution would be to dedicate a reserve team of medical personnel in the way a government entity deploys a fire service or army as a dedicated standing force. currently, a hybrid for this type of concept is accomplished through the mobile medical teams and tent hospitals designed by the national disaster medical system (ndms), an element of the federal emergency management agency (fema) in the united states department of homeland security. although this does not employ a round-the-clock standing team, it does utilize a`stand-by' team of medical and allied health volunteers who are trained and routinely exercised to operate mobile hospitals. currently, these teams would likely be inadequate for a mass casualty scenario with tens of thousands of victims, but still they are somewhat helpful in areas where the standing facilities have been destroyed, impaired or are inaccessible. the hurricane katrina incident demonstrated the clear value of expert, co-trained military medicine assets. mobile hospitals have reasonable value in some circumstances and should always be part of the planning including safe and secured storage of required equipment and assets, but community-wide plans to enhance existing facilities for surge capacity should still supercede all other plans. inter-hospital agreements to facilitate transfers of patients to balance out surges throughout the system should be in play in the best prepared communities. such agreements will also include specialized storage facilities for antidotes and antibiotics, perhaps in a separate, undisclosed and protected storage facility, but close enough for easy access. the regional hospitals should band together and purchase these items in bulk to leverage economies of scale (cheaper prices), but they should also coordinate receipt so that expiration dates on the drugs will be staggered and not all expiring at once. such coordination would also include the use of healthcare and ancillary personnel in case of overload at a given hospital or incapacity of another. not only will prospective cross-credentialing be accomplished ahead of time using familiar mechanisms, but the process may even be facilitated by course completion in advanced disaster life support and hospital disaster life support types of courses [ , , ] . in all likelihood, arrangements should first focus intra-murally. for example, they may prioritize the use of nurses from the same hospital system (i.e., many hospital systems operate more than one hospital) because of the similarities in policies, procedures, liability coverage and payroll considerations. such coordination of efforts would be a massive under-taking, but well-prepared communities will want to cooperate in such approaches. also, since many disasters are multinational and often occur in under-resourced countries with relatively poor infrastructures, the creation of dozens of international disaster teams by the united nations or other organizations worldwide could be considered. equipped with fast transport aircraft and mobile emergency units, these teams would best be available on any site within less than hours and will work closely with local organizations. very likely, each disaster team will be staffed and operated by a multinational force, and most likely a standing military team. as in any other military organization, teaching and training in disaster medicine will be part of military education in all countries and the teams will continuously drill and work together in coordination on a routine basis. if anything has been learned in recent disasters, it has been the clear value of the military. another lesson learned was the value of standardized training, not only for the military, but for the civilian population as well. after , the american medical association (ama), working with several major academic centers, began to help development of a family of standardized, interoperable, multi-disciplinary, all-hazards courses to deal with the medical aspects of disaster medicine and counter-terrorism [ ± ] . working in close conjunction with university-based trauma center teams as well as multiple federal and military agencies and, more recently, other professional societies such as the american college of emergency physicians (acep) and the society of critical care medicine (sccm), the ama courses are beginning to lay the groundwork for standardized training and improved personnel preparations for disasters [ ± , ] . during hurricane katrina, the louisiana state department of health attributed many of the medical evacuations that were accomplished quite successfully, to the use (and previous training in) adls as well the use of a table top disaster scenario called ªhurricane pamº. like advanced cardiac life support and advanced trauma life support, the advanced disaster life support course provides hands-on, multi-disciplinary scenarios in which participants learn to provide antidotes and other resuscitative skills in simulated austere, hazardous conditions requiring the donning and use of high-level ppe in insecure environments [ ] . in addition to the advanced disaster life support course, a prerequisite basic disaster life support course [ ] provides intensive exposure to the didactic elements of disaster preparation, be it chemical, biological, radiological, or traumatic in nature [ , ] . within the next ten years, it is predicted that the basic disaster life support course will be required for every medical student, paramedic student, nursing and other applicable allied health personnel in the usa [ ] . the advanced disaster life support course will also be provided to applicable trainees and nursing staff in critical care areas including advanced life support ambulances, emergency departments, and critical care areas. it is also predicted that specialized in-hospital spin-off courses (e.g., hospital disaster life support) will address elements of decontamination tactics by custodians, engineers and others. the sccm has already laid much of the groundwork for such training with some of their course developments [ ] . such endeavors will hopefully become similar to the efforts conducted by the international liaison committee on resuscitation (ilcor) for cardiac resuscitation medicine using evidence-based approaches and worldwide consensus. in addition to being involved in such standardized training, paramedics and emergency medical technicians should also be trained to deliver prophylaxis in a public emergency preparedness situation such as a smallpox or yersinia outbreak or even an influenza pandemic. prospective rules about who can be denied or provided vaccination or antibiotics and how one receives protection from liability should be addressed ahead of time in the most prepared systems. in addition to healthcare workers, certain societal infrastructure personnel (e.g., elected officials, water, power, communications, media personnel) may be prioritized as well. also, anticipating a major event, facilities should develop a cadre of antidotes, antivirals and antibiotics for biological threats. more importantly, they will need to ratchet up icu equipment, ventilators and respiratory care equipment as well as ppe and decontamination equipment. ambulances and emergency departments and hospitals at large should be fortified by new computerized technology that enhances detection and discrimination of abnormal gases, chemicals, aerosolized biologicals and other threats in ventilation systems and ambient air, just as a carbon monoxide detector or geiger counter would provide sentinel detection of carbon monoxide or radioactivity in one's home. medical records will be electronically stored and also duplicated and stored at distant sites in case of medical facility destruction and population displacements. new ventilators will need to be impervious to chemical and biological agents and provide protected ventilation in such environments. in addition, artificial hemoglobin-based oxygen carriers that can be stored in ambulances or in far-forward military conditions should be researched and eventually placed in massive storage places as well and ready to use for mass casualties [ ] . some products now in early test stages can be stored without refrigeration for several years and are likely to be standard equipment in all critical care settings, be it prehospital, emergency center or icu settings [ ] . again, all of this will require a new level of international cooperation particularly because many natural disasters can be superimposed upon on-going complex emergencies, including on-going famines, civil wars or rebel insurgencies [ ] . such circumstances can further complicate rescue and restoration of normalcy [ ] . there is a worldwide spiraling risk for more frequent catastrophic events involving multiple casualties, not only in terms of acute injury and illness, but also subsequent psychological and public health concerns. today, such events will likely be multinational in nature, even when localized to a particular venue and this require international cooperation in terms of prevention, mitigation and relief. the best approach to preparing for disasters is to expand, modify and enhance current local catastrophic anachronisms: the past, present and future of disaster medicine infrastructures and capabilities for managing the multiple types of disaster scenarios and create a number of inter-facility cooperative agreements in advance. aside from safer internal locations for icus and surgical theaters, certain structural changes will need to be installed such as modified ventilation systems, protected water supplies, decontamination mechanisms and security renovations. a key strategy will be to proliferate interoperable, multi-disciplinary, all-hazards training initiatives such as the ama national disaster life support courses. purchases of cadres of antidotes, antibiotics and hemoglobin-based oxygen carriers should be coordinated regionally, stored in secure locations and made readily-available for the applicable disaster scenario. advanced disaster life support¾, version . . american medical basic disaster life support¾, version . core disaster life support¾, version . medical response to terrorism: preparedness and clinical practice. lippincott bioterrorism and medical risk management bioterrorism and public health, st edition ten golden rules for urban multiple casualty incident management multiple casualty incident plans: ten golden rules for prehospital management responding to emergencies ± review of the phillips petroleum explosion, march issue. council of state governments field management and critical care in mass disaster fundamentals of disaster management, nd edition. society for critical care medicine bovine hemoglobin-based oxygen carrier (hboc- ) for resuscitation of uncontrolled, exsanguinating liver injury in swine differences in world responses to natural disasters and complex emergencies key: cord- -zpn h mt authors: chaffee, mary w.; oster, neill s. title: the role of hospitals in disaster date: - - journal: disaster medicine doi: . /b - - - - . - sha: doc_id: cord_uid: zpn h mt nan when the first rain began to fall in houston,texas, in june , did hospital staff know they would soon be providing care for hundreds of patients without electrical power or running water in flooded hospital buildings? on april , , did the emergency department staff arriving for the day shift at oklahoma city hospitals know that a former soldier was driving a rented van filled with pounds of ammonium nitrate toward the murrah federal building and that they would soon be faced with bombing victims? in , did restaurant patrons in wasco county, ore., have any idea, as they selected food from salad bars, that they would soon be evaluated in hospitals for profuse, watery diarrhea from intentional food contamination by a religious cult? in march , did the toronto healthcare workers who were caring for patients with respiratory symptoms know they would soon become infected with severe acute respiratory syndrome (sars) ? we can be quite certain that none of them knew. the capricious nature of disaster implies victims and responders are generally caught unaware. but we do know some things. we know there will be hurricanes, typhoons, tornadoes, earthquakes, mudslides, fires, and blizzards this year. we know people will pick up firearms, make bombs, and inflict pain and suffering on others. we know there will be casualties from train accidents, cars crumpled in chain reactions, building collapses, and explosions.we know infectious diseases will do what they do best: spread, sicken, and kill. we know terrorists have not given up their violent assaults. we know there will be mental health symptoms in accident survivors and the caregivers who respond to their needs. it is the hospital, at the heart of the health system, that will receive the injured, infected, bleeding, broken, and terrified from these events. we know the victims will seek life-saving care, comfort, and relief at hospitals, but many u.s. hospitals continue to prepare for disaster as though it will not happen to them. there are more than hospitals in the united states that form a diverse patchwork of healthcare services. u.s. hospitals vary greatly by geographic location (urban, suburban, and rural); financial and management structure (for profit, not-for-profit, private, public); type of care (general medical services or specialty care, such as psychiatric or pediatric); and government affiliation (department of defense,veterans health administration, or public health service). any of these hospitals may be called on to respond to the next disaster or may be the victim of a disaster. many experts believe that these hospitals are not adequately prepared to respond effectively ( the hospital was of little significance in american healthcare before the civil war. only hospitals existed in when the first survey was conducted-a time when no proper gentleman or lady would venture into a hospital by choice. the murky medical practices of the s offered little that couldn't be found in homes, and physicians had little in their armamentarium to change the course of disease and injury. however, discovery and scientific advance changed that. effective anesthesia, surgical antisepsis, antibiotics, the x-ray, and other advances turned the hospital into a place of comfort, hope, and healing. the th-century hospital became a sophisticated financial institution, the core of medical education, and the site of dazzling technological display. medical advances offered aid not only to the chronically ill but offered hope to those who suffered acute trauma or medical or psychiatric emergency. past events illuminate the variety and complexity of demands placed on a hospital in a disaster: the potential impact of disaster is staggering. the release of tons of methyl isocyanate from the union carbide factory in bhopal, india, in december exposed more than , to the deadly gas and killed about in the first week after the release. in september , workers scavenging a dismantled cancer clinic in goiania, brazil, took home a source containing cesium- . they sold it to a junkman who showed the glowing item to friends and neighbors. once radiation exposure victims presented to hospitals, and the release became well known, hospitals were overwhelmed. although were actually exposed and showed signs of radiation sickness, , people were evaluated. when the aum shinri kyo cult placed sarin on five trains in the tokyo subway system on march , , people made their own way to hospitals, were transported by authorities, and hospital staff and rescue personnel were contaminated due to poor or nonexistent decontamination procedures. on sept. , , when u.s. hospitals and healthcare professionals were confronted with the worst attack on american soil, and again during the anthrax attacks along the eastern seaboard, individuals and organizations responded heroically. a powerful change in thinking, also called a paradigm shift, occurred after the terror attacks: the health system came to be viewed as a foundation of national security. another perspective has changed as well. in the event of a disaster, emergency medical services (ems), police, and fire have long been recognized as first responders. however, just recently, hospitals also have been designated as first responders-and first receivers. the value of the hospital in national security has been increased, and hospitals are recognized as safe havens in communities, the public expects hospitals to be prepared to care for their needs, and the hospital is now recognized as a first responder in emergencies. however, hospitals remain significantly underprepared to respond as effectively as the public expects. most importantly, preparedness is at direct odds with productivity. daily operating requirements stretch most hospitals' resources. allocating funds to improve emergency response capabilities that may never be used could be viewed as foolhardy. community integration is now seen as necessary, but hospitals (other than those in networks or that are government facilities) have had few reasons to build healthy relationships with other hospitals in their communities. to meet the needs of communities in a disaster, business competitors must work as partners. hospitals play a vital role in the health,social structure,and economic life of a community. patients expect hospitals, and health system workers, to be available to provide care for them in all circumstances. a level of preparedness that was viewed as adequate in the past is no longer seen as acceptable. to be more highly prepared and to be able to respond effectively, hospitals must make substantial investment in equipment, training, facilities improvements, and supplies. hospitals depend on public trust; poor performance during a disaster could be financially crippling to a facility. rubin writes that hospitals are expected to handle whatever they receive and do it right the first time. hospitals are vulnerable to the stresses of disaster responses due to a number of inherent characteristics: • complexity of services: hospitals are facilities that provide healthcare but must also function as laundromats, hotels, office buildings, laboratories, restaurants, and warehouses. • dependence on lifelines: hospitals are completely dependent on basic public services: water, sewer, power, medical gases, communications, fuel, and waste collection. • hazardous materials: the hospital environment contains toxic agents and poisonous liquids and gases. • dangerous objects: heavy medical equipment, storage shelves, and supplies can fall or shift during an event such as an earthquake. multiple forces have placed hospitals in a precarious preparedness posture. the capacity of the health system has been scaled down to a bare minimum to cut operating costs. emergency departments are crowded with the uninsured and the underinsured who have no other access to care. the nursing workforce has withered, and physicians have left practice due to uncontrolled liability insurance costs. many hospitals determine their surge capacity by the number of patients they could comfortably care for using standard spaces, quality care standards, and additional teams of personnel to help. in reality, a disaster is not going to comply with the limits of hospital capacity. if bombing victims arrive at a -bed community hospital, spaces will need to be converted and used that planners may have never imagined, such as chapels, hallways, and offices. nurses accustomed to a certain nurseto-patient ratio may find the ratio in a disaster much higher and have to adapt practice accordingly. surge capacity must not be viewed only as the number of beds or spaces that can be allotted to care for patients, but it must include all supporting hospital services that are involved in patient care. if hospital services fail during a disaster, the hospital fails the population depending on it. the population includes not just the victims of the disaster, but the others presenting for needed care-women preparing to give birth, patients with chronic disease exacerbation, and children with lacerations that need sutures. a vital hospital emergency management program acts as an insurance policy that increases the chances of continued operations under difficult circumstances. an effective hospital emergency management program guides the development and execution of activities that mitigate, prepare for, respond to, and recover from incidents that disrupt the normal provision of care. the program should include the following components: • emergency manager: the emergency manager is the primary point of leadership in the development, improvement, exercise, and execution of the hospital's emergency management plan. • emergency management plan: the plan identifies the hospital's response to internal and external emergencies. deliberate (advance) planning permits the development of strategies while the organization is not under pressure to react. • executive leadership: hospital executive leadership charts the course for an organization. a hospital that lacks executive leadership committed to emergency preparedness will be significantly hampered in its efforts. • strategic planning: the hospital's strategic plan is the blueprint that guides all efforts to achieve its mission. it is critical that emergency management and preparedness efforts are woven into strategic planning. • emergency management committee: extremely broad membership is desired to ensure all hospital operations that will be stressed in a disaster are integrated and well prepared. • hazard vulnerability analysis (hva): the hva is a tool used to assess the risks in a specific environment. the emergency management plan can be tailored to address the hazards most likely to affect hospital operations. • vulnerability analysis: every aspect of hospital operations that will be depended on in a disaster should be assessed to determine whether there are weaknesses present that fail when stressed. hospitals in the u.s. navy medical department and a number of civilian hospitals in new york have had their level of preparedness assessed using the hospital emergency analysis tool (heat). the heat examines more than factors that contribute to effective emergency preparedness and response. after the systematic analysis by a team of experts, the hospital receives an after-action report that documents strengths and weaknesses and permits the development of a strategic plan to improve preparedness. • staff training, exercise, and continuous improvement: the joint commission on accreditation of healthcare organizations requires hospital staff members involved in the execution of the emergency management plan to receive orientation and education relative to their role in an emergency. exercise of the emergency plan is also required. lessons learned should be integrated into plans to continuously revise them. a commitment to the following philosophies will enhance hospital emergency preparedness: • imagine the unimaginable: when flood waters rise in a community, when a tornado touches down and demolishes an elementary school, when a disgruntled hospital employee opens fire with an automatic weapon in the emergency department, when a passing train derails and spills toxic chemicals, or when a wildfire closes in, it is too late to update an old plan, train staff to respond effectively, check phone numbers, and stock disaster supplies. disaster complacencybelieving a problem won't happen to you or your hospital-is a significant threat to effective planning and response. • protect the staff: only a true obsession with self-protection will ensure that staff members are not injured or become ill during disaster response. adequate stockpiles of gloves, masks, and other equipment must be available, along with training and leadership commitment to self-protection policies. • build in redundancy: expect the primary plan to fail and build in alternatives to every emergency measure. • rely on standard procedures whenever possible: people perform best in unusual situations when they perform activities that closely mirror what they do under normal conditions. • maintain records: patient care records are critical to obtaining reimbursement for disaster care provided. • plan to degrade services: normal levels of services cannot be maintained during disaster response. identify services, such as elective surgery, that can be temporarily curtailed or minimized so that personnel and resources can be reassigned. the federal government has implemented programs to augment local and state capabilities when they are overwhelmed. the united states has a well-established emergency medical safety net: the national disaster medical system (ndms). the ndms has two primary capabilities designed to enhance disaster medical response. the first is specialized disaster response teams who augment the medical emergency response at the site of disaster. the second ndms capability is a plan to share the inpatient bed capacity of the civilian and federal health systems in the event either system is overwhelmed with patients requiring inpatient care. ndms federal coordinating centers (fccs) play a regional role in maintaining a supply of ndms hospital members and providing training and exercises. when the ndms is activated, fccs coordinate patient reception and distribution of patients being evacuated. hospitals enter into a voluntary agreement to participate in the ndms. they must be accredited and generally have more than beds. the agreement commits a hospital to provide a certain number of acute care beds to ndms patients; however, it is recognized that hospitals may or may not be able to provide the agreedupon number of beds. hospitals that receive ndms patients are reimbursed for care by the federal government. the strategic national stockpile the strategic national stockpile (sns) was established in as the national pharmaceutical stockpile. it is now managed by the u.s. department of homeland security and serves as a national repository of antibiotics, chemical antidotes, antitoxins, intravenous therapy, airway management equipment, and medical/surgical items. the stockpile is designed to supplement local agencies that are overwhelmed by a health emergency. the noble training center in anniston,ala., (on the site of the former fort mcclellan army base) is the only hospital facility in the united states that trains healthcare professionals in disaster preparedness and response. the department of homeland security operates the noble training center, which offers a variety of training programs, including one for hospital leadership. more information is available online at: http://training.fema. gov/emiweb/ntc/. even though the federal government has many emergency response assets that can help in the response to an emergency, experience has shown that hospitals must be prepared to be self-sufficient for to hours after an event. a comprehensive hospital emergency management program must address a number of critical elements to adequately protect patients and staff and permit the facility to continue to operate. these are discussed in the following. just as one team leader is necessary for a controlled response to a cardiac arrest, an organized approach is essential to a successful hospital-wide emergency response. the hospital emergency incident command system (heics) is designed to provide that coordination. developed and tested in orange county, calif., in , it provides structure to response. heics uses: • a reproducible, predictable chain of command • a flexible organizational design that can be scaled to the scope of the problem • checklists for each position to simplify response and carefully define each task • a common language that permits communication with outside agencies the eoc will serve as the command post for operations during an emergency response. it should be fully operational and integrated into local and county emergency operations (box - ). hospital disaster drills have often been treated as annoyances and are planned in ways to render them futile. exercises are generally announced (unlike actual events), planned during regular business hours, and rarely include all hospital operations that will be affected by an actual event. hospitals are encouraged to drill individual units-frequently and during nights and weekends-and then build up to full, functional exercises involving management of moulaged "casualties." community participation is critical to identify elements that work or that need fine-tuning. only through exercise will the plan be adequately stressed so that failure points are identified. the facility's structural integrity and essential services are an often overlooked part of preparedness. box - recommended equipment and supplies for a hospital eoc (hvac) system so that it can be shut down and, ideally, so that specific zones can be manipulated to control airflow in the building in case of contamination • maintain a fuel source for full-load demand for to days' duration • develop a plan for the management and disposal of increased volumes of contaminated waste maintaining the physical security of the structure is important on a daily basis but becomes more of a challenge during a disaster. to ensure that the environment remains safe, egress must be controlled. additional elements of the physical security plan should include the following: • a security force with full-time security responsibilities; the force should have undergone criminal background checks and professional law enforcement training. • all entrances and exits should be controlled, monitored, and capable of being locked. • the hospital should be able to perform perimeter security protection ("lockdown") within minutes of notification. • hospital staff should be trained and drilled on the performance of lockdown. • hospital leadership should know what triggers the execution of a lockdown procedure. • a plan should exist for supplementing security staff in a disaster. it is critical that a hospital be able to rapidly assess the impact of a disaster on its operations and communicate the status to leadership in a situation report (often referred to as a "sitrep"), or a rapid needs assessment (ran). the assessment should, at a minimum, include the following: • the extent and magnitude of the disaster and the scope and nature of casualties • the status of operations and any disrupted critical services • the impact of disruptions on operations and the ability to sustain operations hospital staff must be able to receive timely and accurate notifications in a disaster, including when and where to report and for how long and other essential information. contact information for all staff members must be continuously updated and tested. additionally, the facility must be able to receive warnings and notifications from external agencies and be able to send warnings. triage is performed daily in emergency departments, where the most critical are treated first. but during a dis-aster, triage procedures must adapt to become like what is used on the battlefield, where the greatest good is offered to the greatest number. multiple disaster triage systems exist, including start (simple triage and rapid treatment), id-me (immediate, delayed, minimal, expectant), and mass (move, assess, sort, and send). it is important that a hospital use a system that is consistent with what is being used by services delivering patients to the facility. whatever system is selected, there must be predisaster training and exercises. when casualties present to an emergency department in numbers that overwhelm the facility, an alternative area must be available to manage overflow. the alternative triage area should be lit so that it can be used at night, weatherproofed, and temperature-controlled. a plan for working with the media will be needed. it is not recommended that media personnel be permitted access to a hospital during a disaster, but rather be provided regular, factual updates on activities and the status of the facility at a predetermined meeting place. risk communications involve using credible experts to deliver carefully worded messages to communicate most effectively in a high-stress, low-trust environment, such as a disaster. preparing hospital leaders in risk communications principles will ensure that they are able to communicate effectively to the public via the media. there is conflicting evidence about the value of certain types of mental health services in the wake of disaster, but it is clear that every disaster creates emotional trauma victims. primary victims are those who have been directly affected by the disaster. secondary victims are rescue workers in whom symptoms develop, and tertiary victims are relatives, friends, and others who have been affected. the critical incident disrupts a victim's sense of control as daily life is abruptly changed. hospitals must plan for providing mental health services to disaster victims but must also consider the needs-acute and long-term-of the hospital staff who attempt to respond to an overwhelming event. it is recommended that hospitals have trained crisis intervention teams that are well integrated into the emergency management plan. in the event of an intentional act that results in mass casualties, not only must a hospital care for the victims, but it has a critical role in bringing perpetrators to justice. hospital staff members require training in proper management of potential evidence-in both collection and preservation. evidence collection containers, including -gallon drums for patient decontamination run-off, should be available as well as bags to preserve other types of evidence. law enforcement agencies and forensic departments can provide training and guidance. staff members should be familiar with and follow procedures for maintaining chain of custody for evidence that is collected during patient care activities. a disaster will place significant demands on the food service system of a hospital. the adequacy of food supplies for patients and staff should be evaluated. because a hospital may need to be self-sufficient for several days in a disaster, a -to -day supply of food products is advisable. food service personnel should be included in disaster exercises. volunteers may or may not be of assistance, depending on their relationship with the hospital and their background. a volunteer pool that consists of individuals who serve regularly at the facility, are familiar with standard procedures, and participate in exercises can add valuable manpower to a disaster response effort. on the other hand,disasters will draw volunteers who wish to assist,a phenomenon known as "convergent volunteerism," in which unexpected and uninvited healthcare workers arrive and wish to render assistance at a large-scale incident. these "freelancers" may cause problems or may even be impostors. despite "just-in-time" supply schedules and empty warehouses, hospitals should maintain dedicated disaster supplies and arrangements for rapid resupply in the event of a disaster. disaster response will rapidly deplete critical supplies-administrative as well as clinical. conducting realistic exercises will help with the determination of the adequacy of stock and can be done without opening actual supplies so they can be restocked. disaster supplies can be rotated into the daily-use stream to ensure stock does not expire. experience with disasters has demonstrated a number of predictable pitfalls that occur in hospital disaster response. because immediate on-scene control of a disaster is chaotic and communication is often problematic, patients will present to the closest hospital available. this often leaves other nearby facilities with capacity and personnel that go unused. hospital personnel must be experts in protecting themselves, or they will become part of the problem and fur-ther stress the facility. some controversy exists over the level of protection needed in certain environments, but it is clear that masks (n ) and gloves (latex or nonlatex) will prevent transmission of biological agents. communications failure has often been identified as a predictable failure in disaster response. hospitals need to examine both internal communications systems (with staff and patients) and with external agencies. multiple layers of redundancy are essential to deal with expected failures and include the use of -mhz radios, dedicated trunk lines in the emergency operations center, two-way communications for hospital units and essential personnel, communications-on-wheels (cows), and access to amateur radio (ham) operators. the last resort is using runners who carry messages. hospitals must be able to identify and decontaminate patients who have been exposed to radiation or a compound that poses a threat to the patient's health and the safety of the facility. if the hospital depends on an external agency or has decontamination equipment that requires time to set up, an immediate alternative must be in place, such as a hose and hose bib outside of the emergency department. consideration should be given to patient privacy, managing patient valuables and clothes, and handling weapons brought into the hospital. a trained, exercised, and well-equipped team will be the foundation of successful efforts. hospitals will benefit from having a plan to care for children and other dependents of staff. in a disaster, staff will be called on to work extended hours, and usual family care arrangements may be unavailable. the creation of emergency patient admission packs that are maintained with disaster equipment will facilitate the admission of a large number of patients. if an automated patient tracking system is used, a back-up manual system should be available. all systems should be able to manage unidentified (john and jane doe) patients. many hospitals have wholly inadequate or nonexistent plans to manage mass fatalities. morgue space is generally limited in most facilities, so additional surge capacity must be identified in advance. arrangements for refrigerated storage trucks, refrigerator space, and other alternatives, including ice rinks, should be addressed with socially sensitive plans. complex cultural and religious issues may come into play in the event that there are contaminated remains and should be examined in advance. emergency drugs must be available at the point of care. often they are secured in pharmacy departments or warehouses, resulting in precious minutes of life-saving time being lost as personnel try to locate and obtain critical medications. in addition to drugs needed to respond quickly to nerve agents and other emergency situations, stockpiles of antibiotics should be maintained to provide prophylaxis to patients and staff. in a disaster, patients converge on the place they know they can obtain care-the hospital-and they arrive using any means possible. furthermore, with the victims of disaster, come their families, loved ones, and the media-all who have very important needs that must be addressed. hospitals can no longer approach disaster planning with a minimalist attitude that relies heavily on luck and belief that it will be someplace else that gets hit by the disaster. the hospital that received the most patients from the rhode island nightclub fire got lucky-the victims began arriving during a change of shift so there were two shifts of nursing staff available. however, the hospital also attributes its effective response to having drilled critical departments and procedures. emergency planning is the backbone of preparedness, but events will occur in each disaster that demand creative responses under pressure. this ability to respond flexibly is known as planned innovation. good plans will use general "all hazards" templates for disaster management but will permit independent initiative and a tailored response to a specific situation. the u.s. health system appears to be emerging from the dark ages of emergency planning. a minimalist attitude of preparedness was acceptable in the past despite the regular occurrence of natural disasters. the threat of terrorism and the resulting health system impact have stimulated investment in research, a resurgence of disaster training in nursing and medical schools, and visionary projects such as er one. er one is a national prototype for a next-generation emergency department. located in washington, d.c., it is developing new approaches to the medical consequences of terrorist attacks, natural disasters, and emerging illnesses. more information is available online at: http://er .org. the next phase of hospital emergency management will be a renaissance if creative planning prevails over naysayers, if resources are applied to priority preparedness activities, and if healthcare leaders are committed to ensuring that all who depend on hospitals will receive the care they need in a disaster (box - ). the care of strangers-the rise of america's hospital system combined external and internal hospital disaster: impact and response in a houston trauma center intensive care unit implications of hospital evacuation after the northridge, california, earthquake lessons learned from the activation of a disaster plan: / two new york city hospitals' surgical response to the a test of preparedness and spirit emergency department impact of the oklahoma city terrorist bombing tragedy and response-the rhode island nightclub fire the station nightclub fire and disaster preparedness in rhode island mass decontamination: why re-invent the wheel? meeting new challenges and fulfilling the public trust: resources needed for hospital emergency preparedness recurring pitfalls in hospital preparedness and response pan american health organization. principles of disaster mitigation in health facilities health care at the crossroads-strategies for creating and • auf der heide e. principles of hospital disaster planning department of health and human services. (includes recommendations on prehospital and hospital care preparing for the psychological consequences of terrorism-a public health strategy. this publication of the national academies of science includes an examination of current infrastructure and response strategies guide to emergency management planning in health care regional care model for bioterrorist events • the hospital emergency incident command system • the international critical incident stress foundation box - hospital preparedness and response resources sustaining community-wide emergency preparedness systems dvatex: navy medicine's pioneering approach to improving hospital emergency preparedness advanced disaster medical response-manual for providers. boston: harvard medical international trauma and disaster institute critical incident stress making room for outside the box thinking in emergency management and preparedness key: cord- -lqwyomxz authors: liu, jinguo; wang, yuechao; li, bin; ma, shugen title: current research, key performances and future development of search and rescue robots date: journal: nan doi: . /s - - - sha: doc_id: cord_uid: lqwyomxz frequent natural disasters and man-made catastrophes have threatened the safety of citizens and have attracted much more attention. the rescue mission under disaster environment is very complicated and dangerous for a rescue team. search and rescue (sar) robots can not only improve the efficiency of rescue operations but also reduce the casualty of rescuers. robots can help rescue teams and even replace rescuers to perform dangerous missions. search and rescue robots will play a more and more important role in the rescue operations. a survey of the research status of search and rescue robots in japan, usa, china and other countries has been provided. according to current research, experiences and the lessons learned from applications, the five key performances of a search and rescue robot are survivability, mobility, sensing, communicability and operability. multi-technique fusion and multi-agent intelligent network are considered to be requirements for the future development of the search and rescue robot. disaster prevention, disaster reduction and disaster rescue are the important parts of national public safety. they are also crucial for the safety of citizens and their estates. search and rescue robotic technique is an urgent needed, strategic and core technique for national development. it will be important and strategic for national economy and safety. in recent years, people's safety has been greatly threatened by frequent natural disasters such as earthquakes, fires and floods; the man-made dangers such as terrorism and armed conflicts; biochemical virus such as anthrax, severe acute respiratory syndrome (sars), avian flu; and toxic substances and the radioactive substances such as nuclear leakage. they have attracted extensive concern. although people have improved their alert and response capabilities to various disasters, there are still fewer adequate prepa rations for devastating disasters. many people still died because of unprofessional and time pressure rescue operations [ ] [ ] . a new field and challenge in robotic research is how to effectively fuse the multidisciplinary knowledge such as robotic technology, rescue technology and disaster science, hence develop intelligent robots for the search and rescue operations. according to the time when a disaster occurs, a disaster rescue operation can be divided into three stages: the predisaster rescue operation, the on-disaster rescue and the postdisaster rescue operation. the pre-disaster rescue operation mainly aims at the disasters known in advance. the rescue operation includes disaster prevention and elimination of catastrophes, evacuation and transfer of materials. the ondisaster rescue operation aims at time-consumed disasters such as fire, flood, gas and radioactive substances. it mainly includes fighting against disasters. the post-disaster rescue refers to taking the search and rescue operation afterwards short-time disasters such as an earthquake and sudden explosions. there is no clear boundary among the above three stages. however, the rescue operation in all stages has two problems: the complexity of the environment and unpredictable dangers. taking an urban environment as an example, the population of cities and the urban population density have quickly increased, which leads to that high-rise buildings, underground projects, large business establishments and cultural/entertainment facilities have been rapidly built. all these make the rescue operation too complicated to be dealt with. in some extremely dangerous catastrophes including the fire in an explosion, the flammable, explosive and toxic gases and the easily second-collapse building site after an earthquake, the rescue staff are eager to know the inner situation when they can not perform an in-depth reconnaissance. in such a case, search and rescue robots can improve the efficiency of the rescue operation and medical treatment to reduce the casualties. they can not only help the rescue team in rescue operations, but also replace rescue staff in search and rescue missions. generally, robots can play an increasingly important role in a disaster rescue operation. in recent years, especially after the . attack, many countries in the world began to develop various anti-explosive/ anti-terrorism robots as well as search and rescue robots for disaster protections and relief in the sight of their national security strategies. meanwhile, because a search and rescue robot has lots of potential applications and wide markets, some companies have also been involved in the research and development of search and rescue robots. additionally, the international robot competition, robot world cup (robocup), initiates a special rescue competition "robocup rescue", which has provided a test platform for the theory and simulation technology in rescue robotics. currently, the technology of a search and rescue robot is developing from theoretical and experimental research to applications. in , ieee international workshop on safety, security and rescue robotics (ieee ssrr p ), which held in june in kobe, expected that robotics would provide an effective solution for the next-age disaster mitigation and become one of the indispensable components of the social infrastructure. the attendances came from different countries or regions. their research on rescue robotics is different, comprehensive and diversified because of the difference in the level of skills, geographic and political factors, disaster types, ruins and the robot tasks. in the following sections, a survey of the research status of search and rescue robots in japan, usa, china and other countries will be introduced separately. as a country with rich nuclear power and frequent earthquakes, japan has performed a relatively comprehensive program to research and develop search and rescue robots. after the hanshin awaji (kobe) earthquake in , a complete disaster rescue and protection system has formed. japan ministry of education, sports, culture, science and technology has launched a national project, special project for earthquake disaster mitigation in urban areas (ddt project) in . a part of this project (development of advanced robots and information systems for disaster response) aims at developing the advanced robots and information systems for disaster response. this project includes more than groups with a period of five years. participants include universities, companies and the national institute. the topics of the research include the robot systems of observation in environmental disasters, sensor technology, human interface technology and system integration. a public test site was established at kawasaki for the project and the international rescue system institute was organized. the "disaster response strategy" of the international rescue system institute is the core part of the ddt project. the major work in their plans is to conduct research on robotics, intelligent sensors, portable terminal devices and man-machine interface; to develop intelligent information collecting systems; as well as to transmit, compile and generalize the information by a network. professor hirose who is in tokyo institute of technology is one of the pioneers in rescue robot research. he has developed many robots in his laboratory such as "acm", "genbu", "soryu" and other series prototypes in the view of biomimetics and the super mechano-systems [ ] [ ] (http://www-robot.mes.titech.ac.jp/robot.htm, - - ). with his colleagues and students, he has made great contributions to the biomimetics and its application in search and rescue operations. figure shows the parts of the rescue robots developed in hirose's laboratory. considering the most important thing is to locate the lives in debris and the robot must be in a narrow space, they have developed the souryu series. in the fire-fighting scene with water tubes, they have developed the water-driven multi-wheel robots named genbu-i, genbu-ii and genbu-iii that use high-pressure water as their power to move and distribute water. professor kamegawa in tokyo institute of technology also proposed a new rescue robot platform [ ] . as shown in fig. , the robot is composed of multiple tracks and it can enter into a narrow space. with the active joints or passive joints between adjacent units, it is good at crossing barriers and adapting to the ground. in kyoto university, osuka et al. developed a four-section rescue robot "moira" with four sides equipped tracks [ ] . as shown in fig. , the robot used each four motor to drive four tracks simultaneously and separately, which made it good at shuttling in the ruins and free of tipping. figure shows a deformation robot "cubic-r" developed by tabata et al. [ ] . with tracks around, this robot can be in a contraction model like a cubic and it can be turned into a variety of other models. figure shows the information collecting robot "ma- " developed by professor matsuno et al. from the university of electro-communications [ ] . figure is the rescue mobile robot "resdog" developed by nagatani et al. in okayama university (http://usm.sys.okayama-u.ac.jp/~keiji/research/ prj-rescue/rescue.html, - - ). in the bottom suspension of the robot, several passive triangle type tracks provide excellent terrain adaptability. figure shows the utility mobile robot for search (umrs) series rescue robots developed by professor takamori in kobe university [ ] . the robots are expected to be used in inspection operations in ruins. the formers are track-type vehicles whereas the latter type adopts flexible driven joints. www.jaeri.go.jp/english/press/ / /, - - ; http://www.jaeri.go.jp/english/press/ / /, - - ). by remotely controlled, resq series robots have designated missions such as collecting early information (resq-a), collecting detailed information (resq-b), and collecting sample (resq-c). rabot is co-developed by japan atomic energy agency, naka institute, and fusion nuclear technology. with high mobility, it can easily go up or down stairs. in chiba university, nonami et al. performed an extensive research on mine detection robots and air unmanned planes (http://mec .tm.chiba-u.jp/~nonami, - - ). as shown in fig. (a)-(c), the detection system at the front of a mine detection robot has high sensitivity. the aerial search and rescue robot in fig. (d) is wireless controlled by ground operators. figure shows the operation robot resq series and rabot developed by japan atomic energy agency for the implementation in the atomic nucleus radiation sites (http:// in japan, some large companies are also involved in the research and development of rescue robots. they usually cooperate with research institutes or universities. enterprises provide the institute with the necessary fund support for the research and test site. they are also a bridge between products and markets. figure mounted on the caterpillar tracks that were powered by a diesel engine, it can chug along at kph, guided by the operator perching in the protected cabin at the front of the robot. enryu's most striking feature is its two huge hydraulically operated arms with moving steel grips. each of them can be stretched to m and can lift up kg. after the . attack, search and rescue robotic technology has attracted increasing attention in usa. the rescue operation at the . attack is considered to be the first appli cation for search and rescue robots. lieutenant colonel john blitch (ret.), the director of the center for robotic assisted search and rescue (crasar), requested a team of robot experts and suppliers to assist in search efforts at the world trade center (wtc) disaster site. new york city's office of emergency management directly requested crasar's response. after several hours of the terrorist attack, crasar quickly responded to the wtc disaster. this is the first known application of robots for usar. eight types of the rescue robots are shown in fig. [ ] . as shown in fig. (a)-(c), some types of robots from inuktun are micro vgtv, micro traces and mini traces, respectively. they have been mostly used in ruins for their small size and light weight. among them, micro vgtv and micro traces were proved to be more efficient than mini trace in constrained space. foster-miller companies also used the three robots: talon, solem and urbot shown in fig. (d)-(f). with the better sensor and load-carrying capacity, they are larger than the robots from inuktun because they have the nasa's military background. solem was used in ruins. talon and urbot were used for the inspection in interior buildings. the irobot also used two types of robots in rescue operations: packbot and atrv. the tracked packbot had remarkable traction and self-adjustment ability. the big atrv had a large wheeled mobile platform. in usa, a lot of university research centers, national research institutes and companies also conduct researches on search and rescue robots. in center for robotic assisted search and rescue (crasar), a non-profit research center based at the university of florida that is led by robin murphy crasar, has developed many robotic technologies to assist search and rescue teams [ ] . as shown in fig. (a), the rescue robot bujold is equipped with medical sensors. the tracked robot has high mobility and excellent detection capabilities. meanwhile, the robot can collect information such as survivors, physical information and environmental information and then transmit them outside. the scout robot in fig. (b) is developed by stoeter et al. from the university of minnesota [ ] . with simple sensor modules, locomotion unit, and specialized operational tool, it can be used for multi-robot's parallel information collection. the robot has flexible protection wheels on outer side. with two inspection/locomotion arms, terminatorbot, the physical structure of which is very cleverly designed as shown in [ ] . with the fast stair climbing ability, it is simple and easy to be controlled. figure (e) provides a rescue mobile robot with an elephant nose like a manipulator developed by wolf et al. from carnegie mellon university [ ] . the mobile robot has a mobile platform, which can greatly increase the mobility and exploration space of the lends urbie in many different applications. such robots could investigate urban environments contaminated with radiation, biological warfare, or chemical spills. they could also be used for search and rescue in earthquake-struck buildings and other disaster zones (http://robotics.jpl.nasa.gov/tasks/ tmr/ hybrid.html, - - ). in usa, the search and rescue uva or helicopter also attracts the researchers' great attention. the vision-guided robot helicopters shown in fig. (a) from cmu can quickly and systematically search a very large area to locate the victims of an accident or a natural disaster. they can be sacrificed under very dangerous conditions to save human lives. prime examples include flying close to a forest fire to look for stranded individuals, searching in contaminated areas and identifying potential radioactive leaks after a nuclear reactor accident (http://www- .cs.cmu.edu/afs/cs/project/ chopper/www/index.html, - - ). the ar yamaha rmax shown in fig. (b) is an autonomous uav from nasa ames research center, which provides a platform for intelligent surveillance in application domains ranging from security and military operations to scientific information gathering and land management (http://human-factors.arc. nasa.gov/apex/docs/papers/aaaiss /aaaiss .html, - - ). the rescue helicopter shown in fig. (c) comes from air search rescue. this association is exclusively organized for charitable, humanitarian and educational purposes, more specifically, it is a qualified multi-rescue disaster and missing persons organization which provides life saving search, rescue and recovery with involvement of law enforcement, fire rescue, emergency medical and general services such as specially trained canine search dogs, underwater scuba recovery teams, ground search with atv's, helicopters, airplanes, with no compensation for services render, all our non-paid board of directors and volunteers provide around the clock emergency services (http://www.airsearchrescue. com/helicopter_main.htm, - - ). in china, robotic scientists were aware of the importance of the research and development of search and rescue robots since the s. many universities and institutes had laid stress on the search and rescue robots in various fields such as underwater rescue robot, uavs, and ugvs [ ] [ ] [ ] . manipulator. figure (f) shows a modular reconfigurable rescue robot conro developed by shen et al. from southern california university [ ] . it can change its configuration into different ones including snake, six-legged, or circle upon the requirement. figure (g) is a three-dimensional locomotion snake-like robot developed by haith et al. from nasa (http://media.nasaexplores.com/lessons/ - /fullarticle. pdf, - - ). it has high mobility under unstructured environments. figure (h) is a modular reconfigurable robot polybot designed by yim et al. from the research center parc [ ] . it can fluently change its configuration to adapt to different terrains. the urbie series shown in fig. is jointly developed by jpl, irobt, cmu and usc from the mobile robot program. in the darpa advanced technology office, this program has enlisted jpl's machine vision group in leading the design and implementation of its perception urban robot. urbie's initial purpose is mobile military reconnaissance in the city terrain; therefore, many of its features will also make it useful to police, emergency and rescue personnel. with the hybrid structures with track, wheel and leg, the robot is rugged and well-suited for hostile environments and its autonomy in disaster's search and rescue application, notable achievements had been made in. in june , the national project-"tracked and wheeled fire-fighting robot" that jointly held by shanghai fire research institute of ministry of public security, shanghai jiaotong university and shanghai fire bureau were successfully completed. the fire-fighting robot, also known as a self-propelled water bubble fire fighting vehicle, is a new type of fire rescue equipment with various fire-fighting techniques. the fire fighting robot shown in fig. are developed by shanghai qiangshi fire-fighting equipment ltd. co., which were sponsored by shanghai fire research institute of ministry of public security. the fire-fighting robots, which come from the laboratory to the production workshop and at last to fighting in the real fire, greatly improve the fire rescue equipment of china (http:// www.qs .com/asp/product_list.asp (in chinese), - - ). to complete the national tenth-five " " program "robot operating in dangerous and extreme environment" and to meet the requirement of advanced robots in national's anti-terrorist, riot and unexpected incidents, the experts from the "robotic technology group" organized two symposiums with the theme of "dangerous and extreme environment robots" in march and "sudden emergency response advanced robot" in august , respectively. in october , the ministry of science and technology, the ministry of public security, headquarters of chinese people's armed police force and the automation field of the tenth-five program first proposed the theme of anti-terrorist and against riot robot research with the aim to develop the extreme environment robot. especially on october , , in the first anti-terrorism and against-riot robot symposium, proposals had been proposed to develop the public security robot for the olympic games and the world expos. a complete public intelligent protection and rescue system for the olympic playgrounds or the other important places will be set up with the assistant of advanced inspection robots for ground, wall and pipe, mini uav for ultra-low-altitude flight and the inspection robot for shallow water. with fund support of the national program, the shenyang institute of automation (sia), chinese academy of sciences (cas) had developed a serious of dangerous and extreme environment robots where search and rescue robots were an important part. the snake-like robot in fig. (a) is developed for unstructured environment's inspection and rescue operations [ ] . with a wireless control system, the snake-like robot can use manifold of d locomotion gaits such as serpentine, concertina, side-locomotion and rolling. the onsite scene can be transmitted to the operator by the micro-camera installed on the head of the snake-like robot. based on the study of the snake-like robot, a link-type reconfigurable modular tracked robot named amoeba-i had been developed in sia for a search and rescue operation. this robot has three modules, nine mobile configurations and three symmetrical configurations: line type, triangle type shown in fig. (b) and row type. it can change its configu rations and gaits to meet the requirement of [ , ] . the water surface rescue robot shown in fig. (c) is under wireless control within a distance of km. as shown in fig. (d) , the product prototype of an extreme environment robot, which can complete antiterrorism and against-riot task, had been successfully developed by sia and guangzhou weifu company with authorized copyright. the prototype shown in fig. (e) is the next generation of the anti-terrorism and against-riot robot. the robot with compound structures of the wheel, leg and track shown in fig. (f) is recently developed in sia for the unstructured environment mobile robot. it can overcome the complex environments such as rugged terrain, obstacles and stairs. it can also be widely used in inspection, investigation, handling, fire fighting and destruction of dangerous materials. on september , , the "china-japan rescue and safety robotics center" was set up in shenyang. the center is jointly sponsored by sia and the international rescue system in japan with the aim of achieving a strong alliance to promote the robotic technology in search and rescue application. after the . attack, the research on search and rescue robot has also attracted the attention of other countries. the artificial intelligence laboratory of system science and engineering institute, rome university in italy initiated the "rescue project". the canadian department of defense established the search and rescue robot research project for the national security. researchers and robocup participants in england, iran and other countries also have shown great interests in the mechanism, sensor, control and simulation of search and rescue robots. in the robcup , sharif university was the only competitor that could travel in the orange and red arenas. the present version of sharif university's rescue robot emdad , as shown in fig. (a) , is a tele-operated robot. an operator remotely controls the robot through a tcp/ip wireless local-area network (wlan) and receives the images and sounds of the scene when the robot is moving on. the software developed for this robot consists of a user-friendly interface, control programs, simple versions of path drawing and planning and stereo vision image processing programs. in the next version, additional software will be used to provide more autonomy for victim detection, collision avoidance and decision making (http://linux.ce.sharif.ac.ir/~mobasser/ rescue .htm, - - ). in the robocup , which held in padova, italy, the first three robot winners in sequence are the "robrno" shown in fig. (b) from brno university of technology, czech republic, the "cedra" shown in fig. (c) from sharif university of technology, iran, and the "iutmicrobot" shown in fig. the working environment of search and rescue robots is unpredictable and unstructured. both the environment and the task are dangerous for the robots. according to the exiting research of search and rescue robots in the world and the experiences and lessons learned in their application in the . attack, the most key performances required for a search and rescue robot are survivability, mobility, sensor, communication and operation [ , , [ ] [ ] [ ] . survivability of search and rescue robot mainly reflects the reliability, durability and adaptability of a robot platform. survivability in the possible environment with the dangerous gas, toxic liquid, biochemical materials, radioactive substances, extreme temperatures and the risk of secondary collapse is very important. for instance, in a fire disaster, the robot platform should overcome the extremely high temperature and be paid special attention in materials selection. in a dangerous gas or toxic liquid, the robots must face the threat caused by toxic corrosion; therefore, both material selection and structural sealing are important. in the disaster ruins with acute edges, the safety of the robot's wires and the surface hardness should be considered. considering the power supply of search and rescue robots, both the wired supply and the wireless way are required to ensure the rescue operation hours. another requirement in the survivability of a search and rescue robot is the flexibility of software and hardware to take different actions in different cases, region and operations. disasters are so changeable that disasters of the same type will not result in similar damages, and the same disaster in different regions will have different effects. therefore, a search and rescue robot should have adequate adaptability and forecast for the changing environments. robots should have the intelligence to respond to the challenges and the instable/disturbing factors in the environment. a robot's mobile platform is very important because the mobility is urgently required in a search and rescue environment. the working environment is complex with too many debris and narrow spaces. the robot should be small enough to overcome it. however, it should be much larger to overcome the surrounding obstacles because it is easy to get tipover if the center of gravity is too high. on the other hand, the robot should overcome the obstacles as many as possible. the stability and the self-adjusting ability are very important in avoiding dropping into fragments. being repeated, modularized and fault-tolerance, the link-type snake-like structure is proved to be one of the most efficient mechanisms for the search and rescue operation. in the unstructured environment, it is unavoidable that the robot will be damaged or part of it will fail out, therefore, fault-tolerance and fault-handling are important in such cases. recently, a reconfigurable modular search and rescue robot is considered to be an ideal solution for the paradox. moreover, the disaster ground is usually soft for dusts, muddy for water leakage from the water pipe or firefighting equipment and rugged for debris, the robot should have high mobility and adaptability in such case. regarding the existing wheeled, tracked and legged type mobile mechanism, the hybrid mobile structures have been extensively adopted. sensors are the most vulnerable components for a search and rescue robot. they have three applications: robot control, environmental inspection and victims or survivals detection. in robot control, the robot must be aware of its right position, posture, speed and inner status to keep itself work normally. such equipment includes charge coupled device (ccd) cameras, laser rangefinders, ultrasonic range finder, contact sensors, force sensors, infrared sensors and global position system (gps) sensors. in environmental inspection, environmental information is very important for robot's working status, operation efficiency, saving energy and preventing accidents. environmental inspection includes air quality (oxygen, hydrogen sulfide, methane and carbon dioxide) inspection and detection of temperature, humidity and radioactive substances. environmental information determines the effects on a human body to avoid the rescuer getting into the similar dangerous situation. environmental inspection includes both environmental geology and topography for the two reasons: ) to avoid the environments with obvious threat to robots; b) to avoid causing greater damage and a secondary collapse. the static/dynamic ground, as well as its shape and characteristics, is usually different. therefore, terrain detection is difficult. in victim or survivals detection, objects include the victims or survivals' body, clothing, footprint, voice information, temperature infor mation, apparel information, position information and the unique human-ray findings, are used to judge the existence information and lives of victims. under some special cases, the same detection system can also be used to search for the victims of animals. in a sensor system, the video information is crucial to a search and rescue robot because in rescue process the video information can be utilized by the operator to get the onsite observation. a video can be used like the vision information collector for the remote operator to find the victims. however, a camera is not the ideal visual navigation or the victim's inspection equipment. a head lamp must be equipped for each camera first. in collapsed buildings, all the ground has a thick layer of dust that leads to all the things being gray. if the victims have slight movements, the dust of the ground will be significantly changed. therefore, color camera is indispensable. new technology such as digital temperature camera has good recognition ability, but it has too high requirement to an operator. sonar can not work at such a case, because there are too many edges and corners that are noncontinuous. the ground-penetrating radar, microwave radar and laser detector have good results; therefore, the cost and energy consumption are unbearable. another solution is to use the artificial intelligence technology, nanotechnology, or bionic technology to develop low cost sensors. the information processing and fusion problem exists in multi-sensors. because the search and rescue operation has the limited ability in data processing, most complex tasks such as information and data processing should be designated to outer computers. this will impair its real-time performance. therefore, the distribution of this task should be reasonable. communications of a search and rescue robot include three aspects: between operators and robots, between operators and victims, and among many rescue robots. all communications should be wireless. the ideal situation is that the autonomous robot has the ability to move in all environments, locate the victims, and then communicate with a rescue team. in fact, there is a lot of software processing and it is difficult for the robot to complete it independently. a human-machine interface is indispensable. rescuers must predicate what will happen to make good use of existing resources. in many cases, the robot is not only a tool, but also the substitute of operators. therefore, communications between operators and robots include the robot control and the effective transmitting of information collected by robots. the two main factors are the accuracy of control commands and the completeness of signal processing. communications between operators and survivals are mainly voice and image transmission. important bilateral audio transmission equipment is microphone. according to audio interaction, survivors can not only know the arrival of rescue teams but also guide the rescue operation to further look for other victims. an audio message is a very good tool, but it also has shortcomings. the rescue scene is very noisy with the roar of various machines. voice discrimination is difficult. the communication among rescue robots is blocked by ruins. currently, there is no efficient way to accomplish this, whereas, it is really urgent to be solved. the capability of an operation is considered to be a syn thetical index of a search and rescue robot. mainly two issues exist. the operability denotes that the robots are easily to be operated. the manipulative ability denotes that the robots have the operational ability to some tasks. in operability, different types of rescue robots perform differently. the robot must be controllable and easy to be controlled. the mostly used platforms are light-weighted, small-sized, and portable. the manipulative ability globally embodies the survivability, mobility, sensors, communication and humanmachine interface. it mainly includes the following three aspects. ) exploration. the commander and operator determine the location of the dangerous disaster scene and then use the rescue robots for data sampling and recording or recording the building's d geographic information system (gis) and physical information. according to the information, the rescue commander or correlative staff determines whether the working site is safe or not to minimize the risk of rescue teams. ) search. the search and rescue robot goes into the narrow space or caves where is unavailable to the rescue team to search or identify the victims or survivals. ) rescue assistant. the rescue robot provides a series of services such as carrying the necessary equipment, supplying the urgently needed material to the survivals, being the mobile communications interim, communicating with the operators and the survivals, planning the safe route for the survivals, saving the survivals independently, protecting the survivals from unpredictable dropping fragments, and transporting the victims or survivals. generally, there are different requirements for the rescue robots at different rescue stages. the rescue robot or the rescue operation should adapt to the requirements and perform corresponding operations. china is one of the few countries with serious disasters in the world. the frequent disasters have various types and wide geographic distribution [ ] [ ] [ ] . the representative disasters such as traffic accidents, mine disasters, earthquakes, floods, fires and typhoons-based disaster in china brought great destruction to public safety and national economy and attracted great attention of the experts/scholars in the related fields [ ] [ ] [ ] . currently, the research on the search and rescue robot mainly refers to the implementation of a single platform. because the search and rescue robots gradually come from laboratory into the application, and with the environmental and manipulative requirements of search and rescue robots, many technologies integration and multi-agent networks are the future developmental tendencies of search and rescue robots. because a search and rescue robot is developed for the dangerous and complex disaster environment, the research and development of a search and rescue robot and using autonomous intelligent robots in disaster environments to search and rescue are new challenges in robotics research. a disaster environment has uncertain and unpredictable characteristics. autonomy, flexibility, redundancy, faulttolerance, reliability, practicality and durability are the key performances of a rescue robot in the application. when in a real application, it is inevitable to use the remote control and monitor technology, human-computer interaction, multisensor technology, navigation and positioning technology, machine intelligence, network technology, multi-agent coordination and control technology and the specially related technologies for the disaster scene. figure shows some of the traditional disciplines such as mechanical technology, sensor technology, control technology, signal processing technology, computer science and some newly subjects such as artificial intelligence technology, new energy technology, new materials technology, multi-sensor data fusion technology, network technology, remote operation of remote control technology, ergonomics, bionics, and a number of related disciplines such as psychology and disaster science, engineering, rescue, the ruins of engineering, geology, nursing, and other technical disciplines. various categories of knowledge's integration will provide an effective operation of the rescue robot system. it can be safely obtained that a search and rescue robot system is the core technology that urgently needed by national development in a high strategy level. it involves a lot of factors such as national security, national economy and national technology competitiveness. it will play an important role and have a major strategic significance in the national economy development and security. in a disaster rescue operation, the ground rescue robots, unmanned aerial helicopters, ground rescue workers, medical personnel and ground ambulance vehicles form a multi-agent three-dimensional network to achieve multi-agent communication and information sharing. as shown in fig. , they are distributing in the disaster area, defended area, and public areas to perform rescue operations. the disaster area refers to the disaster sites where a catastrophe may continue to occur. compared with the disaster area, a public area is the relatively safe area facing the public and the media. the defended area separating the disaster area and the public area is used for an emergency rescue operation. ground mobile robots can be designated with variety of different tasks. ground robot teams need to have mobility in ground, shallow marshes and swamps. it is very important to rapidly and correctly collect the information in order to initial rescue activities. therefore, unmanned helicopter systems and a rescue center should be the transit points for information. the information provided by uav facilitates rescue teams facilitating the detailed investigation and the rescue plan. unmanned aerial helicopters are unusually transported by rescue vehicles. operators in a rescue vehicle operate the uav to investigate the disaster scene to provide high-value information by using high-precision gps and inertial navigation detection to achieve high-precision flight path and the high-precision measurement of observing locus. medical staff and ambulances are mainly organized for the rehabilitation and treatment for rescued personnel. the complex rescue network will be a large-scale intelligent rescue system. disaster prevention, mitigation and rescue severely affect the safety of people's lives and their properties. a rescue operation plays an important role in public safety. in an extremely dangerous and terrible disaster, search and rescue robots can replace rescuers and help them in related rescue operations. search and rescue robots have wide applications not only in an urban search and rescue operation, fire protection, public security, mining and environmental protection, but also in other areas such as national defense, military and even planetary exploration. search and rescue robotic technology is urgently needed and is one of the core technologies at a national strategic level. it will play an important role and have a major strategic significance in the development and security of the national economy. (this paper was written in commemoration of the th anniversary of the tangshan earthquake.) snake robots to the rescue human-robot interaction during the robotassisted urban search and rescue response at the world trade center walking and group robots for super mechano-system development of mobile robots for rescue operations sequentially connected multiple-unit rescue robot platform development of mobile inspection robot for rescue activities: moira development of a transformational mobile robot to search victims under debris and rubble - nd report: improvement of mechanism and interface a rescue robot for collecting information designed for ease of use development of umrs (utility mobile robot for search) and searching system for sufferers with cellphone development of a robotic system for nuclear facility emergency preparedness-observing and work-assisting robot system analysis of the robotic-assisted search and rescue response to the world trade marsupial and shape-shifting robots for urban search and rescue autonomous stair-hopping with scout robots terminatorbot: a novel robot with dualuse mechanism for locomotion and manipulation multi-sensor, high speed autonomous stair climbing a mobile hyper redundant mechanism for search and rescue tasks hormone-inspired adaptive communication and distributed control for conoro selfreconfigurable robots distributed control for -d metamorphosis research on the development strategy for extreme environment robots. robot technique and application research on snake like robot and its application in urban search and rescue. robot technique and application new developments of the extreme environment robots in china. robot technique and application link-type shape shifting modular robot for search and rescue analysis of tipover stability for novel shape shifting modular robot after action report to the joint program office: center for the robotic assisted search and rescue (crasar) related efforts at the world trade center review of the key technologies in extreme environment robots. robot technique and application mobility and sensing demands in usar review of accidents and disasters in china in the year review of the main meteorological disasters in china during the years from natural disaster loss in china is the third largest in the world natural disasters and disaster management in china. disaster reduction in china system engineering for earthquake prevention and disaster reduction in china. disaster reduction in china analysis of main types and characteristics of natural calamity in china acknowledgements this work was partly funded by the chinese academy of sciences innovative research fund (a , f ) , and the gucas-bhp billiton scholarship. key: cord- - gzdu authors: liou, shwu-ru; liu, hsiu-chen; tsai, hsiu-min; chu, tsui-ping; cheng, ching-yu title: relationships between disaster nursing competence, anticipatory disaster stress and motivation for disaster engagement date: - - journal: int j disaster risk reduct doi: . /j.ijdrr. . sha: doc_id: cord_uid: gzdu nurses are the largest group of healthcare providers and are often the first line responders to a disaster event. nurses' disaster competence, motivation for disaster engagement, and factors that impact their motivation to respond to disaster events need to be understood. the purposes of the study were to determine the predictive relationships between taiwanese nurses' disaster competence, anticipatory disaster stress, and motivation for disaster engagement. a cross-sectional design was used to analyze data collected between august and december from eight hospitals in southern taiwan. ninety participants who met the recruitment criteria completed and returned questionnaires with an . % response rate. data collection involved administering the disaster nursing competence questionnaire, anticipatory disaster stress questionnaire, and the motivation of disaster engagement questionnaire. the results indicated that anticipatory disaster stress was positively correlated with disaster competence and motivation for disaster engagement. disaster competence and willingness to join a hospital disaster rescue predicts an individuals' motivation for disaster engagement. the results of the study add to the understanding of factors that correlate with nurses' motivation to participate in disaster events. by understanding these factors, the government and healthcare administrators can design disaster education plans and other strategies to improve taiwanese nurses’ motivation to engage in disaster events. natural and man-made disasters are increasing in frequency and severity worldwide over the past decade. examples of major disasters in taiwan include the severe acute respiratory syndrome (sars) outbreak in , the kaohsiung massive gas explosions in , and the taiwan water park blast in . these disasters have resulted in many injuries and fatalities, as well as economic losses, serious environmental disruption, and lasting psychological trauma among survivors [ , ] . according to the world disasters report [ ] , there were recorded disasters from to , and . % of these reported disasters occurred in asian countries. asians accounted for the largest number of people affected by these disasters. in fact, the percentage of disasters occurring in asia was % in the - decade, and it increased to % in the - decade [ ] . likewise, the frequency and intensity of disaster events in taiwan have noticeably increased in recent years. in , the center for research on the epidemiology of disasters reported that taiwan was one of the top countries in terms of disaster mortality that year [ ] . these statistics amplify the importance of sound disaster training and preparation so that nurses can respond effectively and appropriately during a disaster event in taiwan. in taiwan, during disaster incidents, nurses are expected, with limited resources, to attend and work in chaotic disaster sites to quickly provide nursing care to a growing number of survivors. in light of this, issues about the current level of competence, skills, and experience in disaster preparedness and response among nurses have been valued and emphasized [ , ] . studies focused on disaster nursing in taiwan and other countries revealed that existing preparedness for and competence in disaster response among hospital personnel including nurses is less than optimal [ ] [ ] [ ] and is often fragmented, or not available at all [ ] . moreover, they may not be ready to face future disasters because of an inadequate disaster competence such as a lack of awareness of the roles and skills needed when encountering disaster events [ ] [ ] [ ] [ ] [ ] [ ] . high levels of psychological and emotional stress are frequently reported in emergency or disaster responders [ , ] . studies found that nurses felt psychologically unprepared when asked to engage in disaster events [ , ] because the events might exceed their capacity to function well, or they worried about their personal loss or their families' welfare during disaster relief [ , ] . additionally, nurses had less desire to report to work during an emergency or disaster event, although most strongly believed that they are responsible for working during such situations [ , ] . moreover, few nurses were motivated to engage in practical preparation and obtain the experience required to deploy in response to a disaster event [ , ] . in one study, some nurses openly commented that they were frustrated and were not motivated to engage in disaster trainings because of their heavy workloads and lack of time for attending educational programs [ ] . yet, other surveys reported that many hospitals or service organizations do not frequently conduct exercises to determine their level of preparedness for disaster management, which may be due to the economic burden of undergoing training exercises [ ] . therefore, it is critical to understand how to help disaster nurses overcome personal stress and assist others, such as colleagues and survivors, to effectively cope with stress as well [ ] . nurses are the largest group among the healthcare provider workforce and play an important role during the emergent phase of a disaster and throughout the phases of disaster preparedness and recovery [ ] . therefore, disaster competence and preparedness among nurses is necessary to effectively manage unpredictable events. however, the exploration of nurses' perspectives on disaster nursing remains limited in taiwan. therefore, the purposes of the study were to determine the level of and relationships between taiwanese nurses' disaster competence, anticipatory disaster stress, and motivation for disaster engagement. the motivation for engagement in disaster events can be explained by the self-determination theory developed by deci and ryan [ ] . the theory suggests that people are often moved to act by two types of motivation: intrinsic or extrinsic. the theory also proposes that three basic psychological needs-competence, autonomy, and relatedness-are important for self-growth and must be met for healthy functioning, promoting intrinsic motivation, engagement behavior, and maintaining motivation over a period of time [ , ] . competence refers to the mastery of experiences in the practical world. an individual's perceived competence can enhance their motivation for an action only when it is accompanied by a sense of autonomy and relatedness within an organization [ ] . in addition to the psychological needs that influence motivation, personnel involved in disaster events are prone to exhibiting psychological problems and distress [ ] . for nurses, psychological distress may affect their commitment to attend or remain at a disaster situation site [ , , ] . therefore, we proposed that anticipatory disaster stress and disaster competence are factors in nurses' motivation to engage in disaster events. this study used a cross-sectional design to understand factors related to nurses' motivation to engage in disaster events. using convenience sampling, nurses who: (a) had a registered nursing license; (b) were employed full-time by hospitals for more than one year; and (c) were willing to sign an agreement to complete questionnaires; were invited to participate in the study. before data collection, the sample size was calculated using g*power (version . ) with two-tailed, α level of . , and an estimation that the effect size for correlation between measured variables was at least medium (r ¼ . ). eighty-eight participants were needed to achieve a power of . . more nurses were invited to participate in the study because of possible incompletion rates. nurses distributed over eight hospitals in southern taiwan responded to our invitation to participate in the study. ninety nurses returned completed questionnaires with an . % response rate. the study was approved by the institutional review board (irb b ) before recruitment began. a packet containing a cover letter, questionnaires, informed consent, and two addressed-andstamped envelopes were mailed to nurses who were interested in participating in the study. the cover letter described the purposes of the study, the participants' rights and confidentiality. they could complete the study surveys at any place they felt comfortable with. they could decline or stop participation in the study whenever they felt uncomfortable. participants were asked to send back the signed informed consent and questionnaires separately by using the two addressed-andstamped envelopes if they agreed to participate in the study. on average, surveys were completed in less than min. data were collected between august and december of . there was no disaster in taiwan or any neighboring countries that might have influenced the participants' responses during the data collection period. demographic survey. we designed the participant information sheet based on the self-determination theory that individual differences are important factors that may influence individuals' motivation to engage in actions. in this study, individual differences are defined as a nurse's personal characteristics that may influence their preparedness and motivation to engage in disaster events, such as gender, age, seniority in the hospital, educational level, hospital type, work unit, and job title. the disaster nursing competence questionnaire (dncq). the dncq developed by the research team, based on a literature review, contains items used to measure nurses' perceived competence level when responding to disaster events. on a -point likert scale ranging from (not familiar) to (very familiar), a higher score indicates a higher level of disaster nursing competence. in the study, cronbach's alpha for the dncq was . . the principal component analysis for the validity showed that . % of the variance of the disaster nursing competence could be explained by the dncq. anticipatory disaster stress questionnaire (adsq). the anticipatory disaster stress questionnaire was developed by the research team according to literature reviews and consists of items used to measure nurses' anticipation of stressors when encountering disaster events. using a -point likert scale scored from (strongly disagree) to (strongly agree), a higher score indicates greater perceived stress while facing disaster events. in the study, cronbach's alpha for the adsq was . . the principal component analysis showed that . % of the variance of the anticipatory disaster stress could be explained by the adsq. motivation for disaster engagement questionnaire (mdeq). the mdeq, developed by the research team, was used to measure nurses' motivation to engage in disaster events or preparedness activities. with three items on a five-point likert scale (ranging from to ), a higher score indicates a higher level of motivation to participate in disaster events. in this study, cronbach's alpha for the mdeq was . . principal component analysis showed that . % of the variance of the motivation in disaster engagement could be explained by the mdeq. data were analyzed with the use of spss version . . demographic information, levels of disaster competence, anticipatory disaster stress, and motivation for engagement in a disaster event were analyzed with descriptive statistics such as frequency, mean, and standard deviation. before inferential analyses of the data, the normality of all variables was examined using the shapiro-wilk test. results showed that the dncq and adsq were normally distributed, whereas mdeq was not normally distributed. relationships between measured variables were examined using the pearson correlation when the variables were normally distributed, and the spearman correlation was used when variables were not normally distributed. the reliability of the scales was tested using cronbach's alpha coefficients, and the validity was tested with principal component analysis. hierarchical regression was applied to understand the predicting relationship of individual differences, disaster competence, and anticipatory stress on motivation for engagement in disaster events. the mean age of the nurses was . (sd ¼ . ) years. on average, they worked . months ( . years, sd ¼ . ) as a nurse and . months ( . years, sd ¼ . ) in their current hospital. most participants were females ( . %). while . % of them had an associate's degree, . % had a bachelor's degree ( . % were in the fouryear bachelor program and . % were in the two-year rn-bsn program), and . % had a master's degree. seventy-eight nurses worked as registered nurses ( . %) or nurse specialists ( . %), and . % worked in the emergency room (er) or intensive care unit (icu) in nonmedical centers or regional hospitals ( . %). over the past years, more than half of nurses attended either in-service education or conferences about disaster nursing ( . %) and attended disaster practices held by their hospital ( . %). most hospitals where the participants worked held massive disaster courses ( . %) and practices ( . %) every year. only . % of the participants had attended a disaster field rescue; . % had attended disaster management at their hospital; and only . % had attended care management of disaster aftermaths. more than half of the participants agreed ( . %) or strongly agreed ( . %) to join a hospital disaster rescue if they were asked, while . % disagreed and . % strongly disagreed to join a disaster rescue. the levels of disaster nursing competence, anticipatory disaster stress, and motivation of disaster engagement among participants were presented in table . the mdeq, dncq and adsq were significantly inter-correlated (r ranged from . to . ). the dncq was correlated with a greater number of times attending onsite practices, number of times attending in-service education or conferences about disaster nursing, number of times participating in care management of disaster aftermaths and stress of managing a disaster in hospital. the adsq was correlated with the number of times attaining onsite practices held by hospital in the past years, number of times attending in-service education or conferences about disaster nursing and the stress caused by managing a disaster in hospital. the mdeq was correlated with the number of times attending in-service education or conferences about disaster nursing and the stress caused by managing a disaster in hospital. however, effect sizes of all these correlations were low to moderate. most of the demographic variables had no statistically significant impact on nurses' disaster competence, anticipatory disaster stress, or their motivation for disaster engagement. as shown in table , participants who attended the in-service education or conferences about disaster nursing in the past years had higher scores on the dncq. participants who completed graduate school had lower scores on the adsq compared to those with an associate's or bachelor's degree. those who were more willing to join hospital disaster rescues had higher levels of adsq and mdeq than those who were less willing to participate. those who had never attended care management of disaster aftermaths had higher scores on the mdeq. because the number of times attending in-service education/conferences and stress caused by managing a disaster in hospital were correlated with the mdeq, and the mdeq differed by whether nurses attended care management of disaster aftermaths beforehand and their willingness to join hospital disaster rescues, these four variables were entered in the first set of regression analysis. as shown in table , regression analysis showed that attendance of disaster aftermath care management was included in the model and % of the variance of the mdeq could be explained (f ¼ . , p < . ). this study aimed to explore the relationships between disaster competence, anticipatory disaster stress, and motivation for disaster engagement among hospital nurses in taiwan. in addition, the factors associated with the motivation for engagement in disaster events among nurses were identified. we found that hospital nurses' level of disaster competence was not high. our findings were similar to previous studies that reported a low level of self-reported familiarity with preparedness among nurses for large-scale emergency or disaster events [ , , ] . this finding implies that most hospital nurses may not be ready or confident in their abilities to respond to disaster events. contrary to prior studies which revealed that work unit or specialty, work experiences, educational level, and gender were associated with disaster competence [ , ] , our analysis did not support such findings. rather, we found that nurses who exhibited higher competence had attended in-service education or conferences about disaster nursing. interestingly, most hospitals held massive disaster courses or practices every year; however, nurses' attendance rates to these educational offerings were not high. in addition, although the participation rates of field drills were high, nurses did not perceive that they were competent in disaster management. this situation is similar to williams et al.'s article which reviewed studies and found that the effects of disaster training on health care workers' knowledge and skills in disaster response were inconclusive. the authors suggested that hospitals should urgently examine and find the most appropriate methods for disaster preparedness practices for nurses in order to augment the authentic efficiency of the training [ ] . the psychosocial problems faced by nurses involved in disaster events are of much concern. researchers indicated that nurses may be unprepared educationally and psychologically for disaster relief [ ] . one study that was conducted to determine the international research priorities for disaster nursing found that psychosocial aspects ranked the highest [ ] . however, in our study, the level of anticipatory disaster stress was not high. this finding is different from prior concerns that the mdeq was used to measure motivation of disaster engagement, adsq was for anticipatory disaster stress, and dncq was for disaster nursing competence. *p < . , **p < . (two-tailed). nurses often reported that disaster events exceeded their ability to function and caused imbalances between professional duties and personal stress, such as their families' safety and personal loss [ , , ] . since most nurses in our study did not have any experience in disaster field rescue and also did not attend disaster management at their hospital, it may be hard for them to imagine how stressful it would be to participate in a real disaster management situation. this may be the reason for the finding of a low level of anticipatory disaster stress. additionally, although the level of anticipatory disaster stress was not high, only . % of nurses agreed or strongly agreed to join their hospital's disaster rescue when they were asked to do so. further analysis found that the participants who strongly agreed to join a hospital disaster rescue had significantly higher stress levels than nurses who did not agree to participate in a disaster relief. somehow, anticipatory disaster stress existed, but only for nurses who have motivation to attend disaster events in the future. in the study, the degree of nurses' motivation for disaster engagement was not high. the results correspond to the earlier studies, which indicated that few nurses intended to report for work during disasters [ , , ] ; moreover, few nurses have the motivation to engage in practical preparation and obtain experiences in response to a disaster event [ ] . specifically, we found that nurses who had attended care management of disaster aftermaths had lower motivation for disaster engagement. the fear of being incapable of managing disaster aftermaths and the worry that no one can take care of their family or children when they cannot get out of their duty might have made them reluctant to attend field rescue or care management of disaster aftermaths [ , ] . former surveys reported that nurses did not feel supported or motivated to engage in disaster preparedness because of their heavy workloads, and the hospitals in which they were employed did not regularly conduct exercises to prepare them for disaster management [ , , ] . although hospitals in taiwan held disaster education or practice every year, nurses reported being physically and mentally exhausted by their heavy daily workload on top of having difficulty in finding the time to participate in educational programs that were not directly work-related. therefore, as shown by a previous study that showed a perceived well-ordered organizational climate can arouse individuals' motivation and consequently cause emergent behaviors [ ] , a perception of being supported by the work environment is a meaningful motivational factor in healthcare workers' decision to work during a disaster. interestingly, the study found that nurses who were more competent in disaster nursing felt more stress. this situation might be because nurses may believe that they will never be competent enough when facing an unpredictable disaster. additionally, disaster competence and anticipatory disaster stress were significantly and positively correlated with nurses' motivation to engage in disaster events. however, both disaster competence and anticipatory disaster stress could not predict motivation to engage in disaster events. the self-determination theory proposes that competence is one of the significant factors influencing individuals' motivation in engagement behaviors [ ] . and, other studies pointed out that individuals would move toward activities and took on responsibilities or challenges when they felt more confident in their disaster competence and knowledge [ , , , ] . in our study, nurses' did not perceive high level of disaster competence and therefore might not be motivated to participate in disaster management. the sampling method in the study is convenience sampling. participants were only invited from eight regional hospitals in southern taiwan. these reasons may have caused a selection bias in sampling. in addition, . % of our participants were emergency or intensive care nurses although they might be the first line nurses to manage disaster events. therefore, the generalizability of the study findings to all taiwanese nurses is limited. because the study used a cross-sectional design, the findings cannot establish a causal relationship between variables. the findings of this study contribute to the body of knowledge regarding motivation for disaster engagement among hospital nurses and furnish implications for nursing administration, practice, education and research. we have recommendations for policy, research, practice and education. the study indicated that the rates of attending in-service education, disaster field rescue, and care management of disaster aftermaths among hospital nurses were not high. nurses' disaster competence and motivation for disaster engagement were not high as well. these findings highlight the necessity of further research to explore nurses' concerns and needs in-depth when they participate in disaster-related activities. the results of the further research can offer information for healthcare administrators to make more practical policies to enhance nurses' disaster competence and further increase nurses' motivation to participate in these activities. the study found that even though hospitals held disaster courses and trainings every year, nurses had a worryingly low level of disaster competence, which correlated with their low motivation to participate in disaster rescue. providing realistic disaster training using simulations, tabletop exercises [ , ] , and virtual reality/augmented reality/mixed reality exercises may improve individuals' interests and understanding about disaster situations and disaster knowledge and skills. this would further increase nurses' confidence in disaster management. the insufficiency of disaster competence among nurses revealed in the study emphasizes the important role of nursing educators in preparing nursing students with the knowledge and skills for disaster management. disaster nursing is a generally neglected topic in nursing education. in most nursing schools in taiwan, disaster nursing is taught as one or two units in courses of public health nursing (required course) or emergency nursing (elective course). it is urgent for nursing schools to develop a stand-alone disaster course for both undergraduate and graduate programs to increase nurses' awareness of disaster and prepare table predictive relationship of dncq and adsq with mdeq. step step for future nurses who are competence in disaster management. this study sheds some light to provide a better understanding that the degree of disaster competence may impact the motivation for disaster engagement among hospital nurses in taiwan. it appears that disaster competence and stress play an important role for nurses when encountering disaster. this situation should alert hospital administrators to reexamine the appropriateness of their training programs and their nurses' needs when it comes to training for disaster preparedness. stress management and counseling programs also need to be provided. the best and suitable methods for disaster practice to augment the authentic efficiency of training and to promote nurses' motivation for disaster engagement should be further explored and developed. this work was supported by the chang gung memorial research program in taiwan (cmrpf g ). no conflict of interest has been declared by the authors. resilience in the face of disaster: prevalence and longitudinal course of mental disorders following hurricane ike the effectiveness of disaster training for health care workers: a systematic review international federation of red cross and red crescent societies annual disaster statistical review world health organization (who) & international council of nurses (icn) australian nurses volunteering for the sumatra-andaman earthquake and tsunami of : a review 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residents' disaster preparedness after the meinong taiwan earthquake: a test of protection motivation theory australasian emergency nurses' willingness to attend work in a disaster: a survey disaster preparedness among nurses: a systematic review of literature evaluation of a tabletop emergency preparedness exercise for pharmacy students supplementary data to this article can be found online at https://doi. org/ . /j.ijdrr. . . key: cord- - eehtxin authors: rebmann, terri; english, judith f.; carrico, ruth title: disaster preparedness lessons learned and future directions for education: results from focus groups conducted at the apic conference date: - - journal: american journal of infection control doi: . /j.ajic. . . sha: doc_id: cord_uid: eehtxin background infection control professionals (icp) who have experienced disaster response have not been assessed in terms of the lessons they have learned, gaps they perceive in disaster preparedness, and their perceived priorities for future emergency response training. methods focus groups were conducted at the apic conference to evaluate icps' perceived needs related to disaster planning topics, products they feel are needed for education and reference materials, and lessons learned from past disasters. results icps' role in disaster preparedness and response is essential, even in noninfectious disease emergencies. infection control issues in shelters, such as overcrowding, foodborne illness, lack of restroom facilities, inadequate environmental cleaning procedures and products, difficulty assessing disease outbreaks in shelters, inability to isolate potentially contagious patients, and too few hand hygiene supplies can contribute to secondary disease transmission. other important topics on which icps need to be trained include surge capacity, employee health and safety, incident command system, educating responders and the public on disaster preparedness, addressing changing standards/recommendations, and partnering with public health. icps need quick reference materials, such as checklists, templates, tool kits, and algorithms to better equip them for disaster response. conclusion infection control must continue to partner with public health and other responding agencies to address gaps in disaster planning. in , the united states experienced disasters that cost more than $ billion each in damages and made it the second highest year in terms of the number of natural disasters occurring in a single year. similar experiences have occurred around the world in the past few years. natural environmental disasters, such as hurricane katrina in the united states and the tsunami in asia; infectious disease disasters, such as the anthrax bioterrorism incident in the united states; plus the outbreak of severe acute respiratory syndrome (sars) in canada and other countries have illustrated the tremendous medical, social, and economic impact a disaster can have on any country. historically, infection control professionals (icp) have responded to health care-associated infections and public health infectious disease outbreaks. beginning in the late s, many icps expanded their role to become involved in bioterrorism preparedness planning. some recent disasters occurring in the early st century, such as sars and hurricane katrina, have illustrated the importance of icps becoming involved in planning and response for all types of disasters to decrease secondary morbidity and mortality. icps who have experienced disaster response have not been assessed in terms of the lessons they have learned, gaps they perceive in disaster preparedness, and their perceived priorities for future emergency response training. these icps' experiences should be assessed, and their lessons learned should be incorporated into development of reference materials and future training for icps. the purpose of this study was to evaluate icps' perceived needs related to disaster planning topics and products required for education and reference materials. specific aims of the needs assessment included the following: ( ) to determine disaster-related education products or reference materials, ( ) to prioritize disaster preparedness topics for future icp training and reference materials, and ( ) to determine lessons learned from past disasters. the authors developed the questions for this study. all members of the association for professionals in infection control and epidemiology, inc. (apic) who were registered for the national apic conference were invited to participate in the focus groups, regardless of age, race, gender, or work location (within or outside the united states). the only inclusion criteria were attendance at the apic conference and participation in a disaster response in the past. the authors recruited potential participants via phone calls and e-mail. one focus group met each day in a meeting room located in a hotel near the conference site on june , , and , . a meal was provided to the participants as an incentive for their participation. the nominal group method was used to elicit information on the topics of interest. the focus group method of using opening-ended questions was used to elicit details from participants' experience with disaster response as to why those categories were chosen and lessons learned from past disasters. participants were informed that information collected would remain anonymous and that all responses were voluntary. focus group sessions were audiotaped, and the tapes were transcribed verbatim. content analysis included identifying, coding, and categorizing participants' response to the questions of interest. in addition, major themes that emerged were identified and categorized. quotations that characterize the major themes are reported. the words enclosed in brackets of the quotations are used to explain the respondents' quotes and are not the participants' words. subjects' demographic data were obtained for descriptive statistics. the institutional review boards of st. louis university, national naval medical center, and university of louisville approved this study. apic headquarters funded the costs of the focus groups and audiotape transcription. annual educational conference were contacted. thirtytwo participants took part in the focus groups: the first focus group had participants, the second had , and the third had . a description of the participants' demographic characteristics is reported in table . focus group participants reported that they resided in states from across the united state; participants were from canada, and participant has worked in multiple countries. twenty-five participants ( . %) are certified in infection control. the participants reported that they had been involved in responding to a variety of types of disasters ranging from power outages and floods to terrorism and infectious disease emergencies; most ( %, n ) had been involved in the response to multiple events. the participants identified many types of education products/reference materials needed for future disaster response and disaster preparedness education topics on which the participants believed that icps need to be trained. the education products that received the most votes during the nominal group method portion of the focus groups are outlined in table . the education topics that received the most votes during the nominal group method portion of the focus groups are outlined in table . in addition, a number of themes emerged from the focus groups related to emergency preparedness issues encountered in previous disasters. one of the most frequently cited topics of importance to disaster planning was the need for better infection control in community-based shelters. focus group participants from a variety of types of disasters indicated that infection control was lacking in crowded shelters and that this contributed to secondary disease transmission. ''infection control in shelters is important. we had a child in a shelter in alabama, not [hurricane] katrina, but prior to that, with meningitis, and they'd been there for several hours, and no one realized they had been there. we needed fast treatment [to prevent secondary spread]. and there were outbreaks of diarrhea [in the shelters].'' ''when they set up these shelters, they really don't have any idea about what they're going to do for hundreds and hundreds of people [to accommodate] handwashing and [provide] restroom facilities.'' focus group participants listed some specific infection control issues that must be addressed in shelters, such as overcrowding, foodborne illness, lack of restroom facilities, inadequate environmental cleaning procedures and products, difficulty assessing disease outbreaks in shelters, inability to isolate potentially contagious patients, and too few hand hygiene supplies. by far, lack of hand hygiene supplies or the inability to perform hand hygiene was the most frequently cited infection control issue in community-based shelters. icps recommended that disaster planners arrange to have a dedicated individual(s) for hand hygiene and infection control in alternate care sites: ''[in disasters] there ought to be people that are just responsible for hand hygiene. i know we talk about it in the hospitals, and we push it, push it, push it, but really in a disaster. hand hygiene is probably the most important thing.'' icps stressed the need to perform real-time assessments during disaster response, including general disaster response needs as well as disease surveillance. ''in shelters and out in the community, [you need to] go and see: do they need food, do they need child care, do they need deceased care? you know, what do they need? do they need an ambulance to get someone to a higher level of care?'' ''you have to come up with a list of what everyone needs to run a clinic. how many bottles of disinfectant do we need, how are you going to mix it, where are you going to store it?'' icps also discussed the difficulty in assessing disease outbreaks during disaster response, even in noninfectious disease emergencies. ''you know the thing about disasters is that you see a lot of diseases that you don't get normally.'' ''one of the major problems i had immediately post one component of surge capacity that was stressed was staff surge capacity or the ability of a facility to have sufficient numbers of staff to handle an influx of patients. comments such as ''staffing is going to be a major issue'' illustrated the importance of this issue to participants. the number of available staff was mentioned as contributing to a facility's ability to stay open and provide patient care or halt routine procedures to accommodate disaster victims. ''the biggest [problem] i've seen [after a disaster hits]-and i've responded to many different kinds [of disasters]-is the staff wanting to leave. so your facility staff has just gone home to do something for their home, or to be with their family, and your nurses are trying to get out the doors, and only a basic crew is remaining. so how do you continue with your current, everyday operations when your staff just left?'' ''[surge capacity is] a big issue because we've got to switch over to responding to the disaster and then which of our routine services can we stop, and when do we need to restart those services?'' focus group participants discussed the importance of monitoring and managing employee health and safety issues during disaster response. doing so will have the advantage of maximizing staff surge capacity by keeping staff able to continue working without contributing to secondary disease spread. icps mentioned a number of employee health issues, such as monitoring staff's mental health, holding daily staff meetings to communicate how they were doing, providing adequate time for rest and sleep, having appropriate personal protective equipment, and ensuring food safety. one important component of employee health and safety is to teach staff to protect themselves before attempting to rescue disaster victims. as one participant explained, ''you have to take care of your staff. [sometimes] you have to stop what you're doing, which [in our case] was evacuating patients [from flooded areas], because. the staff was getting injured.'' if health care staff does not protect themselves before entering a potentially dangerous situation, ''you've got more casualties than when you started.'' another participant described a situation in which a physician could have potentially harmed himself by not following the appropriate procedures during a response to a possible anthrax incident: focus group participants discussed many problems and challenges related to the chain of authority in disaster response and use of the incident command system (ics). problems included a general lack of knowledge or experience with ics, inability of responding agency leaders to function within ics in noncommander positions, and reluctance on the part of individuals in command positions to make decisions. comments such as, ''i think that incident command is not very well-known or understood in general outside of [first responder groups]'' indicated that participants feel that hospital and public health staff needs additional training on ics. a frequently heard complaint was the difficulty of trying to function within the ics when responding agency leaders were assigned to noncommander positions. this led to mixed messages being communicated to staff and general confusion because no one knew who was in charge. this problem was mentioned in relation to a variety of disasters. ''we had the major blackout in new york city, and . nobody knew who to answer to, nobody knew who was responsible, who was in charge.'' ''i think it all goes back to . the chain of command, and who really is in charge. if you don't know who's in charge of your facility and people are trying to make a decision and they each have their own little miniagenda [it's confusing]. . d.c. is a phenomenal example of [a jurisdiction with many responding agencies] . there's many, many, many chiefs.'' ''[after hurricane] katrina . everybody wanted to be in charge, but then when they were in charge, nobody knew what they wanted to do.'' although the ics is intended to streamline disaster response communication and reporting, focus group participants pointed out that it only works when staff know the system and everyone follows the system appropriately. participants also discussed the advantages to the ics and the importance of being in compliance. they stressed that responding agencies should be educated regarding why they need to follow the ics. one participant suggested explaining the financial appeal of following ics to a facility to get everyone on board: focus group participants frequently mentioned ''just-in-time'' training as vital to an effective disaster response. participants indicated that all responding staff will require some level of training during the disaster response, but they also stressed that disaster planners need to ''think outside the box'' in terms of the groups for which they plan just-in-time training. one participant described it in this way: ''it's not going to be health care workers that we're going to be Ôjust-in-timeÕ training with, it's probably going to be college students . so they can train the other volunteers. or it . may be families teaching families how to care for each other.'' participants indicated that just-in-time training can improve disaster response by decreasing dependency on the health care system, allowing health care to focus on the truly ill victims. they also stressed that it must involve public service announcements and should be coordinated through the ics' public information officer. these announcements should include information on ''what is recommended, [whether people should] shelter in place . whether [people should] go to the er or not.'' participants felt that communicating this information and training to the public will prevent '' , people [from] . show[ing] up at your hospital.'' focus group participants stressed that it is important to have education or reference materials that do not rely on electricity because power outages may occur after disasters. they emphasized that disaster responders need education or reference tools that are ''rechargeable in some way other than electricity,'' such as a personal digital assistant (pda) that uses batteries. another option suggested by focus group participants was to have paper versions of reference materials and notebooks for recording information. one participant described it this way: ''when we thought [hurricane katrina] was coming, we started bringing a bunch of notebooks, and we walked out the door with those, and then we were out of power for weeks. those notebooks were the only things we had. .'' focus group participants discussed the importance of icps partnering with public health in disaster preparedness because icps are often the liaison between public health and hospitals in a community. participants indicated that establishing a partnership between hospitals and public health enhances the entire community's ability to respond more effectively during a disaster. icps who had responded to various types of disasters mentioned this lesson learned. ''i think we learned from the last hurricane that [infection control's] interface with the county health department is so important. they become your best friend. i think that's a huge lesson, and i think that if we learned nothing else from that hurricane, we learned that.'' ''i think it's critical that both [infection control and public health] get together and start way up front, knowing who the people are that are working at the health department in the kind of areas that are going to affect you, and we in health departments have to find our partners in the private side, so we get [disaster planning] done up front, and we know each other and we plan together.'' icps also stated that partnering with public health would bridge gaps in public health's knowledge of infectious disease emergency planning and foster the reciprocal sharing of information. icps felt that some public health professionals ''are not very well trained'' on communicable disease issues ''because they're so stretched in everything they have to cover, they don't necessarily have the expertise in infection control and infectious diseases in all of the public health departments across the country.'' one participant stated that public health frequently calls their hospital during a disaster and asks, ''can you help us out with what we should tell the public about this and this and this?'' icps felt that they should share their expertise of infection prevention and control knowledge with public health, which would result in a better prepared community. shared training and participating together in disaster exercises were mentioned as ways that icps could share information and education with public health. participants indicated that working together through disaster exercises and training programs would strengthen the relationship between public health and icps. one participant described it in this way: ''[training and exercising together] made everybody on the same level, and everybody gets along better now after that.'' one challenge participants identified that was unique to infectious disease emergencies was the difficulty in maintaining staff compliance and trust in the face of changing practice recommendations/standards. this was most evident in infectious disease emergencies involving a new agent (such as sars) or in a new situation (such as anthrax used in a bioterrorism attack as opposed to naturally occurring disease). icps indicated that disasters involving an element of the unknown and frequent changes to practice as likely to create an evolution of fear and mistrust in health care workers and first responders. focus group participants indicated that the fear of a potential avian influenza pandemic is causing many education and planning challenges in their facility and community. one of the biggest challenges is related to the unknown mechanism of transmission for avian influenza, resulting in conflicting guidance that has been released and the recommendation to change isolation precautions midway during the response to an outbreak. focus group participants stressed that changing recommendations and standards also have legal and ethical considerations. the general public does not always understand why medication recommendations (such as postexposure prophylaxis for anthrax) change, and this can be interpreted as discrimination in that it appears that health care and public health are providing a lower standard of care for different victims. one participant described the challenges and potential legal consequences of changing recommendations/standards midway through disaster response this way: the focus group discussions provided several important findings. information provided by the focus group participants highlights a number of educational/reference materials that are needed for future disasters. most of these consist of quick reference materials, such as checklists, templates, charts, tool kits, and algorithms. participants recommend that these materials be available in paper versions or electronically using products such as pdas that do not require electricity so that they may be accessed during times when electricity is not available. participants also provided a list of educational topics for icps. mass casualty incidents, infection control during disasters, communication, incident command, physical plant needs, improving health care worker basic knowledge of how infectious organisms are transmitted, and business continuity issues were all identified as being essential training topics. icps' role in disaster preparedness and response is considered to be essential, regardless of whether it is an infectious disease emergency, such as outbreak of an emerging infection or bioterrorism, or a natural disaster such as a hurricane or earthquake. although icps are essential to disaster preparedness and response, icps indicate that participation is not always easy. icps' role in disaster response can be complicated by a lack of supplies, inability to conduct real-time surveillance, difficulty in communicating information between facilities, too few staff, need to provide training to nonhealth care individuals, and challenges in functioning within the ics. disasters involving an element of the unknown, such as an outbreak of a new or reemerging pathogen, increase the difficulty in response. changing standards and recommendations must be communicated carefully to prevent mistrust among the staff and/or the general public. failure to do so can impinge on a facility or community's ability to mount an effective disaster response. another notable finding from this study is that even natural disasters can result in significant public health crises if infection prevention and control strategies are not implemented rapidly and appropriately. infectious disease outbreaks following disasters can devastate a community, and icps' expertise is needed to help prevent secondary spread within alternate care sites as well as their facility. to be most effective, icps need to partner with public health professionals in their region before a disaster and establish strong linkages between hospitals and community agencies. these partnerships can strengthen facility preparedness and maximize a community's ability to respond to a disaster. they should also result in stronger health care and public health systems by strengthening surveillance, communication, and basic infection prevention and control needed for day-to-day duties as well as disaster situations. overall, the focus group method of inquiry served as a valuable tool in eliciting rich, detailed information about icps' opinions of lessons learned from past disasters. structured surveys with closed-ended responses opposed to the open-ended questions used in this study may have revealed different opinions about references materials needed for future disasters and educational priorities for icps. it is not known whether the icps who chose to participate differed from those who were eligible but chose not to participate. it is also not known whether icps who have no experience with disaster response may have provided different answers compared with experienced icps in terms of preferred training topics and reference materials. however, this study was designed to elicit information from those who have responded to an actual disaster to identify gaps in preparedness in real situations rather than simulated events in disaster drills. icp preparedness for all types of disasters, especially infectious disease emergencies, has become essential. this study identifies lessons learned from past disasters and highlights gaps in disaster preparedness most in need of being addressed: infection control in mass casualty incidents, behavioral health issues, communication, incident command, and maintaining quality of care in suboptimal situations. disaster planners must continue to address gaps in disaster preparedness. one way to accomplish this is through the creation and distribution of icp-specific educational tools and reference materials for disaster preparedness and response. the topics identified by experienced icps should be used as the basis for these new educational initiatives. five billion-dollar disasters were recorded in infection control practitioners' perceptions and educational needs regarding bioterrorism: results from a national needs assessment survey nominal group technique: a user's guide focus group fundamentals the authors are the - chair and members of the apic emergency preparedness committee and this research was conducted in their role as members of this committee. a primary goal of this project was to provide information to be used in apic strategic planning and meeting membership and organizational needs. the authors thank the other members of the apic emergency preparedness committee who assisted in project development and design. the authors would also like to thank the focus group participants for their dedication to past and future disaster preparedness, as well as the time taken to participate in these focus groups. without your knowledge and experience, none of this would be possible. key: cord- -yfaji cv authors: kim, yong-kyun; sohn, hong-gyoo title: disaster theory date: - - journal: disaster risk management in the republic of korea doi: . / - - - - _ sha: doc_id: cord_uid: yfaji cv to find a conclusive definition for contemporary purposes and uses, we look at many of the various definitions of disasters through cataclysmic events, historical records, public policies, laws, and organizational usage. our natural progression leads us to modern theories of disaster and disaster risk management (drm) that have had to tackle new types of disasters that are being brought about by the interconnectivity of societies, people, diseases, technology, etc., increasing in magnitude and complexity like what was seen in fukushima, japan, in and on-setting disasters like climate change. after looking at all the historical evidence, we come to a definition for the term disaster for modern usage and what it means for policy implications. risk as "the probability of harmful consequences, or expected loss (of lives, people injured, property, livelihoods, economic activity disrupted or environmental damaged) resulting from interactions between natural or human induced hazards and vulnerable conditions" (undp ) . in the national infrastructure protection plan (nipp ), department of homeland security (dhs) considered risk elements as "threat nature and magnitude, vulnerability to a threat, and consequence that could result." haddow et al. ( ) noted that risk is composed of ( ) the probability and frequency of a hazard occurring, ( ) the level of exposure of people and property to the hazard, and ( ) the effects or costs, both direct and indirect, of this exposure. the korean word for risk is "wiheom" or "wiheomdo." finally, the origin of the word "crisis" is the greek word "krinein (separate; critical moment);" and it has been used as the medical term of "decisive moment of life and death." quarantelli ( ) viewed that a crisis of a certain organization appears in the three following interrelated conditions: ( ) a type of threat including organizational value, ( ) sudden occurrence of an unexpected event, and ( ) need to respond collectively as the outcome may seem more negative otherwise. the term "crisis" is defined as "a difficult or dangerous situation that needs serious attention" in the merriam-webster's learner's dictionary (webster dictionary ) . the korean word for crisis is "wigi." the term indicates a dangerous crucial moment or time and the state to make the final decision on a critical matter. the term "wigi" is a combination of the two characters: "wi" meaning danger and "gi" meaning chance. in the same context, lee et al. ( ) defined crisis as an "incomplete state that desperately needs a significant change or the turning point to determine whether to proceed with, modify, or end an event or a behavioral process." disaster means a condition where the damage cannot be overcome without national or external assistance due to lack of capacity or resources of the damaged community or local/state governments uniqueness korea a presidential decree regulates the magnitude of disaster, which can be financially supported by the national government usa disaster is classified into emergency and major disaster declaration depending on the magnitude of the damage japan disaster caused by natural hazard was historically emphasized in act unisdr a comprehensive approach considering human, physical, economic, or environmental losses and impacts is emphasized fritz considers disaster as the disruption of the essential functions of the social system quarantelli considers disaster as what is caused by natural or technological hazard that is beyond the knowledge of modern society jeong ( ) saw the word "crisis" as natural disasters such as typhoons, heavy snowfalls, and floods; human and technical disasters such as explosion, traffic accidents, and collapse; comprehensive risk situations in various contexts such as terrorist attacks, status of diplomatic relations with north korea, failure of various policies, financial difficulties of firms, stores, and state, crimes, spread of diseases, and various scandals. the terms related to disaster can be summarized as table . . summarizing the discussions above, "disaster" can be conceptualized as follows: • a state that cannot be recovered to the original state with the ability of the community due to great damages in human life and property • inclusive of disasters triggered by natural, technological, or social hazard the term "disaster" will be used embracing natural, technological, and social disasters that the whole community need to cope together reflecting the characteristics of contemporary societies. therefore, in this book, we will define "disaster" as "a status of community or nation's being seriously damaged by natural, technological or social cause and difficult to recover from the damage with its own resources, requiring the whole community to cope together." this definition is similar to the definition of disaster by unisdr and consistent with the definition by laws in korea, japan, and the usa. originates from the old french word "sauf" meaning "not damaged or not harmed," or the latin word "salvus" meaning "not damaged or healthy" the condition of being safe from undergoing or causing hurt, injury anbo security originates from se (¼without, liberation) + cura (¼care, concern, or distress) the state of being protected or safe from harm wiheom (do) originates from the spanish word "risque," known to be used from the mid-seventeenth century a probability of harm that encompasses threat/hazard, vulnerability, and consequence wigi crisis originates from the greek word "krinein" (separate) dangerous crucial moment or time in this context, referring to "jaehae" as natural disaster and "jaenan" as human-caused disaster is not appropriate, which had been commonly used in korea from to ; it is still partially used. both "jaehae" and "jaenan" should be used as terms pointing out natural, technological, and social disasters. to be more precise, "jaehae" means the damage caused by hazards, and "jaenan" means the situation that creates or is likely to create damage. like the concept of disaster, its categorization is also very diverse. the typical one is a categorization by disaster cause. the other ways include categorization by the characteristics of the event, phase-related categorization, and categorization by surgical and medical disaster. in korea, the current framework act on the management of disasters and safety classifies disasters into natural and social disaster. its original version enacted in classified disasters into natural, human-caused, and social disasters, but the same act when it was amended in integrated "human-caused disaster" and "social disaster" into "social disaster." thus, disaster in the current korean law is divided into "natural disaster" and "social disaster." the categorization by disaster cause is a typical way about disaster type. most of renowned organizations dealing with disaster data, such as center for research on the epidemiology of disasters (cred) and munich re, and many scholars have used disaster cause as the principle of disaster categorization. the official categorization of disasters in korea is "natural disaster" and "social disaster" regulated by disaster-related laws, which are differentiated by causing phenomenon. the countermeasures against natural disasters act, formerly the disaster control act and the disasters and safety act, defined disaster-related terms as below: • countermeasures against natural disasters act (act no. , amended on march , ) the purpose of this act is to prescribe necessary matters concerning natural disaster prevention or recovery and other countermeasures against natural disasters, in an effort to preserve national land and to protect lives, bodies, and properties of nationals as well as key infrastructures from disasters caused by natural phenomena, such as typhoons, floods, etc. this act defined "jaehae" as any damage caused by "jaenan" and encapsulated "jayeon-jaehae," meaning natural disaster and "pungsu-hae," meaning disaster triggered by hydrological hazard as specific examples of "jaehae." article (definitions) the definitions of the terms used in this act shall be as follows: . the term "jaehae" means any damage caused by "jaenan" under subparagraph of article of the disasters and safety act (hereinafter referred to as the "framework act"); . the term "jayeon-jaehae" means any disaster caused by typhoon, flood, heavy rain, strong wind, wind wave, sea wave, tidal water, heavy snowfall, lightning, drought, earthquake (including any earthquake-caused tsunami), yellow dust or other natural phenomena corresponding thereto, from among disasters falling under subparagraph ; . the term "pungsu-hae" means any disaster caused by typhoon, flood, heavy rainfall, strong wind, wind wave, sea wave, tidal water, heavy snowfall or other natural phenomena corresponding thereto. • disaster control act (enacted on july , , act no. and abolished on june , ) this act, abolished when the disasters and safety act was established on march , , states that the purpose of the act is to establish a disaster and safety control system of the state and local governments, establish a system for prevention of and countermeasures against disasters as well as emergency rescue, declare a special disaster area, and define matters such as emergency measures necessary for disaster management in order to protect the lives and property of citizens from disasters due to artificial causes. this act was enacted to prepare for human-caused disasters, such as arson and building collapse, rather than natural disasters, such as drought and floods. thus, it targets technological disasters, such as explosions, collapse of bridges, traffic accidents, and chemical, biological, and radioactive accidents, like the leakage of hazardous material and environmental pollution incidents. • framework act on the management of disasters and safety (enacted on march , , act no. ) the framework act on the management of disasters and safety that took effect in categorized disaster into natural, human, and social disaster and defined them as follows: article (definitions) the terms used in this act shall be defined as follows: . the term "disaster" means any of the followings, which actually causes or is likely to cause any harm to the lives, physical safety and property of citizens and the state: (a) disasters caused by a typhoon, flood, downpour, strong wind, wind and waves, tidal wave, heavy snowfall, lightning, drought, earthquake, sandy dust, red tide, ebb and flow and other natural phenomena equivalent thereto; (b) damage beyond the scale prescribed by presidential decree, such as a fire, collapse, explosion, traffic accidents, chemical, biological and radioactive accidents, and environmental pollution incidents and other accidents similar thereto; (c) damage caused by the paralyzation of the state's backbone systems, such as energy, communications, transportation, finance, medical treatment and water supply, and by a spread, etc. of infectious diseases. . the term "overseas disaster" means those which actually cause or are likely to cause any harm to the lives, physical safety and property of citizens of the republic of korea outside the territory of the republic of korea, and which require the government to take measures thereon. • framework act on the management of disasters and safety (partially amended on august , , act no. ) types of disasters were categorized into natural and social disasters in the disasters and safety act partially amended on august , , defining them as follows. the korean government classifies standardized disaster types on the standard crisis management manual as shown in table . according to the statutory classification of disasters summarized above. article (definitions) the terms used in this act shall be defined as follows. . the term "disaster" means any of the followings which actually causes or is likely to cause any harm to the lives, physical safety and property of citizens and the state. (a) natural disasters: disasters caused by a typhoon, flood, downpour (the korean word "howoo"), strong wind, wind and waves, tidal wave (the korean word "hae-il"), heavy snowfall, lightning, drought, earthquake, sandy dust (the korean word "hwangsa"), red tide (the korean word "jeokjo") outbreak, ebb and flow (the korean word "josu"), and other natural phenomena equivalent thereto (b) social disasters: damage beyond the scale prescribed by presidential decree, such as a fire, collapse, explosion, traffic accidents, chemical, biological and radioactive accidents, and environmental pollution incidents and other accidents similar thereto, and damage caused by the paralyzation of the state's critical systems, such as energy, communications, transportation, finance, medical treatment and water supply, and by a spread, etc. of infectious diseases under the infectious disease control and prevention act, and contagious animal diseases under the act on the prevention of contagious animal diseases enforcement decree article (scope of disasters) "damage beyond the scale prescribed by presidential decree" in subparagraph (b) of article of the disasters and safety act (hereinafter referred to as the "act") means the following harm: . harm to human life or property for which measures at the level of state or local government are required; . other harm deemed by the administrator of the national emergency management agency to be necessary for disaster control, and which is equivalent to the harm referred to in subparagraph damage on cultured marine products and fishery production facilities due to a discoloration of seawater to red or light brown caused by an explosive growth in phytoplankton density ※ article of the act on the prevention of and countermeasures against agricultural and fishery disasters 「methods regarding the monitoring, prediction of red tide, and damage prevention」(directive of ministry of maritime affairs and fisheries) drought a prolonged shortage of water supply in a certain region due to a period of below-average precipitation or insufficient available water resources: it can be categorized as a meteorological drought, a hydrological drought, an agricultural drought, or a socioeconomic drought depending on its usage tidal wave damage by level rise due to the effects of tides, weather tidal waves, swells, and abnormal waves in costal or estuarine waters social disaster forest fire trees, weeds, fallen leaves, etc. in a forest or in an area adjoining to a forest are burned by a fire artificially or naturally ignited ※ article of the forest protection act chemical accident all situations that occur because a chemical flows out or leaks out to humans or the environment due to the fault of a worker as at the time he/she works, such as replacement of facilities, defects in facilities or deterioration of facilities, a natural disaster, a transport accident, etc. ※ article of the chemicals control act (continued) disaster type definition water pollution accident that oil, toxic substance, or sewage or wastewater is discharged to river, causing continuous large-scale suspension of water intake or perish of fishes and significant effects on the people's living and natural ecosystem large-scale marine pollution accident accident caused by the crack of oil tank due to sinking, stranding, or collision of a ship resulting in a significant and extensive damage to the people's living and natural ecosystem and requiring comprehensive measures at the government level utility-pipe conduit accident occurred on the facility installed underground for smooth maintenance, aesthetic improvement, preservation of road structure, and smooth traffic flow by accommodating underground facilities (electricity, gas, waterworks supply facilities, communication facilities, drainage system, etc.) commonly collapse of dam accident of leak or overflow occurred due to natural disaster such as large-scale flood or earthquake or structural defect of dam, concerning the collapse of dam large-scale subway accident accident occurred due to the collision, derailment, fire, explosion or flooding of electric train in operation, causing casualty or expecting the suspension of train operation for a long period of time large-scale high-speed railroad accident accident occurred due to the collision, derailment, fire, or explosion of high-speed train in operation, causing casualty or expecting the suspension of train operation for a long period of time large-scale fire at multiuse facility accident at a facility used by the many and unspecified general public concerning which has a high concern of large casualty and property damage in case of large-scale fire radiation exposure from a neighboring country situation requiring national protection measures due to a large-scale radiation exposure or radiation contamination exposure accident from a nuclear facility of neighboring country marine vessel accident accident occurred due to the collision, fire, explosion, stranding, sinking of vessel, loss of loaded cargo, or other hull damage large-scale casualty accident at workplace accident of large-scale casualty such as physical explosion related to tasks at the workplace, largescale collapse accident at construction site, choking accidents due to oxygen deficiency, acute poisoning accident due to exposure to chemicals, or other equivalent accidents multiuse facility large building collapse accident accident at a facility used by the many and unspecified general public concerning large casualty and property damage in case of collapse of building (continued) paralysis of essential national financial information function due to natural disaster, strike, terrorism, and electronic infringement on the financial information system which is the key national infrastructure safety of nuclear facility disaster caused by radiation leak or radioactive contamination from a nuclear power plant and research reactor facility electric utility serious impediment to national life and paralysis of national functions due to anxiety about the electricity demand and supply caused by increased demand, defected facilities, and social conflicts demand and supply of oil serious hazard to the national safety and the stability of national economy due to imbalance between demand and supply of oil caused by foreign oil producing countries health and medical services serious hazard to national health due to the paralysis of healthcare system drinking water national crisis situation such as suspension of drinking and industrial water supply due to water pollution, destruction of facility due to natural and artificial disasters, and strike and cyber terror cargo transport situation which may cause or lead a significant crisis in the national logistics system due to refusal of (continued) by cred and munich re the cred is a research institute founded in by lechat, a professor in belgium and has been studying international disasters and disputes for over years. it has been a world health organization (who) collaborating center since and is operating an international disaster database called emergency events database (em-dat). the disaster classification system of em-dat is in four levels: generic group, subgroup, main type, and subtype. generic group, the highest level of the system, classifies disaster into natural and technological disasters. the natural disaster category is divided into six subgroups: biological, geophysical, climatological, hydrological, meteorological, and extraterrestrial disasters. each subgroup in turn covers disaster types and more than subtypes. more detailed information can be found in the em-dat report (cred ) . natcatservice provided by munich re group in germany is another database related to disasters that wins global recognition, using a natural disaster classification system similar to em-dat. natcatservice enters all natural disasters that cause human and physical damages regardless of scale, but it does not mention artificial/technological disasters (munich re ) . in , cred and munich re developed and presented a joint standard classification system for natural disasters (cred and munich re ). this can be considered the international standard classification system for natural disasters. this system classifies disasters into five levels, dividing disaster into two generic disaster groups of natural disasters and technological disasters. natural disasters are then divided into six disaster groups, geophysical, meteorological, hydrological, climatological, biological, and extraterrestrial, each of which is then classified into main type, subtype, and sub-subtype. however, this system is limited in that it cannot present a detailed classification system for artificial/technological disasters, as munich re does not have the classification for such disasters. threat and hazard identification and risk assessment the threat and hazard identification and risk assessment (thira) is a four-step common risk assessment process that has been designed by the dhs in the usa. this process helps the whole community identify risks, and enables the community to build local resilience to the risks. according to thira, threats and hazards are divided into three disaster type definition people in cargo truck transport business to cargo transport as a group without justifiable grounds resulting in suspension or setbacks of cargo transport gps signal interference service interruption of national infrastructure due to intentional or unintentional interruption of gps signal reception for national core infrastructure and service using gps cosmic radio wave disaster related to radio wave occurred due to change in electromagnetic energy existing outside of the earth's atmosphere types as listed in table . . the natural hazards are the types that result from acts of nature, such as flood, earthquakes, drought, pandemics, epidemics, or more. the technological hazards are the types that result from the accidents or the failures of systems and structures, such as transportation accidents, collapse, hazardous materials spills, or more. the human-caused incidents are the types that result from the intentional actions of an adversary, such as terrorism, sabotage, cyber incident, chemical attack, biological attack, or more. classification of disasters by their cause has been useful for deciding governmental actions toward disaster recovery because it clearly indicates the responsibility of who will pay for what, e.g., supporting disaster victims and/or providing disaster relief. however, the categorization is not useful for disaster response because the response way is not different depending on its cause. therefore, a new prism is needed. kim et al. ( ) have analyzed the occurrence of large-scale disasters in korea since and the government's response to them and have proposed new optics for classifying disaster types for advancing disaster responses. to this end, two important elements were considered: the evolutionary or devolutionary pattern of the magnitude of disaster damage and the roles and responsibilities of responding agencies. regarding the first element of the pattern of disaster damage, three types can be derived: ( ) events with measurable prediction of large-scale damage, ( ) events with unpredicted high social shocks with quick evolution and devolution independent of its magnitude, and ( ) events slowly evolving to large scale. large-scale damage caused by typhoons, torrential rain, and heavy snowfall can be predicted according to weather forecasts and precedence. train crashes and building collapses are types of disasters that suddenly evolve and devolve, leaving not only physical damage but also a shock to the social fabric. finally, foot-andmouth disease, infectious disease, and red tide are disasters that commence on a small scale, or with little notice, but over time become considerable disasters that require large-scale disaster response tactics. the reason why this classification is important is that the response system, such as the timing of the operation of the central disaster and safety countermeasure headquarters (cdschq) and the central disaster management headquarters (cdmhq), is different depending on the progress or evolution of the damage. secondly, the scope of the overall coordination that cdschq should undertake varies depending on whether there are one or more disaster management authorities. the role of the coordinating authority becomes important for typhoons, torrential rain, and heavy snowfall, since they are types of disasters that simultaneously cause damage to various facilities, which will result in various agencies, such as the ministry of construction, the ministry of agriculture, the ministry of environment, etc., engaging the disaster together. for effective response to these types of disasters, it is important for the coordinating authority to support the human and material resources necessary for the various disaster responses by the disaster management agencies. on the other hand, for the disasters such as aircraft accidents, infectious diseases, and dust storms, expertise and experience are concentrated in specialized disaster management authorities, meaning it is efficient for the agencies responsible for those disasters to respond. the category by kim et al. ( ) is very useful in developing an optimum disaster response system fitting the disaster cause and evolutionary path. in this book, we will propose the disaster category for effective disaster response based on the category by kim et al. ( ) as outlined in table . . dombrowsky ( ) suggested event-related concept and phase-related concept as disaster categorization. the event-related concept is composed of time, space, and severity, while the phase-related concept is composed of pre-emergency phase, emergency phase, warning, and post-emergency phase. methods of classifying disasters include one in terms of emergency and medicine. in the field of emergency and medicine, disaster is classified into surgical and medical disasters. the purpose of this categorization is to treat efficiently patients during disasters by securing effectiveness of first aid on-site and hospital treatment. surgical disasters are mostly those in which victims are injured, and they refer to disasters in which damage from physical disasters appears in the form of injury. medical disasters or disease disasters refer to chemical disasters that cause hindrance to respiratory organs and metabolic systems due to the leakage of chemicals, radioactive matters, or toxic agents. this classification method has significance in that it is possible to predict the conditions of the patients in disasters and effectively manage medical resources accordingly (kim and lim ) . in case of instant disaster with single primary response agency, such as dam failures, major rail accidents, and maritime accidents, the cdschq and the cdmhq are established simultaneously; the cdmhq takes charge of response, and the cdschq coordinates the pan-governmental support primary response agency takes charge of its own responsibility in the early stage of the event. as the damage evolves, the charge is transferred to the cdschq. this type of event includes infection, animal disease, red tide, and green tide contemporary society is becoming vulnerable to new types of disasters, such as new epidemics including ebola virus and middle east respiratory syndrome coronavirus (mers-cov), new animal diseases including bovine spongiform encephalopathy (bse) and hpai, and complex disasters such as the tohoku earthquake and tsunami in along with typical types of disasters like typhoon, fire, and building collapse. in addition, the characteristics of complexity in modern times require new and innovative approaches that are different from current response ways. there has recently been much research in various fields, such as sociology and science of public administration, in order to understand what increases disaster complexity in modern times. this section will review representative disaster theories and find how these theories explain major disasters that occurred in korea and around the world. based on this understanding, we will recommend the desirable policy change for effective disaster response in korea. representative theories, such as heinrich's law, normal accident, risk society, and complexity theory, will be reviewed in the following section. herbert william heinrich, who was an assistant superintendent at an american insurance company, presented an important study in based on his analyses of a wide range of accidents. he coined the notion of heinrich's law, which states that, for every major accident, there have been preceding minor accidents and signs of anomaly (heinrich ). heinrich's law is therefore also known as the law of : : . in other words, an accident that is large enough for people to notice is only a small tip of an iceberg and is always antedated by countless other accidents and happenings that warn of the upcoming disaster. through a scientific statistical approach on industrial disasters that were once believed to take place unexpectedly, heinrich found that massive disasters occurred due to negligence on minor defections. originally, the heinrich's law was applied to industrial disasters, but it is now extended to rules related to accidents, disasters, and failures throughout all kinds of areas in contemporary society. the : : rule is meaningful in that it sets up a rule to explain quantitatively the process of an evolutionary incident, starting from a small accident and resulting in a catastrophic event. he also applied the domino theory to disaster areas and indicated that in order for disasters to take place, an inappropriate "direction of flow" occurs sequentially: many causes interact with complexity, and those causes generate interwoven influences. as a result, phenomenon called disaster or accident takes place, and ultimately it causes human and physical disasters, which is a major argument of the domino theory. the theory emphasizes fundamental elements before accidents to take place and explains there are three potential elements as follows: the first condition -human genetic component or socially undesirable phenomena the second condition -flaws caused by the first condition the third condition -unsafe actions, mechanical and physical, according to the second condition among the three conditions that cause a disaster, the first condition of inherited elements or social environment and the second condition of inherited or acquired human defects are hard to be rectified; however, the risk by the third condition can be significantly reduced through safety education and strengthened safety devices. in other words, heinrich insisted that if the third condition is effectively eliminated, disaster can be prevented before it occurs (heinrich ) . the sampoong department store collapse accident in korea is a typical example of the heinrich's law. the accident happened because no countermeasures had been taken even though there were many signals before the accident. the department store opened its business with inborn structural problems during the construction process: about tons of installation equipment was installed on the rooftop, which was four times more than its original design load, and reinforcing bars were out of place. along with problematic construction, poor management was another cause of the accident: minor symptoms such as cracks in the ceilings and damage to the floor of the rooftop (potential elements of ) were overlooked by staff and maintenance crews. in addition, although customers and employees raised several concerns about the general health of the building, such as vibrating sound from an air conditioner and many cracks in the wall, no specific actions were taken, even after receiving evaluations from experts ( small accidents). neglecting potential elements eventually led to one huge accident with casualties (one massive accident) (lee et al. ) . we found that most of the major social disasters, such as the seongsu bridge collapse, the sampoong department store collapse, the daegu subway fire, and the sewol ferry sinking accident, have common things to cause the disasters: improper alteration of use, insufficient safety culture, insufficient safety inspection, and insufficient safety infrastructure. heinrich's law indicates the direction of disaster response that korea should follow: institutional reforms for strengthening disaster and safety management, improvement of safety inspection, expansion of safety education, and enhancement of disaster and safety infrastructure. in the book normal accidents, charles perrow, a professor of sociology at yale university, insisted that complex systems, such as nuclear power plants, chemical factories, aircrafts, ships, dams, and gene manipulation, hold a risk of tragedy. thus, there are some unavoidable accidents called normal accidents that have a high probability of occurring regardless of safety measures and devices (perrow ) . charles perrow proposed the normal accident theory based on the empirical evidence of the three mile island (tmi) nuclear power plant accident that took place in pennsylvania in , the first nuclear power plant crisis to have occurred. perrow ( ) defines a normal accident, which he also refers to as a system accident, as "an event that involves the unanticipated interaction of multiple failures, reflecting the characteristics of high-risk system in which multiple and unexpected interactions of failures are inevitable." perrow's theory insists that accidents in today's cutting-edge technological societies are closely related with complex technological and mechanical structures with built-in risks and those risks are therefore a normal part of our lives. an extremely complex system, in which individual technologies interact with one another closely and inseparably through an endless loop, is prone to catastrophe caused by a series of breakdowns whenever one of the interwoven elements begins to dysfunction. it is nearly impossible for humans to predict such technical failures (park ) . perrow noted that conflicts of interests might exist between a given organization and its members and that organizations are also subject to external political and social environments. technical solutions are therefore not enough, particularly as it is impossible to ensure the total control and containment of risks in such highly complex private facilities as nuclear power plants and petrochemical factories, at which minor errors can lead to complete failures (perrow ). the three mile island accident is considered as the typical example of normal accident. this brought widespread panic to the usa as large portions of one of the reactor's cores partially melted, releasing radioactive gases and hazardous iodine into the surrounding environment. the direct cause of the accident was officially recorded as a mistake by operational staff; however, the complexity of the disaster is a hidden root cause of the catastrophic event. therefore, as perrow indicated, complex systems with built-in intensive risk, such as nuclear power plants, require that centralized and decentralized management should be considered simultaneously. there have been a lot of industrial accidents around the world. accidents, such as the india bhopal chemical factory accident, the chernobyl nuclear power plant radiation leak, and the bp gulf oil spill, indicate that industrial safety measures need constant improvement through comprehensive understanding about high-risk technology and systems. some scholars criticized that the normal accident theory overemphasizes the vulnerability of high-risk facilities; the high reliability theory is a typical example of the critics. professors from uc berkeley and weick, an organizational theorist, proposed the high reliability theory based on research of organizations fraught with disaster risk, such as national aeronautics and space administration (nasa), the nuclear industry, aviation, nuclear carriers, swat, and massive petrochemical facilities in the usa. the high reliability theorists insist that sophisticated quality controls, a settled safety culture, built-in safety by cross-check, and continuous education and training can prevent disasters at high-risk facilities. irrespective of these critics, perrow's normal accident theory provides a beneficial lens through which we may view and analyze risks in contemporary society. because the theory explains risks as a matter of organizational characteristics of the ecosystem, it overcomes the shortcomings of the science and technology-centered approach. it provides sociological explanations for organizational risks that are likely to cause massive collateral damage, such as in petrochemical factories and nuclear power plants (jeong ). after the earthquake that occurred on september , in korea, social interest in the safety of high-risk facilities such as nuclear power plants and old industrial complexes has increased. in accordance with etkin ( ) , who noted that careful thought should be given to the construction of complex tightly coupled systems, the korean government should entirely overhaul the safety of risky facilities such as nuclear power plants, industrial complexes, and chemical plants. moreover, there is a need for society-wide attention and efforts to provide a more sophisticated safeguard system. around the s, an in-depth exploration on new risks that occurred in modern society was conducted by european scholars, such as luhmann, giddens, and beck (lee ) . ulrich beck, the german sociologist, suggested the concept of risk society as a solution to structural and deep-rooted problems of industrial societies, including science and technical safety issues, which started in the mid- s (lee et al. ) . in his book world risk society ( ), ulrich beck argued that the modern society is a "risk society" replete with risks all throughout and emphasized the multiplication of cross border risks and international dangers that single nationstates cannot tackle on their own (beck ) . during his lecture at seoul national university in , beck pointed out the similarities between the asian financial crisis in the s and the chernobyl nuclear plant accident in , stressing the importance that all nations must work together to reduce the global risk on the basis of a common understanding that they are facing the same global risk. beck also considers this emerging risk as a result of the de-bounding of traditional national boundaries in the spatial, temporal, and social dimensions. beck defined risk society as a society where socially produced risk is inherently accompanied by socially produced wealth (oh ) . he also insisted that industrial society should be addressed through a comprehensive perspective, which includes social, historical, and technological views (beck ). as the world entered into a contemporary society, new types of risks, combined with secondary, supernatural, and artificial uncertainty, had arisen, and those risks were beyond a dimension of traditional response methods (lee ) . the background with such phenomena includes a complex structural change that is understood as the term of postmodernity. generally, risk, unlike danger that indicates direct and physical loss, is based on the probability of prediction or control: a new concept of "uncontrollable risk" needs urgent attention because this type of risk denies the applicability of currently available risk theories and risk control mechanisms, arising new threats (beck ). the concept of risk society by beck has a critical meaning to korea's drm. the increased risk can be also found in urbanization in korea. lee et al. ( ) emphasized the increased risk due to urbanization by showing the increased disaster risk following urban development with the change of green space to paved road. korea has also suffered from newly emerging disaster risks, such as severe acute respiratory syndrome (sars), foot-and-mouth disease, and mers-cov. therefore, an innovative and cooperative approach to disaster risk suggested by beck needs to be reflected in designing resilient future. complexity theory began from researching complex natural phenomena such as meteorology. just as lorenz proved with the butterfly effect, the contemporary society embedded with complex network needs to take different countermeasures against disaster. the fukushima nuclear power plant accident of japan, a great flood in thailand, and new types of epidemics such as mers-cov are representative examples of disasters that the contemporary society is newly facing. the complexity theory is useful for understanding the characteristics of contemporary disasters and finding appropriate countermeasures. on march , , the fourth strongest earthquake struck japan, since japan started to observe earthquakes, with a mega tsunami and aftershock that caused more than , deaths. also, the earthquake destroyed the nearby fukushima nuclear power plants and caused radiation leakage. this disaster showed signs of complex disaster. due to the fukushima accident, air, soil, ocean, and underground water were exposed to radioactivity, and damages from contamination influenced largely not only japan but also the whole world continuously. the severe flood in thailand is a typical example that a disaster that happened in one country affected the regional economy. due to a heavy rain, combined with low topographic characteristics of thailand and high tide of seawater, two thirds of the land in thailand, including parts of bangkok, was flooded, causing significant damage to the entire manufacturing industry. the flood did not affect just thailand. for example, many japanese companies' production facilities located in the central region, having developed the area for the manufacturing of automotive and electronic goods, were inundated during the flood. the intensity of the flooding caused all of the facilities to be shut down, which caused tremendous economic loss for both countries. additionally, the shutdown of the automotive plants caused a reduction of japanese auto and parts deliveries to other major markets like japan, the usa, and europe. in case of the electric and electronic industry, hard disks became in short supply due to flooding of hard disk manufacturing factories. due to this, the production of semiconductors by intel became inadequate, resulting in a short supply of semiconductors to the world's semiconductor market. moreover, it caused a price increase of computers worldwide. also, since the severe flood occurred right before the tourist season, the number of tourists in the fourth quarter decreased by approximately %, and additionally induced damages occurred in other industries, such as transportation and food services. due to the influence of the heavy flood, the estimated economic growth rate of thailand in was lowered from . % to . % (korea institute for international economic policy ). table . shows the summary of damage that occurred to the japanese economy due to the heavy flood in thailand. this table shows that the flood was not just problematic for thailand but indicates that a disaster occurring in one country does influence other countries. the contemporary society is facing new types of epidemics and animal diseases, such as sars ( ), h n virus ( ), foot-and-mouth disease ( ), and mers-cov ( ), which did not exist in the past, and such symptoms have a high possibility of becoming more frequent due to increase in trade and traveling with foreign countries. pelling ( ) argued that complexity theory possesses a very important lesson to understanding ways to cope with disasters. for example, one of the characteristics of complexity theory is "emergence," which shows a trait of disasters that take place with unexpected causes at an unexpected place. according to drabek and mcentire ( ) , "emergence" appears while people change organizations in the process of making temporary organizations and responding to disaster situations. beck's risk society and perrow's normal accident theory share the similar understanding with complexity theory in that the emerging risk in modern society is closely related with its increased complexity. therefore, the core elements of complexity theory, such as nonlinearity, self-similarity, fractal, self-organization, and emergence, are essential in understanding disaster characteristic and innovating disaster response methods in modern society. as disasters started to become complexed and intensified, scholars and stakeholders began to look for new theories and methods to improve disaster risk knowledge and organizational capabilities. starting in the s, several theories, such as petak's four-phase model, mcloughlin's comprehensive disaster management procedures, and the new public administration theory, were developed to deal with these new complex and intensified disasters and to help modernize and reform institutions that were becoming too antiquated to deal with modern disasters. organizations such as the usa's fema, created in the s, used the progressing knowledge and concepts to help it mature in the s, and the un and world stakeholders, who came together in the early s to produce the hyogo framework for action (hfa), used the foundations' insights to increase disaster resilience around the world. investigating the historical progress of such knowledge and the evolution of response organization is important in figuring out what logical steps should be made for a resilient future as well as in strengthening organizational capabilities to better deal with complex and intensified disasters. in , petak proposed a four-phase model to identify the role of governments and stakeholders in each disaster management phase. he divided pre-disaster management and post-disaster management according to the progress of disasters and countermeasures and explained disaster management procedures in a timesequential manner: . disaster mitigation . disaster preparedness . disaster response . disaster recovery petak emphasized that the clear delineation of roles and responsibilities of all levels of governments and stakeholders is essential for effective disaster management four main areas in japan reduced production by % nippon steel corporation adjusted release of the crude steel in japan due to effect of reduced automobile production honda suspended the operation of four-wheeled vehicle plant in malaysia toshiba had trouble in hard disk drive (hdd) production pioneer had trouble in the production of car navigation system, relocated from thailand to malaysia deteriorated business results expects billion yen decrease in sales automobile possibility of sales decrease of billion yen for five automobile companies suspended distribution suspended the transport based on flooded areas paid insurance tokio marine and fire insurance co., ltd. began investigation to provide insurance to japanese client companies (petak ) . petak's model influenced the basic structure of the framework act on the management of disasters and safety (hereafter "disasters and safety act") in korea, which is shown in fig. . . the new public administration theory emphasizes that a government can provide better public service to citizens by adopting business management principles to public management (rosenbloom and goldman ) . the theory aims to overcome the problems of a typical bureaucracy and to improve the efficiency of the public sector by adopting business management skills and by emphasizing output and outcome of public policy rather than the input to implement the policy (rosenbloom and goldman ) . the theory was accepted through the national performance review project during the clinton administration, and laid the foundation for fema's reformation (waugh and streib ) . the demand for the reformation of fema started from hurricane hugo, which hit north carolina and the virgin islands in , causing $ billion in damages. in the aftermath of hurricane hugo, the loma prieta earthquake struck california, a fire broke out in oakland, and hurricane andrew struck florida and louisiana, dealing a massive blow to the two states. disappointed by fema's ineffective response to these massive natural disasters, political groups and citizens in the usa raised the need to improve fema's performance, which was endorsed by the clinton administration in (anna et al. ). james lee witt, appointed as director of fema by president clinton, emphasized disaster mitigation and shifted from recovery-oriented policy to preventionoriented policy. additionally, he insisted that disaster mitigation investment should be based on the assessment of the effectiveness. consequently, government policy has continued to embrace this line of thinking. to quantify the future savings of hazard mitigation activities, the multihazard mitigation council (mmc) of the national institute of building sciences (nibs) analyzed three major hazard mitigation grant programs: the hazard mitigation grant program, project impact, and the flood mitigation assistance program. the independent study proposed the following significant findings: ( ) for every dollar spent on mitigation, four dollars was saved from future spending; and ( ) fema mitigation grants beget nonfederally funded mitigation activities (nibs ) . the new public administration theory affected the development of disaster management in korea: the increased investment to structural and nonstructural measures for disaster mitigation and the evaluation of the effectiveness of disaster mitigation and recovery projects in the s are typical examples of the effect of the theory. although the theory receives criticism in that it does not consider the characteristics that disaster management has as a public service, it can provide a useful prism to improve the effectiveness of disaster management policy by focusing on the outcome or performance of the policy, rather than the input. public governance has been acknowledged as a way to improve public-private partnership in disaster management. in the public governance theory, rules govern the behavior of actors not as the result of official authority or market equilibriums, but according to the consensual process among participants, based upon networks and cooperation. the concept of collaborative networks in disaster management entails the assumption that parties involved in disaster management have diverse cultural backgrounds and are bound to experience conflicts. effective cooperation in this setting requires cultural sensitivity and mutual understanding from all participants. collaborative networks, moreover, are becoming important because, in modern society with emerging and complex risks, it is not possible to ensure perfect preparations and resources for all possible disasters and because a specific organization or one single agency cannot perfectly control all response agencies involved in managing disasters (waugh and streib ) . the advantage of public governance theory is that it strengthens shared responsibility by enabling diverse social groups to participate in the decisionmaking process so as to tackle uncertainty with social intellect and make policy decisions based on the social consensus. the theory emphasizes cooperation, public participation, problem-solving, and openness as key principles of disaster management. it aims to form a collaborative risk governance system consisting of diverse actors, including governments, businesses, and civil society organizations, in which national government serves as facilitator in promoting the development of a decentralized collaborative network among local governments, nonprofit organizations, and various public services. however, there is an opinion that the public governance theory is hard to be applied to emergency response. in other words, in an urgent disaster response process where there is not enough time to make a consultation, the process of negotiation through mutual discussion and consultation is not appropriate (waugh and streib ) . the argument seems reasonable, but recent researches have shown that interagency cooperation is becoming more important in an emergency situation. moynihan pointed out that establishing network governance in advance are an essential element in achieving the two objectives of "interagency cooperation" and "coherent response" in a crisis situation for effective disaster response (moynihan ). public governance theory is also important in the development of the disaster response system in korea. the recent major disasters in korea, such as the mauna ocean resort gymnasium collapse accident, the sewol ferry sinking accident, and the middle east respiratory syndrome, taught korea important lessons that cooperation among all relevant organizations, such as on-site response agencies, local disaster and safety countermeasure headquarters (ldschq), various line ministries involved in the cdmhq, and the cdschq, is essential for effective disaster response and relief. therefore, the korean government should develop an interagency cooperation plan and execute a joint field training program; demanding the participation of all relevant organizations specified above. in late , more than federal organizations related to civil engineering and defense had fragmented responsibilities for hazard mitigation and disaster response, resulting in no coordinating organization taking the full responsibility for the entire phase of disaster management. president jimmy carter created fema in for this reason. the establishment of fema made it possible to unify the fragmented responsibilities of emergency preparedness and response resources (anna et al. ) . mcloughlin ( ) proposed an integrated emergency management model. considering disaster as an incident or condition that threatens the survival of organizations, he was concerned with the fact that troubles in cooperation among related agencies repeatedly occurred during disaster response since various public and private groups had been engaged in disaster response without comprehensive coordination. he argued that a comprehensive and integrated emergency management system could sustain administrative capabilities during emergencies and protect property and life through a series of circulation processes under the cooperation of the federal, state, and local governments. this model emphasizes that each local government and the federal government should cooperate to protect life, property, and government functions through a program of mitigation, preparedness, response, and recovery (cho ) . quarantelli ( ) also emphasized that comprehensive disaster management is essential in modern times in order to build a comprehensive and unified organization that manages all types of disasters. he argued that a dispersed or separated approach, by which each line ministry is responsible for its own disaster; devoid of a coordinating agency, cannot deal with complex and intensified disasters in modern times. additionally, he asserted that a comprehensive and integrated method be used when managing disasters because: first, disasters have become more complex and capable of destroying the functionality of typical community operations, meaning that dividing disasters into natural or human-caused ones is inadequate for effective response; second, there is an underlying commonality among governmental departments to respond to disasters; therefore, comprehensive measures are required for a unified effort; third, the planning process and its contents for disaster response by each department has commonality, thus, it is ineffective that each department develops its own response plan; finally, the shared response resources among the governmental departments reveals that a move to a comprehensive management format is feasible since vital resources are similar in each department (quarantelli ). global cooperation for effective disaster relief had been a pivotal issue among the international society. to improve the international cooperation for disaster relief to affected nations, the united nations established a responsible agency, labelled as "the united nations disaster relief organization (undro)," in . since then, the international community has been working for developing a systematic disaster management framework; disaster response plan, disaster prevention measures, and scientific and technical solutions to disaster risk have been discussed and adopted. in particular, technical approaches, such as vulnerability analysis for disasters and early warning measures, have been tried. additionally, the scientific approach played a key role in the evolution of disaster management through a variety of research on how to identify hazard and assess vulnerability (unisdr ). in , the international society began to prepare the international decade for natural disaster reduction framework to promote more systematic disaster management (unisdr ). the international community established the un humanitarian emergency assistance and the international search and rescue advisory group (insarag) mechanism in . also in , systematic mechanisms for disaster response were introduced by building the united nations disaster assessment and coordination (undac) mechanism. the international conference held in in japan adopted the yokohama strategy that emphasized the paradigm shift from recovery-oriented policies to prevention-oriented policies. in , the name of the international strategy for disaster reduction was adopted with the title "safer world in the st century: disaster and risk reduction." since then, a comprehensive policy framework to cope with increasing global risk has been developed in earnest (unisdr ). in december , a tsunami hit countries in the eastern-western-southern asian regions, such as indonesia, sri lanka, and india. in the wake of the catastrophic event, national governments, international organizations, un agencies, and other stakeholders agreed to adopt "the hyogo framework for action (hfa): building the resilience of nations and communities to disasters," to mitigate global disaster risk for - . with the hfa, disaster management moved toward building resilience based on social consensus and strengthening shared responsibilities among all stakeholders. in march , all national governments also agreed to the sendai framework for disaster risk reduction - (sfdrr), which is the first major agreement on disaster management in line with post- development agenda. the sfdrr aims for the significant reduction of disaster risk and losses with the following four priority actions: understanding disaster risk, strengthening disaster risk governance to manage disaster risk, increasing investment in disaster risk reduction for resilience, and enhancing disaster preparedness for effective response and to "build back better" in recovery, rehabilitation, and reconstruction. the drr-related global agenda in various fields will be further reviewed and analyzed in chap. in order to link them with disaster resilience in the future. in the s, massive disasters continued to occur throughout the world. national governments have reformed their disaster response system to deal with massive disasters. the usa reformed its drm system after / in , shifting from a typical natural and human-caused disaster management paradigm to comprehensive security (park and cho ) . within this context, since the s, civil defense and civil protection became important concepts in disaster management. civil defense was originally designed to protect citizens from calamities, such as war, but it was gradually expanded to encompass drm, reducing civilian casualties during disasters. alexander ( ) suggested that the role of the state and the civilian in disaster preparedness be shifted from civil defense to civil protection. this is because civil protection is an appropriate concept to reinforce the protection of people against external risks, meeting the need to protect people from typical disasters, such as natural and technological disasters, as well as emerging risks, such as new infectious diseases, terrorism, and cyber attacks, while civil defense was useful to cope with the invasion of an outside force which was a severe threat during the cold war era. one of the most important features of civil protection suggested by alexander is a shift from providing public safety service by the government to encouraging public participation. when a national government provides public safety services, it usually prefers to use a top-down approach: command and control, a hierarchical decision-making system excluding citizen's participation, strengthening law and order, and rules through the principle of confidentiality. however, the civil protection concept by alexander put stress on a bottom-up approach: emergency preparedness and response ensuring public participation and cooperation, problemsolving approach, and openness principles. as a result, risk governance is the most critical issue in civil protection, ensuring the cooperative interaction among the government, the private sector, and civil organizations to replace the existing hierarchical bureaucratic system. alexander ( ) addressed hurricane katrina as a typical failure case of civil defense with a top-down approach, requesting a shift from a top-down approach to a bottom-up approach, along with improved risk governance. this section will describe disaster response institutions in korea, the usa, japan, and other nations. the analysis of one nation's disaster response institution requires huge efforts and a large amount of work. due to limited time and space, this section will focus on the basic structure of disaster management organizations for normal times and emergency situations at national and local levels. the disaster response institutions in korea, the usa and japan will be analyzed first, and then those in australia, germany, switzerland, and the united kingdom (uk) will be analyzed. in korea, the ministry of public safety and security (mpss) is responsible for the overall coordination of the nationwide disaster response based on the disasters and safety act. after the presidential election on may , , the ministry of interior (moi) has been preparing for the revision of the government organization act, which includes the establishment of ministry of public administration and safety (mopas) by integrating mpss with moi and the establishment of korea fire service and korea coast guard as ind ependent agencies. the act is expected to be reviewed and decided by the national assembly in late . in addition, the crisis management center under the national security council in the blue house (presidnet's office) is expected to work as a control tower for national crisis, such as the sewol tragedy. the korean government has developed its disaster response system suitable for normal times and emergency situations at the national and the local levels. organizations for normal times are composed of disaster management agencies, disaster-management supervision agencies, emergency rescue agencies, emergency rescue, and relief support organizations. in addition, central, city/do, si/gun/gu committees are being operated to deliberate matters on disaster and safety management under their responsibilities. disaster management agencies take charge of all phases of disaster management activities that are related to their responsibilities. the agencies include national administrative agencies, local governments, local administrative agencies, public institutions and organizations, and other organizations prescribed by presidential decree. disaster-management supervision agencies are responsible for disaster response when a disaster or an accident occurs in accordance with the responsibilities prescribed by presidential decree. for example, the ministry of education is responsible for disasters in schools and school facilities, the ministry of environment is responsible for environmental pollution accidents, and the ministry of employment and labor is responsible for large-scale human accidents occurring in places of work. table . shows the disaster-management supervision agencies by disaster or accident type in korea. emergency rescue agencies are responsible for carrying out life rescue, first aid, and other necessary measures to protect the lives and property of citizens when a disaster is likely to occur or when a disaster occurs. the agencies in charge include fire hqs and coast guard hqs, under the mpss, city/do fire headquarters and si/gun/gu fire stations, and regional headquarters of the korea coast guard and coast guard stations. to support rescue activities, presidential decree prescribed emergency rescue and relief support agencies, which are equipped with human resources, installations, equipment, operation systems, etc., that are necessary for emergency rescue and relief service. to deliberate and decide crucial matters related to disaster and safety management at the national level, the central safety management committee, chaired by the prime minister, is operated. in addition, the safety policy coordination committee, chaired by the minister of public safety and security; the central disaster broadcasting consultative committee, chaired by a person appointed by the minister of the ministry of science, ict and future planning; the central private-public cooperative committee, chaired by the vice minister of public safety and security; and a civilian representative are being operated to advise, consult, deliberate, or sometimes decide disaster and safety management issues under their responsibilities. at regional and local levels, a city/do safety management committee, a si/gun/gu safety management committee, a city/do disaster broadcasting consultative committee, and a si/gun/gu disaster broadcasting consultative committee are operated. when disaster occurs or is likely to occur, emergency response organizations are established and operated to take timely and proper measures at national, regional, and local levels. the emergency response organizations at the national level include the cdschq, chaired by the mpss; the cdmhq, chaired by the head of the relevant disaster-management supervision agency; and the central emergency rescue control group (cercg), chaired by the head of the central fire headquarters for disaster occurring on land and the chief of the central rescue center for disaster at sea, respectively. the local emergency response organizations include the city/do disaster and safety countermeasure headquarters (city/do dschq), chaired by mayor or governor, and the si/gun-gu disaster and safety countermeasure headquarters (si/gun/gu dschq), chaired by the head of si/gun/gu. for rescue activities, the local emergency rescue control group (lercg), chaired by the head of the fire headquarters and a chief of a fire station, is operated; when disaster occurs at sea, the head of a si/gun/gu emergency rescue control group and the head of a city/do emergency rescue control group shall be respectively construed as the chief of a regional rescue center and the chief of a metropolitan rescue center under article of the rescue and aid at sea and in the river act. when disaster occurs or is likely to occur, the mpss will immediately hold a situational meeting to supervise the initial response, rescue, and first aid operations. in particular, in the event of a major disaster, the ministry will operate the cdschq and coordinate the intergovernmental disaster response activities. in case of an oversea disasters, the minister of foreign affairs shall exercise the authority of the head of the central countermeasure headquarters, and in cases of radioactive disasters, the chairperson of the nuclear safety and security commission shall exercise the authority of the head of the central countermeasure headquarters, respectively. in case government-wide integrated response is necessary, the prime minister may exercise the authority of the central countermeasure headquarters. in such cases, the minister of public safety and security, the minister of foreign affairs (limited to cases of overseas disasters), or the chairperson of the nuclear safety and security commission (limited to cases of radioactive disasters) shall be the vice head. when a disaster occurs in a jurisdiction, the mayor or provincial governor and the head of a si/gun/gu shall set up their own dschq and coordinate the response and recovery operations. in order to efficiently operate the cdmhq under article - ( ) of the disasters and safety act, the head of the disaster-management supervision agency shall predetermine necessary matters for organizing, operating, etc. of the cdmhq and exercise the authority of the head of the headquarters. also, local disaster management headquarters shall be established to work as an action team of cdmhq in the disaster area. the disaster response organizations during emergency situations is shown in fig. . . the disaster response plan in korea consists of three parts: the standard risk management manual, the working-level manual for risk response, and the manual for actions-at-scene. as of may , kinds of standard risk management manuals, working-level manuals for risk response, and , kinds of manuals for actions-at-scenes have been prepared and utilized. the standard risk management manual, prepared by a disaster-management supervision agency, delineates roles and responsibilities of related agencies in disasters at the national level, which shall be the guidelines for preparing the working-level manual for risk response. the working-level manual for risk response is a document stipulating the measures and procedures necessary for responding to actual disasters in accordance with the functions and roles of the disaster-management supervision agency and support agencies, which are stipulated in the standard risk management manual. the manual for actions-at-scene, prepared by implementing agencies, such as local governments, stipulates in detail the procedures for actions to be taken by an agency that directly performs its duties at a disaster scene. the standard risk management manual shall be prepared by each disaster management supervision agency that is regulated in table . . however, the standard risk management manual for disasters involving many disaster management authorities, such as typhoon and drought, can be prepared by the minister of mpss. the working-level manual for risk response shall be prepared by related support agencies that are designated by the standard risk management manual. the manual for actions-at-scene shall be prepared by an agency designated by the working-level manual for risk response. the head of the si/gun/gu may develop several disaster types of manuals for actions-at-scenes in consolidation as needed. the manuals delineate roles and responsibilities of the disaster-management supervision agency, related support agencies, and implementing agencies. on the other hand, the operational functions of disaster response of each agency shall be designated by action plans for disaster response by function under article - of the enforcement decree of the disasters and safety act. the functions for disaster response, similar to the emergency support function (esf) of national response framework (nrf) in the usa, are described below: . managing disaster situation . supporting emergency livelihood stabilization . supporting emergency communications . emergency restoration of facilities damage . restoring damaged energy supply facilities . supporting disaster management resources . traffic countermeasures . supporting medical and disinfection services . environmental arrangement at disaster scenes . supporting and managing volunteer work . maintaining social order . searching, rescuing, and emergency support at disaster areas . publicity of disaster management in summary, the two axes of the disaster response plan in korea are three levels of manual and functional action plans. the manual describes the roles and responsibilities of primary response ministries and related agencies, and the functional action plans describe how each agency performs its key response functions in line with its roles and responsibilities. the disaster response organizations during emergency situation are: cdschq, city/do dschq and si/gun/gu dschq for overall coordination; cdmhq and ldmhq for the implementation of their own responsibilities; cercg and lercg for search and rescue; and support agencies. both the establishment and evolution of fema and dhs in the usa had influenced the disaster management system in korea; in particular, the establishment of the national emergency management agency (nema) in and the establishment of the mpss in . in addition, the integrated disaster management formed by the dhs, the nrf, and the national incident management system (nims) has also influenced the evolution of the disaster response system in korea. dhs, established in , is responsible for national security and disaster management. fema under dhs is in charge of all phases of disaster management, including national preparedness, public and private capacity assessment, mobilization of resources for emergency management and disaster relief, and long-term recovery plans. at the state level, the disaster management department focuses on strengthening the linkage between the federal government, the state, and the local governments and assisting the local government in disaster prevention, preparedness, response, recovery, and relief. when a disaster occurs, the emergency operations center (eoc) commences operation and responds to disasters in accordance with a preestablished disaster response plan (eop, emergency operation plan, or cemp, comprehensive emergency management plan). local governments have a primary responsibility for the whole process of the localized disaster, prevention, preparedness, response, and recovery of disaster, and for the activation of eop followed by executing the eoc to respond to disasters. when a disaster that exceeds the capacity of a local or a state government occurs, federal government's assistance and involvement is requested and is provided through the joint field office (jfo). the usa performs disaster management through nrf and the nims. be that as it may, the catastrophic events on september , ( / ), and august , (hurricane katrina), saw the federal government's failure to provide proper support to state and local governments for effective disaster response. after that, there is an increasing demand for the federal government to respond to disasters proactively by federal emergency declaration to large-scale disasters and pre-deployment of federal resources to states. however, the basic principle of disaster management in the usa is still that local governments are primarily responsible for all disasters, with the support from state and federal governments concerning disasters that exceed the capacity of local governments. the disaster management organizations of the usa are summarized in fig. . . the dhs was established in january to integrate the prevention of terrorism and the function of disaster management under one department's coordination in the wake of the september , terrorist attacks and the mailing of anthrax spores. dhs took charge after the commencement of the national strategy for homeland security and the homeland security act. the dhs carries out tasks that include the suppression of terrorists' attack, minimization of damage, prevention, preparation, response, and recovery in the emergency plans for all domestic and international dangers that threaten the usa. the dhs consists of the office of intelligence and analysis (oia), the information analysis and infrastructure protection (iaip), the chemical and biological (cb) weapon management service, the state affair safety service, secret service (ss), and fema. fema, which is the most well-known organization among the various organizations of the dhs, is responsible for various tasks that include the disaster risk reduction at all levels, the reduction of property loss through various risk-based emergency management programs for the preparation, response, and recovery, and the protection of people's lives and main facilities. fema was established in as an organization coordinating the response and recovery of disasters during the carter administration. however, the initial phaseout of fema was not that high. it had grown into a member of the administrative cabinet and a ministerial level organization during the clinton administration through the establishment of an integrated response system and the strengthening of preventative and mitigation programs after failing to respond effectively to several large-scale disasters such as hurricane hugo. through the establishment of fema, various agencies related to disaster response were integrated into one agent under the direct control of the president and capable of comprehensively responding to various human-caused disasters and natural disasters. after the dhs was established, fema was incorporated and operated as a bureau under the dhs. in the early days, under the dhs, fema's status was weakened since antiterrorism and security were the first priority of the nation. however, after hurricane katrina, the importance of disaster management has been highlighted, and fema has also been strengthened as the independent deputy-minister level agency. fema, headquartered in washington, dc, operates local offices and provides regular disaster support personnel who can respond immediately in case of a disaster. the central organization for when an emergency occurs includes the jfo. the jfo is established by fema for coordinating between state governments and federal agencies after the president declares a state of emergency, and jfo plays a pivotal role in providing coordination between federal, state, and local governments and non-governmental organizations (ngos) and private sector accident supports. the head of a jfo is called the federal coordinating officer (fco), who is designated by the president and carries out the comprehensive coordination and the management of support activities using the resources secured by the federal government. in general, the state and local governments have an organization dedicated to disaster management: a disaster management department at the state level and an emergency office at the local level. a local emergency office (leo) normally consists of divisions handling emergency operation, information and communication, administrative task related to disasters, prior identification of risk, and the modification and supplementation of a risk management plan. in the event of a disaster, the eoc is set up to coordinate or support the disaster response at the site and responds to the disaster in accordance with the incident command system (ics). disaster response plans in the usa are developed at the federal, state, and local levels. at the federal level, the nrf and the nims constitute overall responsibilities of the dhs, fema, line ministries, and other agencies. the purpose of the nrf was to connect government agencies with ngos and the private sector and transparently assign and coordinate key roles and responsibilities nimbly. the nrf consists of the base document, the esf annexes (esf annex), the support annexes, and the incident annexes. table . shows the organization of the nrf. the local disaster response plan is carried out through the preparation of an eop by each area. the plan incorporates all aspects of disaster management in any given area, and it guides the roles and responsibilities of all related agencies for disaster response, depending on the size and complexity of a disaster. eop consists of the basic plan enclosed with the annex including the esf, the administrative and financial support plan, and the incident annex. nims provides national response doctrine for the whole community to work together based on the principle of the nrf. the nims defines standardized command and control principles to enable various response agencies to coordinate in the event of a terror and disaster. it provides a standardized response principle that allows federal, state, local governments, and nongovernmental organizations to respond consistently to a disaster regardless of the cause, size, location, or complexity of the disaster. to this end, it defines concepts, principles, organizations, rules, procedures, and terminology that provide a structured framework that is flexible, applicable, comprehensive, and geographically balanced for all types of disasters. the on-scene commander of the nims directs and controls the response at the incident site, and the head of the eoc is responsible for supporting the incident site while coordinating and managing local resources from outside the incident site. the components of the nims include preparedness, communication and information management, resource management, technical support, continuous management, and maintenance. in , fema developed "state nims integration" to facilitate states to adopt the nims. the guidelines require states to develop both an "emergency operation plan" and a "procedural document." the eop is a response plan that adapts the disaster response principles and the emergency support functions specified in the nrf tailored to the situation of the state. the procedural document consists of general principles for disaster response, standard action procedures, on-site operation guides, and job aids. each standard operating procedure (sop), the instruction for carrying out esf tasks to enable the smooth support for disaster response in the field and how to carry out those disaster response tasks, contains the guiding principles listed in the esf. it can be drawn from fema's actions that the modified us disaster management system would emphasize comprehensive, integrated, and mutual cooperation among the relevant organizations and stakeholders. to solidify this new emphasis, fema announced in seven guiding principles to cope with national emergencies: comprehensive, progressive, risk-driven, integrated, collaborative, coordinated, flexible, and professional (emergency management ). describe key roles and responsibilities around the nation and structures for implementing nationwide response policy and operational coordination for all types of domestic emergency events emergency support function annexes specify the federal resources and capabilities to provide emergency support for functional areas and identify coordinator, primary agency, and support agency for each functional area support annexes describe common and basic supports to the majority of incidents: critical infrastructure and key resources support, financial management support, international coordination support, etc. describe the response methods for seven incident categories: biological, catastrophic, cyber, food and agriculture, mass evacuation, nuclear/radiological, and terrorism. the basic act for disaster management in the usa is the stafford disaster relief and emergency assistance act. it gives the state the right to request support from the federal government and the right of the federal government to supplement resources to requesting state. additionally, it gives the president the right to declare emergency or major disaster in order to provide federal assistance. the homeland security act and the post-katrina emergency management reform act are also important disaster-related laws. japan has been exposed to various natural and human-caused disasters, such as earthquake, typhoon, and hazardous material contamination. to cope with those threats, japan has developed a comprehensive disaster management system at the national and local levels. the "basic act on disaster control measures," enacted in , functions as the backbone of the disaster management system in japan. the japanese government enacted the law in the wake of typhoon vera (isewan typhoon), which caused deaths, , injures, and property damage of approximately . trillion yen. since then, the "basic act on disaster control measures" has become the foundation for carrying out all measures related to disasters including emergency countermeasures and recovery as well as the disaster prevention, and this law handles disaster prevention measures in each field comprehensively. after the great hanshin-awaji earthquake on january , , japan revised the master plan for disaster prevention completely, and the "basic act on disaster control measures" was partially revised to reflect the lessons learned from the earthquake. the great hanshin-awaji earthquake, which led to a full modification of the master plan for disaster prevention, resulted in deaths, , houses destroyed completely, and property damage of trillion yen, which accounted for . % of gross domestic product (gdp) at that time. with the occasion of several huge disasters, the disaster management system in japan has been appropriately modified so that a more systematic disaster response can be provided through central disaster prevention meetings. a central disaster prevention meeting (chairman, prime minister) consists of the prime minister, the minister of disaster prevention, related ministers, the representatives of designated public agencies, and people with knowledge and experience designated by the prime minister. this meeting carries out the preparation and implementation of a master plan for disaster prevention and emergency measure plans and the examination of important items regarding disaster prevention according to the advice of the prime minister. the fire and disaster management agency under the ministry of internal affairs and communications, which is equivalent to the central firefighting headquarters in korea, was established based on article , paragraph of the national government organization act and article of the firefighting organization act. the fire and disaster management agency under the ministry of internal affairs and communications takes charge of planning and drawing up firefighting administration procedures and policies of various laws and standards. this agency has no direct right to command firefighting at the local level but handles tasks in an adversarial, instructional, and coordination role. the general affairs and planning department (bureau) and disaster prevention sections in the general affairs division have been established to carry out cooperation and coordination tasks since the cooperation and coordination between relevant local divisions are important for disaster management. the local disaster prevention meeting is divided into prefectures and municipalities. the local crisis meeting of prefectures consists of heads of local administrative agencies, self-defense forces, and superintendents of education with the prefecture governor as the manager. the head of the municipality takes charge of the municipality local crisis meeting. these two agencies take charge of contact and coordination between relevant agencies in case of a disaster and play a role in establishing and implementing a disaster prevention plan to handle each step effectively including disaster prevention, emergency disaster measures, and disaster recovery. the local emergency organization is the local disaster relief center. the local disaster relief center is installed according to a local disaster prevention plan in case a disaster is expected or a disaster occurs. the local disaster relief center is responsible for carrying out disaster prevention and emergency disaster measures related to the relevant prefecture or municipality according to the local disaster prevention plan of the relevant prefecture or the local disaster prevention plan of the municipality. the central/local and normal times/emergency response institutions of japan are summarized in table . . the disaster management system in japan has been established into central and local disaster management systems and regular and emergency disaster management systems to enable a smooth communication among divisions. japan, where various disasters occur frequently, has established various systematic disaster response plans just as the disaster management system. the disaster response plan consists of a "master plan for disaster prevention" for the central government and a "local disaster prevention plan" for the local level. the "master plan for disaster prevention" is a comprehensive long-term plan for disaster prevention prepared by the central crisis meeting, and it is based on the basic act on disaster control measures. it is responsible for determining the comprehensive and long-term plan for disaster prevention, the key points for the disaster prevention task plan and the local disaster prevention plan, and the preparation standard for the disaster prevention task plan and the local disaster prevention plan. based on such disaster prevention plans, japan has prepared for disaster prevention in three steps including prevention, emergency measures, and recovery and redevelopment. each step contains the basic policy for disaster prevention, mutual linkage around the country between public agencies and local governments, and measures to share disaster prevention information between disaster prevention agencies and residents. the central disaster prevention plan and the local disaster prevention plan are executed identically. disaster management in australia utilizes a comprehensive and integrated approach (ema ) . each provincial and local government, in accordance with federal guidelines, establishes a disaster management act that puts forward how local disaster entities should actively and effectively prepare against regional risks. such a decentralized legal system gives each state or local government the responsibility and the flexibility to carry out disaster countermeasures tailored to the characteristics of disasters, which have occurred or are to occur in each area of australia. one of the most influential events that moved opinion for the improvement of disaster management in australia was a large-scale fire called the tasmanian bushfire that occurred on february , . this large-scale fire resulted in deaths, displaced from families, and , ha of land damaged. this fire made the australian government recognize the importance of a disaster management system at the federal level, which resulted in the establishment of the natural disaster organization (ndo) in . this organization was strengthened in due to the needs of more systematic disaster preparedness, and its name was also changed to emergency management australia (ema). currently, ema performs its duty as the standard central organization for disaster management and, based on the commonwealth government disaster response plan (comdisplan), takes charge of planning and the coordination for disaster management at the state, district, and local governmental levels in australia. disaster management in australia is divided into four levels: federal, state, district, and local. the disaster management system is handled by ema at the federal level, whereas disaster management groups (dmg) -state/district/local -manage the disaster management system at the state, district, and local levels. at the federal level, the australian government has established separate disaster management systems suitable normal times and emergency situations, respectively. the ema division in the attorney general's department carries out normal disaster management: national disaster management, planning, coordination, -h disaster status monitoring, international support, and cooperation tasks. in case of emergency situations, the federal government carries out disaster management through the australian government crisis coordination centre (ccc), an emergency center coordinating disaster responses for all line federal departments and state, district, and local governments. the state, district, and local governments in australia also have two types of disaster management systems suitable for normal times and emergency situations, respectively. during normal times, the dmg is the primary organization to deal with disaster management, particularly focusing on prevention and preparedness, which is managed by the department of the premier and cabinet (premier of state government), consisting of the premier of each state government, all state ministers, and the army commander of each state government. the dmg develops and operates disaster management plans, strategies, and policies and supports state, district, and local management groups. in case of an emergency, the manager of the dmg should appoint a disaster coordinator in advance for the cooperation and coordination between the federal government, other state governments, and relevant organizations within state governments. on the other hand, the disaster coordination centre-state/district/local (dcc) was established to handle and operate a disaster management system during emergencies more systematically. the dcc consists of divisions representing each state government, the bureau of meteorology under the federal government, the australian defense force, the australian red cross, and the australian government ) insurance parliament at the senior officer level, and is responsible for decisionmaking and coordination regarding support of resources to local, district, and state governments according to the level of the disaster situation occurrence. the disaster response plans in australia have also been separated into a federal level and a local-level disaster response plan. the disaster response plan of the federal government is the comdisplan, which specifies competent disaster organizations in the six states and seven territories of australia, and the contents and procedures for resource support and cooperation between state governments. the disaster response plan at the state, district, and local levels is called the disaster management plan (dmp) or guideline-state/district/local and consists of four parts: prevention, preparedness, response, and recovery for strategic policies to deal with disaster by delineating roles and responsibilities for each phase in disaster management. the roles and responsibilities of each department and agency are specifically described in esfs. for more specific response activities, the response phase is subdivided into four steps: alert, lean forward, stand up, and stand down. two record-breaking disasters have occurred in australia since . the black saturday bushfires that occurred on february , , resulted in large-scale forest fire damage in the southeastern region of australia. more than forest fires occurred simultaneously resulting in a more significant damage occurrence, and these forest fires resulted in deaths and forest loss of , ha (victorian bushfire reconstruction and recovery authority ). a series of floods called the queensland floods occurred in western brisbane, queensland, on december , . these floods resulted in more than dead, more than missing, and approximately , homes and businesses flooded (queensland floods commission of inquiry, ). these floods were recorded as the largest floods within years, and the continuous rain for weeks made the damage greater. the australian government is in the process of improving its disaster management system in the wake of these two catastrophic events, which is worthwhile to be monitored. according to germany's basic law, the primary responsibility for disaster management rests on local and state governments, and the federal government provides financial, human, and physical assistance to local and state governments when a large-scale disaster occurs that exceeds the capacity of the local government or the state government. in the event of a disaster beyond the capacity of the state, the state will be supported by police departments and military forces in the neighboring states. and if necessary, the state receives the support of the police department, military forces, and technical support from the federal government. the federal ministry of the interior (bmi, bundesministerium des innern) is in charge of coping with major disaster or nonmilitary crisis that require the intervention of the federal government. in particular, the federal office of civil protection and disaster assistance (bbk, bundesamt für bev€ olkerungsschutz und katastrophenhilfe), established in may under the ministry of the interior, is responsible for responding to disasters in an integrated manner through systematic cooperation with other federal, state, and local governments in the event of largescale disaster. bbk has been expanded from the federal office of administration (bundesverwaltungsamt) as the importance of civil protection has increased in germany, in the wake of the september terrorist attacks in the united states in and the floods of the elbe river in germany in august . the main responsibilities of the bbk include the development of a comprehensive civil protection plan, dissemination of emergency information to citizens in crisis situations, critical infrastructure protection, and education and training for civil defense. the joint situation and information center (gmlz, gemeinsames melde-und lagezentrum von bund und ländern) in the bbk is responsible for monitoring disaster situations, disseminating disaster information, and international requests for help. when a large-scale disaster occurs in germany, the federal ministry of home affairs calls up the crisis task force (krisenstab). the task force works jointly with relevant departments within the federal government, agencies under the ministry of interior, and state liaison officers. in the event of a major type of catastrophic event that can be a national crisis, the ministry of interior will form the joint task force with responsible ministries. for example, if a nuclear accident or an illegal use of radioactive materials happens, the bmi and the federal ministry for the environment, nature conservation, building and nuclear safety (bmub, bundesministerium für umwelt, naturschutz, bau und reaktorsicherheit) will form the joint crisis management task force. when pandemics or biochemical terrorism occurs, the bmi and the federal ministry of health (bmg, bundesministerium für gesundheit) will form the joint task force. the german local system consists of the state (länder) government, the city or county (kreis) government, and the municipal government (gemeinde). disaster management organizations in germany's local system are different depending on the characteristics of each region; however, departments dealing with internal affairs mostly take charge of disaster management. in recent years, there have also been a growing number of states establishing disaster risk protection departments (gefahrenabwehr) by experiencing increased terrorism and massive natural disasters due to climate change. the central/local and normal times/emergency institutions of germany are summarized in table . . each state government develops and operates its own disaster response plan. for example, hessen is the state government that has the disaster response plan under the title of katastrophenschutzpläne (emergency plans). katastrophenschutzpläne (emergency plans) of hessen specifies the contents regarding necessary information in the event of disaster and means to be used. also, in case of a very severe disaster such as nuclear risk that targets a specific object, it is required to establish and operate sonderschutzpläne (special protection plans) separately. figure . shows the katastrophenschutzpläne (emergency plans) in hessen, germany, and it shows the contents regarding the sonderschutzpläne (special protection plans). the english translation of fig. . is: § disaster protection plans the disaster protection plans shall contain, in particular, the necessary information on the emergency aid, the alarm, and the means of assistance available in a disaster. they must be coordinated with the neighboring disaster control authorities. special protection plans are to be drawn up for special dangers. the uk, based on the tradition of local autonomy and accountability of citizen and local governments, utilizes a bottom-up disaster management system. in , the cabinet office, a guide to emergency response and recovery was released with eight core principles: anticipation, preparedness, subsidiarity, direction, information, integration, cooperation, and continuity (cabinet office a). the basic act for disaster management in the uk is the civil contingencies act (cca), . the uk has developed its disaster management system suitable for normal times and emergency situations at the federal and at the local levels (korean association for local government studies ) . at the federal level, the civil contingencies secretariat (ccs) was established in to take charge of the overall coordination of disaster management during normal times, whereas the cabinet office briefing room (cobr) and the civil contingencies committee (ccc) take charge of disaster response in case of emergency situations. the ccs is headed by the permanent secretary, vice-minister level official in the cabinet office, and it takes overall responsibility for disaster management in the uk. if needed, the minister of the home office (or the cabinet office) reports to the national assembly for sharing emergency information or hearings after hit by disaster. the ccs carries out the emergency response tasks including anti-terrorism and disaster restoration tasks and is responsible for identifying and making preparations for a crisis during an emergency situation. the cobr and the ccc are activated for the federal government to act when catastrophic events occur. the activation process and procedures are decided depending on the level of emergency, specifically at level and level ; and at . disaster theories and progress of disaster management in modern times level , the responsible minister takes the leading role as chairman, and at level , the prime minister serves as chairman. table . shows the three levels for disaster response, in which the roles and responsibilities of each agency at the federal and the local levels are delineated differently. the cobr and the ccc focus on cooperation between the federal and local governments and support tasks rather than command and control. also, highranking officials can participate in the cobr, receiving and processing a report of situation, for prompt disaster management. figure . shows the block diagram of cobr. the cca categorizes agencies for disaster response into two categories according to their roles and duties with different obligations. the category responders are the agencies that have priority for response. the category responders consist of police services, fire and rescue services, health bodies, maritime and coastguard agency, local authorities, and environment agency. the police normally control and coordinate the activities at and around the scene. there are, however, exceptions, for example, the fire and rescue service takes the responsibility at the scene of a major fire. category responders consist of a wide range of private sector bodies that have an important role, but not routinely involved in the core of multi-agency emergency response and recovery work. utilities, telecommunications and transport providers, highways agency, strategic health authorities, and health and safety executives are included in the category responders. a local resilience forum (lrf) is a private and public joint organization of local governments, military officials, corporations, and civic groups that analyzes risk factors and establishes the risk management plan. the main aim of the lrf is to assist multi-agency and multi-sectoral cooperation. the lrf has regular meetings at least once every months to strengthen regional resilience, and category responders should participate in the meetings. the lrf is not a legal entity, nor does the lrf have powers to direct its members. nevertheless, the cca and the regulations provide that responders, through the forum, have a collective responsibility to plan, prepare, and communicate in a multi-agency environment. the police serve as chairman for the lrf, and a manager is assigned to each of the areas classified according to the police administrative district. a regional resilience forum (rrf) is a high-level organization of the lrf to coordinate plans for large-scale emergencies that are difficult to handle locally and to coordinate with the central government. the rrf divides areas into local units, and a table . disaster step as the standard of disaster management system in the uk ((cabinet office, b)) step disaster support system by step step (significant) the competent agency provides supports and cooperation at central government level step (serious) the national crisis committee is organized with the competent minister as the chairman step (catastrophic) the national crisis committee is organized with the prime minister as the chairman local government office is located in each local unit, and the regional director of government offices serves as chairman. the strategic coordinating group (scg) and the regional civil contingencies committee (rccc) are local emergency organizations for coordinating multiagency cooperation. the scg is a type of accident response and recovery center consisting of government branches, military, police, fire, hospitals, and private local committees in the relevant area at the local level for accident response, and all government officials dispatched to the jurisdiction of the central government are under the direction and control of the local director. the rccc is established when an emergency crisis exceeds the local level, and its composition and system are similar with the rrf. the disaster management in the uk is shown in table . . the disaster response plan in the uk is also operated separately into national and local disaster response plans. the national disaster response plan in the uk is carried out through the national contingency plan (ncp). the ncp describes initial response, accident response, responsibility and compensation, role and responsibility of central government, international support, and cooperation for each type of disaster, and it becomes the foundation for the disaster plan of the central government. the uk has also prepared a disaster response plan for flood under the ncp since flood occurs frequently, which is the guidance for accessing specialist flood rescue mutual aid. the guidance for accessing specialist flood rescue mutual aid specifies the strategic approach of the government for preparing for and responding to a flood, and it is responsible for providing comprehensive emergency response guidelines to all flood rescue service providers including public and private volunteer organizations including the utilization of existing and future flood relief assets. also, the guidance for accessing specialist flood rescue mutual aid presents the role and responsibility for each agency regarding floods as well as the action procedure (sop) to enable prompt response in case of a flood. the local disaster response plan in the uk is carried out through the strategic emergency plan (sep). the purpose of the sep is to present the direction of regional response activities and methods, through which the disaster response strategy and disaster response plan of each cooperation organization is prepared. the sep is managed through the lrf organized in each area, and the lrf is responsible for developing a more detailed implementation plan on the basis of what was given by rrf. in switzerland, cantons and communes have the authority and responsibility for disaster response, and the federal government intervenes only in the event of a national crisis. particularly, switzerland has a disaster management system based on a close cooperation among the federal, state, and local governments, a proactive role of the military in disaster response, and a strong civil defense system. the basic act of disaster management in switzerland is the federal civil protection and civil defence act (bzg, bundesgesetz über den bev€ olkerungsschutz und den zivilschutz). at the federal level, the federal office for civil protection (babs, bundesamt für bev€ olkerungsschutz) under the federal department for defense, civil protection and sport (vbs, eidgen€ ossisches departement für verteidigung, bev€ olkerungsschutz und sport) is responsible for disaster management. under babs, national alarm center (naz, nationale alarmzentrale) operates h all around the year in order to monitor situations, disseminate disaster information, and respond to disasters when necessary. since its establishment in , naz has designated radioactivity, chemical accidents, and the collapse of bridges due to a natural disaster as major disasters, making preparations for such disasters, and naz has also established the linkage system between major facilities and competent authorities to judge the situation in case of a disaster. the office for civil protection, sport, and military (bsm, amt für bev€ olkerungsschutz, sport und militär) takes charge of the normal-time disaster . rccc (regional civil contingencies committee) . lrf (local resilience forum) . scg (strategic coordinating group) management system at the local level. bsm is divided into four departments, and the department related to disaster management is included in the citizen and nation protection division. the manager of bsm changes according to the conditions of the state government. the five local-level emergency services utilize an "integrated system" (verbundsystem) which allows for an autonomous or a cooperative response, depending on the severity of the situation. in an extended or severe disaster situation, any of the police, fire brigades, health and ambulance services, technical agencies, or civil defense organizations can partner up to handle the crisis; this can be done at the communal or at the cantonal level. additionally, based on federal government guidelines, which includes the basic principle of disaster management and civil defense, the physical plan for disaster response, and the technical and structural countermeasures, state and local governments develop and manage their own disaster response plan. for planning and preventative measures for natural hazards, the five civil-security agencies follow the national platform for natural hazards (planat) guidelines. the swiss civil-security agencies, basing their planning activities on "risk-based planning" and "integral risk management," have developed common prioritization procedural guidelines (riko) and an online tool (econome). the guideline and the online tool, based on "protection objectives" (schutzziele), are also designed to keep natural hazard management projects cost-effective. when it comes to implementing a project, the babs have developed a tool (kataplan) to identify and classify various risks and the planning of response measures by cantonal agencies. the babs have also developed a learning program (lernrisk) and assessment software (riskplan) (babs ; bfu and babs ) . until now, we have described the disaster management system in six countries. table . shows the national and local disaster management organizations during normal time and emergency situations. social advancements in contemporary society beget new techniques and technologies. thus, new risks due to the application of the new technologies are continually springing up, and difficulties predicting uncertainties increase in parallel with new risks. furthermore, due to the development of information technology, the rise of interdependence increases propagation or chain properties to expand continuity in type, range, and scope (oh ) . the contemporary society can be featured with a change in natural environment such as climate change, socioeconomic environmental change such as aging, urbanization, and polarization, international environmental change such as each country being networked, and an entrance of complexity which indicates characters such as emergence, self-organization, and adaptation. due to these changes in environment, the contemporary society can be represented as increase of complex general set up the strategic objective for national safety, crisis management, and disaster relief and established the comprehensive drm system. in summary, most developed countries are in the process of shifting from a top-down, fragmented, and hazard-oriented disaster risk management approach into a comprehensive, integrated, and human-centered approach. while this is happening, special attention is being paid to "low probability and high impact" focusing events that are located in the long tail of the power-law distribution. symbolic and practical interpretations of the hurricane katrina disaster hazard mitigation and preparedness babs ( ) leitfaden kataplan: kantonale gefährdungsanalyse und vorsorge bfu and babs ( ) pragmatisches risikomanagement mit riskplan online risikogesellschaft: auf dem weg in eine andere moderne. frankfurt am main, suhrkamp beck u ( ) world risk society cabinet office ( b) responding to emergencies the uk central government response concept of operations disaster data: a balanced perspective national incident management system dhs ( ) threat and hazard identification and risk assessment guide: comprehensive preparedness guide again and again: is a disaster what we call a "disaster? emergent phenomena and the sociology of disaster: lessons, trends, and opportunities from the research literature principles of emergency management supplement emergency management australia (ema) ( ) emergency management in australia: concepts and principles disaster theory: an interdisciplinary approach to concepts and causes disaster relief and emergency assistance act, as amended, and related authorities fema ( ) national response framework: third edition fritz ce ( ) disaster and community theory introduction to emergency management, th edn hessisches gesetz über den brandschutz, die allgemeine hilfe und den katastrophenschutz national comprehensive crisis management: theory and reality research on effective disaster relief planning disaster classification for optimal disaster response in korea economic loss due to thailand flood in and policy implications to korea business korean association for local government studies ( ) a study on the comparison of disaster and safety management system in major advanced countries study on the change of risk structure in korea and its social and cultural effect a terminological and etymological study about safety damage situation in thailand big flood and implications for korean companies building an integrated emergency management system in korea introduction of disaster prevention. donghwa tech, hwaseong-si mcloughlin d ( ) a framework for integrated emergency management the network governance of crisis response: case studies of incident command system standard crisis management manual munich re ( ) natcatservice, global distribution of insurance premiums per capita crisis management system in korea: focusing on nuclear power plant and oil transportation the role of u. s. military forces and its implication for the korean military during disaster management natural disaster and development in a globalizing world. routledge, london perrow c ( ) normal accidents: living with high risk technologies what is a disaster? the need for clarification in definition and conceptualization in research technological and natural disasters and ecological problems: similarities and differences in planning for and managing them queensland disaster management arrangements public administration: understanding management, politics, and law in the public sector victorian bushfire reconstruction and recovery authority ( ) victorian bushfire reconstruction and recovery authority day report living with hazards, dealing with disasters: an introduction to emergency management collaboration and leadership for effective emergency management oecd studies in risk management: innovation in country risk management most developed countries have put stress on developing an effective disaster response system to cope with emerging risk interwoven with complexity and climate change. the policy implications through the comparative analysis can be summarized as follows:first, many countries aim for an integrated organization that considers both natural disasters and social disasters. the usa has endeavored to build an integrated disaster management system through the establishment of fema, and since the / terror attack, the dhs has been integrated to take charge of disaster management and terrorism. the dhs set the national preparedness goal to reflect the insights and lessons learned from hurricane katrina and to build a comprehensive organizational capacity for the entire nation that includes federal, state, and local governments and the private sector.japan and the uk have an organization that control and coordinate disaster and emergency response directly under the prime minister. the cca of uk and the cabinet office of japan are both small in size, but they are characterized by a very high level of authority for the overall coordination of disaster policies. according to the types in the reorganization of disaster management proposed by the organization for economic cooperation and development (oecd), the case of the usa corresponds to the first case, "super-ministry," and japan and the uk correspond to the second type, "a relatively small and highly influential body under direct authority of the head of government" (wyman ). disaster response plans are also being developed within national and local governments using an integrated disaster management style for all hazards approaches (waugh ) .second, all stakeholder engagement for disaster response is highly recommended. the usa successfully established the disaster risk management system by promoting the engagement and commitment of all levels of governments, citizens, and ngos. australia and japan also developed standard operating procedures indicating citizenry roles and activities in case of emergencies. in addition, australia developed checklists to enhance citizenry participation for disaster preparedness. japan has enhanced citizenry participation and preparedness by strengthening citizenry education and training. korea should improve the participation of local governments, ngos, and citizens to drm by providing guidelines and incentives and enhancing the governance-based approach.finally, many countries have stressed the clear accountability of each government and interlink between the national government and local governments. most countries, such as australia, germany, japan, and the usa, empowered local governments for disaster response and engaged in the national crisis situation. in addition, the interlink between national and local disaster response planning was also emphasized. the usa improved interlink between nrf and nims at the federal level and eop at the state and local levels. in australia, the attorney key: cord- -civfvk authors: su, tong; han, xue; chen, fei; du, yan; zhang, hongwei; yin, jianhua; tan, xiaojie; chang, wenjun; ding, yibo; han, yifang; cao, guangwen title: knowledge levels and training needs of disaster medicine among health professionals, medical students, and local residents in shanghai, china date: - - journal: plos one doi: . /journal.pone. sha: doc_id: cord_uid: civfvk background: disaster is a serious public health issue. health professionals and community residents are main players in disaster responses but their knowledge levels of disaster medicine are not readily available. this study aimed to evaluate knowledge levels and training needs of disaster medicine among potential disaster responders and presented a necessity to popularize disaster medicine education. methods: a self-reporting questionnaire survey on knowledge level and training needs of disaster medicine was conducted in shanghai, china, in . a total of randomly selected health professionals, medical students, and , local residents provided intact information. the total response rate was . %. results: overall, . % of these participants have received systematic disaster medicine training. news media ( . %) was the most common channel to acquire disaster medicine knowledge. although health professionals were more knowledgeable than community residents, their knowledge structure of disaster medicine was not intact. medical teachers were more knowledgeable than medical practitioners and health administrators (p = . ). clinicians performed better than public health physicians (p< . ), whereas public health students performed better than clinical medical students (p< . ). in community residents, education background significantly affected the knowledge level on disaster medicine (p< . ). training needs of disaster medicine were generally high among the surveyed. ‘lecture’ and ‘practical training’ were preferred teaching methods. the selected key and interested contents on disaster medicine training were similar between health professionals and medical students, while the priorities chosen by local residents were quite different from health professionals and medical students (p< . ). conclusions: traditional clinical-oriented medical education might lead to a huge gap between the knowledge level on disaster medicine and the current needs of disaster preparedness. continuing medical education and public education plans on disaster medicine via media should be practice-oriented, and selectively applied to different populations and take the knowledge levels and training needs into consideration. over the past decade, the intensity and frequency of natural and man-made disasters have been noticeably increasing all over the world. hurricane, earthquake, flood, outbreaks of infectious diseases, nuclear leakage, oil spills, and other disasters in recent years have caused huge economic losses, serious environmental disruption and lasting psychological impairment to the survivors [ ] [ ] [ ] [ ] [ ] . community residents are the very ones directly affected by disasters. therefore, self-rescue and mutual-aid are essential to form the first defense line. disaster relief and assistance are mainly carried out by medical rescue teams, which are constituted of health professionals from on-call health agencies such as military medical systems and centers for disease control and prevention (cdc) [ ] . hence, community residents and health professionals as the key components of first responders should be sufficiently trained to perform timely and effective medical rescue [ ] . disaster medicine training, an integrated part of efficient disaster preparedness, is vital for community residents to perform timely self-rescue and mutual-aid and also for health professionals to develop comprehensive skills [ ] . since the ' . terrorist attack, many countries have put emphasis on disaster medicine training and have sponsored various researches focusing on a wide range of disaster medicine, including description and assessment of the current disaster medicine training programs in order to improve the efficiency of disaster rescue. however, these researches on disaster medicine have mainly been conducted in developed countries, while data from developing countries are scarce [ ] [ ] [ ] [ ] [ ] [ ] . from a global perspective, disaster frequently attacks developing countries with weak public health infrastructure and often results in severe consequences. in china, the severe acute respiratory syndrome (sars) in - resulted in , cases and deaths [ ] . the devastating earthquake in sichuan, china, in caused more than , deaths, , missing and , wounded persons [ ] . however, disaster medicine has not been included either in the undergraduate curriculum of medical schools or in the continuing medical education in china. in the past decades, chinese medical education system has experienced flexuous reforms [ ] [ ] [ ] . traditional medical education and assessment criteria have been largely clinically oriented, while disaster medicine has been long neglected [ ] . recently, efforts have been made to implement disaster medicine education in china. the current program of disaster medicine education focuses on developing particular small scale training programs, such as short-term training course of disaster nursing for undergraduates, psychosocial training program for mental health workers, and emergency preparedness training program for public health staff [ ] [ ] [ ] [ ] . however, current knowledge status and training needs of main players on disaster medicine were unknown. to the best of our knowledge, only one study surveyed the disaster medicine education needs of health professionals who participated in the earthquake rescue, but their related knowledge was not evaluated [ ] . in this study, we evaluated the knowledge levels and training needs in populations that are most likely to be involved in disaster rescue. these data are essential in developing proper medical training programs of disaster medicine. three groups of participants in shanghai, china, were enrolled in this cross-sectional epidemiological study: health professionals, medical students, and community residents. a stratified cluster random sampling strategy was used to select health professionals and medical students. a total of health professionals were composed of medical practitioners, medical teachers, and health administrators. the medical practitioners were clinicians, public health physicians, nurses, and medical technicians from two comprehensive tertiary hospitals and three cdcs. the medical teachers and medical students were selected from medical schools. health administrators were from the municipal health bureau and district health bureaus. a multi-stage sampling method was used to select , community residents. we first randomly selected communities in the yangpu district. in each community, we randomly selected , , , , and residents ( residents per community) at the age of , years, - years, - years, - years, - years and . years, respectively, according to the census data of age composition in shanghai. a structured questionnaire for health professionals/medical students was designed by three investigators (ts, hz, and gc) based on the university examination data bank of emergency medicine, preventive medicine, and health management, as well as published literatures [ , ] . after two rounds of discussion among the investigators and three rounds of discussion with external experts, final version of the questionnaire was made of three sections. the first section included demographic information such as age, gender, educational level, medical profession, and disaster rescue experience. the second section contained multiple-choice questions (q -q ) as a knowledge test covering various aspects of disaster medicine. in this section, participants could get one score for each correctly answered question and zero for an incorrect answer. the full score was . the third section had multiple-choice questions regarding the training needs of disaster medicine. the first questionnaire is presented as questionnaire s . based on this questionnaire, we designed the second questionnaire for community residents (questionnaire s ). the second questionnaire had multiple-choice questions (q -q ) as a knowledge test. eight questions were included in both questionnaires due to their importance in disaster medicine (table s ) . before each survey, trained research assistants would give detailed instructions. the participants were then asked to finish the questionnaire independently. informed consent was initially distributed to every candidate study subjects to help them make a fully voluntary decision on participating or declining. participants who provided their written informed consent were included in this study. the study protocol conformed to the declaration of helsinki and was approved by the ethics committee of second military medical university. descriptive statistics were conducted for demographic characteristics. differences in categorical variables were determined using the chi-square test. analysis of variance (anova) was used to compare the total scores on average among different participants. student-newman-keuls (snk) test was used to correct for multiple comparisons. multivariate linear regression was used to analyze the factors contributing independently to the knowledge score. a beta coefficient was calculated to indicate the effect of each independent variable on the score. all tests were two-sided and conducted using spss version . (spss, chicago, il). a p value of , . was defined as statistically significant. a total of ( . %) health professionals, ( . %) medical students, and , ( . %) community residents provided complete information. of the , participants, , ( . %) were men and , ( . %) were younger than years. table shows the demographic characteristics. most of the health professionals had a bachelor's degree or higher in contrast to community residents ( . % vs. . %). health professionals were composed of ( . %) medical practitioners, ( . %) medical teachers, and ( . %) health administrators. of the medical practitioners, were clinicians, were public health physicians, were nurses and the remaining were medical technicians. the professional titles of health professionals were research assistant ( . %), senior research assistant ( . %), assistant professor ( . %), associate professor ( . %), and full professor ( . %). of medical students, ( . %) majored in clinical medicine and ( . %) majored in public health. among community residents, . % had no stable employment or retired. of all participants, ( . %) had disaster relief experience and ( . %) had ever received systematic training of disaster medicine. for all , participants, most of them ( . %) had low or moderate self-estimated knowledge concerning disaster medicine, and media (newspaper, magazine, internet, and tv/radio) was the most common channel to acquire knowledge on disaster medicine. table depicts the correct answer rates to the questions (q -q ) in the knowledge test using the first questionnaire. the questions were correctly answered by . % of the professionals and students except q , q , and q . average total score of the knowledge test was . ( % ci = . - . ) for health professionals and . ( . - . ) for medical students (p = . ) ( figure a ). although the score of the two populations was not significantly different, there were significant differences in correctly answering individual questions: q , q , q , q , and q ( figure a ). in health professionals, the score was . ( . - . ), . ( . - . ), and . ( . - . ) for medical practitioners, medical teachers, and health administrators, respectively (p = . for the comparison of three groups) ( figure b ). for pairwise comparison, snk test showed that medical teachers' average score was significantly higher than medical practitioners' (p = . ) and health administrators' (p = . ), while there was no statistically significant difference between medical practitioners and health administrators (p. . ). the rates of correctly answering questions (q , q , q , q , q , q , q , q , and q ) were significantly different among medical practitioners, medical teachers, and health administrators (p, . ) ( table ) . for example, in answering q , medical teachers did better than medical practitioners (p = . ) and health administrators (p, . ). moreover, the knowledge level was also significantly different among clinicians, public health physicians, nurses, and medical technicians, especially in correctly answering questions (table s ) . clinicians performed better than public health physicians (p, . ) ( figure s ). in medical students, the score in public health students ( . , % ci = . - . ) was higher than that in clinical medicine students ( . , . - . ) (p, . ) ( figure c ). the rates of correctly answering questions (q , q , q , q , q , q , q , and q ) were significantly different between the students of majors (p, . ) ( table ) . table shows the rate of right responses to the questions (q -q ) in community residents. the questions were correctly answered by . % of community residents except q and q . after stratified by educational level, the score of well-educated (bachelor or higher) group ( . , . - . ) was significantly higher than that of poor-educated (junior college or lower) group ( . , . - . ) (p, . ) ( figure d ). the rates of correct answers to questions (q , q , q , q , q , q , and q ) were significantly different between the two groups (p, . ). we compared the rates of correctly answering the common questions in both questionnaires (table s ) between health professionals and community residents. the rates were generally figure . comparison of the total score on average of disaster medicine knowledge test. a. health professionals and medical students: no significant difference (p = . ); b. three groups of health professionals: total score on average of medical teachers was significantly higher than that of medical practitioners (p = . ) and health administrators (p = . ); c. medical students of two majors: total score on average of public health students was significantly higher than clinical medicine students (p, . ). d. community residents of different educational levels: total score on average of those with high education background was significantly higher than those without (p, . ). doi: . /journal.pone. .g lower in community residents than in health professionals ( . % vs. . %) except q ( figure b ). multivariate linear regression analysis indicated that educational level (b = . , p, . ) and professional title (b = . , p = . ) were significantly associated with an increased knowledge score, whereas age was inversely related to the score (b = . , p, . ), in health professionals. educational level was the unique factor significantly associated with an increased score in community residents (b = . , p = . ). public health major was the factor significantly associated with an increased score in medical students (b = . , p = . ). a. health professionals vs. medical students: p, . for q 'self-rescue measures in an earthquake', q 'triage and treatment priority', q 'concept of first aid abc', q 'tourniquet hemostasis', and q 'skills of psychological assistance in post-disaster relief'; b. health professionals vs. community residents: p, . for q 'cardiopulmonary resuscitation procedure', q 'difference between remote and urban rescue', q 'self-rescue measures in an earthquake', q 'location of temporary toilets during disaster rescue', q 'skills of psychological assistance in post-disaster relief', and q 'epidemic prevention strategies after a disaster' and p, . for q 'fracture fixation and transport' and q 'self-rescue measures in a high-rise fire'. doi: . /journal.pone. .g table depicts the training needs of health professionals and medical students. the overall opinions on teaching method, course arrangement, and teaching material were consistent among the two groups. more than half of these participants selected 'lecture', 'practical training', and 'disaster movies or videos' as preferred teaching methods. most participants chose 'required course for public health professional' as the major training course, and preferred using 'national unified textbook' as standard teaching material. however, medical teachers considered that 'practical training' and 'disaster movies or videos' were not appropriate for teaching disaster medicine, in contrast to medical practitioners and health administrators. most health administrators believed that disaster medicine training should be a required training subject not only for public health professionals but also for clinicians. table shows disaster medicine training needs of community residents. the majority ( . %) selected 'need to learn disaster medicine' and 'need of disaster medicine course for children'. about half of community residents selected 'lecture' and 'practical training' as preferred teaching methods. more than % of community residents selected 'willing to participate in disaster simulation drill regularly' and believed that 'community volunteer team for disaster relief should be set up and willing to participate volunteer team'. compared to community residents with lower educational level, those with higher education background considered that 'systemic study' was more appropriate for teaching ( . % vs. . %, p, . ). figure presents the key contents concerning disaster medicine training prioritized by health professionals, medical students, and community residents. more than % of health professionals and medical students selected the contents of 'first aid skills', 'epidemic prevention and control', 'psychological problems in post-disaster relief', and 'principles of disaster disposal' as important contents; while most community residents chose 'first aid skills' and 'basic concepts of disaster medicine' as important contents. significant differences existed among subgroups within each group of participants. for example, compared to medical practitioners, medical teachers considered that 'triage and evacuation' was less important ( . % vs. . %, p = . ) (table s ) . twenty-five items covering most aspects of disaster medicine were provided for the selection of interested training contents (table s ). figure presents the most interested contents of disaster medicine training prioritized by health professionals, medical students, and community residents. health professionals selected 'basic principles of disaster rescue' ( . %), 'treatment principles and first-aid skills' ( . %), and 'psychological relief' ( . %) as the most interested contents, while community residents selected 'basic principles of disaster rescue' ( . %) and specific disaster events such as 'earthquakes' ( . %) and 'fire disaster' ( . %). in this study, we evaluated the current knowledge levels and training needs of disaster medicine among health professionals, medical students, and community residents in shanghai, china. in general, our results reflected a high vulnerability of our populations when facing disaster. the knowledge level of disaster medicine was not satisfactory in health professionals except medical teachers. although the majority of the health professionals received formal medical education, few of them have ever received systematic training of disaster medicine (table ) . for health professionals and medical students, less accurate responses to q , q , and q (table ) indicate the low levels of knowledge on disaster psychology and disaster administration. the two components have been long neglected and should be added to disaster medicine training and specially addressed to these involved in psychological relief and administrative tasks. lack of knowledge regarding ptsd is an issue needs to be particularly addressed. because of the cultural perception in the chinese society, psychological health hasn't been widely accepted as a critical component in traditional medical and public health education. even though there is a rising awareness of its indispensible importance in recent years [ ] , relevant educational program and public health campaign are still lagging behind. in health professionals, the significant differences among different professions ( figure ) were mainly presented in their answers to the questions covering aspects: self-help and first-aid skills, triage and evacuation, psychological relief, and population vulnerability assessment. health administrators did not show their proficiency in disaster administration and disaster rescue organization, for they poorly answered the related questions such as q . leadership training programs could effectively improve the emergencyhandling capability of health administrators who might be involved in disaster rescue [ , ] . moreover, there were significant differences in knowledge levels among specialties (clinicians, public health physicians, nurses, and medical technicians) of medical practitioners. clinicians showed higher knowl- table . training needs of community residents and their differences between the educational level groups (number, %). edge level than other specialties, even on the aspect of epidemic prevention and control (table s and figure s ), which is one of the major tasks of public health physicians. the differences in the knowledge level indicate that the medical education in china had been largely clinically oriented; and little attention has been paid to public health preparedness, especially disaster preparedness. future training plans should clearly define the roles of public health physicians and health administrators in disaster rescue and enhance their capabilities to meet up-to-date requirements [ ] . the main reason of the lack of disaster medicine knowledge for health professionals might be that disaster medicine has rarely been included in medical school curriculum and continuing medical education, and no appropriate public health programs focusing on disaster preparedness. surprisingly, public health students showed a higher knowledge level than clinical medicine students (p, . ) ( figure c ). after the sars outbreak, the importance of public health preparedness has been emphasized with a curriculum restructure for public health major students. in addition to the traditional courses such as epidemiology, training programs for public health preparedness such as health management has been added as the main courses for public health major in some medical schools. however, disaster medicine is being developed as a training course in only a couple of medical schools in china. our results indicate that future public health physicians are expected to perform better in disaster rescue. interestingly, the knowledge level of health professionals was inversely related to age, which is in contrast to the general belief that older professionals have more experiences and therefore more knowledgeable. one possible explanation is that the young are more likely to have frequent access to modern media such as the internet and thus gain 'exposure' to updated information on disaster medicine. community residents displayed very poor knowledge and skills of disaster medicine. not surprisingly, community residents generally lacked specialty knowledge such as 'cardiopulmonary resuscitation procedure' and 'difference between remote and urban rescue' (table and figure b ). an important finding is that community residents with higher education background had higher knowledge level of disaster medicine than those without ( figure d ). thus, it is urgent to tailor community training programs for the residents with different education background and popularize disaster medicine education via modern media. this study also pointed out the training needs of disaster medicine. most participants selected 'lecture' and 'practical training' as preferred teaching methods. most health professionals and medical students suggested that disaster medicine should be a 'required course for public health professional' and asked for a 'national unified textbook' as standardized teaching material. most community residents believed 'need to learn disaster medicine' and 'need of disaster medicine course for children', and selected 'willing to participate in disaster simulation drill regularly' and 'community volunteer team for disaster relief should be set up, and willing to participate volunteer team' (table , table ). these results indicate that the training needs of disaster medicine is very high in chinese society and disaster medicine trainings should be executed as indispensable courses for health professionals, medical students, and community residents. meanwhile, the three groups of participants selected some different key and interested contents for disaster medicine training (figure and figure ). this reflects that distinct perception of disaster determines the different needs of disaster medicine training in different populations. similar differences in several items of the training needs were also presented among the subgroups of study participants. training programs such as disaster simulation and disaster exercise have proven to be effective and can rapidly deliver core elements of disaster medicine and improve the knowledge level and ability of disaster response [ , , ] . therefore, future continuing disaster medicine education should focus on developing practice-oriented and core elements-highlighted training courses. except the high-level interests in 'basic principles of disaster relief', there were some differences of interested contents among different populations, indicating future training program design should consider both core elements and interests, and customize to different needs. as medical teachers were more knowledgeable in disaster medicine than other populations surveyed ( figure b) , they should play a leading role in disaster medicine training. based on these data, we suggest a diagram flow of disaster medicine training as the shanghai model in figure s . the present survey was conducted in shanghai, one of the areas with well developed economy and affluent medical resources in china. after further evaluation, the shanghai model of disaster medicine training suggested in this study should be validated and generalizable to other developing areas where the problem of unmatched economic development and disaster medicine education also exist. these data also provide useful evidence to help developing disaster medicine training plans in other developing world. the current study had limitations. our community participants were from one district (yangpu) in shanghai chosen by cluster sampling. sample sizes may influence results if comparing subgroups within clusters. furthermore, other groups of disaster first responders such as firefighters and military personnel were not included in the current survey. future studies focusing on these special groups will provide valuable information for disaster preparedness. in conclusion, this large epidemiological study provided important data concerning knowledge level and training needs among the populations that would be involved in disaster rescue or affected by disasters. from a health education perspective, disaster training programs are urgently needed, with specific emphasis on certain contents, such as psychological relief and administrative skills. our study enables a more comprehensive evaluation of current disaster preparedness situation and facilitates designing future disaster medicine training programs in china and other developing countries. figure s comparisons of the total scores on average and rates of correctly answering important questions among clinicians, public health physicians, nurses, and medical technicians. a. comparison of average scores; b. comparison of correct answer rates. (tif) figure s suggested diagram of disaster medicine training (shanghai model). table s list of the same questions in two questionnaires. (doc) questionnaire s questionnaire for health professionals and medical students. questionnaire s questionnaire for community residents. 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flores-haro, genevieve; zucker, lucas title: the (in)visible victims of disaster: understanding the vulnerability of undocumented latino/a and indigenous immigrants date: - - journal: geoforum doi: . /j.geoforum. . . sha: doc_id: cord_uid: lcmsg r as climate change advances, communities across the united states are adapting to the increased threat of wildfires, drought, heatwaves, and infectious diseases. such disasters are expected to become more frequent and severe. now more than ever, it is crucial to understand how these events amplify existing inequalities, and how to lessen the resulting harms. differences in human vulnerability to disaster stem from a range of social, economic, historical, and political factors. we argue that given their social status, undocumented latino/a and indigenous immigrants are particularly vulnerable to disasters and require special consideration in disaster planning. they are disproportionately affected by racial discrimination, exploitation, economic hardships, less english and spanish proficiency, and fear of deportation in their everyday lives— their pre-disaster marginalized status. in the case of the thomas fire in california's ventura and santa barbara counties, we show that emergency response and recovery efforts ignored their needs. resources were directed toward privileged individuals, leaving local immigrant rights and environmental justice groups to provide essential services such as language access to emergency information in spanish and indigenous tongues; labor protections for farmworkers endangered in the fields; and a private disaster relief fund for undocumented immigrants ineligible for federal aid. the article concludes with preliminary participant observations from the covid- pandemic response in the region, indicating how lessons from the fire have informed official actions. as governments grapple with the increasing severity of disasters, understanding the differential impacts on undocumented immigrants can help improve disaster planning to protect the most vulnerable and stigmatized populations. on december , , the thomas fire started north of the city of santa paula in ventura county, california. it grew quickly to nearly , acres ( square miles), spreading into santa barbara county in less than hours. the fire lasted over days, destroying structures, resulting in massive blackouts, forcing more than , residents to evacuate, and causing over $ . billion in damage (climate signals, ) . its explosive growth was driven by a combination of climate-related factors, including dry foliage, low humidity, and intense santa ana winds that gusted up to miles per hour. at the time of final containment on january , , the thomas fire would be classified as the second largest wildfire in california history. more than firefighting personnel were assigned to it -one of the biggest forces ever assembled for fire suppression in the state (vercammen et al., ; fovell and gallagher, ; cal fire, ; etehad and mejia, ) . media outlets across the country reported on the loss of hillside mansions and impacts to wealthy homeowners and farmers (hersko, ; yam, ) . the thomas fire, however, also endangered the health and livelihoods of thousands of undocumented latino/a and indigenous immigrants. california is home to an estimated . million undocumented immigrants, many of whom are farmworkers or are employed in service jobs such as housekeeping and landscaping. in ventura and santa barbara counties, undocumented individuals are estimated to account for more than percent of the population or , people (hayes and hill, ) . the thomas fire exposed how emergency response and recovery efforts ignored their needs. resources were directed toward wealthy individuals, leaving local immigrant rights and environmental justice groups to provide essential services such as language access to emergency information in spanish and indigenous tongues; labor protections for farmworkers threatened by heavy smoke; and a private disaster relief fund for undocumented immigrants ineligible for federal aid. undocumented immigrants (particularly indigenous individuals) usually experience socioeconomic precarity; the wildfire intensified their already difficult situation (boyd-barret, ; van eerten, ; limon, ) . using the case study of the thomas fire, we argue that given their pre-disaster marginalized status, undocumented latino/a and indigenous immigrants require special consideration in disaster planning. their differential vulnerability to disaster is mainly a consequence of structural inequality (farmer et al., ; nixon, ) . within a given area, these inequalities intersect along the lines of race, gender, indigeneity, immigration status, health care access, and income (crenshaw, ; davies et al., ) . as governments attempt to address the increasing severity of wildfires, understanding their differential impacts can help inform better disaster and climate adaptation planning to protect the most vulnerable populations (mendez, ) . recent research points to the urgency of these issues and underscores how climate change is making wildfire seasons longer and more severe. on average, wildfires in the western united states burn six times the acreage they did years ago (kenward et al., ; schoennagel et al., ; abatzoglou and williams, ) . differences in human vulnerability to this growing threat stem from a range of social, economic, historical, and political factors (thomas et al., ) . this includes unequal access to disaster preparedness resources, contrasting legacies of forest management practices, and the expansion of residential development into the wildland (davies et al., ; cignarale et al., ) . both disaster and climate change policy have increasingly employed the concept of "contextual vulnerability" to account for these interactions between societies and changing environments, to evaluate how they expose specific groups to greater harm, and to target responses more effectively (o'brien et al., ; hess et al., ; fellman, ; hess, ) . this article examines the importance of understanding the contextual vulnerability of undocumented immigrants in responses to disasters, contending that actions taken and challenges faced by community-based groups in california's central coast region during and after the thomas fire provide an important model for more inclusive disaster planning. the article concludes with preliminary participant observations from the covid- pandemic response in the region, showing how lessons from the fire have informed official actions, and offer new directions for research on this unfolding crisis. our findings and recommendations can help inform prevention, mitigation, and recovery planning, as well as reduce the impacts of disasters affecting undocumented immigrants. contextual vulnerability provides a framework for understanding the relationships between the "slow violence" that environmental injustices wreak on poor communities of color over the course of decades, on the one hand, and the effects of fast-moving, dramatic disasters such as wildfires, on the other (farmer, ; ahmann, ; scheper-hughes and bourgois, ) . not only are these communities more vulnerable to disaster because of the long-term cumulative harms they already face; the conditions that make slow violence possible-marginalization and disregard for them by those in power-also magnify short-term dangers. as described by nixon ( ) , the term "slow violence" conceptualizes slow-moving injurious and deadly harms, stemming from human-caused environmental degradation or climate change. it is a form of violence that is "neither spectacular nor instantaneous, but rather incremental and accretive, its calamitous repercussions playing out across a range of temporal scales" (nixon , ) . slow violence builds on the idea of ''structural violence,'' but emphasizes change and movement over time as well as space, extending the typical conception of violence as a fixed and immediate event (dillon, ; davies, ; galtung, ) . for nixon ( ) , slow violence poses a problem of visibility and representation, insofar as its effects are often unseen to most people, particularly to those in positions of power (cecire, ) . in the case of the thomas fire, undocumented immigrants in the central coast were rendered invisible to policymakers and disaster relief organizations by systemic racism and cultural norms regarding u.s. citizenship and who is deemed a "worthy disaster victim." society routinely treats undocumented immigrants, as well as other marginalized groups, such as the homeless, as "less than human, outside the norm and disposable" (vickery, , ) . these forms of exclusion directly shape disaster planning and response (lerner, ) . acts of slow violence thus do not begin with malicious intent but are usually the result of neglect or ignorance concerning the most marginalized populations (rice, )-an observation confirmed by our experience with this research. following our november briefing on wildfire impacts to undocumented immigrants at the california office of emergency services, one senior official commented, "before all these fires, i had no idea so many of the farmworkers were indigenous" and discussed the need for more nuanced approaches in disaster planning. this is despite the fact that indigenous peoples from mexico have migrated to california's agricultural regions in large numbers since the s (maxwell et al., ; kresge, ) . the homogenization of immigrants here shows how biases can be embedded within disaster policy. according to a state auditor's report, released the following month, emergency officials routinely overlook the state's most vulnerable populations, as they make preparations for foreseeable wildfires, floods, and other disasters (howe, ) . the audit focused on the emergency alert, evacuation, and shelter plans adopted by the california office of emergency services and ventura, sonoma, and butte counties prior to wildfires in - . "given the weaknesses we identified in the three counties' plans and the struggles local jurisdictions have had in assisting people with these needs," the audit said, "the state must take a more active role in ensuring that local jurisdictions maintain effective plans for responding to natural disasters" (howe, , ) . echoing nixon's account of "slow violence," a migrant community organizer commented on the report, "i don't think it's any sort of nefarious plan, i think it is more implicit bias and not including vulnerable communities in the [planning] process. disasters are exacerbating the hardship of people who already were bearing the brunt of inequality" (serna, ) . the specific ways in which disasters exacerbate existing inequalities can be described and addressed in practical terms through the lens of contextual vulnerability (o'brien et al., ) . in an extensive study, davies et al. ( ) have shown that vulnerability to disaster is the result of the socioeconomic context in which the event occurs. access to resources and the ability to reduce exposure and recover from wildfire are not uniformly distributed. the researchers found that communities of color -specifically those census tracts with a majority black, latino, or native american populace -are percent more vulnerable to wildfires compared to other census tracts. traditional analyses often obscure these differences, which stem from multiple intersecting factors (maldonado et al., ; johnson, ) . for example, according to cox and kim ( ) , older adults of lower-income status, particularly blacks and latinos, are less prepared for a disaster than their younger counterparts due to the stratification of access to disaster preparedness knowledge and resources. similarly, another study (baldassare et al., ) , found that "whites [in california] are twice as likely as latinos to say they are knowledgeable about disasters even though latinos ( %) are by far the most likely group to be very worried ( % asians, % blacks, and % whites)." in california's rural, low-income, and immigrant communities, residents often do not have the required resources to pay for insurance, rebuild, or invest in fire safety, which increases their vulnerability to wildfire. in recent years, these disparities have made recovery from wildfires even more difficult, as some landlords engaged in price gouging in regions that were already facing a housing shortage (fixler, ) . such outcomes have major environmental justice implications, in that certain populations, due to their socioeconomic status, must live with a disproportionate share of impacts and suffer the related health and quality of life burdens (mendez, ; agyeman et al., ) . understanding the vulnerability of communities is increasingly urgent because the risks of wildfires, drought, extreme weather, and infectious diseases associated with climate change are materializing sooner than projected (bedsworth et al., ) . in response to these threats, environmental health scholars (boyce and pastor, ) argue for approaches to climate change policy that adopt "contextual vulnerability" as part of a multidimensional view of such climate-society interactions (morello-frosch et al., ; shonkoff et al., ) . from this perspective, "reducing vulnerability involves altering the context in which climate change occurs, so that individuals and groups can better respond to changing conditions" (o'brien et al., , ) . to fully understand the complete picture of vulnerability to disasters associated with climate change, it is necessary to utilize approaches that recognize that any complex system involves multiple variables (physical, environmental, social, political, cultural, and economic) (fellman, , ; cardon et al., ) . a contextual vulnerability framing also can address the ways in which wildfire intersects with various aspects of human identity. in the social sciences, the concept of "intersectionality" has been used to highlight how categories of culture and identity overlap, heightening the effects of discrimination, exclusion, social inequality, and systemic injustice in the lives of specific individuals (crenshaw, ; dhamoon, ; brah and phoenix, ). an intersectional approach to wildfire emphasizes how certain people suffer worse effects because of overlapping factors that are often measured separately (kaijser and kronsell, ; bauer, ) . little empirical research exists on undocumented immigrants' differential vulnerability to disaster. this study complements research by davies et al. ( ) , collins ( ) , collins and bollins ( ), and wigtil et al. ( ) that explores the associations between race, place, and wildfire. building on the concepts of contextual vulnerability and slow violence, we offer a more holistic view of wildfire, one that simultaneously explores the intersection of human identities with the specific geographies and varying temporalities of disaster and environmental change. the case of the thomas fire especially underscores the complex intersection of race, class, indigeneity, gender, and immigration status as they relate to wildfire vulnerability. our research moves beyond the homogenization of immigrants as a vulnerable group to analyze their unique intersectional identities that together generate disparate disaster outcomes. toxic smoke from wildfires, for example, has extremely harmful effects for undocumented immigrants working outdoors without access to protective equipment such as masks. these individuals are already exposed to pesticides, and their immigration status, economic precarity, and lack of transportation can prevent them from receiving health care or regulatory relief. moreover, they are often afraid to seek help and restitution during and after a disaster, largely because us government agencies routinely subject them to surveillance, detention, and deportation. in this context, factors such as limited english and spanish proficiency, and heightened discrimination toward undocumented immigrants, can also have profound effects (fussell et al., ; grabovschi et al., ) . the response of community-based groups during and after the thomas fire points to ways in which deliberately crafted disaster planning and climate adaptation policy can help alleviate, rather than reinforce, these existing disparities. this research was undertaken through a case study of latino/a and indigenous immigrant workers, residents, and community leaders who lived in santa barbara and ventura counties during the thomas fire. an interpretive approach utilizing qualitative methods was adopted to enable in-depth examination of the experiences of respondents during and after the wildfire (yanow and schwartz-shea, ; bevir and rhodes, ; rhodes, ; drennan, ) . the study's interpretive methods included three components: participant observation; semi-structured interviews; and archival analysis. participant observation involved the coauthors, flores-haro and zucker, residing in the study area and conducting fieldwork during - with the indigenous migrant rights group mixteco/indigena community organizing project (micop), and the environmental justice organization central coast alliance united for a sustainable economy (cause), respectively. the research team conducted semi-structured interviews with respondents. interviews were selected by assessing the professional networks the team developed while working in public policy in the region. these networks provided a degree of trust and personal connections that resulted in greater access to key stakeholders. several of the people interviewed remain involved in climate change and disaster planning or engage in the local economy as undocumented workers. in order to address sensitive issues, many of the interviewees requested anonymity. in such circumstances, the references indicate only the type of work the individual engages in. the interviews were used to collect qualitative data that answered explanatory 'how ' and 'why' questions (yin, ) about the wildfire response and recovery experiences of immigrant communities. archival analysis focused on a review of policy literature, grey literature, relevant government/nongovernmental websites, and news articles to assess gaps in government disaster response for undocumented immigrant communities in the region. this research was supplemented by a january workshop held at the yale school of forestry that convened california policymakers and environmental justice/immigrant rights advocates together to conduct a scoping analysis of the fire's impact to undocumented immigrants (arksey and o'malley, ; anderson et al., ; o'brien et al., ) . the researchers also conducted a follow-up briefing with the california office of emergency services in november . the findings from the scoping analysis were utilized by the office of california governor gavin newsom ( ) to help develop $ million in disaster planning grants for vulnerable communities at high risk for disasters. the transcripts of the informant interviews and scoping analysis were content analyzed for key themes using inductive coding (i.e., themes were not predetermined but emerged from the data through review and comparison) (thomas, ; glaser and strauss, ; ritchie et al., ) . to increase the reliability of coding, content was see also davis ( ) for a history of race and class politics of wildfires. micop unites indigenous leaders and allies to strengthen the indigenous migrant community. cause seeks to invoke environmental justice for people in the central coast through research, organizing, and advocacy. interviews were conducted by flores-haro and zucker as part of their employment with micop and cause and were completed prior to the start of this research project. these interviews with immigrant workers/residents were given pseudonyms to protect their identities. méndez conducted interviews between august and may , with local/state government officials and staff at community-based organizations involved in providing services to immigrants. reviewed independently by each researcher and themes identified were compared, reconciled, and compiled (burnard, ; pope et al., ) . reconciled themes were transcribed into a spreadsheet for analysis (see table for summary). through an interpretive approach (yanow and schwartz-shea, ), we sought to understand not only the impacts themselves but how perceptions and the experience of impacts translate into actions to improve disaster and climate adaptation planning (alkon, ) . this approach is supported by fire social science literature that has focused on the feedbacks between social groups, governments, and the landscape to better inform the development of inclusive vulnerability reduction strategies (paveglio et al., ; toman et al., ; carroll et al., ) . data developed through this approach, moreover, facilitated an understanding of the lived experience and intersecting identities of undocumented immigrants and how these factors shaped their disaster outcomes. this is particularly important, since relatively few studies have analyzed the disaster impacts of undocumented immigrants from their own perspectives. the central coast is home to a large proportion of california's multi-billion-dollar agriculture industry; ventura and santa barbara counties annually generate $ . billion and $ . billion respectively (williams, ; fisher, ) . data from the us census bureau ( ) indicates that there are , farmworkers in ventura county and , in santa barbara county. these figures likely underestimate the size of this population, due to the difficult nature of counting undocumented farmworkers through the census (farm bureau of ventura county, ). estimates further suggest that although it employs fewer workers than california's san joaquin valley, the central coast supports some of the most profitable-per-acre farming in the state, making the hardships facing farmworkers all the more glaring (o'connor, ). dire socioeconomic conditions and health hazards exist for many california farmworkers, particularly undocumented indigenous immigrants. the following indicators from the most recent california agricultural workers health survey (villarejo et al., ) and the national agricultural workers survey (hernandez and gabbard, ) provide an overview of these inequalities: • the mean and median personal annual income for farmworkers in the united states were in the range of $ , -$ , (hernandez and gabbard, ) . • % of farmworkers in the united states have no health insurance (hernandez and gabbard, ) . • one in five male farmworkers in california has risk factors for chronic disease: high serum cholesterol, high blood pressure, or obesity (villarejo et al., ) . • of california farmworkers, % of men and % of women have never had a medical or clinic visit (villarejo et al., ) . • the median educational attainment for farmworkers in california is th, th, or th grade (villarejo et al., ) . • where california farmworkers live, the number of residents per dwelling unit is . (villarejo et al., ) . for central coast farmworkers, there are persons per dwelling unit, as compared to table key themes identified by informant interviews. an overall . in the region (wadsworth, ) . • nearly % of hired crop workers in the united states are not authorized to work in the country (hernandez and gabbard, ) . according to a cause report ( ), of nearly local farmworkers surveyed in the central coast, two-thirds believe their working conditions are dangerous or harmful to their health. previous research has shown that farmworkers also live in some of the worst housing in the region. in their work with this population, micop and cause often encounter families occupying dilapidated homes and trailers or converted garages that lack access to clean water, proper drainage, and electricity. because they are "already at substantial physical risk by virtue of working in agriculture, exposures from housing could place their health in additional jeopardy" (quand et al., , ) . the existing research on housing conditions and their associations with farmworker health, however, is limited (maxwell et al., (maxwell et al., , kresge, ) . the california indigenous farmworker study (mines et al., ) further estimates that in the central coast, % of farmworkers are from a mexican indigenous group (for example, mixteco or zapoteco). it is estimated that over , indigenous people from southern mexico live in ventura county, while santa barbara county is home to a population of , (mines et al., ; cause, ) . climatic change, soil erosion, drought, and socio-economic issues in their ancestral mexican farmlands, as well as economic opportunity in california, have drawn indigenous migrants to the central coast in search of agricultural work (roge et al., ; roge and astier, ) . concentrated in labor-intensive sectors such as row crops (i.e., strawberries and raspberries) and cut flowers, indigenous migrants perform an increasing amount of the arduous labor which contributes to the profitability and affordability of fresh fruits and vegetables (maxwell et al., ; kresge, ) . of the individuals served annually by micop, % are from the mixtec community, with % coming from the zapotec community, and the other % from indigenous groups such as the purepechas from michoacan, huave and otomi from oaxaca, maya from the yucatan, and nauhatl from central mexico. the disaster literature typically groups latino/a and mexican indigenous immigrants into one large ethnic group in terms of their characteristics and experiences before, during, and after disaster. they are homogenized without consideration of the intersecting traits and contextual factors that create unequal disaster outcomes. however, scholars have noted that important differences exist within the latino/a and indigenous population, including variances among legal residents and their undocumented counterparts (stough et al., , ; hernandez et al., ; farquhar et al., ) . indigenous people such as mixtecs are not of hispanic or latino/a descent and migrate from regions in mexico with unique cultural and linguistic traditions. mixtecs throughout california are culturally and linguistically isolated. many are illiterate, and most speak neither spanish nor english, but only their native language, mixteco, a pre-columbian language with a logographic writing system. there are nearly variations of the language, some differing greatly from one another. these realities impede their ability to obtain appropriate health care, housing, and education, negotiate with their employers to improve their work situation, and exercise their basic civil rights (maxwell et al., (maxwell et al., , kresge, ) . non-spanish-speaking indigenous persons, moreover, are less likely to file complaints about workplace safety or labor rights abuses, and persons who physically appear indigenous may confront discrimination from both nonindigenous latinos and from anglo americans (lee et al., ) . previous studies have identified two primary areas of concern for indigenous farmworkers: ( ) disrespect and discrimination based on their unique languages and cultures, and ( ) a lack of basic occupational health and safety information and equipment in their daily work lives (farquhar et al., , ) . these dire conditions also extend to indigenous workers in domestic, landscape, and other industries in the central coast, who provide services to many of the more affluent hillside neighborhoods in the region (waheed et al., ) . the forms of discrimination and unsafe labor conditions faced by both undocumented indigenous and latino/a immigrants provide a baseline condition that predisposes them to higher levels of exposure and sensitivity, as well as a lower adaptive capacity in the face of disasters. in this regard, as one informant and former resident of santa barbara commented, the undocumented immigrants are the invisible population living and working behind "the bougainvillea curtain." they are struggling to survive in a region of wealth and prosperity. this idiom references the fast-growing evergreen vine with an explosive magenta color visibly adoring the gates of luxurious estates for added privacy. many specific factors related to the general conditions outlined above heightened the contextual vulnerability of undocumented immigrants during and after the thomas fire. these included inadequate provision of emergency response information, lack of oversight for occupational health and safety, disruption to transportation systems, exploitative practices in the housing market in the fire's aftermath, and the ineligibility of undocumented immigrants to receive federal disaster relief aid. because of the ways in which the fire's impacts were addressed and measured, the worst-affected communities essentially became invisible to emergency services, civic leaders, and mainstream relief agencies during and after the days that the fire raged. here, we detail these forms of neglect and the ways that organizations such as micop and cause responded to them. prior to the fire, local governments had not considered the unique needs of undocumented latino/a and indigenous immigrants in their disaster and emergency plans. one in three residents of ventura and santa barbara counties speaks spanish or another language at home (ca census, ). however, emergency warnings during the thomas fire-which detailed evacuation areas and shelters, road and school closures, the need for n respirator masks to protect individuals from unsafe air quality, and the lack of safe drinking water in some neighborhoods-were initially only available in english. emergency information online later included an option for google translate in spanish (an internet-based multilingual translation service), but the ventura county offices of emergency services failed to assign staff for live translation during a disaster event. "the smoke irritated our eyes and we couldn't work because the whole sky was covered in smoke. that's when they finally sent us home. but we didn't receive information about evacuations or any emergency information before then." -hector, farmworker, oxnard in response to the public agencies' inability to provide multilingual resources in a timely manner, micop produced translated written, audio, and video versions of public safety information on their own website, social media pages, mobile telecommunications applications such as whatsapp (used in many immigrant communities), and their low-power community radio station throughout the disaster. it is estimated that these combined communication platforms reached over , users in the region (micop, ). providing emergency information in various formats is particularly important to indigenous communities. the high level of illiteracy and the oral nature of indigenous languages such as mixteco make radio and other audio/visual forms of communication essential to provide clear and accurate information. micop also collaborated with county and state partners to enhance their translation resources, and days after the fire started, real-time updates were finally provided by ventura county. the advocacy of local community groups and the outcry over the lack of equitable language access to emergency information led the counties of ventura and santa barbara to hire full-time spanishspeaking public information officers in the months after the fire. the experiences of undocumented immigrants in the region also highlighted the need for broader policy change at the state level. in response to lobbying by micop and cause, state assembly member monique limón (along with support from the california latino legislative caucus) enacted into law assembly bill in . this bill provides state resources to counties to help translate emergency information and made some disaster related grants contingent upon the county government providing information in the most commonly spoken language other than english. micop and cause's lobbying efforts continued the following year with the enactment of senate bill . this legislation requires counties to engage vulnerable populations when updating emergency plans to ensure that local disaster preparedness and response activities (i.e., alerts, communications, evacuations, and sheltering) are culturally competent and meet diverse needs. this bill prioritizes reaching culturally diverse communities including immigrants, and low-income communities of color, among others. some of the deadliest effects of wildfire are not the burning of neighborhoods themselves, but the acute and chronic health impacts of smoke (black et al., ; reid et al., ; reardon, ) . , premature deaths annually in the united states are attributed to wildfire smoke inhalation, a number which is projected to rise to more than , by the end of the century due to climate change (ford et al., ) . wildfire smoke spreads far beyond the originating point of a fire. for example, in the central coast, smoke that begins in wealthy, sparsely populated foothill communities often settle in densely populated flatlands (or valleys) where many farmworkers live and work (cause, ) . wildfire smoke disproportionately impacts outdoor workers, who perform heavy manual labor. farmworkers, moreover, are exposed to the most densely concentrated smoke plumes, for longer periods of time, while simultaneously undertaking arduous work, and with the least effort made to monitor their exposure compared to other groups (farquhar et al., ; cause, ; mines, ; black et al., ) central coast farmworkers were especially hit hard by the thomas fire. heavy smoke filled the air for weeks. public health officials recommended that the general public wear n respirator masks even when taking small trips outside. these officials further recommended that sensitive populations (those with asthma, young children, and the elderly) stay indoors, and all population groups were advised to refrain from strenuous activity. during the initial days of the fire, thousands of farmworkers continued working in the fields, the vast majority without masks, as many agricultural companies pushed a surge in labor to safeguard their crops from smoke and ash. this led to health impacts including coughing, headaches, difficulty breathing, nausea, and nosebleeds, as well as long-term effects such as respiratory illness (black et al., ; reid et al., ; reardon, ) . cause, micop, and future leaders of america (fla) volunteers distributed over , n masks and brought national media attention to the issue. however, on several occasions some farm managers chose not to distribute the masks and prevented volunteers from providing them directly to workers. in other instances, managers were seen only distributing the respirator masks to male workers. "during the fire, i worked days without a mask. it caused me headaches and watery eyes, as well as a cough. we were scared because we were very near where the fire was occurring. the masks were not handed out until the state came to regulate." -marisol, farmworker, oxnard according to the centers for disease control and prevention ( ), agriculture ranks as one of the most hazardous industries due to difficult working conditions and chemical exposure to pesticides. in particular, women may face greater hazardous workplace exposures and negative health outcomes, because agriculture is predominately a male space, which can create conditions of discrimination and harassment (habib et al., ; kuang, ) . these existing gender inequities in the workplace can be further exacerbated during disasters. according to micop, women in domestic work also suffered disproportionate impacts during the wildfire. one worker reported to the organization, that she was instructed to remain and safeguard a home in a fire evacuation zone as her employer fled for safety. the domestic worker found herself trapped by roadblocks and mudslides for about a week. during this time, she was exposed to unsafe air, and the threats of the fire overtaking the home. when the evacuation orders were lifted and the roads reopened, the domestic worker was asked by her employer to grab a few items from the house before she left (shyong, ) . despite the vulnerability of farmworkers and domestic workers, the california division of occupational safety and health (cal/osha) closed their local offices during the first five days of the thomas fire. after receiving phone calls from the public and at the urging of members of the california latino legislative caucus, cal/osha reopened their offices. however, regulators had no legal authority to protect workers from wildfire smoke. the following year, due to advocacy by cause, micop, and the latino caucus, on july th, , the california occupational safety and health standards board adopted emergency regulations requiring outdoor employers to provide respirator masks when the air quality index reaches the level of "harmful" (where the level of fine particles in the air is parts per million or greater) due to wildfires (cal/osha, ). the protection of outdoor workers from wildfire smoke faces unique challenges. during wildfires, wind speed and direction are constantly changing, making prediction of air quality difficult. moreover, stores often run out of respirator masks during a fire. micop staff were told at one home improvement store that the limited inventory of masks was only being sold to "regular customers" and they were not allowed to buy in bulk to distribute to farmworkers. in another instance, volunteers distributing respirator masks were barred from entering fields, chased off by supervisors, or threatened for trespassing. cultural complexities add to this picture. farmworkers are accustomed to difficult and dangerous working conditions including regular exposure to dust and fumigant pesticides in the air, and often wear cloth bandanas that some mistakenly believe can protect them from fine particulate matter. furthermore, written forms explaining the use of masks can be unreadable to farmworkers with limited literacy or who speak indigenous languages. above all, the complex chain of contracting and subcontracting within the agriculture industry leaves corporate leadership in faraway offices, without accountability for the conditions of their workers. for example, despite mega-agricultural distributor driscoll's official policy of providing n masks, local advocates who visited many of their farms observed farmworkers picking strawberries without protection from the smoke. in other examples, farmworkers noted: "the smoke ruined and affected the fruits we were picking. i also suffered from coughing and allergies all throughout the fire." -maria, farmworker, oxnard "we all got sick. our throats closed in from breathing too much smoke and our kids couldn't go to school. we had to buy our own masks and goggles because our eyes were irritated when we worked." -francisco, farmworker oxnard loss of housing stock and transportation infrastructure also impacted the whole region, but it particularly affected low-income renters and commuters. the city of santa barbara lies in a scenic location between the mountains and the ocean, both driving its economy, while also leaving its infrastructure vulnerable to disruptions from disasters. approximately , commuters travel the us highway from more affordable areas of ventura county into santa barbara daily, with no other viable path into the city (molina, ) . when the highway was severed by debris flows from the thomas fire, thousands of commuters were cut off from their jobs. some commuters with more resources utilized expensive alternatives like driving for hours to circle around the mountains, renting private boats, or purchasing long-distance train tickets. schools and hospitals reported severe shortages of teachers and nurses. but daily-wage earners like housekeepers and landscapers were particularly affected. unable to pay for transportation alternatives, they lost weeks of income, and many were ineligible for unemployment benefits. moreover, the fire impacted housing in a region with an already tight housing market. many higher income homeowners inflated the rental market while their homes were rebuilt. in santa barbara's eastside, a low-income immigrant neighborhood where many families work in domestic service in the expensive homes and hotels nearby, renters organized to fight their landlord, investment company empire usa, which, the day after the fire started, raised rents by hundreds of dollars (caa, ; cause, ) . while the loss of housing stock is often one of the most discussed impacts of wildfire, the ripple effect in the entire housing market can have the most consequences to low-income tenants who live far away from the footprint of the fire. several undocumented workers noted the fire's effects on their transportation, housing, and employment options: -santiago, landscaper, santa barbara "i work as a housekeeper and it was difficult and hard to survive financially. my husband also lost income due to the thomas fire and debris flow. we had to ask our friends and family to loan us money in order to pay rent, food, bills and medical exams because i'm ill from a lung disorder. i need medical attention and i don't have insurance. my husband also lost tools he left in montecito." -rosa, domestic worker, santa barbara "the day the fire started, the sky was covered with smoke and we were sent home. the next day we didn't work because it was dangerous due to the fire. we lost power because it was cut off by the fire and we lost food and milk for the kids. during the mudslides, we couldn't get to work and were told to stay home for days." -roberto, farmworker, oxnard one of the largest gaps in safeguarding communities from disasters is the federal exclusion of undocumented people from receiving aid from the federal emergency management agency, (fema) and the disaster unemployment assistance program. millions of californians are undocumented immigrants, and disproportionately high numbers work in sectors heavily exposed to the effects of wildfire and other disasters. their families are further exposed to disaster due to lack of language access to emergency warnings, minimal economic resources to evacuate and rebuild homes, and lower rates of health care and home insurance coverage (stough et al., ; hernandez et al., ; farquhar et al., ) . despite being on the front lines of disaster, explicit exclusion from recovery and relief efforts leaves undocumented immigrants without a safety net in california's nearly year-round wildfire season. cause, micop, and fla adopted a disaster relief model first developed in sonoma county, in northern california's wine country, which had been hard-hit by the october tubbs fire. advocates in that region created the "undocufund" to aid undocumented immigrants impacted by the fire. like the original sonoma undocufund, the undocufund (named after the area code in ventura and santa barbara counties) provided direct financial relief to undocumented immigrants who lost their jobs, families who lost homes or incurred health care costs from the disaster. in total, the undocufund raised more than $ million to support over immigrant families in - . the undocufund benefited from the existing networks local immigrant rights organizations had established statewide, allowing them to connect and replicate the fund quickly. additionally, the longestablished relationships between the partner organizations and their roots within immigrant communities enabled the undocufund to recruit dozens of volunteers and reach large numbers of affected households. much of the financial support came from philanthropic foundations as well as individual donors. despite the initial financial support, local organizers still had limited resources and a long waiting list of individuals requesting aid. the waiting list further increased in november , when the woolsey fire broke out in ventura county just east of the burn scar of the thomas fire. moreover, they found it difficult to attract additional donors to fully fund their program; one foundation, concerned about political consequences, only donated on the condition of anonymity. "my husband was deported just before the fire. i was really struggling to find work in the fields. i finally got hired the first week in december but was let go once the fire and smoke grew too big and the fruit spoiled. as the only breadwinner, i had to borrow money from friends and family to feed my kids. our food went bad due to the power outage, adding to our expenses. i am grateful for the undocufund assistance. i am still in need of help and continue coming to micop for other services." -lorena, undocufund recipient, oxnard "the disaster relief assistance was like water to me, and at last i could sleep soundly." -miguel, farmworker, oxnard the undocufund also faced other significant organizational challenges. none of the founding groups had experience in delivering disaster relief services, and only of those organizations had background in providing direct assistance to communities. while sonoma county's undocufund provided a blueprint, local groups determined that the model needed to be customized to the central coast, including accounting for indigenous language support and operating across two geographically large counties. additionally, in developing the undocufund, the steering committee underestimated the impact on overhead and administration costs. micop, as the organization housing the undocufund, keenly felt these impacts. at any given disaster recovery assistance clinic, there would be paid micop staff providing language support in mixteco, as well as completing applications alongside volunteers. micop was further impacted due to the high volume of checks that needed to be processed through their finance department. this work, nevertheless, introduced the founding organizations to the disaster relief world. following the fire, for the first time, the fund's steering committee members were invited to participate in long-term disaster recovery meetings in ventura and santa barbara counties, as well as voluntary organizations active in disaster (voad) workshops. through these meetings and the operation of the undocufund, it became clear that mainstream disaster relief organizations, such as the red cross and salvation army, were lacking in cultural and linguistic competency. while these organizations were interested in collaboration, such as pooling case and contact information in a centralized database to reduce administrative work, this could also have put disaster aid recipients in legal peril because the proposal would have been paid for by the department of homeland security (dhs), which houses immigrations and customs enforcement. staff at the undocufund rejected this proposal, choosing not to compromise the confidentiality and trust that the community had placed in them. from the outset, the undocufund organizers recognized the need to fill the gap in regional disaster relief services, but they understood that larger structural changes were also required. local community organizations lack the scale, resources, and capacity to competently fill the disaster relief gap left by local and federal governments. moreover, other regions struck by disasters are likely to encounter more challenges because there are no immigrant-serving organizations at all. with this in mind, organizers along with the california latino legislative caucus approached the office of california governor newsom for assistance. as a result, in , the governor included $ million in the state budget for disaster planning grants focused on vulnerable communities at high risk for disasters. it is often assumed that disasters such as wildfires do not discriminate on the basis of race or social class of their victims (davis et al., ; bradley, ) . however, as this research shows, the extent of disaster impacts has been greater in undocumented latino/a and indigenous immigrant communities. our analysis illustrates how a contextual vulnerability framework can more effectively evaluate the social determinants (race/ethnicity, class, gender, indigeneity, and immigration status etc.) of a community's adaptive capacity, as well as their sensitivity and exposure to a disaster. it allows for a holistic exploration of the disproportionate impacts felt by certain populations at every stage of a disaster (zakour and harrell, ) . individuals from immigrant communities, likewise, are often negatively affected by more than one of these social determinants (maxwell et al., ) . these intersecting factors require policymakers to recognize that disasters exacerbate existing inequalities, and develop inclusive disaster and climate adaptation planning interventions to better safeguard immigrant communities that include: ) drawing on immigrant community knowledge; ) embracing immigrant communities in disaster planning; and ) bolstering civil society organizations' capacity in disaster relief and planning efforts. while wildfires may not discriminate, these disasters are not unanticipated, isolated "natural" phenomena. the destruction from wildfires is a product of human decision-making that often disproportionately impacts marginalized communities due to existing structural inequalities in society (bradley, ; davis et al., ) . in this sense, every part of a disaster -including vulnerabilities, preparedness, response, and rebuilding -is to some extent a social calculus (smith, ; ahmann, ; schlosberg and collins, ) . it follows that the question of who fully recovers is also embedded in human decisions that prioritize some lives over others (nix-stevenson, , ; ahmann, ; kelman, ) . in disaster planning, there is a strong need to better analyze the socio-cultural context and processes that produce structural inequality, and how events like wildfires can intensify existing inequities (vickery, , ) . for instance, in our case study, structural inequality in the housing market caused thousands of low-income workers from ventura county to commute into more affluent employment centers in santa barbara. such patterns can create serious economic disruption when transportation systems are severed by disasters. existing disparities in health status due to environmental injustice (such as pesticide exposure and heat-related illnesses and exhaustion), unsafe working conditions, exclusion from health coverage, and lack of culturally competent medical care are also exacerbated by compounding health impacts from wildfires. furthermore, prevailing economic insecurity among undocumented immigrants due to labor exploitation and exclusion from social safety net programs intensifies when workers most exposed to disasters are denied access to emergency aid due to their immigration status. according to several social justice advocates we interviewed, the most important solution to advance disaster recovery for these communities is to first address the longstanding systemic oppressions they have struggled with, spoken out about, and organized against for decades. when wildfires surge, undocumented immigrant communities are often hit hardest. they tend to be located in areas where it is difficult to prepare for and recover from disasters (quand et al., ) . despite these disadvantages, the state of california has failed to map wildfire vulnerability based on socioeconomic status. without an accurate identification and mapping process, the state is unable to provide local governments and community-based groups with a reliable rendering of the populations most vulnerable to the impacts of wildfire. most importantly, by failing to identify socially vulnerable communities across california, government entities are unable to understand in advance where to target limited resources and programs . while academic studies such as davies et al. ( ) have developed a socio-ecological mapping approach using us census tracts to measure wildfire vulnerabilities for minority and poor communities, this approach still renders some populations invisible. for example, their map shows santa barbara and ventura counties as having low levels of social vulnerability due to the large proportion of economically secure households in the region. however, as shown in our study, undocumented immigrant communities were among the most impacted during the thomas fire. undocumented immigrants in particular are undercounted in the us census, and may not be reflected in such analyses, in part because they often avoid interaction with government representatives for fear of deportation (van eerten, ; fazel-zarandi et al., ) . this vulnerability-mapping approach also fails to account for the complex web of impacts caused by wildfires, rippling beyond destruction of property within the perimeter of the fire itself. toxic smoke flows down from burning mountainsides, settling in densely populated valleys below and threatening outdoor workers. lavish hillside mansions are destroyed or evacuated, leaving low-wage immigrant gardeners, housekeepers, and caregivers unemployed. tourism throughout the region shuts down, putting thousands of hospitality sector employees out of work. from the loss of housing and infrastructure to the closure of schools and job sites, multiple regions are impacted beyond the census tracts identified in vulnerability mapping models and landscape risk maps. for example, a low-income immigrant family living outside a burn area, who lose several weeks of wages without eligibility for disaster relief assistance, may be more impacted than a high-income homeowner who lives within the fire-risk zone. this is because their property is covered by a homeowners' insurance policy, which also pays for hotel accommodations for them in the interim. the focus on threats to property rather than the disruption to livelihoods or public health perpetuates the inequities that underlie disasters like wildfires. through the thomas fire, we see how social vulnerability mapping indices can provide a limited representation of reality. such spatial/ proximity-based analyses often miss invisible populations, such as undocumented immigrants. while they offer a broad-scale picture, "they the city of oxnard, where the majority of undocufund recipients live, is not identified in state wildfire risk maps. landscape fire risk is considered minimal because oxnard is surrounded by a wide plain of irrigated agricultural fields. conversely, in the wealthy city of montecito, where celebrities like oprah winfrey live, homes are identified as the highest risk on such maps. can also fail to capture more localized information … that is often better collected using qualitative methods" (wigtil et al., , ; fischer et al., ; neale et al., ) . these data limitations should caution policymakers against depending on a single framework for understanding social vulnerability. several practitioners have argued that governments should integrate indices with the experiential knowledge from community residents through ground-truthing methods. this would help ensure that the "public processes involving the development and application of vulnerability mapping are inclusive and participatory to generate well informed decisions" (raval, , ; jacobs, ) . nonetheless, as state and local governments develop more holistic vulnerability mapping techniques, they should also be cognizant of protecting the identification of undocumented immigrants from federal authorities interested in the information for deportation purposes. immigration status, moreover, has received little attention in disaster vulnerability mapping research. though a large proportion of disaster studies have considered race and ethnicity in vulnerability indices, impacts experienced by legal and undocumented immigrants require an intersectional and contextual research approach (collins and bollins, ; wigtil et al., ) . for example, public health studies of immigrants have found that within the same racial and ethnic group, immigrants received significantly less medical and preventive care than their non-immigrant counterparts. these studies cite language and cultural barriers, a digital divide in access to care and information, disparities in health insurance, and a lack of familiarity with the local health care system as potential factors that account for these findings (lucas et al., ; siddiqui et al., ; wu et al., ; davis et al., ) . grabovschi et al. ( ) argue that these factors are frequently combined with chronic poverty, especially for recent immigrants, and with an increase in the prevalence of chronic diseases. they conclude that "immigrant status is an important vulnerability aspect that often co-exists and may synergistically interact with other recognized factors involved in health care disparities" ( , ) . further research addressing these interactions beyond race and ethnicity would be beneficial for policymakers to identify the most vulnerable populations and develop appropriate solutions aimed to overcome disparities in disaster impacts. based on preliminary research, we have found that structural inequalities similar to those exposed by the thomas fire were also in play during the initial months of the covid- pandemic (march through june ). these similarities, while troubling, also suggest that the precedent of the thomas fire can directly inform responses to other disasters and public health crises. while millions of californians were the first in the nation to shelter-in-place to prevent the spread of covid- , farmworkers in the state were deemed essential and required to continue working in the fields. the pandemic impacted food supply chains throughout the state, as crops were at risk of being left unpicked, highlighting how deeply the agricultural system depends on migrant workers. many undocumented farmworkers, however, were working in fear. they lacked proper health and labor protections, information about the risks they faced as essential workers, and were excluded from unemployment benefits should they contract the virus or lose work (jordan, ) . farmworkers are especially vulnerable to covid- . many have no health insurance, and they are an ageing labor force confronting high rates of respiratory disease and hypertension -important factors that put them at greater risk of complications from the virus (coleman, ) . for workers on the central coast, spring was the worst possible time to be exposed to a novel virus. the month of may is peak strawberry season, and pay structures switch from hourly to piece rate. farmworkers are incentivized to work fast, often risking their own health (castillo, ) . according to a representative from cause, unlike workers in other professions, "you can't pick strawberries over zoom" (referencing an online video platform). the representative further elaborated about the inherent challenges in the agriculture industry that during disasters are magnified. "[through] the layers of contracting and subcontracting…messages get lost along the way. safety directives seem like they're coming [down] strong from the top, but by the time they reach workers in the fields it's like a game of telephone" (castillo, ) . furthermore, communicating the risk of covid- in the fields is particularly difficult. there is no word for "virus" in mixtec. when the outbreak first occurred, advocates from micop rushed to develop linguistic and culturally appropriate communications for indigenous communities. their methods centered on information about an "unknown sickness" and describing the symptoms over micop's local radio station and social media channels (borunda, ) . such messaging is important because maintaining social distancing at work to slow the spread of the virus is difficult for farmworkers. many labor shoulder-toshoulder without masks, gloves, or adequate sanitation facilities, and they often share buses and carpools to the fields. overcrowded and dilapidated housing conditions also place these essential workers at greater risk for contracting covid- (coleman ), as do significant barriers to testing and scarcity of masks (borunda, ) . lessons learned from the thomas fire, however, have yielded important improvements in disaster planning and response for undocumented communities. largely due to political pressure from advocates and the california latino legislative caucus (the largest racial/ ethnic caucus in the legislature), governor newsom was persuaded to issue strong guidance to local governments for agricultural worker protection during the pandemic. this guidance has enabled community groups to push for masks and social distancing measures in workplaces and farmworker housing, as well as the ability to report employers not complying with public health standards. but most importantly, the latino caucus' advocacy led to the governor establishing a temporary "disaster relief fund" for undocumented immigrants, who make up percent of the state's workforce (cllc, ). the fund is supported by the state with $ million, and $ million from philanthropic partners. it provides individual assistance of $ and up to $ for households. in announcing the fund, newsom stated that undocumented immigrants not only are over-represented as essential workers, but "also pay into the system…last year paying more than $ . billion in taxes" without receiving benefits from government assistance programs (sheeler, ) . these measures begin to diverge from typical conceptions of "slow violence" and inaction by the state. the invisibility of slow violence and the long-term nature of solutions needed to reduce it have normally allowed government officials (and philanthropic organizations) to ignore the resultant harm to marginalized populations without fear of repercussions from voters or other interest groups. as a result, the general political approach to slow violence can be described as "yes, but not now, not yet" (nixon, , ; farmer et al., ) . california's new demographic reality as a majority-minority state, however, has made the latino caucus influential in passing important policy agendas in the capitol (mendez, ) . following the thomas fire, the caucus better attuned themselves to the deficiencies in the state's disaster planning process. they funded audits of agencies and enacted several important disaster-related laws (as noted above) (cllc, ). in essence, the latino caucus is attempting to make the "invisible" victims of disaster, "visible" to the state. further research and analysis will be needed to establish whether these initiatives are sustained, since changes in political leadership can quickly shift policy priorities, budgets, and values. california is a state with diverse social demographics and a history of frequent disasters. the impacts from the thomas fire and covid- pandemic to undocumented latino/a and indigenous immigrant communities provide important examples of the need to proactively develop interventions to better safeguard vulnerable communities during a disaster. in light of our analysis, we recommend the following interventions that would directly address the contextual vulnerability of these communities: improved language access for emergency information; inclusive disaster and climate adaptation planning; funding for community-based organizations; the protection of workers' occupational health and safety; a permanent statewide disaster relief fund for undocumented immigrants; and the provision of health care coverage for unauthorized workers. state and local governments should be required to translate emergency communications into languages most commonly spoken in an affected area, ensuring all residents receive clear, linguistically accessible communication during disasters. however, language translation alone is insufficient to ensure effective communication about emergencies. such communication also requires an understanding of the cultural dynamics of a community: even within english-speaking communities, a lack of awareness of socioeconomic differences, diverse gender expressions and identities, educational levels, age, and religion can inhibit effective emergency planning (cjlcem, a (cjlcem, , b . for these reasons, local governments should also be required to integrate the diverse cultural and linguistic needs of their residents during the next update to their disaster and emergency plans. specifically, plans should address, at a minimum, how all populations within a jurisdiction are served by emergency communications; evacuation and sheltering; disaster mitigation and prevention; and preparedness. in updating these plans, local governments should collaborate with community-based organizations in order to develop culturally appropriate emergency response and planning resources. communities often know best when it comes to living with disaster. inclusive disaster and climate adaptation planning (including social vulnerability mapping) should take into account the knowledge and expertise of local residents. research has shown that in areas where the community is highly involved in disaster risk reduction activities, losses from disasters are significantly lowered (maskrey, ; van niekerk et al., ; allen, ) . to further ensure participation and strengthen capacity, federal, state and local governments should provide appropriate funding to community-based organizations working directly with vulnerable populations. community-based organizations have stronger cultural competency in engaging with communities of color and immigrants, greater levels of trust, and more flexibility to explicitly assist these populations. in community-based planning processes, vulnerable communities are actively engaged in the identification, analysis and interventions, monitoring, and evaluation of disaster risks. this approach helps reduce their vulnerabilities and enhance their capacities. implementation processes can include various structural and nonstructural activities such as community training, disaster response drills, community early warning systems, community-based participatory vulnerability mapping projects, etc. (gero et al., ; henly-shepard et al., ) . states have an important role in protecting vulnerable workers from disasters through new worker protection regulations such as those passed by california to mandate that employers provide respirator masks to shield outdoor workers from wildfire smoke. likewise, to ensure agricultural worker protection during pandemics, county governments should require masks and social distancing measures in workplaces and farmworker housing. new staffing structures should also be required to provide rapid responses during disasters and improved infrastructure for worker education and outreach. a greater level of collaboration between worker health and safety agencies, agricultural commissions, and those responsible for air quality, weather monitoring, and natural resources is also crucial. moreover, labor protections should be extended to domestic workers during disasters. state and federal workplace safety codes do not prevent an employer from ordering a domestic worker to stay in a mandatory evacuation zone. additionally, there is no legal protection from retaliation, including firing, if a domestic worker refuses to work in hazardous conditions caused by a disaster (shyong, ) . state governments should develop and codify into law an emergency disaster relief fund for undocumented residents. such funds would help safeguard domestic workers, farmworkers, and other lowwage, predominantly immigrant outdoor workers directly affected by disasters. state-level disaster relief funds, moreover, would help relieve the financial burdens under-resourced community-based organizations incur in the management of such funds. states should provide dedicated funding for access to health care coverage for unauthorized workers and their uninsured family members. in addition, urban planners and health officials should work collaboratively to consider the disparities in health status and access to health care for the development of more accurate disaster vulnerability assessment modeling. disasters pose a greater threat to communities with limited resources and lacking access to health care, and acute illnesses occurring during a disaster often evolve into chronic health needs during the recovery stage. state intervention is essential to ensure that these events do not create or exacerbate existing disparities in health and health care access (stefandou et al., ; bridgewater et al., ) . in conclusion, current efforts to mitigate and adapt to disasters often exclude undocumented immigrants, making them more vulnerable to impacts. in this respect, we have argued that such interventions are ultimately political in nature -choices are being made that often disempower these communities and withhold vital government protections and resources. as governments confront the challenges of climate change events and other disasters, it is imperative that they help embrace and engage undocumented immigrants, who are often the most vulnerable and stigmatized in society. the work done by communitybased organizations during the thomas fire and the covid- pandemic highlights how a contextual vulnerability framework can better assist undocumented immigrants to respond and recover from disaster. to help spur policy change, activists, practitioners, policymakers, and scholars alike must continue to make such stories visible. the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. about undocufund impact of anthropogenic climate change on wildfire across western us forests social capital, collective action, and adaptation to climate change just sustainabilities: development in an unequal world it's exhausting to 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suffering in silence: a report on the health of california's agricultural workers farmworker housing study and action plan for salinas valley and pajaro valley profile, practices and needs of california's domestic work employers places where wildfire potential and social vulnerability coincide in the coterminous united states crop and livestock report immigrant status and unmet health care needs a mansion on fire on island view drive in ventura interpretation and method: empirical research methods and the interpretive turn access to disaster services social work interventions for vulnerable populations we would like to thank david pellow, hallie eakin, jennifer horney, dean hardy, jonathan london, katherine jacobs, benjamin warner, william funderburk, and lori peek and the nsf supported "enabling the next generation of disaster scholars" fellowship for their generous comments and support. special thanks to senior staff at the california governor's office of emergency services and members of the california latino legislative caucus for discussing with us the implications of the case study findings. we are also grateful to richard matthews, scott bollens, david feldman, leticia ramirez, mukul kumar, and nicola ulibarri for workshopping the manuscript at the university of california, irvine. finally, we acknowledge the yale school of forestry and environmental studies and the yale center for the study of race, indigeneity, and transnational migration for hosting our scoping analysis workshop with california policymakers and advocates. key: cord- -otr authors: wax, randy s. title: preparing the intensive care unit for disaster date: - - journal: crit care clin doi: . /j.ccc. . . sha: doc_id: cord_uid: otr critical care teams can face a dramatic surge in demand for icu beds and organ support during a disaster. through effective preparedness, teams can enable a more effective response and hasten recovery back to normal operations. disaster preparedness needs to balance an all-hazards approach with focused hazard-specific preparation guided by a critical care-specific hazard-vulnerability analysis. broad stakeholder input from within and outside the critical care team is necessary to avoid gaps in planning. evaluation of critical care disaster plans require frequent exercises, with a mechanism in place to ensure lessons learned effectively prompt improvements in the plan. the hazard-specific approach creates a plan that is tailored to a specific type of event. advantages and disadvantages of both approaches are summarized in table . an all-hazards approach has the advantage of being potentially applicable to all possible events; however, it may create a less effective response due to lack of planning for specific challenges (eg, dialysis resources for crush injury-related renal failure after a major earthquake). a hazard-specific approach works well for the disaster events considered during planning; however, an unexpected type of event may result in a challenging response in the early stages of the disaster until the response can be recalibrated. disaster preparedness efforts should include a hazard-vulnerability analysis (hva), which evaluates risk by taking into account the likelihood of an event occurring, the severity of impact should such an event occur, the current state of preparedness, and internal/external capability to respond (risk probability  severity). for health care organizations, the kaiser permanente model provides an excellent example of such a framework and provides some online tools (such as their hazard and vulnerability assessment tool) to help hospitals prepare an hva. generating risk scores or rankings for different types of disaster events can help prioritize preparedness efforts by focusing on the most likely or most severe types of events, keeping in mind the need to maintain some level of all-hazards preparedness in case the hva proves inaccurate or that a highly unlikely event occurs. an hva may be conducted from different perspectives, with different results. federal, state/province, county/region, and local hospitals may note different probabilities, potential impact, and levels of preparedness creating different risk profiles. for example, a nuclear power plant disaster may be much less likely than natural disasters from a federal or state perspective; however, a hospital system located in close proximity to nuclear power plants (such as the one in which this author practices) should likely take such events much more seriously in their planning efforts. even within a hospital, the results of an hva may be more or less generalizable to different areas/programs within the hospital. the emergency department (ed) and operating room would typically experience a huge impact in a sudden onset trauma surge (such as a mass casualty shooting), whereas a bioterrorism or pandemic event with a prolonged incubation period may have a greater effect on the intensive care unit (icu) because of the prolonged need for mechanical ventilation and icu support for disaster-related patients. hence the importance of involving critical care in table characteristics of all-hazards versus hazard-specific approaches to disaster preparedness hospital-wide disaster planning, but also ensuring that the critical care team conducts independent disaster preparedness activities to consider issues specific to the icu. given that critical care is by nature an interprofessional health care effort, the need for interprofessional involvement in critical care disaster planning should be obvious. understanding the potential roles for usual members of the critical care team in disaster planning should help guide expectations and accountabilities in the planning process. in addition, clarity of the nature of the ideal -way interaction with noncritical care stakeholders inside and outside the hospital is essential, thus encouraging the sharing of critical care expertise with others to help with their planning efforts and improving critical care planning with expert internal input. table highlights potential contributions of different stakeholders toward critical care disaster planning, with further details discussed below. critical care physicians possess key understanding of the nature of organ failure and support, and have day-to-day experience with patient prioritization and triage activities. strong critical care physician presence and leadership in disaster planning is essential for developing an adequate and sustainable critical care physician resource plan for disaster events. as part of disaster planning, critical care physicians can help design an education strategy to prepare noncritical care physicians to assist in a disaster event as icu physician extenders, often deployed using a just-in-time approach at the time of a disaster. critical care physicians can also work with physicians in other areas of the hospital likely to provide critical care outside the icu during a disaster, such as the ed, to ensure their planning takes into account critical care capacity. as essential frontline care providers for any critically ill patient, critical care nursing must be involved in icu disaster planning. key factors for consideration include appropriate and sustainable nursing staffing (including potentially modified nurse:patient ratios), modifications to care standards if required, and documentation requirements. planning for use of icu nursing extenders with non-icu nurses requires advance clarification of the scope of non-icu nurses in caring for critically ill patients and creation of just-in-time education support to allow non-icu nurses to augment their ability to contribute during a disaster. critical care nursing leadership involvement will ensure adequate planning for the required interfaces between the icu and other areas of the hospital from a patient safety and administrative perspective, including strategies for bed management and patient flow into and out of the icu. advanced nursing providers, such as nurse practitioners and nurse anesthetists, and other providers, such as physician assistants and critical care paramedics, may provide helpful input during the planning process. in particular, these providers can help others understand how leveraging their enhanced scopes of practice may provide additional support during a severe critical care surge. respiratory therapist expertise is required to ensure appropriate planning for availability of medical gas (especially oxygen) in icu and non-icu clinical spaces, adequate access to airway equipment and mechanical ventilators, and planning for provision of respiratory support in non-icu areas of the hospital. strategies for enhancing capacity for mechanical ventilation may rely on use of unfamiliar ventilators from an external stockpile, or use of modified ventilators (such as transport ventilators or anesthesia gas machines). respiratory therapists may also help with other aspects of hazard-specific preparedness, such as strategies for monitoring of carbon monoxide in mass casualty exposures or delivery of bronchodilators for patients exposed to pulmonary irritants. in many jurisdictions, respiratory therapists with maximized scope of practice can also provide support for nonrespiratory issues, such as intravenous insertion or medication delivery, that can be incorporated into planning for provider oversight of patients during a major surge event. pharmacists appropriate stockpiling of medications is an essential component of critical care disaster preparedness, for which pharmacist input is invaluable. from an all-hazards perspective, generic medication requirements for management of icu patients can be modeled, such as need for sedation and analgesia for ventilated patients, or preventative therapy such as deep venous thrombosis prophylaxis. hazard-specific planning can include medications specific to address the hazard, such as antidotes for organophosphate poisoning, cyanide exposure treatment, or antiviral medications for pandemic influenza. the icu-specific hva can help pharmacists prioritize medication planning during disaster preparedness activities. knowledge of factors such as shelf life of medications, need for special storage such as refrigeration, and costing helps pharmacists provide essential advice for procurement. ideally, stockpiling strategies will avoid unnecessary availability of multiple drugs that can provide the same effect, such as having morphine and fentanyl and hydromorphone available as multiple narcotics. pharmacy input for creation of preprinted order sets to be used during a disaster can help align prescribing by providers with the available drugs stockpiled. finally, given that funds used for disaster preparedness take away from funds required for usual hospital expenses, pharmacy input on cost:benefit ratios of different medication options can help with a fiscally responsible approach to disaster planning and logistics. maintaining appropriate nutrition, early mobilization, and encouraging improved recovery to baseline functional state are essential adjuncts to life-support efforts. encouraging the involvement of relevant interprofessional team members in critical care disaster planning can help determine potential limitations in services during a disaster, suggest mitigation strategies to minimize the impact of a surge in demand for their expertise, and propose educational strategies to use other health care staff and even family members to assist as extenders with less frequent available input from these health care professionals. critical care disaster planning should take into account the tremendous stress of such events on patients, families and clinical staff. more detailed discussion of these issues can be found in other articles in this issue. although prehospital and ed triage strategies should identify and support disaster victims with isolated psychological/mental health issues, nothing precludes the copresence of mental health injuries (novel or exacerbations of existing mental health diagnoses) with critical illness from physical causes. planning for availability of psychiatry and other mental health consultationliaison services should be considered to support patients requiring critical care after a disaster. similarly, family members of critically ill patients will require ongoing support throughout the hospitalization of their loved ones, which may include need for social work and chaplaincy. strategies to ensure effective communication and support of family members when patients require transfer out of the hospital for higher level of care or capacity reasons should be considered in planning efforts. withdrawal of active life support may be required when patients are not benefiting from critical care support and/or if triage decision making requires shifting of resources to patients more likely to benefit, and the involvement of clinical ethicists to support patients, families, and staff members can be very helpful thus requiring consideration during planning. an emerging concept in disaster planning incorporates the concept of mental health/stress inoculation for hospital staff, which may include advance and just-intime deployment to increase performance during the disaster and prevent long-term psychological effects. , trauma, emergency department, and perioperative services during events that cause a sudden and rapid surge of patients to the hospital with mass casualty medical issues, trauma/burns, or other injuries requiring surgical support, impact on the icu can be delayed but substantial as the disaster unfolds. in such circumstances, the ed is usually on the frontline as first receivers of critically ill patients. the ed and icu teams must collaborate during disaster planning to ensure that critically ill patients receive optimal care regardless of their geographic location within the hospital. in the early stages of a disaster, icu planning may need to include a time-limited option to have critical care clinicians support patient care and triage activities in the ed. many patients will require resuscitation and stabilization in the ed before being safe to transport to the icu, and may also require transfer to the operating room for damage control or definitive surgery before transfer to the icu. planning for the orderly and safe transfer of patients from the ed or the operating room to the icu should include strategies for efficient transfer of clinical information and accountability of care. in the event of a nonsurgical disaster creating severe patient surge within the icu and hospital as a whole, disaster planning should include procedures for decision making regarding the cancellation of elective surgery to augment availability of space, staff and, supplies for disaster-related patients. plans for using surgical resources to support critically ill patients in the postoperative recovery room area (as an extended icu) or operating rooms (using anesthetic gas machine ventilators) should be discussed collaboratively. pediatric specialty hospitals that have a distinct pediatric critical care unit often provide regional support for critically ill and injured children. in a disaster event, the dedicated pediatric critical care center may be overwhelmed with patients, or the nature of the disaster may preclude immediate transfer of pediatric patients. therefore, nonpediatric hospitals should plan for management of pediatric patients. this would require potential stockpiling of equipment and supplies appropriate for pediatric patients. advance or just-in-time education for nonpediatric critical care providers to manage critically ill children should be considered ( course currently recommended for this purpose in some jurisdictions is the pediatric fundamental critical care support course offered by the society of critical care medicine , ) , as well as planned partnership with pediatricians to comanage critically ill children with adult intensivists. a disaster may force hospitals to care for obstetric patients beyond their usual complexity case mix or with gestational age earlier than usual, resulting in neonatal patients requiring more support than usually provided at the facility. these patients may have issues related to the disaster, or may be unable to be transferred because of the overwhelming surge in the usual tertiary care facility or because of the disrupted patient transport resources. from a critical care perspective, collaboration with obstetric teams will be required for management of critically ill pregnant patients. neonatal icus may need to work with adult critical care teams to gain access to additional neonatalcapable mechanical ventilators and monitoring equipment for their patients, or may face requests to share their ventilators to support an adult critical care surge. for these special groups of potentially critically ill patients, the critical care team and hospital at large should take account of space, equipment, supplies, and staff to help manage surges for those groups. in the absence of expertise to manage these patient populations, hospitals should consider planning to leverage telemedicine technology [ ] [ ] [ ] to gain assistance from clinical experts at a remote site (which may be different than their usual partners who may be also affected by the disaster and unable to assist). from an all-hazards perspective, a disaster can change the need for laboratory and diagnostic imaging support because of the increased demand for tests and the need for rapid, point-of-care results to minimize delay in clinical decision making and triage decisions during mass casualty events. from a laboratory perspective, disaster planning should incorporate strategies for triaging of laboratory study requests to maximize time-sensitive results impacting on critical clinical decision making. use of existing or stockpiled portable point-of-care laboratory equipment that can be operated by frontline clinical staff can be considered to reduce burden on the laboratory team. bedside clinical monitoring may be used as a laboratory test mitigation strategy in some cases, such as the use of pulse oximetry and quantitative capnography for ventilated patients instead of arterial blood gas testing, or advanced pulse oximeters that can measure carbon monoxide levels as a screening strategy in mass casualty carbon monoxide exposure. certain high-priority threats identified by the icu-specific hva may warrant specific discussion with laboratory services to ensure availability of necessary hazard-specific testing if possible. blood bank services in particular will need to coordinate with critical care and other hospital services to prepare for mass casualty events placing excessive demands for blood products, including a strategy to triage blood product requests in extreme cases. during a disaster, demand for diagnostic imaging studies may outstrip capacity of available equipment and technologists, and availability of radiologists to interpret the studies. use of portable radiographic equipment with an integrated monitor to allow immediate review of images by frontline clinicians may reduce delay in detection of critical clinically important findings. planning for enhanced availability of point-of-care ultrasound can be helpful as a substitute for other diagnostic imaging modalities, or to help triage cases when resources are limited, such as prioritizing computed tomography scan requests for possible abdominal injuries or ruling out of a pneumothorax and avoiding need for portable radiographic equipment. other newer point-of-care technology may help identify patients at higher risk for neurosurgical intervention and again help prioritize patients for access to limited diagnostic resources. an essential element of critical care disaster planning assumes the high likelihood of having to manage critically ill patients outside of the usual icu space. ensuring that appropriate physical plant and space is available, along with information technology support, will reduce some challenges with regard to working in non-icu space. understanding of space capabilities, with the input of facilities engineers, can help with the appropriate planning choices for icu surge space within the hospital and help avoid unpleasant surprises, such as lack of emergency backup power outlets, sufficient medical gas supply, or other limitations. a particular concern is the availability of negative-pressure airborne isolation rooms in the event of a serious airborne-spread biohazard disaster. most hospitals have limited airborne isolation capacity during usual operations. during hospital surge experiences during the worldwide to severe acute respiratory syndrome (sars) outbreak, some facilities were able to modify airflow and erect barriers to create large negative-pressure isolation wards, including icus. planning for various scenarios identified in the icu-specific hva should identify potential physical facility gaps and prompt mitigation strategies. intensive care units are technology-dependent areas of care that rely on sophisticated information technology services for networking of patient care monitors and equipment, electronic drug dispensing modules, and computer access to support icu-specific electronic medical records. in disaster situations, initial receipt of patients in the ed will often shift to a paper-based triage and registration strategy. planning for the transition from the initial crisis phase of a disaster with mass casualties to integration of patients within the electronic medical record will help ensure timely and accurate access and creation of health provider notes, laboratory results, and diagnostic imaging reports. information technology services should also plan for additional need of mobile computers and sufficient wireless network access to manage critically ill patients outside of the usual icu space. the potential need for use of telemedicine services to support management of special populations of patients, as mentioned above, should prompt planning and testing of telemedicine capacity including equipment and network bandwidth in advance to prevent service gaps during a disaster. hospitals typically spend considerable effort and resources on controlling external access to the facility during disaster events to ensure patient and staff safety, deter premature entry of persons requiring decontamination, maintain control of limited resources and supplies, and prevent unauthorized members of the media or other members of the public from compromising patient and family privacy. in the event of strict hospital visitor restrictions, attempts to circumvent security controls can be expected. specific consideration of the security needs of the critical care areas wax (traditional and makeshift) is occasionally overlooked. intense emotional reactions of family and friends of critically ill patients can occur and be compounded in a stressful disaster situation. in the event of implementation of triage activities and a shift from usual standards of care, decisions to withdraw life support from those patients not benefiting from scarce resources can be met with violent objection. physical measures to limit access to the critical care areas may need enhancement, and there may also be a need for greater visible presence of security staff as a deterrent to unacceptable treatment of hospital staff. liaison with security staff should be included as part of the critical care disaster planning process to avoid gaps in security capability. disaster preparedness requires an investment of resources in terms of staff time to commit to planning, equipment, and supplies earmarked for disaster stockpiling, and development of relationships and agreements with external entities. for preparedness to be effective, hospital administration must appreciate the need for planning and endorse recommendations. although the finance elements within a hospital are usually prepared to capture costs incurred while a disaster is in progress to facilitate reimbursement, advance efforts to secure funding support for disaster preparedness through government and other agency grants can mitigate opposition to diversion of funds away from frontline clinical activities. increasingly, hospitals are appointing a lead for disaster preparedness who can act as a liaison between clinicians and administration. given the high costs that can be associated with provision of critical care, particularly in surge situations, clear articulation of the needs for critical care disaster planning may enable the necessary allocation of resources to ensure the planning vision is realized. certainly, lessons can be learned after each disaster event that can lead to identification of problems or gaps in a critical care disaster plan. fortunately, those disaster events are uncommon, but, unfortunately, we cannot rely only on actual disaster events to test plans and maintain disaster competency among hospital staff. frequent disaster exercises can help educate staff on how to function during an actual event, and provide feedback to disaster planners allowing plan improvement before a disaster. disaster exercises may vary in scale and fidelity (fig. ) . the scale of a disaster exercise may be limited to a single critical care unit, involve multiple hospital services, or be expanded to a regional, state, or even national scale. the fidelity of a disaster exercise may be tabletop-based, using patient cards and virtual clinical spaces; may take into account current actual clinical volumes and bed availability; or may use hundreds of actors playing the role of patients, combined with highfidelity patient simulators, scattered throughout actual areas of the hospital for an in-situ exercise. exercises of greater fidelity and greater scale consume more resources to conduct, and may be more likely to interfere with routine hospital operations. however, the greater the fidelity and the greater the scale, the more likely it will be to identify opportunities for improvement in disaster planning. thus, a balance of these factors must take into account local resources, support for disaster preparedness by hospital leadership, and mandatory activities required for hospital accreditation or government funding. beyond generic disaster exercise activities, certain aspects of disaster planning specific to critical care should be specifically addressed in exercise design. critical care leaders and staff should understand the hospital incident command system (hics) preparing the icu for disaster as organized in their hospital, and know how they interface with the hics. critical care would normally fit within the operations branch, under control of the operations chief. in some cases, leadership roles within the hics may be filled by critical care leaders given their broad clinical understanding of the hospital as a whole; however, their responsibilities would be guided by the hics role rather than keeping a narrow focus on critical care. depending on the nature of the disaster event, critical care leaders and clinicians may be asked to assist the hics leadership team as subject matter experts, or participate in task forces or strike groups designed to handle specific problems. certain principles of the hics can be useful in disaster planning on a smaller scale specific to critical care. the concept of span of control, having everyone report to only person, and each person only having to people reporting to them, may be helpful in organizing clinical teams including non-icu staff supervised by icu clinicians. also, the concept of job action sheets that provide guidance for key actions given a particular role can be helpful in reminding staff of key tasks during a stressful disaster event, and can be a valuable teaching tool during an exercise. hospital exercises often emphasize infrequent but important tasks, such as decontamination of patients before entry to hospital, which are important but potentially less relevant to critical care staff. patients should never enter a critical care area without decontamination if required. for biological infectious events, there may be no ability to perform the equivalent of decontamination, because the patients remain infectious and put staff and other patients at risk. exercise and evaluation of advanced infection control strategies (such as conversion to negative-pressure clinical areas, use of infection control coaches), or advanced personal protective equipment (such as powered air-purifying respirator use, safe donning and doffing of equipment) may be of special significance for critical care team preparedness. exercises should also encourage familiarity with stockpile equipment, such as monitoring equipment or unfamiliar ventilators, so that there is some retention of competency in the event of the need to use such equipment in a disaster event. just-in-time education strategies to augment clinical care for special populations (eg, pediatrics) or hazard-specific care (eg, radiation sickness) can be practiced and evaluated for future revision. much of the learning from a disaster exercise takes place during the debriefing phases after the event. a "hotwash" debriefing immediately after the event can capture important lessons; however, another opportunity to capture additional lessons after some time to reflect can also provide further guidance on disaster plan revisions. preparing an after-action report after simulated and real disasters can ensure that lessons learned are captured; however, development of a list of actions including accountabilities and timelines, with a process for follow-up to ensure completion, should reduce the rediscovery of the same recommendations at the next real or simulated disaster. the preparedness phase of disaster management can make or break the response to an actual disaster. teams should aim for an optimal balance between flexible all-hazards preparedness and hazard-specific preparedness guided by the hazardvulnerability assessment. one of the best strategies for ensuring ongoing support for disaster preparedness activities is to identify potential flaws in the current disaster plan through frequent disaster exercises. despite the temptation to divert resources to routine clinical budget demands, an upfront investment in preparedness will hopefully lead to a more efficient disaster response and more rapid recovery to normal operations should a disaster occur. disaster preparedness: are we ready yet? hospital news reassessing the effectiveness of all-hazards planning in emergency management emergency preparedness: california hospital association clinical review: the role of the intensive care physician in mass casualty incidents: planning, organisation, and leadership nurses' competencies in disaster nursing: implications for curriculum development and public health guidelines regarding the role of the certified registered nurse anesthetist in mass casualty incident preparedness and response creating a disaster plan for rt departments pharmacy leader's role in hospital emergency preparedness planning ethical considerations: care of the critically ill and injured during pandemics and disasters: chest consensus statement computer-assisted resilience training to prepare healthcare workers for pandemic influenza: a randomized trial of the optimal dose of training resilience training for hospital workers in anticipation of an influenza pandemic emergency preparedness: manual for anesthesia department organization and management wny hospital pediatric disaster preparedness presentation - recommendations for increasing nyc pediatric critical care surge capacity (draft) the impact of telemedicine on pediatric critical care triage the role of telemedicine in pediatric critical care the use of telemedicine to address disparities in access to specialist care for neonates emergency department management of suspected carbon monoxide poisoning: role of pulse co-oximetry test characteristics of ultrasonography for the detection of pneumothorax: a systematic review and meta-analysis the infrascanner, a handheld device for screening in situ for the presence of brain haematomas hospital preparedness and sars lessons healthcare security professionals learned from hurricane harvey. security management world health organization. hospital and health facility emergency exercises: guidance materials hospital incident command system guidebook key: cord- - h rcih authors: sharififar, simintaj; jahangiri, katayoun; zareiyan, armin; khoshvaghti, amir title: factors affecting hospital response in biological disasters: a qualitative study date: - - journal: med j islam repub iran doi: . /mjiri. . sha: doc_id: cord_uid: h rcih background: the fatal pandemics of infectious diseases and the possibility of using microorganisms as biological weapons are both rising worldwide. hospitals are vital organizations in response to biological disasters and have a crucial role in the treatment of patients. despite the advances in studies about hospital planning and performance during crises, there are no internationally accepted standards for hospital preparedness and disaster response. thus, this study was designed to explain the effective factors in hospital performance during biological disasters. methods: qualitative content analysis with conventional approach was used in the present study. the setting was ministry of health and related hospitals, and other relevant ministries responsible at the time of biologic events in islamic republic of iran (ir of iran) in . participants were experts, experienced individuals providing service in the field of biological disaster planning and response, policymakers in the ministry of health, and other related organizations and authorities responsible for the accreditation of hospitals in ir of iran. data were collected using semi-structured interviews in persian language. analysis was performed according to graneheim method. results: after analyzing interviews, extraction resulted in common codes, subcategories, and categories, which are as follow: detection; treatment and infection control; coordination, resources; training and exercises; communication and information system; construction; and planning and assessment. conclusion: hospital management in outbreaks of infectious diseases (intentional or unintentional) is complex and requires different actions than during natural disasters. in such disasters, readiness to respond and appropriate action is a multifaceted operation. in ir of iran, there have been few researches in the field of hospital preparation in biologic events, and the possibility of standardized assessment has be reduced due to lack of key skills in confronting biological events. it is hoped that the aggregated factors in the groups of this study can evaluate hospital performance more coherently. the deadly pandemics of infectious diseases are rising worldwide. in the twentieth century, have caused death of more than million people in many parts of the world ( ) . in the last relatively mild h n pandemic in , - of people were killed who were not necessarily in high-risk groups ( ) . according to the report of www.warontherocks.com, about cbrn events were reported between and ( ) . also, the possibility of using microorganisms as biological weapons is a real and increasing probability all around the world ( , ) . increasing the tendency to use biological weapons due to increased terrorist attacks, their relative convenience use, and low cost have led to many health concerns ( , ) . between and , - persons were killed in major terrorist incidents nearly every months ( ). hospitals are vital organizations during biological disasters and play a crucial role as a place of care and treatment for such patients ( , , ) . hospitals should have an essential role in biological disasters ( ) ( ) ( ) ( ) . having specialists and staff with knowledge and skills relevant to biological events can play a significant role in reducing mortality and morbidity in the community, especially in the first few hours, which is called the golden time. the result is hospital preparedness to deal with biological events, which improves the response rate and accelerates the process of rehabilitation ( ) . hospital services are differentiated from other institutions by their types of activities, resources, staff, multiple specializations, and equipment used ( ) . the response of hospitals has a multidimensional function (approach) ( , ) . despite the advances in studies about hospital planning and performance during crises, there are no internationally accepted standards for hospital preparedness and disaster response ( ) . to date, there has been no valid methodology for assessing the preparedness of hospitals for disasters ( ) . however, after the onset of disasters, it is necessary that hospitals be prepared to deal with the new circumstance and surge capacity ( , ) . disaster preparedness is recognized as one of the top priorities in the medical field ( ) . this process varies in cbrn events ( ) . according to the recommendation in the process of planning, preparing, and responding to disasters in the health system, it is necessary to use the "all-hazards" approach ( ) . however, in practice, this approach does not seem to be suitable for man-made and technologic disasters such as biological, chemical, or nuclear events. nevertheless, evaluating hospitals' performance during crises, especially the one caused by biological disasters (eg, the epidemic of diseases whether natural or intentional), is a topic that has been dealt with inadequately. since in the face of disasters and biological threats different conditions prevail in hospitals, thus, evaluating the performance of hospitals in such situations requires a different mechanism. in addition, no comprehensive plan has been developed to manage biological events in iran. therefore, the present study was conducted to identify factors affecting hospital response in biological disasters. qualitative content analysis with conventional approach was used in this study. the qualitative content analysis approach was used for subjective interpretations of text data by systematic classification process, coding, identifying categories, or patterns. using this approach, the researcher avoids classification with background thoughts and allows categories formation during the research process ( ) ( ) ( ) . hospitals under the supervision of ministry of health and other relevant ministries responding to biologic events in ir of iran at (including the defense ministry) were included in this study. participants in this project were experts, experienced individuals providing services in the field of biological disaster planning and response, policymakers in ministry of health, and other related organizations and authorities responsible for the accreditation of hospitals in ir of iran. data were collected through conducting semi-structured interviews in persian language with the aim of explaining factors affecting the performance of hospitals in response to biologic threats. initially, the researcher met each participant and presented the research goals and obtained their consent for participation. three participants did not respond to the request and introduced another person as an expert in the field of research. two participants stated that these questions were not in their field of expertise. a total of interviews were done. the age range of the participants was - years. the purpose of the interviews was to explain and explore the factors influencing hospital performance in response to biologic threats. interviews began with simple and general topics and went on to specific questions. some questions were changed during the research (after completing the third interview and analyzing the data). types of questions were as follow: open questions, based on the default, and case-by-case. some of the interview questions were as follow: . what are the effective factors in assessing hospital performance at the time of biological events? . what are the management problems that you have experienced or may experience during a biological threat? . what are the strengths and weaknesses in assessing a hospital's performance of biological threats? . what is the difference between assessing the performance of hospitals in natural disasters and in biological distasters? during the interview, the researcher observed and noted the participants' interactions with the environment and their reactions, which were considered in the data analysis. the number of participants was determined based on the saturation of the obtained codes, so that the new codes were not extracted by new interviews. sampling was done using purposeful and snowball method. the interview took about - minutes. at first, interviews were conducted with the participants, their voice was recorded, and transcription was done a short while after each interview. data analysis began after the first transcription. to analyze the data, the researcher studied the data deeply, reread, and considered the text of the interview, gained understanding of the data, and finally completed the analysis ( ) . after each interview, transcription was done and field observations notes were reviewed several times. the final text was approved by each participant (member check). after the third interview, the questions were redesigned. in this study, interviews and field notes were the analysis units. the texts were divided into content areas and meaning units. meaning units were summarized and codes were extracted. multiple codes were compared with each other in terms of differences and similarities; then, categories and subcategories were formed. the extracted categories were discussed by scholars; finally, the basic and essential meanings of the categories were edited. data collection continued until saturation was reached for each concept. in a qualitative research, rigor shows concepts of credibility, dependability, transferability, and different dimensions of trustworthiness ( ) . to achieve maximum credibility, the research team used a range of expert participants. participants were among authorities of health in ir of iran, officials and staff of biologic laboratories, and some experienced officials from civil and military organizations with a history of managing infectious disasters. after each interview, transcription of texts was performed in a short interval. interviews were listened repeatedly, and the researcher extracted the meaning units. then, based on the condensation and abstracting of meaning units, the codes were extracted. similar codes were placed in subcategories, and the categories were formed according to the similarities and differences between subcategories. in the case of extraction of codes, subcategories, and categories, expert opinions were taken from the research team, and agreement was reached among researchers, experts, and participants about the differences. this study has been conducted in the context of ir of iran. according to researchers' view, the results can be generalized to other countries, but the choice has been left to readers ( ) . this study was approved by the national committee of ethics of ir of iran (code number: ir.sbmu.retech. rec. . ). all participants were aware of the research objectives. informed consent was taken from all participants and their participation was kept confidential. all interviews were recorded with participants' permission and were fully transcribed within a short period after the interview. analysis was done simultaneously. the demographic characteristics of the participants are presented in table . participants answered all the questions during the interview. after analyzing interviews, codes were extracted. codes were categorized in subcategories after analysis. according to the similarities and differences in nature of subcategories, categories were extracted: detection; treatment and infection control; coordination; resources; training and exercises; communication and information system; construction; and planning and assessment. the graphic diagram of the extracted categories and subcategories is shown in figure . table contains extracted categories, subcategories, and common codes by content analysis. after analyzing the data, it was found that all participants considered the ability to detect biologic outbreaks or emergencies in hospitals as an effective factor in hospital performance. the first step in controlling a biologic emergency is to detect the event in a hospital. the subcategories of determining the type of event (intentional or unintentional) and early detection were extracted. - : according to the participants, the delay in diagnosis with subsequent possibility of developing outbreaks of communicable diseases could be a major factor in hospital performance. one of the participants (p ) mentioned, "rapid detection is an important factor in proper performance in biological disasters. in the crimean-congo fever epidemic, if diagnosis was not established on time, the disease would have spread further". - : determining the deliberate or unintentional cause of a biological event can affect hospital performance. in intentional events, the biologic agent may still exist in the environment which will cause the disaster to be continued. another participant (p ) said, "it is difficult to diagnose the cause of deliberate biological events because there is less experience about it. treatment has been discussed on the textbooks, but the bioterrorism detection has not reviewed extensively, and it is very difficult". from the participants' perspective, the ability to treat and control the infection in the hospital was considered as an important factor in the proper hospital performance in biological disasters. the obtained subcategories were as follow: the ability to manage the biologic event and treat patients; the ability to care for the patients; the ability to decontaminate the injured people and surfaces; the ability to perform biologic triage; and pre and post exposure prophylaxis in affected individuals. - : drug therapy of patients and pre and post exposure prophylaxis: the extracted common codes according to participants' interviews were possibility of appropriate response after a biological event in a hospital, prompt and suitable treatment of the patients, having an efficient team of rapid response, the ability to discharge if necessary, pharmaceuticals prescription, having adequate stockpiles, and the ability to perform pre and post exposure prophylaxis. one participant (p ) said, "if prevention is not imminent with different medications and appropriate vaccines, the disease would spread. for example, if respiratory anthrax or plague becomes prevalent, vaccination and appropriate therapeutic prophylaxis are the only way to prevent the disease progress in the community". - : nursing: the presence of skilled and capable nurses was one of the subcategories obtained in this study. nurses who are trained, skilled, and familiar with personal protective equipment may have positive effects on hospital performance. one of the participants (p ) mentioned: "having skilled nurses to care for infectious patients is valuable as patients' treatment in epidemics. one day i went to the hospital for a visit and saw the aids patient wearing a mask. the head-nurse had told him to do so". - : isolation: according to the participants, the ability to isolate patients with communicable diseases in the hospital and in the designated sites for group isolation was an important component of infection control. one participant (p ) said, "isolation spaces are needed based on the causative agent (such as droplet or airborne isolation). in emergency situations, metal partitioning is better, and if not possible, minimal isolation should be executed even with curtains". - decontamination: most participants considered the ability to decontaminate victims efficiently as one of the important factors in hospital performance dealing with biological disasters, which is an important step in decontaminating patients, surfaces, and equipment in proper response to such disasters. one of the participants (p ) stated, "environmental health authorities should be active in tackling the issue. notifications should be declared as soon as possible. environmental decontamination is needed for each disease". - : triage: according to participants, the use of specialized triage in biological events affecting many victims will enhance hospital performance. biological triage which has a different mechanism than other triage systems helps to reduce infection transmission and provide high-speed treatment for people with high-priority care. it also provides the most services in the least amount of time to the largest number of victims. one participant (p ) said, "all hospitals should have a triage system and special checklists." biological triage is necessary. there are no triage systems for infectious diseases in my hospital, so there is not any sorting during an outbreak". - : infection control: participants considered infection control as an essential criterion for hospital performance in biological disasters. the common codes derived from these subcategories are as follow: the ability to control infections during deliberate or natural biological outbreaks; the availability of preventive drugs at a predetermined time during an epidemic of communicable diseases; appropriate vaccination of people at risk; and the safety of hospitalized or outpatients patients in the outbreak of infectious diseases; and waste management. one participant (p ) stated, "to see how a hospital performs, we need to see how much patient's safety is considered. sometimes, with a simple maneuver such as washing hand, transmission of the infection would be prevented". participants considered inter-sectoral and intra-sectoral coordination as an important factor in the proper hospital performance during biological disasters. - : intra-sectorial coordination: a common subcategory was coordination and collaboration within the hospital during a biological disaster, including predetermined inter-organizational tasks. one participant (p ) said, "when epidemics occur, it is highly important that internal parts of the hospital (such as laboratory, radiology, emergency departments, and others) be coordinated. in the early days of influenza epidemic, we did not know where to send the patients' samples for definite diagnosis, which made the process more complicated". - : inter-sectorial coordination: the common codes in this subcategory were as follow: existence of memoranda between hospitals and partner centers (such as organizations for corpses burial, drug production companies, vaccines and personal protective equipment producers, reference laboratories, buildings' owners that can be used for mass storage or isolation). one of the participants (p ) stated, "if there is a suspicious anthrax case and the hospital is a regional one, they should know which laboratory would help, and there should be an accepted guideline for referral". according to participants' viewpoint, the availability of appropriate human resources, necessary equipment, appropriate physical structure, and enough funding has a beneficial effect on hospital performance in biological disasters. these subcategories created the category of resources. - : human resources: according to the participants' perspective, one of the most important factors affecting hospital performance was the availability of human resources in biological emergencies in terms of quality and quantity. defining an organized structure of the staff for the response, duty description for the team, the right staff, and an efficient manager in the hospital seemed necessary at the time of biological disasters. one participant (p ) said, "sometimes we have cases of flu, meningitis, and tuberculosis, but the hospital performance is not appropriate and practical. although training was provided and relative preparedness was expected, during the swine flu outbreak, all staff were afraid and wore masks in hospitals. even the staff in the infectious diseases ward wore masks, which was not necessary and only caused horror. only those who are within a meter of the patient should wear a mask". . : physical structure: based on participants' viewpoint, appropriate physical structure of hospitals to respond to biological disasters is an effective factor in dealing with biological disasters. the proper physical structure of a hospital, enough space for biologic triage, suitable isolation space considering the type of agent, a proper radiology and laboratory structure, and a standard lab were effective subcategories of this category. one participant (p ) said, "one of the performance evaluation factors is whether the hospital has been standardized; having a triage space and decontamination room before entering to the main ward and isolation from the emergency department are highly important. in the influenza epidemic, all hospitals were ordered to separate the patients upon arrival at hospitals, but this was not possible in some hospitals". - : equipment: the subcategories were equipping some ambulances ready for a biologic event, having special and practical equipment when dealing with biological disasters, adequate personal protective equipment, and the ability to maintain laboratory biosafety. one participant (p ) recommended, "having enough equipment to be able to provide good biosecurity is of significant importance. there is not a special stretcher for contagious patients in our hospital, and the lack of a special stretcher for carrying infected patients can impair performance". - : budget: according to the participants' opinion, allocation of appropriate budget for hospital was an effective factor in assessing the hospital performance during biological disasters. insurance of staff and the hospital, and proper allocation of funds were the common subcategories of this category. one of the participants (p ) said, "my hospital manager is concerned about the financial aspect, and he has limitations on training and recruiting human resources. we do not have financial resource even for equipment and training, and our managers do not believe in spending money for managing these disasters. they prefer to deal with tangible issues rather than intangible issues such as biological disasters that have not yet happened". training and exercise influence hospital performance. the subcategories were appropriate educational content in accordance with the up-to-date changes in the field and intermittent exercises. - : educational content: the following subcategories were extracted: having rich and up-to-date educational content with emphasis on biological group a & b agents; providing training on how to use personal protective and prevention equipment, triage, isolation, secure area, control, and treatment; and providing training for misbelief correction. one of the participants (p ) said, "there should be an educational content related to the subject; it can be a part of hospital accreditation. some employees even do not know the correct pronunciation of diseases". - : training: all participants considered staff training as one of the most important factors in hospital performance. the extracted subcategory was receive training in the field of biological agents, including continued and regular education, up-to-date training, and training about preventive and personal protective equipment (mask types and time), isolation types, triage, secure area, and group a & b agents. one participant (p ) recommended, "up-to-date training should be available for staff with an interval of maximum of up to year. our personnel have been graduated many years ago, and their training has not been updated at all". - : exercise: by analyzing the data, intermittent and proportional exercises were obtained as common codes in the exercise subcategory. according to participants, the factors of this subcategory included the need to conduct a biological exercise in the hospital, and presence of a range of exercises such as top table exercise for managers and coordinators and other types of exercises, and execution of intermittent drills within a specified time schedule. one of the participants (p ) declared, "our managers did not have any experience in biological disaster management, even in the form of a drill. we should exercise and learn what we lack". another participant (p ) said, "there should be an exercise index for evaluation (drills about personal protective equipment) ". according to the results of the data analysis, the risk communication system, information security, risk understanding, and surveillance system were subcategories of the communication and information system category. - : risk communication systems: having a risk communication system, information security, risk understanding, and a surveillance system were determined as subcategories of this category. - : information security: information security is important in an outbreak of infectious diseases in hospitals, as non-patients may go to the hospital for fear of panic or patients may not come to the hospital for fear of stigma. the common codes were as follow: the possibility of sending written reports or internal automation to senior officials, laboratories, and the ministry of health, and lack of public notification in some instances. one of the participants (p ) said, "a false outbreak would occur without proper communication with the economic authorities. each time after a rumor about an infectious disease, many will come to hospitals as false patients, and controlling such situations would be very difficult". - : risk understanding: this subcategory was also derived from the information and communication category. participants believed that developing a positive attitude towards the possibility of biological disasters in hospital managers is crucial, because if a manager or staff does not believe in the possibility of biological disasters, there would be no possibility of necessary and timely action. one participant (p ) declared, "hospital managers do not have a proper attitude about this kind of problems. even after being trained by senior officials, they still do not have a good perception of the biologic disasters". - : surveillance system: according to participants, the use of surveillance systems in hospitals and the active registration of infectious diseases were considered as effective factors in hospital performance. one participant (p ) said, "the center for diseases control of ministry of health has a tradition of its own. in the health sector, they have a disease expert who will inform you if something happens. they themselves do not actively seek out any disease". the existence of an appropriate hospital incident command system (hics) for biological events was one of the main obtained categories in this study. extracted categories were the need for existence of a code for the biological crisis, type of system activation, existence of a unique command, use of qualified advisors in a commanding system, and proper organization of the staff. one of the participants (p ) announced, "having an incident command plan during a biological disaster is highly important. commanding systems do not work well in our hospitals in important and dangerous disasters such as earthquake and floods". planning and assessment were among the other key elements that influenced hospital performance during emergencies. risk assessment in hospitals was identified as a basic point in evaluation of hospitals. in the absence of a risk assessment in a hospital, finding priorities for risk reduction measures can lead to resources loss and parallel work. participants considered the factors that impacted hospital performance: the existence of qualified self-assessment mechanisms along with appropriate indicators in assessment checklist and a well-defined cutoff point. extracted subcategories were existence of updated instructions and guidelines, a special response and recovery plan for biologic threats, using the all-hazards approach to preparedness, and a lab plan. another participant (p ) said, "readiness assessment checklist must be completed every - months for each center. our hospitals do not have any assessment checklist for infectious diseases". in this qualitative study, which was done using content analysis, the effective factors for hospital performance in biological emergencies in ir of iran were identified as follow: diagnosis; treatment and control of infection; resources; coordination; training and practice; communication and information systems; construction; and planning and assessment. detecting a biologic event is one of the primary influencing factors in hospital performance. early diagnosis is one of the important factors for initiating immediate action and response to prevent further development of a biological agent ( ) . controlling hospital outbreaks requires rapid diagnosis and search for clusters; then, appropriate controls are executed ( ) . early diagnosis of the disease prevents its spread and can be effective in the timely treatment of exposed individuals and doing biologic triage. while an epidemic is rapidly discovered, its spread can be prevented by isolating patients and prompt prophylaxis. also, recognizing the type of biological disaster (intentional or unintentional) aspect may have an impact on hospital function because management of such biological emergencies may en-counter many complications considering type of agent, genomic manipulation, event location, geological and climatic conditions, and disease spread in the community prior to definitive diagnosis ( ) . over the past decades, the intentional enhancement of using biological agents has increased the demand for risk assessment and monitoring of such events, which often involves modeling approaches based on certain assumptions such as the ability to generate, store, and distribute. the ability to release a biological agent as a weapon does not only result in the creation of airborne transmissible microorganisms but can be transmitted from human to human and spread. management of deliberate transmissible is different from that of non-transmissible epidemics ( ) . another effective factor in hospital performance in biological events is treatment and infection control. in a biologic emergency, treatment measures and timely response to the event are important factors. triage is an important factor in controlling hospital infection during a biological emergency ( ) . most triage systems deal with traumatic or kinetic injuries ( ) . such systems are not applicable to other types of disasters, including biologic emergencies, because some factors (eg, exposure and symptoms) do not affect the infection control and make rapid diagnosis and treatment more difficult. victims are unlikely to be harmed, and there may not be a particular scene of disaster ( ) . therefore, it is necessary to consider a special system of triage instead of conventional systems ( ) . in accordance with burkle's recommended method, biologic triage is used for patients in an incident with a large number of injured people and divides them into groups: ( ) susceptible but not exposed; ( ) exposed but not yet infectious; ( ) infectious; ( ) removed by death or recovery; and ( ) protected by vaccination or prophylactic medication ( ) . in settings where infectious diseases are easily transmitted, deaths from infectious diseases are more likely than traumatic events ( ) . therefore, applying biologic triage is vital for controlling transmission. during biologic emergencies, triage makes it easier to control and treat the patients, prevents loss of resources, and reduces the probability of transmission of communicable diseases, and decreases the burden of hospitalization by reducing the number of visits to hospitals ( , ) . in this regard, access to drug and vaccine supplies and appropriate measures can reduce the number of patients or decrease the disease severity. effective actions in performance are hand washing and self-protection methods for staff, and proper isolation based on the type of disease ( , ) . providing care for patients within the hospital is an important part of patients' treatment and infection control at treatment centers ( ) . therefore, having competent nurses and trained infection control specialists as well as self-protection methods are other measures related to performance improvement ( ) ( ) ( ) ( ) ( ) . in biologic emergencies, one means of differentiation with other common emergencies is the need for self-protection methods of staff, especially physicians and nurses who have close contact with the patients ( , priate measures stops the transmission of the infection between patients and staff, including nurses ( , , , ( ) ( ) ( ) ( ) ( ) ( ) . decontamination spaces of biological patients will make these disasters distinct from others. decontamination is less important in disasters with large number of traumatic patients, but in biological disasters (especially man-made), the entry of noncontaminated patients into hospitals and the implementation of individualized and collective quarantine are of great importance ( , , ) . risk management approaches for infectious disasters are necessary to reduce the risk of secondary contamination with regards to decontamination measures and surveillance ( ) . based on the results of this study, human and financial resources, physical structures of hospitals, and equipment (including personal protective equipment, laboratory, appropriate vaccine, and antibiotics) are effective factors in the proper functioning of hospitals. these findings were consistent with those of other studies ( , ( ) ( ) ( ) ( ) . an appropriate response requires access to laboratory facilities ( ) . decontamination facilities and access to personal protective equipment for triage and decontamination teams are among the limitations of performance in biological events ( , , ) . adequate budget is usually not allocated due to the high cost of preparedness and performance measures in infectious disasters. several studies have shown that the number of public health staff may decrease at the time of biological disasters (such as flu pandemics) ( ) ( ) ( ) . typically, volunteers will meet the required human resources (efficient and trained personnel) in disasters ( , ) ; however, this would not be the case in biological disasters. although the amount of motivation to work during biological disasters varies from country to country, the total amount of motivation is lower than in other events ( , ) . this drop in staff motivation is also evident in the number of volunteers ( ) . however, more research is needed to study the willingness of public health staff in disasters ( ) . therefore, one of the most important factors in biological disasters is the provision and management of manpower required in hospitals. previous studies have shown that male gender, being a physician, having a full-time job, self-protection, and communication equipment for staff, and basic needs such as water have a positive impact on the willingness to work in such events ( , , ) . motivation facilitators for working in infectious emergencies include access to vaccination and personal protective equipment, flexible work shift, taking care of staff children, and information sharing ( ) . regarding the release of a biologic agent, the strategic storage of the vaccines as well as pharmaceuticals for treatment of the agent can be important because easy access to antibiotics and vaccines is very effective. access to ventilators for the management of infectious respiratory disasters is a necessity ( , ) . there are currently antiviral drug storages for responding epidemics that cost a lot ( ) . the lack of funding and financial resources is a major obstacle to the preparedness and proper performance in infectious disasters ( , ) . appropriate supply strategies, adaptation to the severity of the event, and the type of microorganism have a preventive and controlling role in infection from person to person ( , ) . also, having a proper physical structure to respond to biological events is important for proper functioning. this factor has been mentioned in numerous articles ( ) ( ) ( ) ( ) . examples which may be presented here are the existence of a separate entrance door for the emergency department, proper design of the rooms and the hospital, and proper equipment (eg, separate ventilators in the emergency department) ( ) . based on the findings of this study, staff training was one of the main elements of the proper functioning of hospitals in biological events. reviewing articles also indicated that education and training are key elements in disaster preparedness ( , ) . many efforts have been made to explain the capabilities and design of training curricula for management and response to cbrne events, but there is still lack of capability-based plans ( ). emergency department physicians, nurses, and support staff are the main groups for training and education. hospitals will not be able to respond appropriately in disasters without the upgraded educational guides ( ) . training is an important challenge in managing disasters which was obvious in events such as ebola outbreak. control of communicable diseases such as ebola and other infections may be affected by lack of educational materials, curricula (educational curriculum, development of educational contents, training resources, and tools), and educational contents ( ) . most of training courses (during and after ebola epidemic) have been performed for infection control staff and has not been addressed for other stakeholders ( ) . best practices for ebola education are engaging all stakeholders (eg, crisis managers, infectious disease control staff, and health workers) in educational programs. the most important educational challenges are annual budget and misdeclaration of sufficient training in an organization ( , ) . sustained education for combating the spread of infectious diseases requires annual budget, full support of the organization management, and engaging all stakeholders ( ) . the reports show poor knowledge about disaster planning and biological events in emergency departments around the world ( , , ) . it is imperative to ensure full recognition of risk reduction plans in infectious disasters for all those responsible for reducing the risk. in an egyptian study, medical residents had less training on personal protective equipment than specialists and counselors ( ) . however, education in this regard is one of the key points in infection transmission and control. occupational and non-occupational stresses in physicians were more than nurses, indicating the need for further training on the nature of pandemics, the results, complications, and methods of infection prevention ( , ) . in the absence of comprehensive support and failure to address the motivation or needs of professionals, effective education and the use of educational opportunities would be a challenge ( ) . developing educational standards and guidelines for a medical response to disasters (especially cbrn) has a major impact on emergency response to disasters ( content, determining the type of training, and evaluation of tools. a review article of cbrne training courses between - indicated that course evaluation was not done by any study ( ) . essential elements of education are personal protective training, hospital incident commanding systems for emergencies, surge capacity, and assessment and risk determination in accordance with biological disasters ( ) . coordination is one of the disaster management requirements in communities and hospitals. disaster management occurs in a complex context. this complexity is the result of a variety of different functions of the external and internal sectors in a hospital. coordination of these sectors would result in proper disaster management. in this study, internal and external coordination were key factors in response to biologic disasters. the presence of the emergency coordinator promotes health sector preparation activities. coordinators also provide a road map for moving in and out of hospital-crisis-related factors. avery et al indicated that the presence of a coordinator increases the level of readiness in the health sector in a disaster ( ) . this is evident especially in infectious disasters which require more coordination between infectious disease control centers and security sectors. jones et al showed that the coordinator had a direct relationship with the readiness of hospitals in pandemics. the connection was not linked to readiness in other settings such as casualty incidents, general preparedness of the hospital, and inefficiency of the hospital infrastructure. this could be a sign of the difference in infectious disasters. management requirements of such events include provision of vaccines, drugs, and personal protective equipment, and sufficient equipment and personnel resources at local, national, and international levels. memoranda of agreements (moas), memoranda of understanding (mous), and planning partnerships with other hospitals, health centers, government, local authorities, and other providers of support services are examples of out of organization coordination ( ) . capability of hospital external evacuation also requires external organization coordination, which according to the review of articles in the field of interhospital memoranda, has the lowest rate for children and infants ( ) . risk communication is one of the central components of proper performance of hospitals during infectious disasters ( ) . communications and information systems were derived as one of the main categories in this study. when an outbreak occurs and general public health is compromised, direct interventions and treatment options may be limited due to lack of time and the need for resources. therefore, communication, notification, and guidance are often the most important tools of public health in risk management during such events ( ) . communication readiness reduces the response time of the crisis ( ) . other impacts of communication and information systems during disasters are confidence of people in managers and acceptance of protective behaviors, disease surveillance, and reduction of confusion ( ) . to effectively respond, information should be organized in a timely fashion and be disseminated through multiple channels along with appropriate training ( ) . health communication includes key elements: message, receiver, source of information, and the channel for information exchange. the above elements should exist and function properly in any health-related communication plan. communication would be implemented in the field of informing the public as well as in health systems, especially with respect to infectious disasters ( ) . public health stakeholders, although not directly involved in public health emergency management, will take timely decisions, plan, and control timely access to information ( ) . moreover, to effectively implement communication in these disasters, standardized educational content, clear national guidelines, and pre-prepared plans in the field of communication in hospitals are required ( ) . ineffective communication is one of the potential reasons for the failure of infection control in health workers ( ) . hospital communications should be completely clear, scientific, and understandable. health workers are an important criterion for community's trust in resources and their knowledge and dealing with the situation will affect the trust of the community ( ). bonneux et al suggest that the management of unpredictable panic of hospital staff is more difficult than controlling the spread of disease ( ) . the clear release of information can prevent the fear of staff and society ( ) , and a long negative impact will occur with no on time intervention on hospital performance ( ) . understanding the proper risk from leading risk is a decisive factor in disaster management. today, in a world where the information transfer (whether right or wrong) is done at a rapid pace, the perception of risk from truly risky cases is less than estimated, and the risk of rare cases is overestimated ( ) . understanding the risk is related to the mental sensation of control. the threat of an epidemic may in part be frightening because of feeling lack of control that leads to an unwanted activity ( ) . verbal communication and standard communications (eg, guidelines, education, electronic communications, and marketing) are definitive communication pathways in infectious disasters. experiences indicate that traditional methods are unsuccessful in changing and maintaining the best performance in infection control, although newer methods (such as electronic communications and marketing) have some problems. some approaches (eg, involving health staff in the communication processes or up-down communication) can improve communication methods ( ) . the timely identification of cases of infectious diseases with increased patients over a given period of time is a critical necessity for the ipcs. survival systems in hospitals are currently focusing on a small set of microorganisms such as methicillin-resistant staphylococcus aureus, carbapenem-resistant enterobacteriaceae, and clostridium difficile ( ) . there are several pathways for the transmission of pathogens (staff to patient, environment to patient, patient to patient, visitors to patient, etc.) due to dynamic health care in hospitals. better monitoring of the epidemics onset would be implemented by operating the modern and multifunctional surveillance systems, including observing symptom reports in specific time spots, syndromic surveillance systems, prediagnosis and nonspecific criteria monitoring, and health behaviors observation (eg, absenteeism from work or school, pharmacy referral or even search rate in search engines with specific words that indicate an increase in the incidence of infectious diseases) ( ) . although more modern systems such as electronic surveillance systems have high sensitivity, their positive predictive value is low ( ) . united states has conducted surveillance systems and epidemiological surveillance with a large budget in the framework of biowatch program to monitor the deliberate propagation of biological agents ( ) . in this study, an incident management commanding structure in accordance with biological emergencies was found to be the proper structure of the main element of performance. hospital incident command systems are used as a model for disaster response in some countries. this system is an attempt for standard performance of hospitals in disasters ( , ) . in recent years, incident command system has been implemented for iranian hospitals to manage disasters with an all-hazards approach ( ) . application of this system is part of the requirements for the accreditation of hospitals in ir of iran. however, this system has limitations such as not addressing the vulnerability of hospitals and not assessing the hospital performance in disasters ( ) . the participants considered the incident command system (consistent with biological events) as an effective element of hospital performance in biological events. use of the incident command system is part of an appropriate response to cbrn events ( , ) . the hospital incident commanding system is an integrated structure that despite the volume and effects of the events can provide coordination, control, operations, planning, support, and other necessary functions for event management, if properly implemented. it also explains responsibilities clearly leading to appropriate response ( ) . the effectiveness of this system has been indicated in outbreaks of infectious diseases ( , ) . if the response to biological emergencies will be designed as a systematic approach, it would lead to faster response by establishing coordination, speed of communication, recalling staff, etc. ( ) . this adaptation could include selection of specialized infectious and epidemiologic consultants, proper planning, operations based on infection control requirements, treatment and care, and other requirements for managing biological crises. in addition, matching these systems with biological emergencies can speed up the response by increasing external and intra-organizational coordination of multiagent organs ( ) . planning was one of our extracted main categories. the existence of disaster management plans in hospitals is essential to ensure preparedness and response, even before the emergence of events. a disaster management plan is a set of procedures, policies, interactional patterns, roles, and contingencies which are developed to prepare and implement appropriate response to a crisis ( ) . this plan includes staff training plans, responding to potential biologic agents, pollution prevention, rapid communication plans, potential quarantine exposure (individual and group), resource production and planning, and rapid diagnostic plans ( , ) . the existence of evidence-based guidelines is one of the deficiencies in infection control in iranian hospitals. self-assessment, external evaluation, and the use of intra-organizational and external experts for scientific review of guidelines and plans can have a positive effect on improving hospital performance. however, performance evaluation can be assessed in real terms after disasters and from lessons learned ( ) . security issues affecting the health and national systems and context of intentional biologic events were limitations of the present study, which did not allow all selected managers to participate in the study. however, the limitation was resolved by continuing the interviews with the main managers, determining the alternative ones, and continuing the interviews until saturation. hospital management in outbreaks of infectious diseases (intentional or unintentional) is complex and requires different planning than natural disasters such as earthquakes, floods, etc. in such disasters, 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for responding to chemical, biological, radiological, and nuclear incidents organization of a hospital-based victim decontamination plan using the incident command structure incident command structure using a daily management system and the centers for disease control and prevention's patient notification toolkit drives effective response to an infection control breach lessons learned from implementing an incident command system during a local multiagency response to a legionnaires' disease cluster in sydney sars and the hospital emergency incident command system (heics): outbreak management as the mother of invention we would like to thank all of participants who spent their valuable time for interviews and other surveys. all authors disclose that there is not any actual or potential conflict of interest, including any financial, personal, or other relationships with relevant authorities or organizations within years of starting the study. key: cord- -xuwoqy authors: ortiz-barrios, miguel; gul, muhammet; lópez-meza, pedro; yucesan, melih; navarro-jiménez, eduardo title: evaluation of hospital disaster preparedness by a multi-criteria decision making approach: the case of turkish hospitals date: - - journal: int j disaster risk reduct doi: . /j.ijdrr. . sha: doc_id: cord_uid: xuwoqy considering the unexpected emergence of natural and man-made disasters over the world and turkey, the importance of preparedness of hospitals, which are the first reference points for people to get healthcare services, becomes clear. determining the level of disaster preparedness of hospitals is an important and necessary issue. this is because identifying hospitals with low level of preparedness is crucial for disaster preparedness planning. in this study, a hybrid fuzzy decision making model was proposed to evaluate the disaster preparedness of hospitals. this model was developed using fuzzy analytic hierarchy process (fahp)-fuzzy decision making trial and evaluation laboratory (fdematel)-technique for order preference by similarity to ideal solutions (topsis) techniques and aimed to determine a ranking for hospital disaster preparedness. fahp is used to determine weights of six main criteria (including hospital buildings, equipment, communication, transportation, personnel, flexibility) and a total of thirty-six sub-criteria regarding disaster preparedness. at the same time, fdematel is applied to uncover the interdependence between criteria and sub-criteria. finally, topsis is used to obtain ranking of hospitals. to provide inputs for topsis implementation, some key performance indicators are established and related data is gathered by the aid of experts from the assessed hospitals. a case study considering hospitals from the turkish healthcare sector was used to demonstrate the proposed approach. the results evidenced that personnel is the most important factor (global weight = . ) when evaluating the hospital preparedness while flexibility has the greatest prominence (c + r = . ). disaster incidents are one of the most endangering events in human life and emergency solutions are needed because of their sudden occurrence (hosseini et al. ) . as such events have devastating effects; they may cause some disruptions in the society to meet their health needs. man-made and natural disasters can interfere with the activities of some organizations such as healthcare facilities. sometimes the capacity of these facilities may not be sufficient to combat the physical and financial damage they may cause. although the ability to be ready for disasters varies by country, it can be said that in the last century, when the frequency and devastating effects of disasters have gradually increased, no country is fully prepared and safe. turkey, which has experienced many devastating man-made and natural disasters, faces with disasters per year (natural and technological) on average. these resulted in death and injured annually on average according to the figures in the emergency events database (em-dat). the disaster trends of turkey are demonstrated in figure . according to these statistics, these disasters have caused a serious total damage in terms of financial loss. turkey has passed a devastating earthquake in on th august, as can be easily inferred from the figure . also, in the following years after , earthquakes, mine accidents, floods, transport accidents, storms, epidemics, landslides, and miscellaneous industrial accidents have occurred in turkey. all of these disasters, especially earthquakes due to their destructive effects on human loss and financial damage, cause various problems in the operation of hospital operations and health services. nowadays, an overwhelming majority of the world is still fighting against a pandemic. covid- , a new type of coronavirus, is an infectious disease that first appeared on december , in wuhan, china. the world health organization (who) declared covid- later as an epidemic. in nearly months, the infection, which first expanded with iran and italy, is spread all over the world. as of april, , it has caused nearly . million cases and , deaths in the world (who, ) . the world has faced an unusual number of infected people in hospitals. this surge made it mandatory for countries to make their hospitals, field hospitals, or specific pandemic hospitals prepared in a considerable and short time. therefore, it is required to prepare the hospitals and all healthcare stakeholders for the disasters. in hosseini et al. ( ) , preparedness is defined as the inclusion of activities set up to build a mechanism for rapid responses to limit the risks and effects. one of the crucial components of improving disaster preparedness is to evaluate the readiness of hospitals and then propose a ranking of them. hospitals should be prepared for physical infrastructure and resource planning, as they are the only places to provide first care during a disaster. the postdisaster problems encountered by hospitals are stated in the literature as follows (gul and guneri, ; dursun et al. ): a surge in patient arrivals, communication issues, lack of adequate treatment and care area, problems in patient transfer. keskin and kalemoğlu ( ) pointed out that the most important post-disaster problem faced by hospitals is the excessive patient admission. similarly, the lack of coordination between disaster area and hospitals (kurt et al. ) , lack of telecommunication (ishii and nakayama, ) , chaos, and triage difficulty due to patient surge (yamauchi et al. ) are some of the other problems raised in the current literature. from these studies, it is inferred that disasters directly affect hospital activities. since the occurrence of disaster events causes mass casualties, public panic and chaos. most hospitals are unprepared to tackle thousands of patients arrived in case of a major disaster (foxell and mccreight ) . therefore, planning of hospital resources (treatment area, equipment and personnel) and determination of disaster preparedness levels of hospitals can be effective in reducing the damage caused by disasters. on the other hand, another issue related to disaster management is the importance of conducting risk analysis and loss assessment studies for urban areas (pitilakis et al. ; zuccaro and cacace, ; fawcett and oliveira, ) . these studies provide insight into the accessibility of hospitals as well as the assessment of losses and thus how they can affect the needs of healthcare services after a disaster. in this study, a hybrid fuzzy decision making model was proposed to evaluate the disaster preparedness of turkish hospitals. this model was developed using three well-known multicriteria decision-making (mcdm) methods named as fahp, fdematel and topsis. the ultimate target of the study is to determine a ranking among hospitals in terms of disaster preparedness. fahp is used to determine weights of six main criteria including hospital buildings, equipment, communication, transportation, personnel, flexibility and thirty-six sub-criteria under these six main criteria. ahp contains some important characteristics such as pair wise comparison, hierarchy, independency and consistency in decision making. since, fahp is frequently used as a weighting tool in the literature; we use it in this study with fdematel which has ability to evaluate interdependence between all the sub-criteria of the model. finally, topsis is used to obtain the ranking of hospitals. to apply the hybrid decision making model, two different questionnaires are created and assessed by five experts related to the field of disaster management of healthcare facilities. to provide inputs for topsis implementation, some key performance indicators are established and related data is gathered by the aid of experts from the assessed hospitals. the remaining of the study is organized as follows: section provides a review of the literature covering conceptual and research articles regarding the topic of hospital disaster preparedness evaluation. the third section gives the methodology used for the study. initially, applied mcdm methods are described then, the proposed hybrid approach is identified. fourth section concerns with a demonstration of the proposed approach. the evaluation criteria, the decision-making team, implementation of the questionnaires and results of each mcdm method are presented in this section. final section concludes the study with some future research recommendations and limitations of the current work. various conceptual-based and mcdm-based frameworks are proposed in the literature to assess the preparedness level of hospitals (hosseini et al. ; gul and guneri, ; top et al. ). in conceptual-based frameworks, researchers construct their disaster readiness frameworks without using any numerical tools. they directly focus on some dimensions such as structural, non-structural, functional, and human resources. on the other hand, in mcdm-based frameworks, researchers initially determine the main objective, disaster preparedness criteria and sub-criteria, alternative hospitals that will be assessed with respect to concerning these criteria/sub-criteria (the decisional hierarchy). then, a decision matrix is built that includes a weight matrix of criteria/sub-criteria. using this decision matrix, a final decision is made using an mcdm framework such as topsis. in the literature, the number of conceptual-based frameworks and cross-sectional surveybased studies are more than mcdm-based frameworks. as an example, hosseini et al. ( ) proposed a topsis-based ranking model for eight selected iranian hospitals. they ranked these hospitals in terms of disaster preparedness ability. four crucial criteria of structural preparedness, non-structural preparedness, functional preparedness, and human resources are taken into consideration in their study. the weights of these main criteria are assumed as %, %, %, and %, respectively. no mcdm method has been followed to determine weights to these criteria. results the results of the study suggest that any of the observed hospitals are not in on a well-prepared level. in another study, proposed an analytic decision-making preference model for the disaster preparedness of hospital emergency rooms in colombia. the mcdm model includes three well-known methods of ahp, topsis and dematel. gul and guneri ( ) made a conceptual study regarding the preparedness capability of hospital emergency rooms in istanbul, turkey. they combined the data of reports, literature, and one-to-one interviews with experts who experienced the recent istanbul earthquake. the interviews are analysed in terms of some earthquake key statements. the important issues faced during the earthquake from the viewpoint of hospital care are extracted. top et al. ( ) applied a questionnaire about hospital disaster planning in a total of turkish hospitals. a number of questions are included in the study. focus the focus of the questions are is about having any written hospital disaster plan and whether performing an exercise on an annual basis or not. the characteristics of hospital disaster plans are queried with respect to concerning the hospital category (public, private, university and all). unlike the above-mentioned studies, there exist many papers using a cross-sectional methodology, delphi, and similar tools (rezaei and mohebbi-dehnavi, ; saeid et al. ) . for a broad literature review in disaster preparedness of hospitals, scholars refer to the paper of alruwaili et al. ( ) . tabatabaei and abbasi ( ) performed a semi-quantitative cross-sectional study in some iranian hospitals to assess risks during disasters based on the hospital safety index. two different questionnaires were designed for collecting metrics (structural, functional, and nonstructural factors) supporting the evaluation of hospital disaster readiness are the general information of hospitals and disaster ability bythis is not fully numerical or mcdm-based study. otherwise, it benefits from a semi-quantitative disaster preparedness assessment method. similarly, naser et al. ( ) made a cross-sectional study to assess hospital disaster preparedness of public and private hospitals in south yemen. are included to the study. results the results of the study demonstrated that hospitals are in an unacceptable level of readiness. samsuddin et al. ( ) investigated disaster preparedness attributes and hospital's resilience in malaysia. a cross-sectional questionnaire has been performed among malaysian hospitals' staff considering a total preparedness attributes and resilience indicators are used in the study. the results showed that human resources & training and the ability to adapt in a timely manner promptly are were ranked as the most critical attributes. the results can help hospital's stakeholders in malaysia to improve the its preparedness capability. marzaleh et al. ( ) developed a model for hospital emergency room preparedness against radiation and nuclear incidents as well as nuclear terrorism in iran. by utilizing the delphi method, criteria are considered under three main classes, namely staff, stuff, and structure (system). in conclusion of the results, staff preparedness and stuff preparedness had the highest and lowest priority levels, respectively. shabanikiya et al. ( ) designed a tool for hospital preparedness for surge capacity during disasters. they used the delphi method in their developed toolkit as in marzaleh et al. ( ) and assessed components in five categories and sub-categories. the developed tool was used in evaluating hospital preparedness for surge capacity in disasters and planning the future of hospitals against disasters. the current study is differentiated from both studies mentioned under the class of mcdmbased frameworks in some aspects. the first difference concerns the comprehensiveness of the hospital disaster preparedness criteria set. while hosseini et al. ( ) considered four preparedness dimensions as mentioned above, constructed the hierarchy under seven criteria. in ortiz- , the decision-making team identified criteria and sub-criteria to evaluate the readiness of emergency departments for a disaster situation. the criteria set of our study include hospital buildings, equipment, communication, transportation, personnel, and flexibility. these criteria are more inclusive than the two studies and can easily be adapted to potential models that can be developed later. moreover, ortiz-barrios et al. ( )'s study is developed for specific emergency departments. a main dimension similar to the one we use in this study and which we called "flexibility" is not mentioned in hosseini et al. ( ) 's study. the second difference stems from methodological sides. in hosseini et al. ( ) , an assumption and full subjectivity are preferred in weighting the main criteria. the assignment of criteria weights is not clear. any weight assignment is not performed for sub-criteria. unlike this, we follow a group-decision making procedure via an experienced decision team in weighting both criteria and sub-criteria using fahp. besides, none of the studies proposes a fuzzy-based mcdm approach. however, by integrating linguistic expressions and corresponding fuzzy numbers into our approach, we aim to eliminate the insufficiency and preciseness of the crisp pairwise comparison in classical ahp in capturing the right judgments of decision-makers. as discussed above, many studies are existed have been undertaken for assessing hospital disaster preparedness. most of the papers contribute to the literature by proposing conceptualbased frameworks that we discussed. on the other hand, cross-sectional questionnaire-based models that suggest new attributes regarding hospital disaster readiness and review papers that provide a comprehensive overview to of the topic are also widespread. also, our brief review in this section shows the importance of hospital disaster preparedness assessment from the mcdm viewpoint of mcdm throughout the literature. it can be observed that there exist is a wide ranges of mcdm methods used in the literature with applied application to various areas. so far, however, there have been limited papers regarding the use applications of fahp, fdematel, and topsis in hospital disaster preparedness. by doing the current study, we aim to provide some contributions to the literature. these are as follows: . we developed a model specifically dealing with hospital disaster readiness assessment and ranking. this topic has been also addressed in other studies considering a number of service-quality criteria ; our model, however, incorporates on conclusion of the analysis of upon analyzing the published papers, it is observed that our study covers a number six disaster readiness criteria (hospital buildings, equipment, communication, transportation, personnel, and flexibility) and thirty-six sub-criteria representing the entire context of hospital disaster management. under six main headings of, thirty-six sub-criteria under these six main criteria are determined. most of the criteria are proposed and defined for the first time in the literature. . we developed a three-mcdm-integrated approach that includes fahp, fdematel, and topsis. fahp is was firstly used in for determining the initial weights evaluation criteria of hospital disaster preparedness criteria. furthermore, the fdematel method can derive the weights considering was then applied for assessing the interrelations among criteria. therefore, we also applied it to the determination of criteria weights. we have combined these two fuzzy mcdm methods with topsis in this study to rank hospitals in terms of readiness. in view of the characteristics of all these methods either individually and in integrated style, the proposed approach can handle the problem in a systematic and analytical manner. indeed, the hybrid approaches can tackle the limitations that single methods hold (zavadskas et al., ; ortíz-barrios, ) . for instance, topsis uses criteria weights that are usually defined randomly. fahp, specialized in prioritizing decision elements (saaty, ) , has been therefore proposed to address this drawback. on the other hand, fdematel has been incorporated into this approach since fahp is unable to evaluate interdependence among criteria. although anp can be also used to this aim, its application has been proved to be time-consuming and highly complex, especially in models with a significant number of criteria and sub-criteria (kumar and haleem, ) . on a different tack, topsis was deemed as a suitable method for ranking the hospitals according to their disaster preparedness level. this technique was preferred over ahp since the latter method entails many pairwise comparisons given a large number of hospitals. although a pilot application including hospitals is presented in this study, it is noteworthy that the proposed approach has been projected to be used at a national level in turkey where a significant number of alternatives needs to be considered. dea can be also employed for this particular aim; it, however, assumes that inputs and outputs are known which cannot be fully ensured in all disaster readiness criteria (velasquez and hester, ) . in table , we present a comparison with the four aforementioned studies based on some specific aspects. it can be seen from table that the proposed approach meets all three important aspects (pairwise comparison criteria, fuzziness in determination of criteria weights, and interdependence evaluation between criteria), and is more satisfactory in terms of quantity of criteria and coverage of the criteria. the rest of the approaches only cover two aspects at the most. based on the previous considerations, the novelty of this study is as follows: a) the inclusion of fuzziness in the calculation of criteria and sub-criteria weights using the fahp method. this is motivated by the need for dealing with the imprecision and uncertainty of linguistic evaluations which makes the model more realistic and coherent with the real scenario. besides, this aspect has not been addressed by the previous related studies as evidenced in table . b) the evaluation of fuzzy interdependence between disaster readiness criteria through fdematel for facilitating the design of long-term improvement plans by the government and other stakeholders. similar to the point a), this aspect has not been dealt in the reported related literature. c) the incorporation of several criteria that have not been considered in other related studies (i.e. flexibility and contingency staff). a six-step procedure (fig. ) is proposed to evaluate the hospital disaster preparedness and detect the weaknesses that should be tackled by each institution for upgrading their response to disaster incidents: step : a decision-making team is chosen considering their expertise (related to disaster management, healthcare management, and mcdm) and experience (at least years in the turkish healthcare sector) on disaster management and emergency care services. the selected participants (n) will be asked to provide insights on the definition, importance, and influence of assessment decision elements (criteria/sub-criteria) through fahp and fdematel techniques respectively. in this regard, it is critical to define the number of experts participating in the decision-making process so that criteria weights, interdependence results, and topsis scores can be calculated at a high confidence level (cl = % at a minimum) and low error level (e = % at a maximum). step : the assessment criteria and sub-criteria are determined given the related scientific literature, government regulations and experts' considerations. step : fuzzy ahp is implemented to estimate the relative weights of criteria and sub-criteria under vagueness (see sub-section . . ). step : fuzzy dematel is applied to pinpoint the dispatchers and receivers per each cluster while estimating the strength of influence among criteria/sub-criteria (see sub-section . . ). step : fahp and fdematel are later integrated to calculate the final criteria and subcriteria weights with basis on interdependence (see sub-section . . ). step : topsis is finally used for ranking the hospitals on the basis of disaster preparedness. in parallel, weaknesses are identified for propelling the design of focused improvement interventions in each institution (see sub-section . . ). in this subsection, we identify the applied mcdm methods either used in fuzzy sets or in crisp environment. therefore, prior to giving the details of fahp and fdematel method, an overview on the notations of fuzzy sets may be useful. zadeh ( ) introduced fuzzy sets for better reflecting of the human judgments and assessment in decision making. also, the usage of fuzzy sets is better for transforming linguistic decision of human judgment and reflecting uncertainty and ambiguity of the real world decision making processes. hence, many problems have used the fuzzy sets. the inclusion of fuzziness, however, entails more complex calculations compared to the existing related approaches. to tackle this disadvantage, an excel-based decision support system has been properly designed and adopted to accelerate the disaster preparedness evaluation in relation to: i) weighting and prioritizing disaster readiness criteria and sub-criteria, ii) identifying the dispatchers and receivers within the disaster management scenario, iii) ranking the hospitals according to their preparedness level, and iv) defining focused operational strategies for increasing the response of hospitals against outbreaks. one representation of fuzzy sets is the use of triangular fuzzy numbers. a triangular fuzzy number consists of comprises lower, medium, and upper numbers of the fuzzy as = ( , , ) where l, m and u which is crisp and real numbers ( ≤ ≤ ). the membership function of a triangular fuzzy number ( ) can be defined as follows. a triangular fuzzy number is presented in figure . table . defuzzification style: graded mean integration representation (gmir) "# $ % = ( $ + $ + $ ) ( fahp is one of the commonly applied mcdm methods. crisp ahp cannot mirror the subjectivity broadly. although saaty and tran ( ) stated that ahp integration with fuzzy sets cannot be effective, there are many studies in the literature that integrate ahp with these fuzzy sets. some arguments in these studies are as follows. kahraman et al. ( ) stated that ahp cannot reflect the thinking style of human, therefore, the fuzzy extension of ahp has been developed. chan et al. ( ) stated that with fuzzy cluster and ahp integration, mathematical uncertainty would be better expressed and could be therefore used in solving real-world problems. also, wang et al. ( ) expressed that ahp is integrated with fuzzy sets to better reflect uncertainty. therefore, ahp is improved by fuzzy sets to demonstrate uncertainty and vagueness. different improved versions of ahp by fuzzy sets are available in the literature (buckley, ; chang, ) . in this existing study, buckley's ( ) method is applied to determine hospital disaster preparedness criteria. in some fahp extensions, for example in chang's extent analysis, a limitation is released. an irrational zero weight generation problem in criteria weighting (chan and wang, ) is detected in chang's fahp. step -pairwise comparison of each criterion: linguistic terms are used in determining relative importance of each two criteria based on eqs. and . although the saaty natural scale ( : equal importance; : weak importance; : strong importance; : very strong importance; : absolute importance; reciprocals) was initially proposed to denote the preferences between two elements either criteria or sub-criteria (saaty, ) , a shorter and fuzzy version of this scale ( : equally important; : more important; : much more important; , : less important; , : much less important) (eq. ) has been adopted to deal with the imprecision of linguistic evaluations whilst reducing some bias and confusion during the comparison process (pecchia et al. ; ijzerman, van til, and bridges, ; ortíz-barrios et al. ). $ = , , , :;<=>;<?@ < <a b c?;>d e<=ℎ :;<=>;<?@ g < = g , , , , , :;<=>;<?@ g <a b c?;>d e<=ℎ :;<=>;<?@ < ( ) step -fuzzy geometric mean matrix: it is constructed using eq. . step -fuzzy weights: for each criterion, the fuzzy weights are obtained by the eq. . here, e k $ is the fuzzy weight of criterion i and e k $ = ( e $ , e $ , e $ ). here, e $ , e $ , e $ represent the lower, middle, and upper value of the fuzzy weight of criterion i. step -non-fuzzy weights: the best non-fuzzy weights are computed using gmir. finally, the consistency ratio (cr) is calculated via applying eq. - . here, ci denotes the consistency index while ri represents the random index. if cr < %, the matrix is concluded to be consistent and the derived weights are therefore valid for supporting the decision-making process. l" = rs ts ( ) the fdematel method is an improved version of classical dematel method initially proposed by gabus and fontela ( ) . classical dematel considers the relationship between the evaluation criteria in an mcdm problem and classified them into cause-andeffect criteria (akyuz and celik, ; gul et al. ) . the common plus of fdematel is to consider the fuzziness and to provide flexibility in a fuzzy mcdm environment (akyuz and celik, ; wu and lee, ) . step -set up of the expert team. step -determination of evaluation criteria: a five-point linguistic scale is used (no influence, very low influence, low influence, high influence, and very high influence) considering linguistic terms and corresponding triangular fuzzy numbers as given in table . step -initial direct-relation fuzzy matrix: the pairwise comparisons of experts are performed considering linguistics variables, as stated in step . as a result, initial direct-relation fuzzy matrix (u ) of experts is constructed (eq. - ). step -normalized direct-relation fuzzy matrix: in this step, benefiting from the initial directrelation matrix, the normalized direct-relation fuzzy matrix is constructed (eq. - ). step -total relation fuzzy matrix: hereafter the matrix [ , a total-relation fuzzy matrix is calculated as follows . where =̃$ z = ( $ hh , $ hh , ; $ hh ) step : after the computation of matrix e , ;$ + : and ;$ − : are computed. here, ;$ and :̃ show the sum of the rows and columns of matrix e . whilst ;? k $ + :? k shows the importance of criterion <, ;̃$ − :̃ shows the net effect of criterion <. step : defuzzification is the conversion of a fuzzy quantity to a precise quantity (ross, ) . thereafter in this case, ;̃$ + :̃ and ;̃$ − :̃ are defuzzified by using centre of area defuzzification style with eq. ( ). step : in the last step, the cause and effect relation diagram are drawn by the aid of ;̃$ + :̃ and ;̃$ − :̃ . in fdematel, we have used fuzzy arithmetic till step- . in step- , finally, we have applied defuzzification. although some authors from literature have used initially defuzzification then followed crisp dematel, we have done vice versa (si et al. ) . since the nature of our problem is under a situation where the output of the fuzzy process needs to be a single scalar quantity as opposed to a fuzzy set. as we will use crisp topsis in determining hospital rankings in terms of disaster preparedness, we need defuzzified values of weights from fahp and fdematel. therefore, we have applied defuzzification. as stated by oussalah ( ) , in many engineering applications, the need for a numerical value has been usually provided by a defuzzification process. in this study, we use fahp to obtain the relative weights of criteria i (i = , ,…, k) and subcriteria j (j = , , …, n). nevertheless, fahp does not analyse the dynamic interrelations inherent to the healthcare scenario (si et al. ; zhang et al. ) . we therefore propose the integration of fahp and fdematel methods to address this limitation. while fahp provides enough support for conducting short-term interventions, fdematel underpins the definition of improvement actions at a long-term horizon which is consistent with the timetables of the disaster management plans established by governments. the result of this combined approach is a set of weights on the basis of interdependence that are later incorporated in topsis method ( figure ). step-by-step procedure of the integrated fahp-fdematel approach the resulting global criterion importance gcw i (i = , , …, k), local sub-criterion importance pqr $ (j = , , …, n), and global sub-criterion weight gsw j (j = , ,…, n) derived from the hybrid approach can be estimated by implementing eq. , eq. , and eq. respectively. in these formulas, k denotes the total number of criteria whilst n represents the total number of sub-criteria deemed in the mcdm model. on the other hand, (l $ + " $ ) \st and (l $ − " $ ) \st are the prominence and relation parameters of criterion i (i = , , …, k) whereas #l + " % \st and #l − " % \st represent the prominence and relation of sub-criterion j (j = , , …, n) respectively. eq. - combine the weights derived from fahp and f-dematel to calculate the criteria and sub-criteria importance on the basis of interdependence. specifically, f-dematel weights are estimated through the vector length method as follows: u((l $ + " $ ) \st ) + ((l $ − " $ ) \st ) . these weights are further combined with fahp weights by incorporating the vector e (eq. ). lately, the terms topsis initially suggested by hwang and yoon ( ) step-by-step procedure of topsis step : the first step concerns with determination of criteria and alternative set. here, shows the set of alternatives, demonstrates the criteria weights. step : the second step is related to the normalization. it is formulated by eq. ( ). step : the third step presents a weighted normalized matrix which is determined by eq. ( ). step : the positive ideal point (pis) and the negative ideal point (nis) are obtained by eqs. ( - ). where j and j are the benefit and the cost criteria, respectively. step : the fifth step is on calculation of the separation from the pis and the nis. the separation from pis and nis values can also be computed using the euclidean distance formulae as in eqs. ( - ): step : then, the final topsis score is calculated by eq. ( ). by calculating the score in eq. ( ), the ranking orders are determined via a * k c value in descending order. the proper selection of a decision-making team is critical for determining the importance of criteria considered in the assessment of hospital disaster preparedness. likewise, it will provide significant support for identifying the presence of interdependence and feedback within the mcdm model. in this case, seven experts were finally chosen to participate in the decision-making process: academicians ( ), it technician ( ), and disaster manager ( ). it is noteworthy that the academicians are also consultants and researchers who have conducted several projects in the hospital sector. the number of experts (n = ) participating in this application was defined considering cl = %, p = %, e = %, n = (experts fulfilling the inclusion criteria described in step -" .methodology"); and is hence sufficient for obtaining reliable weights. a description of the experts' profile can be found in table : in particular, these experts were selected considering their job title, expertise area (≥ years), and experience (related to mcdm and healthcare). apart from these participants, three researchers with vast experience (≥ years) in disaster management and healthcare logistics acted as facilitators of the decision-making process. specifically, they built the multi-criteria model for evaluating the hospital preparedness when facing disaster situations. in this activity, the decision-making team provided meaningful insights on the criteria to be considered within the model. on a different note, the facilitators also designed the data-collection instruments and indicated experts how to conduct the paired judgments inherent to fdematel and fahp techniques. moreover, they established the indicators underpinning the topsis implementation. it is worth highlighting that this project was initially discussed with the participating experts to facilitate the comprehension on the study goals and obtain feedback before implementation. turkish healthcare regulations, the pertinent scientific literature and experts' opinion served as a basis for defining the criteria and sub-criteria to be included within the disaster preparedness assessment model. a short brief explanation of each decision element was incorporated in the fahp and fdematel surveys for ensuring proper understanding on the model. the final version of the multi-criteria structure is depicted in figure . in particular, criteria and sub-criteria were deemed to rank four hospitals (h , h , h , and h ) and detect their weaknesses as a support for focused improvement. an explanation of each decision element can be consulted in table . in "hospital buildings" (c ) domain, seven sub-criteria were considered: "physical infrastructure" (sc . ), "location" (sc . ), "number of floors" (sc . ), "capacity" (sc . ), "disaster gathering area" (sc . ), "insulation" (sc . ), and "ventilation" (sc . ). "physical infrastructure" (sc . ) evaluates whether the buildings are resistant to disaster such as earthquakes, fire, radiation, nuclear, and terror incidents. "location" (sc . ) is defined as finding the right place for construction of hospitals in terms of the degree and severity of earthquake occurrence. on a different tack, "number of floors" (sc . ) refers to the number of floors that the hospital has. "capacity" (sc . ) measures the total capacity capability that the hospital has in terms of human, medical equipment and treatment areas. on the other hand, "disaster gathering area" (sc . ) assesses the availability of any disaster gathering area of the hospital. "insulation" (sc . ) identifies the capability and/or availability of the insulation capability of the hospital. finally, "ventilation" (sc . ) evaluates the ventilation capability of the hospital. hospital whilst "drinking water" (sc . ) evaluates the availability and management of the drinking water for the hospital. on the other hand, "tent" (sc . ) assesses the availability and quantity of required tents for the hospital whereas "food" (sc . ) represents the availability and sufficiency of food for the hospital under disaster conditions. on a different note, "bed" (sc . ) denotes the availability and adequacy of beds for the hospital under disaster incidents while "triage tag" (sc . ) shows the availability and quantity of required triage tags for the hospital. lately, financing and supplying sources of the equipment are evaluated through sc . and sc . . concerning "communication" (c ) area, three sub-criteria were deemed: "emergency network" (sc . ), "communication tools/device" (sc . ), and "information quality" (sc . ). the first sub-criterion (sc . ) checks the communication ability of hospitals with the institutions having a say in disaster response. the second aspect (sc . ) verifies the type and quantity of communication tools/devices a hospital has. finally, "information quality" (sc . ) evaluates how reliable and effective the communication flows are within a hospital and with their partners during a disaster event. in "transportation" (c ) domain, four pillar aspects were included: "number of vehicles" (sc . ), "helipad space" (sc . ), "safety" (sc . ), and "accessibility (roads)" (sc . ). in this respect, "number of vehicles" (sc . ) considers the quantity of the vehicles that the hospital has for their usage during disaster situations. "helipad space" (sc . ) verifies whether the hospital has an available helipad space for admitting patients transported by helicopter. another element of consideration is "safety" (sc . ) which encompasses the general safety standards of the hospital under disaster situations. finally, "accessibility" (roads)" (sc . ) evaluates the presence and deterioration of roads providing access to hospital in case of disaster. on a different tack, "personnel" (c ) criterion was characterized through six decision elements: "education" (sc . ), "disaster drill" (sc . ), "emergency response team" (sc . ), "coordination" (sc . ), "number of personnel" (sc . ), and "working hours" (sc . ). "education" (sc . ) evidences the education level of hospital staff in terms of disaster preparedness and behaviour in case of disaster. "disaster drill" (sc . ) verifies the implementation of disaster drills for hospital staff and patients. another aspect of consideration in this domain is "emergency response team" (sc . ). in particular, this subcriterion determines the availability/implementation of education/training for emergency medical services. also, "coordination" (sc . ) was considered to examine the coordination level of staff in terms of disaster preparedness and behaviour in case of disaster. other subcriteria to be studied within this factor are: "number of personnel" (sc . ), and "working hours" (sc . ). the first one involves evaluating the quantity of trained staff that the hospital has for facing devastating situations; whereas the second sub-factor represents the number of working hours that the hospital trained staff have in relation to disaster events. the last criterion included in the mcdm model is "flexibility" (c ). for its assessment, four sub-factors were specified: "flexibility in the use of facilities" (sc . ), "contingency staff" (sc . ), "blood bank" (sc . ), and "supply chain of medicines and medical supplies" (sc . ). the first sub-factor (sc . ) considers the administrative areas that can be allocated for taking care of affected people. such areas can be primarily used for providing emergency care to people with minor affectations. on the other hand, "contingency staff" (sc . ) denotes the staff who do not work directly with the hospital but can be further linked for facing the disaster (i.e. professionals who are not located in the disaster occurrence city). another decision element considered in this assessment domain is "blood bank" (sc . ) which verifies the availability of a blood bank for effectively underpinning healthcare during a disaster. ultimately, "supply chain of medicines and medical supplies" (sc . ) has been included into the model considering that hospitals should count on supply chains providing medicines and supplies in the shortest possible time. in this intervention, a survey format was designed for collecting the paired judgments resulting from the fahp application. the format layout proposed in this study (figure ) was found to be comprehensible and easy to complete by the participant experts. in various studies, the appropriate design of the data-gathering tools has been concluded to be effective for decreasing the risk of inconsistency in related decision-making applications (pecchia et al. ; ortiz-barrios et al. ) . as depicted in figure , the following question was asked: table , where the collected judgments were aggregated and organized in accordance with eq. - . after this, the fuzzy weights were computed using eq. . the derived global and local priorities are presented in table . we later proceeded with the estimation of consistency ratios (cr) to check the reliability of resulting weights (table ). considering that cr values are not over the threshold ( . ), the calculated priorities are concluded to be appropriate for their use in the assessment model. it is noteworthy that the biggest matrix (equipment) was found to present very low inconsistency (cr = . ). such findings evidence the effectiveness of the assessment process based on: i) the careful design of the questionnaire, ii) the reduced comparison scale and iii) the high expertise of decision-makers. a questionnaire was also created to collect the paired judgments outlining the interdependence and feedback relationships among criteria/sub-criteria considered in the model ( figure ). in this case, it was asked: "according to your expertise, how much influence each criterion on the left exerts over each criterion on the right?" in difference to fahp, the experts performed the comparisons by employing the five-point linguistic scale (with triangular fuzzy numbers) illustrated in table . the judgment procedure was then iterated until finishing all the combinations "criterion i vs. criterion i" and "sub-criterion j vs. sub-criterion j". following this, the fuzzy paired comparisons were arranged in an initial direct-relation fuzzy matrix (u ) using eq. - . an illustration of matrix ƒ is presented in table . then, the normalized direct-relation fuzzy matrix " was achieved by applying eq. - (table ) . ultimately, the total relation fuzzy matrix … was estimated by implementing eq. - (table ). the prominence #:$ + ;̃ % and relation #:$ − ;̃ % values are calculated considering the results presented in table . such measures were defuzzified using the centre of area defuzzification style (eq. ) and further consolidated in table . receivers and dispatchers were also identified in this table. the results revealed that flexibility (c ) has the greatest prominence ( . ) and is therefore deemed as the main influencer when evaluating the hospital disaster preparedness. hence, flexibility (c ) should be targeted for continuous intervention within the disaster management plans. this was also pointed out by zhong et al. ( ) who concluded that disaster resilience arrangement of hospitals highly depends of flexibility in terms of resources, an aspect increasing the pre-disaster strength of each institution and propelling fast response and recovery. on a different note, significant correlations are observed among criteria (c + r > ) which are consistent with the interactive nature often found in healthcare scenarios (leksono, suparno, and vanany, ) . the interrelations within each sub-criteria cluster were assessed through impact digraph maps (figures to ). the influence diagram for criteria is presented in figure a . in this cluster, the adopted threshold (p) was established as ‹ = oe .o • } = . after defuzzifying the respective total relation fuzzy matrix … . from the graph, it can be discriminated that all the criteria are dispatchers. moreover, several interrelations are observed among these decision elements; some of them are of feedback nature (c -c ; c -c , c -c ; c -c ). in light of the above-mentioned considerations, multidimensional emergency operation plans should be designed, socialized, disseminated, simulated, and deployed by disaster managers to upgrade the performance of hospitals upon facing disaster events. simulation of such plans will provide further analysis on each criterion so that hospital weaknesses can be properly detected and tackled before the occurrence of a disastrous situation. sc . ) . the influence of sc . , sc . , and sc . on the rest of elements is based on the fact that these sub-criteria greatly restrict building, design, and location conditions of hospital infrastructure; aspects often considered by administrators when expanding, relocating, and adapting their facilities to the potential requirements derived from devastations. the influence diagram for "communication" (c ) sub-factors is depicted in figure a . in this configuration, the reference value was stated as ‹ = oe. o o } = . . in this domain, a feedback interrelation was detected between sc . and sc . . the need for constant communication support is critical for effectively underpinning the operation flows within ecns. in the opposite direction, the ecn configuration affects the quantity and deployment of communication devices in each hospital. as also found in the previous clusters, interactions are present in each paired relation which entails high degree of complexity for managers when including these aspects in the emergency operation programmes. finally, an influence map (figure b ) was drawn to analize the interdependence among "transportation" (c ) sub-criteria. the limit value considered in this cluster was set as ‹ = •.oeo • } = . . based on the diagram, the decision elements strongly interact with each other even in a double-direction form as presented in sc . -sc . , sc . -sc . , and sc . -sc . . also, "number of vehicles" (sc . ), "helipad space" (sc . ), and "accessibility (roads)" (sc . ) were concluded to be deliverers whilst "safety" (sc . ) was classified as receiver. it is noteworthy that all transportation modes used in the healthcare system are insights required for the correct deployment of safety measures seeking for protecting victims in the wake of a disaster. understanding the relationship between transportation conditions and patient safety will help disaster managers reduce potential adverse events during catastrophic events and establish guidelines for appropriate risk management. the global priorities of criteria (xlr $ ) and sub-criteria (xqr ) on the basis of interdependence were estimated by implementing eq. and eq. correspondingly. likewise, local interdependence weights of sub-criteria (pqr $ ) were calculated using eq. . the results derived from these equations have been compiled in table . based on fahp-fdematel outcomes, personnel (c ) was found to be the most important factor (xlr ' = . ) when assessing the hospital preparedness when facing devastating situations. little difference ( . ) was also detected between this criterion and equipment (c ). such results invite disaster management planners to fully consider these categories to effectively respond to the shock of disasters and return to stability. indeed, effective management of personnel (c ) and equipment (c ) is critical for upgrading the performance of emergency care networks when facing catastrophic events. for instance, the availability of medical teams, administrative staff, and resources play a key role for ensuring successful onsite-rescue and within-hospital medical care. moreover, sharing medical staff and other resources is one the main activities specified in the memorandums of understanding (mous) signed by hospitals. in particular, the presence of suitable and sufficient personnel and equipment supports hospital response, especially in the aftermath of a disaster. considerable efforts should be then made on c and c to establish appropriate supplier agreements and train medical staff in disaster management so that flexibility (c ) can be effectively pursued as highlighted in the previous section. following this, we have stratified our analysis to look into the importance of each subcriterion in each cluster. for instance, in hospital buildings (c ) category, the most important decision element was physical infrastructure (sc . ) (pqr = . ) whereas the second sub-criterion in the ranking was location (sc . ) (pqr = . ). such aspects represent more than a half of importance ( . ) in c criterion and they should be therefore urgently focused for continuous monitoring and improvement in hospitals. in particular, disaster managers should analyse the current state of the division of internal hospital spaces, the external envelope, structure, services, and contents to grant the safety of medical staff and victims after the catastrophic event. unfortunately, most hospitals fail to include built environment issues in their disaster management plans (cimellaro, reinhorn, and bruneau, ; loosemore and chand, ) . in this regard, it is recommended to: i) check and modify (if needed) the hospital layout to facilitate flow throughout the hospital during a disaster, ii) perform maintenance activities to minimize infrastructure vulnerabilities, and iii) review past disaster experiences and their effects on physical hospital infrastructure. in relation to location (sc . ), it is necessary to lessen the average travel distance for strikes' victims over a range of potential disaster scenarios. hospital location models (arlym et al. ; acar and kaya, ) should be then used for supporting this decision so that timely medical care can be provided to patients. in equipment (c ) criterion, medical equipment for es (sc . ) and medicine (sc . ) were concluded to be the most relevant sub-factors with local weights of . and . respectively. such results call for clearly determining the supplies and medical equipment needed for handling disasters effectively. in this regard, it is vital to partner with supply chains capable of providing the sufficient and appropriate resources during disasters without stockpiling within the hospitals' facilities. prior to this, disaster managers should identify, plan, and coordinate the timely supply of medical equipment and supplies so that hospitals can deliver the appropriate medical care before and after the strike. some other significant recommendations to properly manage these aspects can be found at de jong and benton ( ). looking into the results within the communication (c ) domain, it was concluded that the most critical aspect is emergency network (sc . ) (pqr o = . ). it is noteworthy that failure of hospitals during catastrophic events can highly affect public morale and increase needless deaths. in this sense, emergency care networks (ecns) may alleviate the burden faced by hospitals individually by co-ordinately sharing medical staff, emergency drugs, and other critical resources. thereby, the service level for disaster resources can be meaningfully improved which consequently ensures timely disaster response. notwithstanding the tremendous efforts made by governments in this particular aim, ecns are still at the earlier stages. in this sense, inefficiency factors such as the lack of coordination among hospitals and the presence of non-value added activities should be properly tackled by disaster managers to grant their adequate performance when facing devastating community events. with regards to transportation (c ) category, accessibility (roads) (sc . ) was identified as the most important sub-criterion with a local priority of . . road accessibility to hospital facilities is critical for granting rapid medical care to disaster victims. in this respect, ground failure, imploding buildings to road edges, and bridges collapse may occur and limit the patient flows during catastrophic situations. as accessibility changes after disastrous events (ertugay, argyroudis, and düzgün, ) , it is suggested to: i) evaluate road closure probabilities during the different types of disaster, ii) elaborate a disaster management plan in which hospitals can be pre-allocated to improve accessibility, and iii) implement accessibility models for helping emergency managers to better define emergency routes for evacuation and medical care. in relation to personnel (c ) area, the most critical aspect to be considered during disastrous situations is education (sc . ) whose local weight was calculated to be . . in the presence of unanticipated strikes, disaster management preparedness is recognized as crucial for medical staff and nurses so that effective care can be provided to the multiple victims arriving to the hospitals. indeed, continuing disaster management courses have become an important strategy for avoiding errors that may hinder the response of hospitals before and after devastating events (al khalaileh, bond, and alasad, ) ; hence sc . has been also considered as the sub-criterion with the major interdependence weight in the hospital preparedness evaluation (xqr = . ). some recommendations for effectively managing the disaster preparedness of staff include: i) continuously evaluate the core competencies, skills, and knowledge of physicians, nurses, and other support staff regarding the management of disastrous situations, ii) the inclusion of disaster preparedness in national curricula of medical staff so that worsening of events in mass causalty disasters can be effectively prevented, and iii) the implementation of disaster facility drills given the strong interrelationship found between this element and education. ultimately, blood bank (sc . ) was found to be the most crucial aspect in the flexibility (c ) domain with a local interdependence weight of . . undoubtedly, the use of blood products is vital for effectively addressing the diverse kinds of injuries emanating from disasters (either man-made or natural). in the wake in the past disaster experiences, it is then imperative to optimize the blood supply chain so that the healthcare system can navigate through events deviating from the normal day-to-day demands. in light of these considerations, it is recommended to i) determine the need for blood products depending on the potential disaster coverage, ii) ensure a seven-day supply of blood (simonetti et al. ) , and iii) model and simulate transfusion services throughout the long and short run of a disaster. this chapter details the application of topsis method whose main objective was to rank the hospitals based on their disaster preparedness whereas pinpointing the weaknesses that should be tackled by each institution so that better response can be expected when facing devastating events. moreover, the sub-criteria most contributing to the pis and nis of each hospital can be discriminated so that focused enhancement strategies can be effectively deployed in the practical disaster scenario. initially, a performance indicator (table ) was established per each sub-criterion. following this, initial topsis decision matrix x (table ) was arranged considering the hospital alternatives (" , " , " o , " • ), performance indicators, and sub-criteria. in particular, the performance indicators values were computed considering the mathematical formula depicted in pis and nis were also specified in table by employing eq. and eq. correspondingly. the normalized ratings are later calculated using eq. (table ) whereas the weighted normalized ratings were estimated by applying eq. (table ) . the interdependence weights of sub-criteria were calculated through the integrated fahp-fdematel approach illustrated in the previous section. on the other hand, the euclidean distance of each hospital (" , " , " o , " • ) from the pis (q v n ) was calculated using eq. (table ). in a similar vein, the separation of each hospital from the nis (q v , ) was estimated by applying eq. (table ). the ranking of hospitals and closeness coefficients l v * are shown in figure . such coefficients were computed using eq. . the results revealed that the hospitals performed between . (h ) and . (h ); there is therefore much room for improvement and interventions from the stakeholders. it is then necessary to estimate the distances from pis and nis to identify the weaknesses of each hospital (sub-criteria whose euclidean separation from pis is over zero || euclidean separation from nis is equal to ). in particular, it was found that h evidences low availability of medical equipment -sc . ( . %; separation from pis = . ) which may cause delays in medical care provided during disaster and consequently increase the risk of mortality. moreover, h is the hospital with the farthest distance from the target community -sc . ( km; separation from nis = ), an aspect that may limit the timely medical care also considering the potential collapse of roads and adjacent buildings. another weakness is the non-availability of a helipad space -sc . -which highly restricts the patient transferring process from the disaster zone to hospital facilities (separation from nis = ). additionally, there are no contingency staff -sc . -for facing the disaster situation (separation from nis = ). such disadvantage may compromise the hospital response mainly in large-scale catastrophic situations. on a different tack, similar to h , h concerns about the low availability of medical equipment -sc . ( . %; separation from pis = . ) and non-availability of helipad space -sc . (separation from nis = ) and contingency staff -sc . (separation from nis = ). also, it has the lowest number of floors -sc . ( floors, separation from nis = ) and ambulances -sc . ( vehicles, separation from nis = ), an aspect limiting the capacity for addressing the peaks of demand that may arise from the disaster. moreover, h does not evidence the use of tents -sc . (separation from nis = ) which also restricts its disaster preparedness. the major disadvantage is the number of disaster management programs organized by the hospital -sc . ( training programs; separation from nis = ), a fact that may trigger errors during on-site rescue, patient transportation, and medical care. regarding h , more investment and maintenance intervention is needed for increasing the availability of medical devices -sc . ( . %; separation from pis = . ). in addition, h also has the farthest separation from the target community -sc . ( km; separation from nis = ) and the lowest number of floors -sc . ( floors, separation from nis = ). apart from these findings, it is observed that h presents the shortest % of correctly insulated ed rooms -sc . ( . %; separation from nis = ) and % of rooms with appropriate ventilation -sc . ( . %; separation from nis = ). both conditions may hinder the correct deployment of disaster management plans in the wild; especially during medical intervention similar to h , h does not either denote tent usage -sc . (separation from nis = ). also, the number of beds -sc . -is limited compared to the rest of hospitals ( beds; separation from nis = ). shortage of beds has become a significant barrier for addressing large-scale outbreaks as those expected in the future. moreover, h only has one ambulance -sc . (separation from nis = ) which may not be enough for facing the potential upcoming events (i.e. coronavirus (huang et al. ) ). on the other hand, as all the hospitals participating in this study, no helipad space is available -sc . (separation from nis = ). moreover, h has the lowest number of security guards -sc . ( guards; separation from nis = ) which may not facilitate the patient flow and medical staff protection during a disaster. the number of training programms in disaster management is also low -sc . ( programs; separation from nis = ) and new courses should be therefore implemented for increasing the competences, knowledge, and skills of h workers. lately, this hospital was not found to be flexible as revealed through poor outcomes in the associated sub-criteria. finally, in relation to the leading hospital, the topsis results evidenced the need for intervention in the next sub-criteria: sc . ( ; separation from nis = ), sc . ( . %; separation from pis = . ), sc . (separation from nis = ), sc . (separation from nis = ), sc . ( training programs; separation from nis = ), sc . ( trained employees; separation from nis = ), and sc . (separation from nis = ). communication, transportation, personnel, flexibility and a total of thirty-six sub-criteria. fdematel is hereafter applied to uncover the interdependence between criteria and subcriteria. as a ranking tool, topsis is used to determine a ranking of hospitals. in application phase of the existed decision making model, two different questionnaires are created and assessed by seven experts related to the field of disaster management of healthcare facilities and academicians who are experienced for the disaster management topics. the numerical results demonstrated that "personnel" is the most important factor (with a global weight value of . ) when evaluating the hospital preparedness while "flexibility" has the greatest prominence (with a c+r value of . ). in the light of the numerical results obtained from this study, it is crucial that the observed and analysed hospitals design a better disaster preparedness plan in order to be more prepared against disasters. in relation to the scenario under study, the results revealed that the hospitals performed between . (h ) and . (h ); there is hence much room (gap to target: . - . ) for interventions increasing the current disaster readiness level. these interventions must address the main weaknesses detected in the cited set of hospitals: i) low availability of medical equipment, ii) lack of helipad spaces, iii) low availability of contingency staff, iv) lack of tents, and v) low number of disaster management training programs. thereby, these hospitals will be better prepared for facing future outbreaks in terms of timeliness, quality, and efficiency. this approach is useful for the related research field considering that methods measuring the hospital disaster preparedness levels are lacking (xin and xu, ; zhong et al. ). however, it has some limitations from both methodological and application viewpoints. we consider triangular fuzzy sets in both ahp and dematel stages. considering there exist various new versions of fuzzy set theory that reflect uncertainty and ambiguity of decision making process better, 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authors would like to thank prof. heriberto felizzola-jiménez for their valuable contribution to this research. also, many thanks to giselle paola polifroni-avendaño for her support during this project. ☒ the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.☐the authors declare the following financial interests/personal relationships which may be considered as potential competing interests: key: cord- -d yv mcl authors: hori, arinobu; takebayashi, yoshitake; tsubokura, masaharu; kim, yoshiharu title: ptsd and bipolar ii disorder in fukushima disaster relief workers after the nuclear accident date: - - journal: bmj case rep doi: . /bcr- - sha: doc_id: cord_uid: d yv mcl the global threat posed by the covid- pandemic has highlighted the need to accurately identify the immediate and long-term postdisaster impacts on disaster-relief workers. we examined the case of a local government employee suffering from post-traumatic stress disorder (ptsd) and bipolar ii disorder following the great east japan earthquake. the complex and harsh experience provoked a hypomanic response such as elated feelings with increased energy, decreased need for sleep and an increase in goal-directed activity, which allowed him to continue working, even though he was adversely affected by the disaster. however, . years later, when he suffered further psychological damage, his ptsd symptoms became evident. in addition to treating mood disorders, trauma-focused psychotherapy was required for his recovery. thereafter, we considered the characteristics of mental health problems that emerge in disaster-relief workers, a long time after the disaster, and the conditions and treatments necessary for recovery. the global threat posed by the covid- pandemic has highlighted the need to accurately identify the immediate and long-term postdisaster impacts on disaster-relief workers. we examined the case of a local government employee suffering from post-traumatic stress disorder (ptsd) and bipolar ii disorder following the great east japan earthquake. the complex and harsh experience provoked a hypomanic response such as elated feelings with increased energy, decreased need for sleep and an increase in goal-directed activity, which allowed him to continue working, even though he was adversely affected by the disaster. however, . years later, when he suffered further psychological damage, his ptsd symptoms became evident. in addition to treating mood disorders, trauma-focused psychotherapy was required for his recovery. thereafter, we considered the characteristics of mental health problems that emerge in disaster-relief workers, a long time after the disaster, and the conditions and treatments necessary for recovery. disasters continue to affect people not only in the moment of a disaster but also throughout the long-term recovery process. post-traumatic stress disorder (ptsd) and depression significantly impair the social functioning of those affected and are often recognised as the most visible mental health effects on survivors, as was the case with the great east japan earthquake (geje) of . [ ] [ ] [ ] [ ] in the present study, however, we would like to focus on manic and hypomanic episodes that occurred in the victims of the geje. while bipolar disorder requires medical treatment, social functioning of the patient tends to be maintained during the hypomanic episode. hypomanic patients show symptoms such as elated feelings with increased energy, decreased need for sleep and an increase in goaldirected activity. they could continue to contribute to the community as disaster-relief workers in the disaster-recovery process, which delays the recognition of their treatment needs by healthcare providers. the geje, which was followed by the nuclear accidents, left the affected areas severely damaged and required the victims to contribute as disaster-relief workers for a long period. therefore, after the geje, not a few of the people involved may have continued to work as disasterrelief workers while exhibiting hypomania. in the general postdisaster context, relief workers are considered to be a group vulnerable to mental health problems and have a higher incidence of late-onset ptsd. this may be partly due to the fact that there are many opportunities for relief workers to come into contact with the misery of victims of disasters or adverse situations. in the case of the chernobyl disaster, the long-term effects on the mental health of the population who lived through the events are known. the risk of mental disorder was particularly high among the workers involved in the clean-up efforts after the disaster because they were in constant fear of being exposed to radiation. [ ] [ ] [ ] from this, one can infer the magnitude of the burdens borne by those engaged in the work of providing support to a community during any disaster. in the geje, the risk of mental disorder was also shown to be higher among disaster-relief workers, such as local government employees and tokyo electric power company officials. [ ] [ ] [ ] in this case, being the target of blame and attacks from victims was a major factor contributing to increased risks. in this study, we observed the emergence of bipolar ii disorder and symptoms of ptsd in a local government employee who experienced almost all the events of the geje disaster. even after the acute phase of the disaster, he continued to work diligently as a local government employee for more than years. while he was forced to deal with social conflict caused by aspects of his job, he came across reports of floods in other parts of japan. consequently, he began experiencing symptoms of ptsd and major depressive episodes. the covid- pandemic is, at the time of writing, wreaking havoc around the globe in what is a major health disaster. during the pandemic, many people, including healthcare workers, are expected to work in appalling conditions for extended periods. therefore, understanding how the experience of a long-term, complex and severe disaster affects the mental health of essential responders (who are engaged in essential services) is important in guiding future policies and practices. the patient was a male in his s when he first visited our clinic. he was born and grew up in a town in fukushima prefecture (within km of the nuclear power plant). after he graduated from a college in another city, he returned to his hometown and started working in a town office. he has no medical history of note. after the accident at the nuclear power plant in , an evacuation global health order covering his hometown was issued. the order was lifted in july . he was working at the town office at the time of the earthquake. later, while conducting a tour of the coastal area to check for earthquake damage and to ensure that people had evacuated, he experienced the tsunami near his childhood home. he and his colleague evacuated the lower floor of the house, moved upstairs with his family and watched as the surrounding houses were swept away, fearing that, along with his family and his colleague, he would also be swept away at any moment. eventually, the water receded, but the area around the house was flooded, preventing any movement. mobile phone services collapsed. in the evening, he carried his grandmother on his back and waded through the waters to take refuge on a nearby hill, where about people had gathered. he barely slept during the night. at daylight the next day, he was rescued-along with the other people who were with him-by a self-defence forces helicopter. on the afternoon of the second day, he began engaging in relief work throughout the area. among the tasks and efforts he undertook was aiding the local fire brigade and he was involved in housing the corpse of a man whom he had known since childhood. he would go on to help recover six or seven bodies in half a day. with nowhere to go, he slept that night wrapped in a blanket by his desk in his office. he heard a rumour of a nuclear power plant being in danger and fell asleep in a daze. by the morning of the third day, it was clear that the nuclear power plant was in danger. evacuation orders for everyone within a km radius, followed by a km radius, from the nuclear power plant, were conveyed. on the night of the fourth day, the town office was closed. on the morning of the fifth day, he told his family to flee, although he decided to stay and aid in the relief work being carried out. on the morning of the seventh day, - people-taking refuge at a junior high schoolwere transported to another prefecture aboard seven or eight buses. there were only three staff members remaining, including himself. initially, he felt a strong sense of urgency and was in high spirits. he carried on working for months with the local authorities, which included visiting evacuees. one of the evacuees once made him kneel for hours, scolding him and saying, 'you're here too late'. even after he returned to his hometown, he continued to work as a local government employee. he was involved in a lot of heartbreaking work-such as catching and slaughtering the growing number of untended or escaped cattle and pigs within the evacuation area. in august , after watching the news of the flood damage in another area of japan, he experienced flashbacks of scenes from the tsunami during the geje; these flashbacks made him anxious and made sleeping difficult. this affected his work severely. at that time, he was working in a department of the town and frequently attended briefings in his hometown. he notes that there was a lot of shouting at these briefings. in the same month, he visited a clinic in the city and was diagnosed with ptsd and depression. he was given leave from the time of his initial visit for a duration of about months. his symptoms subsequently improved, and he decided to discontinue treatment. during this time, while taking antidepressant medication, he experienced an uptick in his mood and spent a lot of money on mail order goods besides elated feelings with increased energy, decreased need for sleep and an increase in goal-directed activity. two-and-a-half years later, he became depressed again and visited another psychiatric hospital in the city. this visit began a second leave of absence from his work; he returned to work after months. three months later, he took a third leave of absence after suffering a worsening of his anxiety and depression. his physician, at the time, determined that he needed specialised treatment for ptsd and referred him to our clinic for the purpose of implementing trauma-focused psychotherapy. his first visit to our clinic was years and months after the geje. although outwardly he appeared well groomed, his speech was sluggish. his alcohol consumption increased after the disaster, but he had been abstaining from alcohol for a month and a half before his visit, so we told him to continue. the previous doctor's prescriptions were escitalopram ( mg), mirtazapine ( mg), ethyl loflazepate ( mg) and diazepam ( mg). although we considered this prescription inappropriate for a bipolar patient, we continued this treatment first then started to taper it down. after two general outpatient meetings, a total of sessions of trauma-focused psychotherapy were conducted twice a week. weekly outpatient visits continued for a month. whenever he heard news about an earthquake on the tv, he became anxious; however, he had learnt to respond by practising breathing techniques. the psychotropic drugs were gradually reduced. he returned to work the next month, on a half-day basis, and began working full time after weeks. at that time, he was still taking escitalopram ( mg) and ethyl loflazepate ( mg). we conducted prolonged exposure therapy. in the first session, we listened in detail to comprehend all aspects of his trauma. because he had experienced multiple traumatic events, we asked him to evaluate the degree of subjective distress he felt about the different events. he expressed the following: ( ) on the tsunami: 'i feel like blaming nature, wondering why this once-in-a-thousand-year event happened at this time'; ( ) in reference to the harsh complaints emanating from residents after the disaster: 'it's not just my fault' and 'there's only so much i can do'; and ( ) concerning the scene where corpses were taken: 'why did it have to be this way?' in the second session, he expressed survivors' guilt: 'there was some fear in the trauma part, but i wondered if the loss of an acquaintance was greater. the village where i was born and raised was gone. the person i told immediately after the earthquake to "get out of here fast" also died. i am wondering why i didn't tell them more forcefully. images of the disaster and [the sound of] sirens on fire trucks and ambulances trigger my anxiety. there were other times when we were all talking about the disaster and everyone was normal, and i was the only one who froze'. in the third session, he recalled that he was near his childhood home soon after the earthquake when the tsunami hit and how he had escaped by taking shelter on the second floor. he further recalled that he was left with others on high ground until the following day. in the fourth session, he described the first few days in detail. the moment the tsunami came, he was told: 'there's a tsunami coming, run away quickly'. he recalled that 'the waves were really black, and [that] the water was extremely powerful', and that he 'was rescued by a helicopter with [his] colleagues and [that he] went back to the town office crying'. in addition, on the afternoon of the th , he was tasked with helping recover the deceased; the first person he found and carried was a fire brigade worker who he knew. in the fifth session, he remembered that, after recovering bodies on the afternoon of the th, he received the news that the nuclear power plant was in danger. in addition, after the evacuation order was issued, he had to help evacuate local residents while his family was evacuated to another area. there were times when he was subjected to abuse. he stated that: 'there's so much going on, so much work, it makes me just laugh'. in the sixth session, he was asked to explain, in detail, the scenes when the lifeless body of someone he knew was recovered. he had received a call from the fire brigade, telling him that a body had been found; subsequently, he was sent to pick it up. on recognising the corpse as someone he knew, he thought, 'i could have been dead, that could well have been me rather than him'. in the seventh session, he could recall and express his memories more easily than previously. he said, 'it's over, but why did it take so long?' in the eighth session, we dealt with the tsunami scene again and he recalled the episodes in greater detail. in the ninth session, he was asked to speak about his recollections of the first months after the earthquake and how he lost kg of weight during that period, resulting in a colleague telling him that he looked completely different. in the tenth session, he was asked to repeat his recollections of those first months. he responded by saying that 'it's great that i've been able to organize the memories in my head. before, they were all jumbled up. i have been able to cut out some of the worst traumatic experiences, organize others, and accept the result. so, i've come to understand that it's all in the past'. the patient continued his visits to the outpatient clinic as well as his medication-mainly the mood stabiliser lamotrigine ( mg: in japan, the dosage of each psychotropic drug is usually set lower than in western countries) used for the treatment of bipolar disorder. he voluntarily practised coping techniques, such as breathing exercises, in situations where he felt stressed. every year, emotional instability emerged around march, the day the earthquake struck. in october , the area where the disaster occurred suffered from flooding and water damage due to a major typhoon. he was involved in the management and operation of the evacuation centre that was set up at that time, but later became unwell and needed to take a leave of absence for about a month. trauma-focused psychological interview sessions were conducted following this event, and two traumatic memories were treated, which were left unaddressed in the prolonged exposure method interviews conducted. one recollection concerned the times when he was angrily abused by some evacuees during the period after the geje. the second was about the scene when he was verbally abused at his job. after the two sessions, he recovered and has returned to work and continues to be well. the covid- outbreak, which began in january, has caused intense and extensive fear and anxiety. the patient has reported that the outbreak has brought back memories of the geje, as well as that of the atmosphere of the people at the time, causing him to experience some heightened emotions of fear. he has also realised, however, that for a long time he was too absorbed in and preoccupied by his geje experiences; because of this awareness and acceptance, he was mindful not to be like that this time round. how do the complex and harsh experiences of the geje disaster and its aftermath affect disaster-relief workers? the geje was a complex disaster that involved an earthquake, tsunami and nuclear power plant accident, followed by a series of compulsory evacuations. what are the crucial aspects of the trauma caused by complex disasters? what kind of response does such trauma provoke in the short term and what are the long-term consequences? what kind of measures should be taken to deal with mental health problems caused by complex disasters, including nuclear disasters? important characteristics of the traumatic events experienced by disaster-relief workers in complex disasters, including nuclear accidents, and as demonstrated throughout this case, are as follows: . they intermittently experience multiple traumatic events over an extended period. . the impact of being caught up in social conflicts over nuclear power and radiation exposure is significant, as is receiving strong condemnation and attacks from residents. considering these two points, two further observations can be made: . in addition to the magnitude of the trauma or loss experienced, there may be a mildly manic reaction to dealing with persistent crisis situations in the community at large. in this psychological defence reaction, there is a risk that mental health problems, such as depression and ptsd, would appear or develop a few years after the disaster. . anxiety concerning the health effects of radiation exposure, which is generally considered to be a problem following nuclear disasters, might be neglected. this patient experienced the geje as a local government employee and had an extremely harsh and traumatic time in the months following the disaster. these included the recovery operations, a fear of exposure to radiation, harsh living conditions following the evacuation, separation from his family, and strong condemnation and reprimands as a result of postdisaster social strife and conflicts. despite this strong psychological burden, this individual continued to work diligently for the recovery and reconstruction of the community, which illustrated the strength of his resilience. it is believed that participation in the altruistic activity of contributing to the recovery of the community boosted that resilience. at the same time, it is worth noting that in the present case, the patient demonstrated a hypomanic state. the hypomanic state is pathological, as it involves the avoidance of realistic anxiety. denial of self-damage or fatigue can make selfcare more difficult to implement. however, in the short term, it produces desirable effects by maintaining social activity, which can protect people from being overwhelmed by practical challenges in a disaster situation. this may be an adaptive response which enhances resilience. we would like to draw attention to the fact that the patient did not complain of anxiety concerning the adverse health effects of radiation exposure, which is generally expected in mental health problems associated with nuclear disasters. as in the present case, this may be due to the fact that residents who choose to live in relatively close proximity to the accident site can be seen as a biassed group that does not take the possible global health damage of radiation exposure seriously. it is also possible to think that a manic avoidance of anxiety may be at work here. alternatively, it could be an outcome of the risk communication that took place after the disaster. people living in the area had learnt that the levels of radiation that they were exposed to while living in close proximity to the plant were not the kind that would actually have serious consequences. three years and months after the disaster, the ptsd symptoms-including flashbacks-suddenly flared up after the patient was exposed to news of another disaster in japan. in addition, during this period, the patient endured a situation in which he was required to negotiate, as a representative of the local government (being an employee himself), with residents who were affected by the nuclear accident. however, communication and negotiations did not go well, resulting in strong admonishment. in the case of an elderly woman with symptoms of ptsd caused by the tsunami, as reported by hori et al, the recurrence was also caused by being involuntarily blamed for being involved in a severe conflict among residents in the communal dwelling where she was living. although our patient recovered from his mood disorder by using medication, he had two repeated flare-ups which led to the implementation of prolonged exposure therapy -a psychotherapy focused on ptsd. north and pfefferbaum have argued that less invasive treatments should be prioritised in the immediate aftermath of a disaster as an intervention for post-disaster ptsd, and specialised trauma-focused treatments should be provided only when depression and ptsd symptoms persist. our treatment is consistent with this argument. the actual psychotherapy process involved sorting out a situation in which multiple traumatic events were intricately intertwined, in addition to habituation through the recall of traumatic memories. we also discussed the destruction of his hometown and the loss of his relatives and acquaintances. although improvement was observed following the treatment described previously, emotional instability was sometimes caused by increased stress in daily life; as such, it was necessary to continue the outpatient treatment, including the prescription of lamotrigine ( mg). we also provided psychological education about stress coping. although trauma reactions and feelings of depression may intensify on the anniversary of the geje, he gradually became able to care for himself. in addition, we discussed his tendency to be manically uplifted in crisis situations and overly immersed in his community contributions. however, the traumatic experience of receiving strong condemnation from residents -that could not be addressed in the initial ptsd treatment-necessitated additional psychotherapeutic interviews later on. on the other hand, we should not rely solely on improving the coping skills of patients. because experiencing multiple disasters would increase the suicide rate, the same person should not be repeatedly burdened as a relief worker. the following lessons can be drawn from this case: . the recovery and reconstruction of the community, including a medical system that allows general psychiatric treatment, such as treatment for mood disorders, should be ensured as quickly as possible after a disaster. . it is not easy for those who have an important role in the affected community to reduce their responsibilities in the community during the postdisaster phase. there is also a prejudice against psychiatric issues. awareness-raising activities related to mental health, including psychoeducation about symptoms of mood disorders and ptsd, should be carried out widely in the community, even though this could be difficult after the disaster. the medical facilities where the cur-rent treatment was provided also existed in the areas affected by the disaster. . a system that allows access to specialised treatment focused on ptsd should be developed when necessary. . the public should be made aware that they should refrain from unwarranted severe criticism of local government officials in the wake of a disaster, as it would increase the risk of mental health problems for those who are criticised. ► for the victims of the great east japan earthquake who experienced the earthquake, tsunami, nuclear accident and subsequent evacuation, there are two highly significant points: ( ) the persistence of the crisis situation over a long period (weeks, months or even years) and ( ) the emergence of social conflicts over radiation exposure from an early stage. ► in particular, disaster-relief workers are at a high risk of mental health problems because they are repeatedly exposed to other victims' tragic situations and are prone to be strongly criticised or attacked, even though they themselves are victims of the disaster. ► with respect to postdisaster mental health, both depression and hypomania may emerge. since hypomania is a partial disavowal of difficult realities, decrease in anxiety and increasing physical activity can represent an adaptive response to difficult situations arising after a complex disaster, including a nuclear disaster where the threat is invisible. ► exposure to radiation after a nuclear accident can damage mental as well as physical health, both or either of which may not manifest for some considerable time after the initial disaster, or which may appear following various trigger events. ► in postdisaster patients, mood disorders that are combined with post-traumatic stress disorder (ptsd) may not be controlled without ptsd-focused treatment. psychological distress after the great east japan earthquake and fukushima daiichi nuclear power plant accident: results of a mental health and lifestyle survey through the fukushima health management survey in fy and fy severe psychological distress of evacuees in evacuation zone caused by the fukushima daiichi nuclear power plant accident: the fukushima health management survey mental health and psychological impacts from the great east japan earthquake disaster: a systematic literature review psychiatric outpatients after the . complex disaster in fukushima mental disorders that exacerbated due to the fukushima disaster, a complex radioactive contamination disaster newly admitted psychiatric inpatients after the . disaster in fukushima report from minamisoma city: diversity and complexity of psychological distress in local residents after a nuclear power plant accident a systematic review of health outcomes among disaster and humanitarian responders occurrence of delayed-onset post-traumatic stress disorder: a systematic review and meta-analysis of prospective studies mental health consequences of the chernobyl disaster a year retrospective review of the psychological consequences of the chernobyl accident mental health and alcohol problems among estonian cleanup workers years after the chernobyl accident factors related to the fatigue of relief workers in areas affected by the great east japan earthquake: survey results . years after the disaster longitudinal effects of disaster-related experiences on mental health among fukushima nuclear plant workers: the fukushima news project study the longitudinal mental health impact of fukushima nuclear disaster exposures and public criticism among power plant workers: the fukushima news project study emotional processing of fear: exposure to corrective information efficacy of prolonged exposure therapy for a patient with late-onset ptsd affected by evacuation due to the fukushima nuclear power plant accident longitudinal associations of radiation risk perceptions and mental health among non-evacuee residents of fukushima prefecture seven years after the nuclear power plant disaster changes in risk perception of the health effects of radiation and mental health status: the fukushima health management survey keys to resilience for ptsd and everyday stress coping styles of outpatients with a bipolar disorder building risk communication capabilities among professionals: seven essential characteristics of risk communication enhancement of ptsd treatment through social support in idobata-nagaya community housing after fukushima's triple disaster mental health response to community disasters: a systematic review suicidality risk and (repeat) disaster exposure: findings from a nationally representative population survey hospital staff shortage after the triple disaster in fukushima, japan-an earthquake, tsunamis, and nuclear power plant accident: a case of the soso district mental health crisis in northeast fukushima after the earthquake, tsunami and nuclear disaster acknowledgements we thank all those who contributed to the recovery from the great east japan earthquake.contributors ah was the main therapist of the case and wrote the initial manuscript. yt and mt critically revised the manuscript. yk supervised the case. all authors contributed to the refinement of the paper and approved the final manuscript. key: cord- - ayjej authors: zaki, jamil title: catastrophe compassion: understanding and extending prosociality under crisis date: - - journal: trends cogn sci doi: . /j.tics. . . sha: doc_id: cord_uid: ayjej abstract how do people behave when disasters strike? popular media accounts depict panic and cruelty, but in fact, individuals often cooperate with and care for one another during crises. i summarize evidence for such “catastrophe compassion,” discuss its roots, and consider how it might be cultivated in more mundane times. in the aftermath of hurricane katrina, news reports suggested the natural disaster had quickly been followed by a human one. unchecked by law enforcement, new orleanians had apparently committed countless brazen crimes [ ] . the new york times described the city as a "snake pit of anarchy, death, looting, raping, marauding thugs." i these harrowing stories shaped authorities' reaction to the crisis-for instance, deploying the national guard to "take control" of the city, rather than focusing on humanitarian relief. the stories were also inaccurate. though crime did occur in new orleans following katrina, victims by and large remained peaceful, and many helped one another [ , ] . for decades, social scientists have documented two narratives about human behavior during crises. the first holds that following disasters, individuals (i) panic, (ii) ignore social order, and (iii) act selfishly. this cluster of beliefs characterizes popular media accounts of disaster, as well as lay forecasts. in one study, members of the public generally agreed with statements including "when there is an emergency, crowd members act selfishly," and "when there is an emergency, social order breaks down." agreement further tracked support for "coercive" handling of disaster by authorities, such as keeping the public uninformed. interestingly, police officers-who presumably have more experience with people in crisiswere significantly less likely to agree with these statements [ ] (please see supplementary materials for additional references). the second narrative comes from historical records. far from rendering people antisocial and savage, disasters produce groundswells of prosocial behavior and feelings of community. in their wake, survivors develop communities of mutual aid, engage in widespread acts of altruism, and report a heightened sense of solidarity with one another [ , , ] . unaffected people, too, j o u r n a l p r e -p r o o f descend on scenes of disasters to volunteer, as well as flood them with donations and volunteers, a phenomenon known as "disaster convergence" [ ] . i will refer to positive social behaviors in the face of negative circumstances as catastrophe compassion. catastrophe compassion is widespread and consistent; it follows earthquakes, war, terrorist attacks, hurricanes, and tsunamis, and-now-a pandemic. as covid- spreads, communities around the world have created "mutual aid spreadsheets" to help vulnerable neighbors [ ] and billions of people have engaged in physical distancing to protect public health-perhaps the most populous act of cooperation in history. consistent with its prosocial nature, one recent study found that people expressed greater intent to follow distancing when it was framed as a way to help others, rather than protect themselves [ ] . in addition to being prevalent, catastrophe compassion appears beneficial. prosocial behavior exerts positive effects on helpers-including increases in happiness and decreases in stress and loneliness. following disasters, mutual aid also tracks increases in positive collective outcomes, such as social connection, solidarity, and shared resilience [ ] . psychologists have pinpointed a number of mechanisms that might underlie catastrophe compassion. one pertains to the powerful nature of social identity. each of us identifies with multiple groups, for instance based on our generation, ideology, and profession, and commonly expresses loyalty, care, and prosociality towards members of our own groups. social identity is also malleable. you might be an ohioan and a tuba player, but those identities will vary in salience depending on whether you're at band practice or a buckeyes game. even new identities created in a lab can take on importance, and shift one's tendency to j o u r n a l p r e -p r o o f act prosocially towards people in novel groups. identities also tend to matter most when they contain certain characteristics, including shared goals and shared outcomes. when disasters strike, victims might suddenly be linked in the most important de novo groups to which they've ever belonged. strangers on a bus that is bombed might experience a visceral, existential sense of shared fate, and might thus quickly not be strangers any longer-but rather collaborators in a fight for their lives. as described by drury [ ] , an elevated sense of shared identity is indeed common to disaster survivors, and a potent source of cooperative behavior. a second source of catastrophe compassion is emotional connection. empathy-sharing, understanding, and caring for others' emotional experiences-predicts prosocial behavior across a range of settings. consistent with this connection, a recent study found that individuals' empathy for those affected by the covid- pandemic tracked their willingness to engage in physical distancing and related protective behaviors, and that inducing empathy for vulnerable people increased intention to socially distance [ ] . emotional connection can also comprise mutual sharing of affect across people. after disclosing emotional experiences with each other, individuals tend to feel more strongly affiliated to one another. such disclosures are also a powerful way to recruit supportive behavior in during difficult times and thus buffer individuals against stress [ ] . however, individuals often avoid disclosing negative experiences-for instance because they imagine others will judge or stigmatize them-and thus miss out on the benefits of affect sharing [ ] . disasters thrust people into a situation where their suffering is obviously shared with others. this could in turn lower psychological barriers to disclosure, thus creating opportunities for deeper connection, mutual help, and community. consistent with this idea, in the wake of the j o u r n a l p r e -p r o o f loma prieta earthquake, individuals frequently talked about the disaster and its effects on them for about two weeks [ ] . a similar elevation in emotional conversations was found among spaniards following a terrorist bombing in madrid [ ] . researchers further found that that sharing one week after the attacks predicted increases in solidarity, social support, as well as decreases in loneliness, seven weeks later. as solnit [ ] observes, although few people would want a disaster to befall them, many survivors look back on disasters with a surprising amount of nostalgia. floods, bombings, and earthquakes are horrific, but in their aftermath individuals glimpse levels of community, interdependence, and altruism that are difficult to find during normal times. then, normal times return, and often so do the boundaries that typically separate people. might catastrophe compassion outlast catastrophes themselves, and if so, how? some suggestive evidence emerges from the study of individuals who endure personal forms of disaster-adverse events such as severe illness, family loss, and victimization by crime. such adversity often generates increases in prosocial behavior, which staub and vollhardt [ ] have termed "altruism born of suffering." positive effects of adversity appear to extend in time. for instance, individuals' experience of lifetime adversity reportedly tracks their willingness to help strangers and their ability to avoid "compassion collapse," by maintaining empathy even in the face of numerous victims [ ] . interestingly, this latter effect is partially explained by an increased sense of efficacy (i.e., the belief one can make a difference) among people who have endured high levels of adversity. further, experimentally inducing people to believe in their own efficacy to make a difference for j o u r n a l p r e -p r o o f others increases their compassion in the face of mass suffering [ ] . though speculative, it is possible that during disasters, people witness their own prosocial efficacy firsthand, because the others they help are highly visible-neighbors, friends, victims on whom a spotlight has been shone. as such, highlighting prosocial efficacy in non-disastrous times, by making the targets and effects of helping more visible, could extend individuals' willingness to help beyond disaster contexts. one way to do this is to reify and formalize communities of disaster survivors, so that they can remain visible to each other, and salient to survivors' identity. many such communities already exist-for instance in peer counseling associations that connect and support people who have endured addiction, or lost loved ones to war, or been victims of assault. broader groups, too, often emphasize remembrance of disasters, for instance when cultural rituals and practices commemorate a culture's experience of hardship as a way of bonding individuals and generations. another way to extend catastrophe compassion is to simply remember it, and what it reveals about human social behavior. when people believe others will "go rogue" following disasters, they are expressing one flavor of a more general, dim view of their fellow citizens. individuals tend to be unduly cynical about human nature, for instance demonstrably overestimating the extent that people are driven by self-interest [ ] . cynicism tracks decreases in psychological well being, and can also become self-fulfilling, for instance when people conform to a selfish norm, they erroneously believe others are following. metaphors matter: disaster myths, media frames, and their consequences in hurricane katrina a paradise built in hell: the extraordinary communities that arise in disaster psychological disaster myths in the perception and management of mass emergencies can war foster cooperation social sharing, participation in demonstrations, emotional climate, and coping with collective violence after the march th madrid bombings how to help people during the pandemic, one google spreadsheet at a time don't get it or don't spread it? comparing selfinterested versus prosocially framed covid- prevention messaging the role of social identity processes in mass emergency behaviour: an integrative review the emotional path to action: empathy promotes physical distancing during the covid- pandemic interpersonal emotion regulation: implications for affiliation, perceived support, relationships, and well-being beautiful mess effect: self-other differences in evaluation of showing vulnerability a social stage model of collective coping: the loma prieta earthquake and the persian gulf war altruism born of suffering and prosocial behavior following adverse life events: a review and conceptualization the norm of self-interest key: cord- -ry roidc authors: felsenstein, daniel; shmueli, deborah f.; thomas, deborah s.k. title: introduction to the special issue: cascading effects in disaster risk management cascades - mapping the multi-disciplinary landscape in a post-pandemic world date: - - journal: int j disaster risk reduct doi: . /j.ijdrr. . sha: doc_id: cord_uid: ry roidc this paper introduces the special issue on cascading effects in disaster risk management. it reviews the contributions and highlights their multi-disciplinary interpretations of cascades. it proceeds to discuss whether the on-going unfolding of the covid- pandemic illustrates the cascades metaphor. the cascading nature of disasters poses significant challenges to risk management emerging from the interconnectivity of natural, economic, and social systems that amplifies effects. modern disasters increasingly tend to have domino effects: natural emergencies can rapidly develop into anthropogenic crises. the networked structure of the economy and society means that post-crisis equilibria are rarely stable. the covid- pandemic is a case in point. this initially emerged as a public health issue that escalated into a pandemic creating an economic crisis, social disruption, and calls into question broader socio-economic trends, such as globalization, and the efficacy of supra-national structures such as the eu and the who. the integration of national economies and movement of people means that goods and services are increasingly mobile, and by extension, crises and disasters become more exportable. cascades encompass a range of natural and human-induced hazards, including pandemics and anthropogenic emergencies such as financial fallouts. the amplification of disaster outcomes that arises from the tight interconnectivity of natural, economic, and social systems is fertile ground for new exploration of theory, methods, and empirics of disaster risk science. in terms of theory, cascading disasters call for use of non-linear models, complex and adaptive systems to tackle the challenges of disasters with reciprocal and feedback loops. in terms of methods, cascading disasters demand approaches that distinguish between direct and indirect effects, first order and second order influences, identification threats and causality, along with capturing associative and fuzzy relationships. in terms of empirics, recent disasters have generated multiple opportunities for studying domino effects in a variety of interdisciplinary settings. these range from hazards engineering and planning through social and environmental sciences, public health, epidemiology and emergency medicine, and on to computational modelling and economics. the cascading nature of disasters greatly complicates their analysis. for example, if an earthquake causes flooding, it is generally accepted that the cascading effect of these two disasters is a non-linear and exponential outcome far removed from the magnitude of the original shock (pescaroli and alexander ) . this is because the sequential nature of the disaster (earthquake leads to flooding) adds a compound effect that is narrowly captured by the concurrence of both events at (essentially) the same time. additionally, a multitude of other challenges exist when trying to capture the nature of cascades. these include incorporating recursivity as old events take on a new life becoming new events as they move forward in time (pescaroli and alexander ) , identifying the triggering or tipping point events that animate the cascades (kappes et al. ) and separating out cascades from multi-risk or multi-hazard events (marzocchi et al. ). all of these challenges inject a measure of methodological ambiguity into the discussion of cascades and give rise to many competing conceptualizations. this special issue aims to advance disaster risk management by showcasing a variety of multi-disciplinary approaches for describing and capturing the cascading effects in disaster science. taken together, the compendium furthers the theoretical, methodological, and empirical grounding for capturing the cascade steeped in a rich and varied set of disciplinary moorings. they illustrate the use of a wide-ranging toolbox that includes both qualitative and quantitative approaches. the collection breaks new ground by illustrating how these different approaches can be harnessed to enhance practice in disaster risk management. the contributions to this special issue originate from a scientific workshop on the topic of cascading disasters: theory, methods, and empirics held at the technion -israel institute of technology, haifa, in november . this meeting was jointly sponsored by the israeli national knowledge and research center for emergency readiness, and the dim sea research project at the hebrew university of jerusalem. it brought together leading experts from the fields of industrial management, physics, civil engineering, geography and environmental studies, transportation, urban planning, medicine and public health, public policy and management, and socio-economic modeling. while the interconnected nature of multiple natural hazards is not a new topic on the disaster management agenda (see for example mora et al. ) the integration of physical and social systems poses significant challenges. edward lorenz's much acclaimed "butterfly effect" (lorenz ) essentially describes the cascading effects generated by random and non-linear actions in complex networks. the random events in a market in wuhan, china have released a set of cascading consequences that have diffused across global networks. thus, cascades are inextricably interwoven with networks. theoretically they should be predictable when a transmission break occurs in such networks. the paper by li et al. investigates this claim. it emphasizes the interdependencies existing between networks j o u r n a l p r e -p r o o f which give rise to the so-called networks of networks (non). this coupling of different systems only increases their vulnerability leading to a cascading escalation of failures from the initial power outage affecting an electricity grid to all of the networks that feed off it, such as water, transportation, energy and telecommunications. the many feedback loops between them amplify the cascade. using the tools of statistical physics, they review the dynamics of cascading failures in inter-connected networks, the abrupt transitions imposed on them by exogenous shocks, and the percolation effects across networks given shocks of different critical values and networks of different sizes and typologies. the spatially embedded interdependent networks, such as the cascading effects of an earthquake on a power station, are a particularly interesting case. these locally-escalating shocks can cause substantially more damage than equivalent random shocks. li et al. identify critical values of damage size radii for such shocks that are independent of the size of the network. these findings are particularly important for the protection of critical infrastructures and enabling networks of networks to function even with the collapse of a single system. ben haim examines cascading failures in hierarchal networks from the perspective of info-gap theory. this draws from decision science and optimization to understand making choices under conditions of extreme uncertainty, for example predicting future returns on investments. uncertainty exists with respect to the form of the modeled functional relationship and with respect to the parameter values that animate the relationship. in contrast to the li et al. paper, the ben haim approach to cascades focuses on handling the uncertainty that makes these failures so damaging rather than on the generic attributes of cascading failures, such as network size, topology or behavior rules. the paper critiques conventional optimization techniques and presents an alternative for dealing with cascading failures in static networks grounded in testing the robustness of the decision making at each node in the hierarchy where the potential for cascading failure exists. menoni and boni focus on data collection and analysis for cascading disaster management. they assess multiple incidents occurring across different scales, jurisdictions, and critical infrastructures, and address the lack of systematic collection of evidence essential for understanding how various risk factors, including hazards, exposure and vulnerabilities differentially contribute to diverse disaster events. the wrong dosage of the right action in the aftermath of an extreme event can amplify rather mitigate the overall impact. they posit that data collection systems need to change. most data are fragmented across authorities in different jurisdictions and among private, public, and semi-public stakeholders. significant coordination is needed to restructure the data in a way that common queries can be systematically addressed. in such a system key information regarding the phenomena that triggered the damage and its subsequent rounds of influence would be reported and in this way co-occurring or enchained hazards would be identified. the paper by mizrahi takes a management view of cascading disasters. as such, a cascade is conceptualized as a sequence of poorly managed crises with increasingly cumulative effects over time and space. crisis situations are characterized by collective action. using the tools of game theory, mizrahi analyzes the dynamics of collective action and identifies the key parameters that promote different forms of such action in j o u r n a l p r e -p r o o f response to cascading disasters. the paper outlines four ideal types of cascading dynamics and presents two models (continuous time models and common knowledge models) to analyze the collective actions that emerge from different cascade prototypes. the damage arising from a cascading disaster can be regulated by mobilizing collective effort. for example, in the case of epidemics complete vaccination or alternatively complete contagion can result in full immunity. capturing collective action (including the data referred to by meroni and boni) to understand cascades is key for disaster management. thomas, jang, and scandlyn offer a theoretically-grounded conceptual model of cascading disasters. taking a people-centric lens of how social processes intensify disasters, the model illustrates how cascading disasters almost predictably give rise to socially inequitable disruptions and consequences. the domino and cumulative effects of cascading disasters reveal inequities throughout social systems manifesting in differential impacts and recovery opportunities across communities and subgroups of people. the model interrogates the tension between local communities and larger structural forces that produce social inequities at multiple levels, capturing how those inequities lead to cascading disasters. rey and bar gera investigate how road networks recover from disaster. their approach uses an optimization method (bi-level programing) and numerical simulation. cascade effects in a transportation context appear in the short, medium, and longer terms. over the short term this could be manifested in congestion impacting lifeline services. over the medium term, impacts are felt with respect to interoperability of the road network with other road networks or transportation mode networks such as rail or air. if roads are repaired but complementary networks are not, very little is gained. over the long term, the state of road network recovery can impact supply chains in other sectors of the economy, as well as the demand for travel and mobility in other sectors. thus, a reconstruction scheduling model that accounts for cascades is critical for network recovery. finally, the paper by felsenstein and grinberger examines cascading disasters through the prism of the labor market. they present a micro-economic analysis of the local labor market in the advent of a disaster and use agent-based simulation to animate some likely outcomes. the stylized approach to this exercise conceptualizes the disaster as a dramatic shock to capital stock. in turn, this has a cascading effect on labor reducing demand for workers and shrinking wages. in reality however, this may not transpire in a labor market context. the paper makes the case that cascades influence the local economy via altering local amenities for workers, residents and firms rather than through the impact on capital stock. seen in this way, the cascade simply deepens the original negative shock to productivity by reducing local amenities. the earthquake that destroys capital stock can equally cause the collapse of the local healthcare system or generate an increase in crime. both will have effects on local productivity and both are capital-altering. similarly, the pandemic that locks down the population for fear of collapse of the public health system can release a set of cascading consequences for the economy as labor supply dries up. the above multidisciplinary viewpoints beg the question as to how to interpret the covid- pandemic from a cascading perspective. given the duration of the publication process, some of the contributions in this special issue make direct reference to the pandemic (for example, the papers by mizrahi and thomas jang and scandlyn) while others went into production prior to march , when the who recognized covid- as a global pandemic. the papers by li et al. and rey and bar gera couple cascades with disruptions in critical infrastructure and breaks in network connectivity. from such a perspective, we can imagine covid- causing network failure for reasons both traditionally related to the collapse of essential lifelines such as health system distress and for reasons ostensibly far removed from the collapse of essential lifelines such as worker lockdown. ironically, the covid- crisis has not seen critical infrastructure collapse in those networks generally at risk in the case of natural hazard cascades such as airports, highways, dams and water defenses. in dense infrastructure networks, there is usually much slack and redundancy. if some parts of the network fall because of cascading effects, for example a tsunami that breaches a dam and floods a highway, there is invariably an alternative by-pass. however, cascading effects in the case of a pandemic leave little option for circumvention. super-spreader events, persons, or areas have to be identified and isolated and cannot be evaded (lloyd-smith et al. , fukui and furukawa ) . under funded public health systems and healthcare that functions with just-in-time models of efficiency have little redundancy or surge capacity for preventing or controlling a pandemic. in the case of escalating covid- effects, the ultimate weapon is forced isolation. given the fact that a sustained lockdown of social and economic networks is not politically viable in most liberal democracies, the postpandemic world faces an unprecedented situation whereby the only way to prevent cascading effects of the pandemic through networks is tantamount to dismantling the network. an alternative approach for addressing cascades and exemplified in the paper by thomas et al. is to take vulnerable populations as a starting point and to tackle the escalating (cascading) legacy of inequalities that intensify in the wake of a disaster. for example, low income families living and working in high exposure occupations compound the likelihood of contagion. these front-line populations often work in jobs such as essential services characterized by high contact patterns, low wages, and no possibilities for remote working. cascading effects here are rooted in social and economic networks. worker exposure is firstly physical and subsequently economic as places of work shut down or workers become exposed to the pandemic and are forced to lockdown with the loss of income that this implies. the mizrahi paper, associates cascades with a sequence of poorly-managed crises that have cumulative effects and are mitigated by collective action. using this framework, viewing covid- as a cascading phenomenon has less to do with an escalating collapse (of the health system or the economy) and more to do with the response to this threat. the probability of contagion is mediated as collective action is mobilized. quigley et al. ( ) bring empirical evidence to this theoretical construct. they simulate the cascading effects through a multi-hazard event whereby a natural hazard occurs concurrently with covid- . in such instances disaster relief measures may exacerbate covid- exposure and issues of collective action become paramount. meroni and boni's focus on need (and lack thereof) for comprehensive data which would enable data-driven decision-making, rings strong with the experiences of some countries with covid management. the lack of such data management has led to an inability to put in place the necessary real-time monitoring systems which would enable informed decisions (stock ) . for ben haim, the challenge of covid- lies in the extreme uncertainty that it generates. while the containment of sars, ebola and mers can be considered some kind of historical precedent, the current threat to public health underscores the interconnectedness of global mobility and supply chain networks that did not exist in the past. hitherto it has not been possible to adequately express the magnitude of this threat in terms of probabilities, thereby compounding uncertainty. the challenge is to design a command network that adequately mitigates cascading failures associated with covid- . for example, adequately granular lockdown measures are likely to limit contagion and protect the collapse of the health system, but cascade the economy into upheaval. increased economic disparities will in turn lead to social unrest and loss of political legitimacy. alternatively, the felsenstein and grinberger paper looks neither at the direct damage, such as infrastructure disruption nor at the cumulative response, but rather at the amenity-reducing potential of the disaster. if covid- is mainly a shock to labor supply, the disutility effects to workers from lack of local services and associated neighborhood decline is the relevant point of reference for understanding the pandemic rather than the cumulative effects of the pandemic on productivity as firms and workers go into lockdown. so just how well does the covid- pandemic conform to a cascading event? in the first instance, if cascades are simply a sequence of mishandled crises, many countries may have managed to extricate themselves from their first wave 'corona crises' after two to three months but are now struggling to cope with subsequent waves. the time horizon is crucial here and we still do not know what the correct frame of reference should be. in the case of flagship cascading events such as the sendai-fukushima disaster of after-effects could only be effectively assessed over the long term ( plus years). the current crisis is still not out of the short-term ( - months) phase. the perpetuating feeling of emergency is probably driven by its cascade-like nature. while modern medical advances and societal emphasis on saving lives is likely to mean lower death rates than previous historical pandemics, the cascading effects into economic networks may mean disproportionately higher economic costs than in the past. the indirect and induced impacts of covid- are somewhat different to knock-on effects of cascades. cascades are generally described through impacts on built and engineered systems, for example when flooding bursts a dam that leads to electric outage that contaminates the water system. in contrast, the covid- pandemic leads to inter-sectoral cascading, for example from the health sector to the economy, to domestic and international politics. similarly, cascades tend to cause domino effects in sectors far removed from the initial event. in a parallel fashion covid- emerges from an initial contagion and then extends to the economic and social system causing long-term disruptions. in terms of the economy-wide shock resulting from cascades, covid- has led to near total economic shutdowns in various countries. in economic terms, the coronavirus has induced a shock to labor on the supply side along with both a reduction of consumption and a limited increase in production in certain sectors (food, hospital supplies etc.) on the demand side. the potency of the covid- shock, however, may lie in the 'stagnation trap' that it can induce (bengino and fornaro ) . under this regime pessimistic growth expectations can lead to persistent slumps from which recovery is difficult. in contrast, cascades grounded in the physical destruction of capital stock have induced short-term localized downturns from which local economies tend to build back better (hallegatte et al. ). j o u r n a l p r e -p r o o f stagnation traps covid- : a risk governance perspective, international risk governance center power laws in superspreading events: evidence from coronavirus outbreaks and implications for sir models covid economics building back better: achieving resilience through stronger, faster, and more inclusive post-disaster reconstruction basic principles of multi-risk assessment: a case study in italy broad threat to humanity from cumulative climate hazards intensified by greenhouse gas emissions challenges of analyzing multihazard risk: a review superspreading and the effect of individual variation on disease emergence the essence of chaos a definition of cascading disasters and cascading effects: going beyond the 'toppling dominos' metaphor critical infrastructure, panarchies and the vulnerability paths of cascading disasters a multi-hazards earth science perspective on the covid- pandemic: the potential for concurrent and cascading crises data gaps and the policy response to the novel coronavirus j o u r n a l p r e -p r o o f ☒ the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.☐the authors declare the following financial interests/personal relationships which may be considered as potential competing interests: j o u r n a l p r e -p r o o f key: cord- -qdrcb ce authors: brown, nancy a.; rovins, jane e.; feldmann-jensen, shirley; orchiston, caroline; johnston, david title: exploring disaster resilience within the hotel sector: a systematic review of literature date: - - journal: int j disaster risk reduct doi: . /j.ijdrr. . . sha: doc_id: cord_uid: qdrcb ce within the tourism industry, the hotel sector's vulnerabilities are multi-faceted. this literature discussion scrutinizes how disaster and resilience is framed for the tourism sector, and, more specifically, how the concepts can be applied to the hotel sector. a synthesis of the literature points to the importance of prioritizing disaster resilience building for the hotel sector. the body of literature regarding disasters, tourism, and more specifically hotels, has increased over the last years, still improvements in the hotel sector's disaster preparedness and do not appear to be on the same trajectory. illustrating the predicament of the contemporary hotel industry serves to open a discussion about the value of building resiliency to disaster for hotels. as the numbers of people affected by disasters grows, the importance of providing actionable information to limit the severity of these events on communities also escalates in pace. an important aspect of the world's increasing interconnectedness is the ease and frequency of travel. increased numbers of tourists traveling to places of varying risk has exposed new and uncertain vulnerabilities to the tourism sector [ ] . tourism is vulnerable to disaster because it relies upon infrastructure, the ability to move around freely, and people's perceptions of safety [ ] . within the tourism industry, the hotel sector's vulnerabilities are multi-faceted. a hotel's physical infrastructure (buildings, water, power, sanitation) may be at risk from a variety of natural and manmade hazards placing staff and guests at risk. beyond guest and staff safety, a hotel's ability to continue operations and profitability is often at risk in disasters. the hotel's surrounding environment (sea, forests, natural beauty) can be affected by hazards making their locale less desirable for future tourist in the short term [ ] . hotel vulnerabilities are complex and factors that contribute to risk are often the tourist motivation to visit. disastrous events can influence tourist's choices of destinations [ ] . management of destination image, disruption from extreme weather, and event impacts causing slow recovery may all affect tourism destinations negatively [ ] . examples of this influence can be seen in: the foot and mouth disease outbreak, which is estimated to have cost the united kingdom tourist industry between usd$ . billion and usd$ . billion due to decreased numbers of tourist traveling to the countryside [ ] ; the severe acute respiratory syndrome (sars) epidemic which coincided with japanese outbound tourism dropping as much as % in one month [ ] ; and hurricane katrina's impacts on new orleans which resulted in tourism and hospitality businesses shutting down-affecting , hospitality employees, a decrease of usd$ . million per day in business and leisure travel expenditures [ ] . these examples highlight how disastrous events can affect tourism. people's perceptions can be negatively influenced by media coverage of an event [ , , , ] . in the aftermath of the boxing day tsunami, the hotel industry in phuket, thailand successfully reopened % of their hotels within a week, only to see occupancy rates drop to % [ ] . decrease in tourism can also be due to facility availability and access. in , following hurricane katrina and the new orleans levees failure, the lodging industry in new orleans, which included an estimated , rooms, was almost completely shut down [ ] . following a second major earthquake in five months (february ) christchurch, new zealand lost two-thirds of their hotel inventory [ ] . increasing interdependence of the tourist industry, where a negative event in one location can affect the tourist economy of many countries [ ] . for example, the icelandic volcanic ash cloud caused disruption to air travel throughout europe [ ] . "tourism destinations in every corner of the globe face the virtual certainty of experiencing a disaster of one form or another at some point in their history" ( [ ] , p. ). illustrating the predicament of the contemporary hotel industry serves to open a discussion about defining disaster resiliency for hotels. a cross-disciplinary lens may provide an opportunity to identify connections between the hotel sector's needs (ensuring safety and security of guests and staff as well as remaining operational and profitable) and disaster resilience building. the purpose of this article is to examine the literature and explore important disaster resilience and hospitality industry concepts that can be applied specifically to the hotel industry. defining key terms including disaster and resiliency within a hotel context begins with an examination of the literature. these definitions form the basis for discussion of both disaster effects on hotels and disaster resilience building within the hotel sector. the review synthesizes current concepts of disaster resilience building in the context of the hotel sector, and extracts concepts to inform further development in building disaster resilience into the hotel sector. search word of disaster and hotel provided peer reviewed articles, after duplicates and articles not on topic were eliminated. additional articles and grey literature were captured through reviews of selected articles reference lists. in total articles and papers were identified and thematically coded for this literature review. in order to discuss disaster resiliency, as it applies to the hotel sector, it is important to first explore the literature aimed at defining these terms. the objective is to synthesize common definitions for disaster and resilience as they will apply to this discussion. the concepts of disaster and crisis, as applied to tourism businesses, have been examined by many scholars [ , , , , ] . rockett [ ] writes that definitions may be transient over time, but can serve our current need and allow for common understanding. the most prevalent definitions adopted by authors of tourism sector research has been faulkner's [ ] concept that crises often have a component that could have been controlled by the group being affected (e.g. management failing to react to events in a way that minimizes effects), while disasters occur suddenly and the actual trigger event is out of the control of those affected (e.g. an earthquake hitting a populated area). ritchie [ ] recognises that an overlap can occur, when leadership actions during a disaster then develop into a related crisis, thus confusing the concepts. some authors chose not to tackle the distinction of disaster and crisis but instead use the terms alternately or simultaneously [ ] . [ ] describes disasters as events that are the result of interaction with the physical environment, the social and demographic characteristics of the community within the physical environment, and the built environment the community constructed. disasters are often predictable, and in some cases avoidable [ ] . while many disastrous events are not controllable by human societies, affects may be minimized through action. disasters are often described as a cycle with phases leading from one to the next. a common cycle is the r's; reduction, readiness, response, and recovery [ ] . in this spectrum one reduces (or eliminates) possible risks, readies for risk that cannot be reduced or eliminated, responds to events with the readied preparation, and works toward recovery after the event, including reducing or eliminating possible threats. faulkner [ ] provides six phases of disaster in a tourism disaster management framework. these phases include: ) pre-event, where action is taken to reduce effects of, or eliminate, potential events; ) prodromal, the time immediate prior to an imminent disaster where warnings and plans are initiated; ) emergency, the actual disaster response activities; ) intermediate, where short term issues are resolved and return to normal is being planned; ) long-term recovery, a continuation of previous phase; and ) resolution, the final phase where normal activities resume and review of events takes place. in both of these disaster management cycles the concept remains that the management process begins prior to the onset of an event with planning and risk reduction, continuing through to learning lessons and applying those lessons to future planning. a key concept in the discussion of disaster is that disasters are social disruptions [ ] . the disruption to human society causes the event to be termed a disaster-even though a physical event such as an earthquake may begin the cycle. for example, a magnitude . earthquake that occurs in an undeveloped and unpopulated part of the world is of little consequence. the same earthquake in a developed area has the potential to cause severe disruption and may be termed a disaster. the term disaster can also illustrate a lack of capacity to manage an event. as a description of the resources needed to stabilize the event, a disaster requires recruitment of resources from outside of the affected community [ ] & caribbean alliance for sustainable tourism cast [ ] . examining an event in terms of resources required to respond illustrates that disruption to human systems is integral to defining a disaster. a small hotel with limited resources could experience a disaster that a larger hotel with greater resources might have been able to handle internally with minimal disturbance. for the purposes of this discussion, the definition proposed by faulkner [ ] will form the basis for defining disaster with additional wording taken from [ ] , and rodriguez, quarantelli, and dynes [ ] . for the remainder of this discussion disaster is defined as: a sudden event where the trigger is outside the current control of the affected area (community and/or business), the event disrupts the function of that area and requires additional resources (other than those available within the area) to respond to and recover from the event. the concept of resilience has been explored over many decades among a range of disciplines, including ecology, engineering, psychology, and social science [ , , , , , , , ] . it is worth highlighting that the meaning of resilience, at its heart, remains similar across disciplines, but the nuances and values vary based on application. the root resiliere comes from the latin 'to jump back'; however, in the context of disasters affecting societies this definition falls short, as it may not be possible to go "back" to the state prior to the disaster [ ] . going back to the previous state may also be undesirable, if it means building back to the same vulnerabilities [ ] . resilience is a dynamic condition. many scholars have worked toward finding a shared meaning of resilience. however, in order to study resilience one must first define: resilience by whom; and resilience to what [ , , ] . a universal understanding of resilience is not possible: without frameworks tailored to specific populations, levels of analysis, phase of disaster, and even the unique disaster context, our ability to advance the science of disaster response toward more resilient communities is limited ( [ ] , p. ). for each group, and each circumstance, the meaning of resilience can take on new dimensions. exploring some of the different ways resilience has been applied can be a constructive process toward defining disaster resilience for hotels. resilience definitions vary based on the context. the following discussion explores literature concerned with resilience within the context of systems, organisations, economics, and communities in an effort to understand how resilience may apply to the nexus of disasters and hotels. resilience concepts for systems have undergone numerous interdisciplinary scholarly reviews [ , , , , , , ] . further insights are gained from research in physics, mathematics, psychology, and psychiatry, and ecology by aldunce et al. [ ] , whose work showed that resilience is not just bouncing back to the previous state, instead resilient systems have the capacity to change and adapt to new stresses, and create a new norm from which to continue forward. resilience in complex adaptive systems (cas) differs from engineerbased systems resilience. engineer-based systems resilience looks at returning to previous state of functionality [ ] . cas theory considers a move to a new normal that allows functioning to continue. four characteristics that help a cas to be resilient include: "…capacity for creative innovation, flexibility in relationships between the parts (of the system) and the whole, interactive exchange between the system and its environment, and a crucial role for information in evolving complexity" ( [ ] , pp. - ). a cas can also vary in size and components, moving, expanding and contracting as needed. in the case of hotels, groups of internal departments working together can function as a cas, and those same groups working with external partners can also be a cas. those same groups unable to be innovative, flexible, and collaborate in the face of disaster can delay response and recovery. the ability of a system to adapt and change is critical in our understanding of resilience as applied to larger groups, including business organisations like hotels. tourist destinations can be conceptualized as "… a human-environment system" ( [ ] , p. ). during an unfolding disaster a hotel's management and staff must understand the possible risks to the business, guests, and surrounding area, and have the capacity to cope with those possibilities exists. organisational resilience considers physical properties as well as organisational structure and capacities [ ] . resilient organisations are able to overcome adversity and continue forward, often thriving as they reinvent themselves [ ] . building organisational resilience includes "…reducing the consequences of failure and assuring business/service continuity under adverse conditions" ( [ ] , p. ). in studies of resilient organisations, a few common traits have been proposed. resilient organisations question assumptions about their environment constantly and are competitive [ ] . da.hles and susilowati [ ] write there are three components to a business's resilience: survival, adaptation, and innovation-all working together to make an organisation resilient. for hotels, these actions translate into understanding changing risks in a variety of contexts, and working to limit those risks constantly. resilient organisations employ adaptive strategies in a rapidly changing environment; the adaptations may fundamentally change the organisation in some ways, but allow it to survive into the future [ ] . organisational structure and culture influence adaptive capacities [ ] . as an example, comfort [ ] , in her study of the northridge earthquake response, found the response's networked organisational structure and flexible leadership allowed for higher functioning and quicker decision making. when organisations are too rigid and systematic, with too many layers of bureaucracy, they are less able to create adaptation strategies during dynamic events [ , ] . sawalha [ ] studied resilience of insurance companies in jordan. findings included that the jordanian business model characterised by centralized power and hierarchy, with low levels of autonomy and delegation worked at cross-purpose with resiliency. organisational structure, adaptability, culture, and flexibility features may all influence hotel disaster resilience. large hotel chains may have organisational hierarchies that make quick decision-making, flexibility, and adaptive strategizing difficult. despite the fact that organisations rarely prioritize resilience building, a. v. lee et al. [ ] argue that many traits of a resilient organisation are also traits of successful organisations. obstacles to building resilience in organisations include a lack of tangible ideas and concepts for businesses to adopt or adapt for their organisation [ ] . these challenges have slowed progress in building resilient organisations. it may be possible to overcome some of these impediments by focusing on the intersection of resilient organisations and successful organisations. resilient organisations have improved response to more common daily challenges because they have an increased self-awareness, greater ability to manage their vulnerabilities, and are adaptive and innovative [ ] . capitalizing on this idea a hotel may be able to build success commercially while building disaster resilience. in making a case for organisational resilience building, a. v. lee et al. [ ] proposes adaptive capacity building and pre-planning as components to becoming increasingly resilient to disaster. paton and hill [ ] also suggest the ability of an organisation to adapt and change predicts a business's ability to survive post disaster. organisations need to integrate elements of resilience into their daily philosophy to improve response in the face of adversity [ ] . integrating resilience management into everyday business practices through "encouraging increased situation awareness, improved adaptive capacity, and better identification and management of keystone vulnerabilities" is also important ( [ ] , p. ). thus, the research points to the importance of organisation's adaptive capacity in building resilience. economic resilience is another element of disaster resilience building within the hotel sector. economic resilience is defined as the "… ability or capacity of a system to absorb or cushion itself against damage or loss" ( [ ] , p. ). hotels are fundamentally businesses that must maintain financial viability to continue operations. there are two distinct areas of business resilience: the customer considerations and the supply considerations [ ] . customer-side resilience takes into account disruptions in customer's service, while supply side looks at service disruptions in supply chains. both of these areas are important to disaster resilience for hotels. additionally economic resilience can be broken into two separate measures: static economic resilience concerns the ongoing ability of an organisation to function; and dynamic economic resilience refers to the flexible capacity of organisations to reorganize and stabilize quickly. an important economic resiliency implication is that local tourism businesses are critical to the wider community economy in terms of providing jobs and customers for other businesses [ ] . additionally, hotels that can remain operational in the aftermath of a hazard event often maintain strong occupancy through services provided to response and recovery teams [ , , , ] . the individual business resilience is at micro level of an economy. the industry's resilience (e.g. tourism) is at the meso-economic level, and the community's resilience is the macro-economic level [ ] . accordingly, organisational resilience is linked and connected to community economic resilience. community resilience to disaster is the ability of a group to mitigate and withstand the effects of disaster, however, there is little consensus regarding the components and processes that enable communities to be disaster resilient [ , ] . write that a community's disaster resilience is built on, "… efficacy, problem-focused coping, and a sense of commu-nity…" community resilience has also been defined as "…a process linking a network of adaptive capacities (resources with dynamic attributes) to adaptation after a disturbance…"( [ ] , p. ). these characteristics are identified as: ) economic development -equitable distribution of economic resources within a group; ) social capitalrelationships as resources; ) information and communication -creating common meaning and understandings and systems to move information in times of stress; and ) community competence -the ability to make decisions and take actions as a collective. these diverse facets point to the complexity of community resilience. organisations and communities are inextricably linked [ ] . resilient businesses assist a community in maintaining social continuity in the aftermath of disaster [ ] . resilient organisations improve the ability of communities to respond to disasters [ , , ] . looking at community resilience as a basis for developing a model for building resilience in the tourism sector, bec et al. [ ] use a definition of community resilience that included a group's ability to harness resources to adapt to change [ ] . reviews definitions of community resilience and finds "…they refer to "community" as a large social group…" while an imminent and potentially disastrous event can pose incredible challenges for a hotel operation, disaster preparedness and resilience building can mitigate the consequences [ ] . a hotel is an integral part of its larger community, but may also its own community. building resilience requires participation by all stakeholders, across sectors. disasters happen to all members of a community at the same time, and recovery must happen together as well [ ] . building communities that are resource and capacity rich, and helping them understand risk is at the heart of resilience building. furthermore, planning ways to overcome potential hazards allows communities to take advantage of, and enhance, those qualities and capacities already available to their communities. the sheer number of components that combine to form a community makes assessing dimensions and indicators for community resilience more difficult [ ] . discuss the "multifaceted nature of resilience", which poses challenges in designing assessment to manage the disaster resilience building process. furthermore, conditions of resilience are dynamic, not static, so evaluation of components and measures is required on a consistent basis [ ] . however, resilience in communities can be enhanced through preparedness planning, risk awareness, and communication [ , , ] . hotels, seen through the community resilience lens, are multifaceted groups and need dynamic and collaborative analysis, preparedness, and communication ideas for handling potential disasters. based on a composite of ideas presented in this discussion the definition of hotel resilience to disaster in the context of this discussion will be: a dynamic condition describing the capacity of a hotel, together with its stakeholders, to assess, innovate, adapt, and overcome possible disruptions that may be triggered by disaster. resilience and vulnerability are often linked in research; however, they are not opposite ends of the same spectrum [ , ] . it is possible to be vulnerable in some ways, and resilient in others. vulnerability to disaster describes the extent to which a person, community, organisation, or system is susceptible to negative effects from a hazard [ ] . understanding vulnerabilities to disaster is an integral part of assessing capacities to overcome potential disastrous situations and implementing risk reduction measures. one danger in equating resilience to vulnerability is the resultant circular thinking, "a system is vulnerable because it is not resilient; it is not resilient because it is vulnerable" ( [ ] , p. ). both terms are defined by the specifics (who, when, and what) of the situation [ ] . for example, elderly people are often considered a vulnerable population, however in some situations they prove to be resilient due to their array of experiences to draw from and reduced expectations that the government will come to their rescue [ ] . circumstances can alter resilience and vulnerability of people and groups and requires careful assessment. vulnerability is a condition that is evaluated in a pre-disaster setting, resilience is evaluated by post-disaster outcomes [ ] . understanding vulnerabilities that exist in a community is fundamental to building resilience in a community, and ultimately steps to mitigate those vulnerabilities must be taken to build resilience [ ] . enhancing adaptive capacities in tourism destinations can decrease certain vulnerabilities and build resilience [ ] . "…the concepts of vulnerability, adaptive capacity and resilience are linked: enterprises that are less vulnerable and have more adaptive capacity are likely to be more 'resilient'." ( [ ] , p. ). reducing vulnerabilities and embracing sustainable practices are critical to developing disaster resilience [ ] . hotel's evaluation of their vulnerabilities can improve their adaptive capacities and build disaster resilience. the sendai framework for disaster risk reduction - (sfdrr) highlights that disaster continues to hamper efforts to improve sustainability in many economies (united nations office for disaster risk reduction [ , ] . the new framework reiterates the essential need of public and private enterprise, and refocuses efforts upon reducing disaster risk and building resilience at all levels. specifically the framework challenges the tourism industry to "promote and integrate disaster risk management approaches…given the …heavy reliance on tourism" in many parts of the world ( [ , ] , p. ). sawalha, jraisat, and al-qudah [ ] writes that hotels in jordan are less likely to allocate resources to activities that do not show an ability to generate profits short term. short-term thinking can result in response-oriented approach to disaster management. building disaster resilience for the hotel sector is works in tandem to the objectives and goals of the sfdrr. sustainable tourism considers what tourism, as a part of a bigger system, works toward sustaining, rather than how to sustain tourism activities (s [ ] .). in a hotel, actions taken in the course of business that are unsustainable may ultimately make the operation of the business unstainable too. for example, a hotel that does not account for the health of the local reef in planning tourist activities may damage and degrade the reef making their facility less desirable to snorkelers and reef enthusiasts. "one way to reduce the susceptibility of communities to loss from hazard consequence is to create a community that is sustainable and resilient" ( [ ] , p. ). a disaster resilient community contributes to that community's sustainability [ ] . resilience and sustainability may use different avenues and methodologies but they work toward the same goals [ , ] . to achieve sustainability a community should "maintain and, if possible, enhance environmental quality" ( [ ] , p. ). sustainability can be natural resource centric, but the objective is continued function with no depreciation of quality of life [ ] . a shift that emphasizes sustainable practices may ultimately be good for hotels business in the long term. while there exists much common ground between sustainability and resiliency, redman [ ] suggests that some objectives may be in conflict and the study of these two subjects should remain independent. this opposing view considers that the adaptive cycle of resilient systems may adopt a new norm that is not sustainable long term, in order to continue functioning in the short term. when building resilience to disasters short-term, non-sustainable adaptions are often critical for survival and a part of the process. for example, in a hotel context consider adaptions like petrol powered generators to maintain minimum critical functionality, while this is a non-sustainable solution it is also often a short-term solution required to maintain operations. the body of literature regarding disasters, tourism, and more specifically hotels, has increased over the last years, yet improvements in the hotel sector's disaster preparedness have not kept pace. ritchie [ ] outlines the need of all tourism organisations to assess their vulnerabilities and risks, placing increasing emphasis on planning and prevention, as opposed to the more common focus on response and recovery strategies. there is a need for businesses to consider how they are creating and/or enhancing risks and act to minimize these effects (united nations economic and social commission for asia and the pacific escap [ ] s.awalha et al. [ ] studied five star jordanian hotels and found that disaster management was considered a response and recovery activity, as opposed to a proactive management of variables to decrease the possibilities and severities of risks. faulkner [ ] brings to light that few tourism organisations recognize the importance of risk reduction, planning and preparedness. a history spanning decades of incidents and accidents in the hospitality industry was published in the cornell hotel and restaurant administrative quarterly [ ] . the account included many well-publicized disasters such as the las vegas fire in the mgm hotel and the eruption of mount saint helens (tourism effects on the pacific northwest). this journal editorial explained that the hospitality industry was learning from each of these events, and hotels (as well as restaurants) were reducing their disaster risk with each event. a disagreement is evident in the literature regarding improved disaster management. some literature reflects that hotels are reviewing past incidents and attempting to learn lessons [ ] , and other literature contradicts this assertion [ ] . procedures and plans for handling disasters were found to be nonexistent in a survey conducted by drabek, where hotel guest who had experienced disastrous circumstances participated [ ] . kwortnik [ ] argues that the industry seems to be repeating the same mistakes repeatedly, based on a study of some hotel's reactions to the blackout in the eastern united states. chien and law's [ ] article discussed the hotel industry's widespread concern of the spread of sars, and the lack of guidance for hotels on epidemic topics. during the sars, hong kong experienced an % decrease in tourism as a result of this epidemic [ ] . these examples highlight that implementing lessons learned in disaster preparedness for the hotel industry may be low priority. preparedness planning helps to ensure resources needed for response and recovery are available, by deciding in advance who will do what, when, and where in different circumstances (united nations environmental programme unep [ ] . complete preparedness planning for disasters can also reduce risk [ , ] . writes, "…taking a more strategic or holistic approach to disaster planning and preparation may reduce the likelihood of linked events, 'escalation' or the 'ripple effect' occurring due to the chaotic and complex inter-relationships within an open tourism system." furthermore, preparedness planning for disasters by the tourism industry should be integrated and viewed as essential in a world where growing numbers of disasters are impacting tourism [ ] . the uncertainty of hazards complicates the ability to develop detailed preparedness plans [ ] . even though control over natural forces is rarely possible, the effects of these events on communities can be mitigated and diminished through preparedness efforts. "…surprise is an inevitable event whose magnitude and rippling consequences can be anticipated through knowledge, emerging tools, consensual social collaboration, and preparations to be flexibly innovative" ( [ ] , p. ). in recent years, building disaster resilience in organisations and communities has been studied as one way to combat the unpredictability of disasters. disaster related research for the tourism industry tends to be response and recovery centric, with less attention paid to the preparedness and preventative possibilities [ , , , , , , , ]. the academic discourse on crises and disasters in the tourism sector is often reactive in its approach. hall [ ] reviewed the literature concerning economic and financial tourism crises between - and found surges in literature following events like oil shortages and the attack on the world trade center in new york. combating the response centric focus, some authors have worked to develop frameworks that describe pre-disaster emergency response planning and postdisaster activities. frameworks, models, and planning techniques have been explored and developed for the tourism industry, and to a lesser extent hotels ( [ , , , , , , , , , ] . the tourism industry is encouraged though the growing literature to take action to improve their ability to survive and even thrive in the aftermath of a disaster. in practice, however, a response focused attitude toward disasters seems to continue to be prevalent in the tourism sector. the recent hotel resilient programme provides guidance to strengthen disaster resilience for the hotel sector through design and promotion of a certification programme [ ] . the certification is focused on larger properties, with a more guidance-oriented approach for smaller hotels. the programme, sponsored by the unisdr, gidrm, and pata aims to build resilience to disaster though encouraging disaster risk reduction strategies in three categories, with subcategories [ ] . these categories include building location, design and structural elements, systems design to warn and minimize risk, (e.g. fire protection and evacuation systems), and management risk reduction planning components, which include training, drills, communications planning, and continuity planning. the hotel resilient programme is currently piloting in indonesia, the maldives, myanmar, the philippines, and thailand [ ] . a scoping study, of interviews with hotel and tourism professionals, explains that a hotel's disaster risk and resilience is not currently a priority for guests; however, guest's general interest in safety is increasing. the existing barriers to the programme were consistent with the literature; interviewees identified cost, time, and capacity as potential obstacles to engaging in a certification programme [ ] . this programme offers a great step forward for hotels; however, focus is on disaster risk reduction strategies (e.g. infrastructure, warning, and risk reduction planning). while disaster risk reduction is a component of disaster resilience, this initiative does not seek to address other possible components of organisational resilience. these include organisational structure and flexibility [ , ] , adaptive capacity [ , ] , and less tangible resources such as social capital [ ] . qualities such as sense of community and self-efficacy improve resiliency [ , ] , and may be more influenced by organisational culture than disaster risk reduction strategies. unfortunately, the hotel resilient programme does not delve into these subjects. building preparedness and resilience to disasters in the tourism sector lacks significant progress [ , ] . for example, in , hystad and keller [ ] did a follow-up study, three years after a major forest fire affected tourism businesses near kelowna, british columbia, canada. in the original study, tourism businesses were surveyed regarding their preparedness for disaster. the original study concluded the businesses were not prepared for a forest fire, although an occurrence of an event like this fire was highly probable [ ] . the follow-up study identified % (up from the previous study showing %) of those businesses in their study had a disaster management plan. further analysis of the data revealed that the majority of those businesses had only informal planning. the study's conclusion was that tourism businesses lack the will to improve and develop their own contingency planning ( [ ] , p. ). hotel staffs, along with the organisations, are unprepared to face disasters that may affect hotels. staff members were found to be lacking information on disaster practices and hotels failed to carefully assess their risks [ ] . mahon, becken, and rennie [ ] suggest tourism employees may not have confidence that their employer's plans are sufficient to be effective in the face of disaster. the inclusion of stakeholders, including staff, in disaster management activities is important for the success of preparedness planning and emergency response. disaster planning undertaken by accommodations managers in australia was reported to be at . % in a study by ritchie, bentley, koruth, and wang [ ] . however, the authors recognize the study, while positive trend in increased disaster planning, relied on selfreporting by accommodations managers and did not detail the extent to which the planning had been done. the reactive, rather than proactive, management of disasters and that plans were not necessarily embedded in their organisation was a point [ ] research highlighted. hotels in new orleans, post-hurricane gustav, were closed for up to days, with the median being days [ ] . full service, food and housekeeping, was not restored for - days following the hurricane (only % reported loss of power as reason for delay). lack of staff to run the operation was found to be the primary cause. lamanna et al. [ ] examined new orleans hotels' response to hurricane gustav in . the study showed that while % indicated they had a written plan for hurricane evacuation, only % involved their staff in the process and % had procedures for training staff. % provided an annual exercise for the staff to participate. new orleans hotels have capitalized on lessons learned from previous hurricanes, yet they still have much room for growth and improved resilience. based on these reviews it is clear that tourist organisations, including hotels, are not proactively assessing, and planning, to minimize their risk to disaster. communities must consider carefully the role they play in creating some of the billion dollar losses attributed to disasters [ ] . this idea, viewed through a tourism lens, serves to illustrate that hotels may play a role in creating their risk. high-risk locations and attraction of guest unfamiliar with the area combined with inattention to staff training and preparedness planning can be an expansive and lethal combination. the accommodation sector is vulnerable to disaster based on its / model and sensitivity to external factors [ ] . hotels are often located in highrisk locations based on guest preference to vacation in coastal or alpine environments [ , , ] . as an industry, the tourism sector has been found to avoid openly discussing hazards of any sort [ ] . the marketing literature of hotels is designed to entice guests, thus chooses to minimize any risk potential while highlighting local activities and positive features. tourist can be particularly vulnerable in a disaster due to their lack of familiarity with the region, customs, hazards, and local language [ , , , , ] . this lack of familiarity and knowledge can inhibit their ability to take protective actions. it has been argued that lack of community and business preparedness, and official tsunami warnings exacerbated the effects of the indian ocean tsunami [ ] . guests and locals alike simply did not recognize the immediate danger (as the water receded unexpectedly) and the critical need to head to higher ground. beyond commercial enterprise, caring for communities, environments, or assist in social development is an organisations responsibility, often termed corporate social responsibility [ , ] . in addition to the above responsibilities, henderson expands on this concept, stating that visitors to an area need to be supported and oriented to their new environment. hotels have a corporate social responsibility to have plans to care for, and keep safe, their staff and guests [ ] . a study of hotels in thailand, following the boxing day tsunami, looks further into corporate social responsibility. common traits of socially responsible organisations included, "…investment and involvement in social welfare… compliance with official regulations and a willingness to exceed these…education and engagement of customers and staff about social and environmental issues of concern ([ ], p. ). the hotel sector's responsibility must include placing high value on ensuring the safety of their staff and guests, while also improving their organisation's ability to come through disastrous events and continue to be operational and profitable [ ] . hotels have a responsibility to understand their risk and vulnerabilities-and create strategies to prevent or mitigate events stemming from predictable disasters [ ] . the expansion of the tourism industry gives rise to the need for disaster preparedness and investigation of ways to return to operative capacity [ , ] ). disaster resilience building can decrease effects of events, improve life safety, and get hotels back to operational status. the hotel sector's around the clock, day a year model elevates the importance of disaster resiliency. guests will always be present, as will staff. disaster resiliency for hotels may translate into lives saved, as well as business reputation. however, the idea that disaster preparedness plans, disaster risk reduction activities, and disaster resilience building are separate activities from commercial concerns is reflected in the literature. an example of this disconnect may include managing a profitable hotel business; yet, managers do not prioritize planning for continued operations following a disaster. competition for support and funds can be difficult as preparedness planning and resilience building are hard to quantify in regards to return on time and investment [ , ] . furthermore, tourism operators may not be making headway due to the already voluminous workload, leaving little time to pursue new planning avenues [ ] . promoting benefits to building disaster resilience that also work toward improved profitability and functionality may improve the buyin from management. one study of hotel stock prices indicated socially responsible actions can improve a hotel company's short and long term profitability [ ] . illuminating the value of building resilience-for both day to day operations and in times of disaster may also promote a greater understanding of what a resilient organisation truly looks like [ ] . "…elements of resilience and competitive excellence share many of the same features…", for example, organisations with these characteristics constantly scan for and interpret changes or risks in the environment and develop adaptations as needed [ ] ., p. ). disaster resilience building may be a tandem feature of competitive business practice. the academic literature on resilient organisations suggests that business continuity plans are essential and should provide a range of functions: ) management and information systems to continue as needed for core business functions; ) management's ability to transition from routine to crisis mode; and ) preparedness plans that are designed to ensure operating capacity and capability even under extreme conditions created by a disaster ( [ ] , p. ). business continuity planning is focused on establishing a strategic plan to reestablish key business operations to ensure business survival [ ] . business continuity planning may include such things as audits of facilities, identifying key persons, developing prevention strategies, and acquiring insurance to cover potential losses [ ] . in addition, preparedness planning for organisations must include how to operate in unusual conditions, such as lack of water or power. resilient enterprises analyse disruptions to find positive actions that will carry the business forward. the ability to plan for and manage disastrous situations ought to be integral to management training for tourism professionals [ ] . disaster planning may be integrated into a business's strategic management and planning as the two concepts share the objective of long term survival of an organisation [ ] . strategic plans allow for quicker reaction. lack of planning can result in slow decision-making and slow action plan formulation following an incident. delays can exacerbate the impact. at the same time planning can be challenged by the chaotic nature of an unfolding disaster [ ] . there is an overlap between business continuity planning, strategic management, and resilience building. however, building resilience also considers flexibility, social capital, and innovation in ways that business continuity planning and strategic management may not. clearly if managers are building disaster resilience in their continuity and/or strategic planning, an opportunity to shift the paradigm toward improved disaster resilience exists. tourism's essential and integral ties to the community require a level of responsibility to maintain operative capacity [ ] . the ability for a business within a community to continue to operate during a disaster is foundational to the overarching recovery of the wider community [ ] . a synthesis of the literature points to the importance of prioritizing disaster resilience building for the hotel sector. as the numbers of tourists affected by disasters grows, the importance of providing actionable information to limit the severity of these events on communities, including hotels, also escalates in pace. the literature discussion above scrutinizes how disaster and resilience are framed for the tourism sector, and how these concepts apply to the hotel sector. resilience to disasters for the hotel sector is a dynamic condition describing the capacity of the organisation, together with its stakeholders, to assess, innovate, adapt, and overcome possible disruptions triggered by disaster. integrated into building disaster resilience for hotels is disaster risk reduction activities (including structural and nonstructural analysis that looks at operational and service factors from an all hazards perspective), and preparedness. sustainability of hotel policies and actions need scrutiny. improving resilience requires building adaptive capacity, creating flexible organisations and fostering an organisational culture that promotes self-efficacy, innovation and questions the status quo. to promote building resilience, all stakeholders at every level of the process must be involved. an interactive exchange of ideas promotes growth of social capital and builds resilience. clarified framing and simple tools can promote a hotel's ability to understand, measure, and build resilience, moving more hotels toward embracing disaster resilience as an objective of value-worth the time, effort, and resources required. emergency preparedness for disasters and crises in the hotel industry framing disaster resilience: the implications of the diverse conceptualisations of "bouncing back community resilience to long-term tourism decline and rejuvenation: a literature review and conceptual model linking tourism into emergency management structures to enhance disaster risk reduction the tourism disaster vulnerability framework: an application to tourism in small island destinations the resilience of formal and informal tourism enterprises to disasters: reef tourism in phuket assessing social resilence interorganizational coordination: analysis of van earthquakes 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destination hotel resilient: strengthening the resilience of the tourism sector united nations office for disaster risk reduction (unisdr) hotel resilience: a certification scheme for hotels and resorts to reduce climate and disaster risks and strengthen resilience across tourism destinations in the asia-pacific region developing strategies to strengthen the resilience of hotels to disasters: a scoping study to guide the development of the hotel resilient initiative a theoretical model for strategic crisis planning: factors influencing crisis planning in the hotel industry key: cord- -mwr l authors: granville, francesca; mehta, amisha; pike, steven title: destinations, disasters and public relations: stakeholder engagement in multi-phase disaster management date: - - journal: journal of hospitality and tourism management doi: . /j.jhtm. . . sha: doc_id: cord_uid: mwr l abstract research about disasters in tourism has emerged in earnest since the s covering insights for preparedness and response. however, recently, authors have called for more systematic and holistic approaches to tourism disaster management research. to address this gap, this study adopted a public relations perspective to refocus attention to relationships and stakeholder expectations of destination communities across multiple phases of disaster management. the authors used a mixed method approach and developed a battery of disaster management attributes by conducting interviews and analysing industry documents and the extant literature. these attributes formed part of a survey of tourism businesses. exploratory factor analysis resulted in a two factor solution: i) business disaster preparedness, and ii) destination disaster response and recovery. findings also show that participants reported a gap between the importance and destination performance of these attributes. in particular, tourism businesses perceived destinations did not adequately engage in disaster preparedness activities, which had implications for disaster response and recovery. disasters are unexpected natural or man-made events that injure people, damage property and infrastructure, and threaten the survival of organisations (pearson & clair, ) . past disasters include terrorist attacks, natural hazards, and organisational incidents such as technical errors or corporate malfeasance. the tourism industry is particularly susceptible to the short term and longer term effects of disasters due to: i) disruption of services at destinations and along the transit routes, and ii) the (mis)perceptions of consumers in distant markets. recent examples of disasters to impact on tourism are highlighted in table . disaster management comprises four phases: prevention, preparedness, response and recovery (pprr). prevention involves preventing or mitigating hazard impact such as disaster-proof infrastructure, preparedness ensures measures are in place before a disaster occurs, response comprises effective and efficient reaction to a disaster, and recovery includes the short and long-term efforts to restore communities following disasters (cronstedt, ) . despite the range of disasters and the existence of disaster management and engagement strategies, preparedness levels within the tourism sector remain historically low (faulkner & vikulov, ; hystad & keller, ; paraskevas, altinay, mclean, & cooper, ) . although past disaster experience can motivate action (cioccio & michael, ) , the traditionally low levels of disaster preparedness amongst tourism businesses are attributed to beliefs that disasters are not likely (faulkner & vikulov, ; hystad & keller, ) , and a lack of funds, staff, and time (spillan & hough, ) . a lack of disaster preparedness in the tourism industry has the potential to impede disaster response and recovery for individual destination stakeholders and the economic health of the sector. a key influencer in disaster management, from preparedness to recovery, is the destination marketing organisation (dmo). a dmo is formed as a result of a community seeking to become organised in the pursuit of destination competitiveness, and predominantly coordinates marketing communications (pike & page, ) . some dmos have supported knowledge-building activities related to disasters (blackman, kennedy, & ritchie, ; blackman & ritchie, ), yet the field of dmo involvement in disaster management is relatively new (paraskevas et al., ) . althoughexistingstudieshaveexaminedstrategiesfordisasterpreparedness,responseandrecovery,comparativelyfewstudiesexamine disastermanagementinholisticandsystematicways (faulkner, ; paraskevas et al., ; ritchie, ) . the lack of research covering multiplephasesofdisastermanagementandtherelationshipswithinthe sector potentially limits how the tourism industry manages change, complexity and follow-on disruptions that are commonly associated withdisasters.toaddressthislackofresearch,thisstudyadoptsapublic relations perspective to examine the multiple phases of disaster management from the perspective of key stakeholders in destination communities. public relations emphasises the value of relationships between organisations and their environments. according to one of the most frequently cited definitions, public relations is "the management function that establishes and maintains mutually beneficial relationships between an organization and the publics on whom its success or failure depends" (broom, , p. ) . while public relations is commonly understood as a publicity and promotion function for organisations, its value in relationships and stakeholder engagement deliver sustained and mutually beneficial outcomes. this study focuses on public relations practices around stakeholder engagement that are designed to enhance and/or create capabilities in disaster management and preparedness. building on the opportunity to contribute to existing research and enhance engagement processes, the study investigates tourism destination stakeholders' perceptions of current disaster management preparedness initiatives at their destination. the study contributes to disaster management research in the tourism literature by giving attention to disaster preparedness, response and recovery phases to enhance engagement and build resilience in the sector. in addition, the study builds understanding of the expectations that drive the relationship and engagement between dmos and tourism destination stakeholders in disaster management. the aims of the study were twofold: i) to identify destination management attributes deemed important to stakeholders and ii) to identify stakeholders' perceptions of their destination's disaster management performance. a destination community contains diverse stakeholders with varying levels of vested interests in the success of their destination community (pike & page, ) . for dmos, stakeholder engagement and relationship management are important because they build trust, resilience and performance (sloan, ) . as a key function of public relations, stakeholder engagement is conceptualized in this study as the relationship-building principles that can improve tourism destination stakeholders' business capabilities in disaster management (taylor & kent, ) . there are multiple ways to engage and manage relationships with stakeholders from monitoring to involvement to deep collaboration or integration into decision-making (basu, bose, & ghosh, ; burnside-lawry & carvalho, ) . the relationships between dmos and destination stakeholders create social capital, which is an important part of public relations practice as it enables the achievement of business and social outcomes (taylor & kent, ) . engagement is also an important part of effective disaster management. the role of dmos is most clearly defined in disaster response and recovery which brings a focus on marketing activities designed to restore the industry (blackman & ritchie, ; wang & pizam, ) . although researchers have identified dmos as industry educators that can assist businesses to plan for and cope with the negative effects of crisis (blackman et al., ) , there is limited research that explores the critical relationship between these organisations. engagement around all areas of disaster management will be influenced by the pre-disaster relationships (coombs & holladay, ) , in this case between dmos and destination stakeholders including tourism operators. tourism research shows divergence in these pre-disaster relationships. for example, less interest in destinations and their competitiveness is shown by small tourism businesses whose owner/operators are motivated by lifestyle (thomas, shaw, & page, ) , over business design. however, dmos, their stakeholder engagement strategies and the competitiveness of the destination influences the success of individual tourism ventures and cooperatives (pike, ) . for dmos, the ultimate aim is to achieve alignment between their actions and tourism destination stakeholder expectations, an outcome also shared by public relations. the lack of alignment between organizational and stakeholder interests can reflect in social and economic performance (sloan, ) . in this regard, there has been a relatively small stream of research investigating tourism destination stakeholder perceptions of the effectiveness of the dmo's destination leadership (see for example bornhorst, ritchie, & sheehan, ; donnelly & vaske, ; dwyer, cvelbar, edwards, & mihalic, ; evans & chon, ; selin & myers, ; wagner & peters, ) . within these studies, a noticeable gap is the extent to which destination stakeholders are satisfied with their destination's disaster management. a dmo's disaster management activities are vital in ensuring resilience in the tourism industry. in the context of disaster management, the lack of alignment has the potential to affect how stakeholders, in this case tourism businesses prepare, respond to and recover from disasters. expectation confirmation theory (ect) was originally developed by oliver ( ) who suggested expectations and perceived performance lead to satisfaction. this effect is mediated through a positive or negative confirmation or discrepancy between expectations and performance. for example, if a service exceeds the expectations of the consumer (positive confirmation), satisfaction will occur and if a service falls short of expectations (negative confirmation), dissatisfaction is likely to result (chou, lin, woung, & tsai, ; oliver, ) . ect has been widely used to study satisfaction amongst consumers in marketing environments, urban services and information technology (bhattacherjee, ; chou, kiser, & rodriguez, ; thong, hong, & tam, ; van ryzin, ) . satisfaction levels are predicted through two constructs: expectation of the service and confirmation of that expectation following the experience (bhattacherjee, ) . the expectation provides the base line against which confirmation is assessed in order to determine overall satisfaction. this is due to the fact that high satisfaction implies a number of positive outcomes such as purchase, endorsement, profit or return on investment (bowden, ). in tourism, ect has been applied to examine individual tourist satisfaction with destinations (hui, wan, & ho, ; o'rourke & o'rourke, ; pizam & ellis, ; pizam & milman, ; van raaij & francken, ; weber, ) and with tourism trends such as medical tourism . the application of ect to a service-oriented sector and businessto-business relationship, the focus of this study, is a comparatively unique approach. in the past, researchers' critiques of ect related to the low familiarity of customers with tourism-related services (yüksel & yüksel, ) . applying ect to a pre-existing relationship between dmos and tourism businesses, in part overcomes some of these concerns. this study responds to yüksel and yüksel ( ) call for further empirical research to test the validity of the ect measure in tourism. this study attempts to better understand the relationship between dmos and the tourism organisations they represent within disaster management. this relationship will be examined through the application of ect. through this application, the research will explore current dmo engagement strategies with regard to disaster management within the tourism industry, and consequently the levels of satisfaction held by stakeholders in australia. the research questions for this study are: rq : what functions of destination disaster management are important to tourism stakeholders? rq : to what extent do stakeholders' expectations for and the perceived performance of the destination's disaster management align? to identify the functions of disaster management in tourism and explore congruence between these expectations and performance of destination disaster management, a mixed-method design was adopted. exploratory qualitative research was undertaken as the constructs that defined disaster management were not yet established in the literature. three stages of data collection were used to address the first research question. first, key journal articles and books sourced from disaster management, crisis communication, and tourism literatures were analysed for checklists and lists of disaster preparedness, response, and recovery attributes. second, an internet search revealed five crisis management or disaster response plans from dmos or tourism organisations. these plans represented guides for tourism operators or dmos in the case of risk and disaster and were sourced from state, federal and international organisations. third, six semi-structured interviews were conducted with various individuals working for organisations within the tourism industry in queensland. participants included tourism operators, dmo executives, and members of local government who were involved in disaster management programs for their constituency. participants consisted of two tourism operators, two employees of dmos, and two individuals from local government. the semistructured interviews consisted of four open-ended questions. these real-world insights consequently added a new dimension to the emerging list of attributes. interviews were then transcribed and coded, in an attempt to derive disaster management attributes from the text. manual coding was undertaken, whereby the raw data were first transformed into preliminary codes, then final codes (saldaña, ) . the three lists of attributes were triangulated by comparing and contrasting, and integrating the separate lists into a definitive battery of attributes (berg & lune, ) . similar attributes were combined, and attributes that were only mentioned in one of the lists were eliminated. from these tables, a final list of attributes was developed, as shown in table . an online survey was then used to address the second research question. participants were asked to rate the level of importance of for each of the destination disaster management attributes using a seven point likert type scale anchored at (not important) and (very important). a separate ' ' (don't know/no opinion) nonresponse option was also provided alongside each scale item. participants were then asked to rate their destination's performance for the same attributes, using a seven point scale anchored at (strongly disagree) and (strongly agree). again, a separate ' ' (don't know/no opinion) non response item was used to minimise potential bias of uninformed responses. participants were also asked if they had ever experienced a disaster and about the characteristics of the organisation that the respondent represented. these questions were asked to gain a better understanding of the differences in responses based on participant's disaster experience and an organisation's size, type, industry, age, and geographic location. the target population for the online survey included any individual employed by an organisation operating within or affected by the tourism industry in australia and new zealand. sectors considered as part of the tourism industry for the purpose of this research were: the accommodation industry, visitor attraction, cafes, restaurants, and takeaway food services, clubs, pubs taverns and bars, transport, casinos and gambling services, motor vehicle, travel agencies and tour operator services, sports and recreational services, automotive fuel retailing, retail trade and any trade association representing these sectors (tourism research australia, ) . participants were recruited from two sources. first, databases of destination marketing organisations and tourism trade organisations that agreed to assist with the dissemination of the survey. organisations that agreed to disseminate the survey include destination management and regional development organisations in new zealand, queensland, new south wales, south australia, victoria, western australia, tasmania, and industry associations such in accommodation and aviation in australia and new zealand. this avenue yielded responses. an external panel was sourced from research now, a multi-national market research organisation that complies with research standards through membership to the research association of new zealand, the australian market and social research society and the travel and tourism research association. this resulted in a further participants. the results identified the key functions of disaster management that were considered important amongst tourism stakeholders. by mapping these rankings against stakeholder evaluations of perceived performance of the destination, the results indicate a gap, indicating misalignment in performance. these results are presented next. a total of useable responses were received. the characteristics of the sample are summarized in table . one in five participants had experienced a disaster at their destination. just over half of the participants were from small businesses with less than staff ( %), followed by businesses with e staff ( %) with the remaining % from businesses with over employees. the majority of participants ( %) worked in organisations that had been in operation for five years or more. almost half of the participants ( %) were from businesses operating within the retail sector. other sectors identified included tourism, hospitality, accommodation and consultants. one in five participants was an owner-operator, and a further % held management positions. almost one-third of the participants were located in new south wales ( %), followed by queensland ( %), and victoria ( %). as shown in table , attribute importance means ranged from a high of . for 'has a strategy to handle the disaster situation', to a low of . for 'holds pre-disaster workshops to teach me how to adequately plan for disaster situations'. all attributes had a mean above the scale mid-point with a grand mean of . , indicating face validity. the cronbach alpha for was . , which is well above the identified acceptable level (>. ) indicating strong internal consistency (cronbach, ) . independent-samples t-tests by participants' disaster experience indicated that only one item with a statistically different mean between these groups 'has a strategy to handle a disaster situation' (t ¼ . , p ¼ . ). those who had experienced a disaster were more likely to believe it important for communities to have a strategy to handle a disaster situation. one-way anova did not reveal any statistically significant differences between means by business type, location, or the participant's position within the business or business size. exploratory factor analysis (efa) was undertaken to examine the underlying structure among the variables in the analysis (joseph, hair, black, babin, & anderson, ) . the correlation matrix showed each attribute correlated with every other attribute (pallant, ) . the kaiser-meyer-olkin measure of sampling adequacy (kmo) was . , while bartlett's test of sphericity was significant at the . level. the efa was conducted using principal components analysis with a varimax rotation. the two factor solution explained . % of variance, as shown in table . attributes that loaded onto factor had an individual focus, whereby items were presented in personalized activities designed to enhance disaster preparedness within individual businesses. attributes which loaded onto factor , were deemed to have a disaster response and recovery function that operated at a destination level. this second factor of attributes reflected a strategic focus rather than a tactical approach geared at individual businesses as in factor one. pooled perceived destination performance results are listed in table where it can be seen the means ranged from a high of . for 'keeps up to date with developments in the media regarding the disaster situation' to a low of . for 'holds pre-disaster workshops to teach me how to adequately plan for disaster situations'. in contrast to the importance ratings, seven of the means for the perceived performance ratings along with the grand mean were below the scale mid-point. of these seven attributes, six were items from factor one, which focused on the disaster preparedness activities for individual businesses. gap analysis is a helpful visual aid to highlight the practical implications of the research for stakeholder engagement and relationship building in destination communities. as shown in fig. , there is a gap or misalignment between the importance ratings of and stakeholder perceptions of destination performance for every disaster management attribute. this study shed light on elements relating to public relations and stakeholder engagement in the tourism disaster management in several ways. first, this study identified multi-phase disaster management attributes that were important to tourism businesses, contributing to existing research that is phase-specific. a number of these attributes were rated as very important to tourism businesses, signalling priority areas for tourism destination stakeholders. from a public relations perspective, this information identified the criteria to judge the performance of dmos and created a platform to guide stakeholder engagement activities before, during and after disasters. second, these attributes identified as two factors. factor one, business disaster preparedness, comprised the activities that tourism business expect to be provided by destinations in the predisaster context. the framing of these attributes showed a dependence on the destination to provide support for risk assessment and crisis training among others. taken another way, tourism businesses externalized the responsibility of pre-disaster preparedness to destinations. factor two, destination disaster response and recovery, focused mostly on the latter phases of disaster management with activities that operated at the industry level such as grant assistance and post-disaster recovery communication or promotions. this factor comprised the engagement activities that dmos undertake with emergency services organisations and governments. table triangulated list of destination disaster preparedness attributes. has a strategy to handle the disaster situation keeps up to date with developments in the media regarding the disaster situation co-ordinates and establishes relationships with important groups (emergency services, governments, and police) in order to be ready for a disaster establishes communication and command chains to be followed during a disaster communicates with me about the status of disaster situations including the response and recovery efforts promotes my destination to help bring visitors back to the area following a disaster organises or provides financial help for my business after a disaster through small grants or tax cuts creates an emergency preparedness checklist for me to use during a disaster provides me with access to free online and offline crisis management resources and tools to help my business be disaster ready provides me with crisis management training and advice in the event of a disaster holds drills, rehearsals, and simulations of potential disaster situations conducts a risk assessment of my business' ability to cope with potential disasters provides my business with a written crisis management plan holds pre-disaster workshops to teach me how to adequately plan for disaster situations these factors provided a concise and reliable way to measure disaster management attributes across multiple phases. although these factors were developed and tested in a predominantly australian context, further research could examine how the factors operate in other developed and emerging economies to better understand tourism disaster management practices. third, the study identified a consistent gap between tourism businesses' evaluation of the importance of and destination performance against disaster management attributes. in particular, seven attributes fell below the scale mid-point with six of these attributes belonging to factor one, business disaster preparedness. this finding suggested that tourism businesses perceived that destinations were not performing well in activities that directly engaged them around disaster preparedness. when effectively applied, stakeholder engagement has the potential to enhance tourism business' capabilities in disaster management (taylor & kent, ) . the attributes identified above included a number of areas that have the ability to improve owner/operator and business capability for disaster preparedness, response and recovery. at the same time, seven attributes sat above the scale mid-point with the majority belonging to factor two, destination disaster response and recovery. this finding suggested that destinations were perceived to do a better/adequate job at destination level than at the individual business level. overall, this analysis focused on stakeholder perceptions of performance rather than actual performance. this finding might suggest that destinations need to better engage their stakeholders and communities to enhance visibility about existing work in disaster management. various limitations to this study have been identified. first, despite the relatively large overall sample size within this study, participant numbers for some australian states have been undererepresented, which restricts the ability to generalise findings. difficultly gaining business participants as opposed to individual consumers is an issue faced frequently by researchers, as acknowledged by pike, murdy, and lings ( ) . as such, the use of an external panel organisation was vital in ensuring an adequately sized sample, yet use of such a panel poses limitations for the current study. the utilisation of judgement sampling, specifically the panel organisation's offer of a small incentive to complete the survey may have resulted in cases of self-selection bias. self-selection bias occurs when participants decide entirely for themselves whether or not to participate in the survey. this occurs to the extent that the participants' propensity for participating is correlated with the phenomenon the researcher is attempting to investigate (hall, ) . while acknowledging these shortcomings, results of this research reveal useful insights into the relationship between communities and the tourism operators they represent, and contributes to current understanding of disaster management in australia. this study identified attributes that were important to tourism destination stakeholders across multiple phases of disaster management. the authors also showed the misalignment between stakeholder importance and perceived destination performance against these attributes. in doing so, the work provides a first step for improving stakeholder engagement in ways that can enhance tourism destination stakeholder capability, build resilience in tourism, and 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title: the effects of natural disasters on international tourism: a global analysis date: - - journal: tour manag doi: . /j.tourman. . sha: doc_id: cord_uid: apr oyqa tourism is shaped by a wide range of factors and forces, including exogenous ones that have no direct link with the tourism sector. natural disasters and unexpected events are prime examples of such determining factors, as they have profound effects on individuals and society, and as a result have the potential to affect tourism flows considerably. several theoretical arguments exist why natural disasters and unexpected events could influence tourist destination choices. however, empirical research to confirm the nature and extent of impacts of disasters on tourism is lacking. to address this gap, this paper incorporates a dataset on natural and man-made disaster events into a model of international tourism flows to evaluate the effect of different types of disasters on international arrivals at the national level. findings provide evidence that the occurrence of different types of event change tourist flows to varying degrees. although in some cases a positive effect is estimated, in general the impacts are negative, resulting in reduced tourist arrivals following an event. understanding the relationship between disaster events and tourism is helpful for destination managers who make critical decisions in relation to recovery, reconstruction and marketing. earthquakes, tsunamis, floods, bush fires, hurricanes, droughts and heatwaves have always occurred. these events have formed part of the wider 'riskscape' that humans have learned to manage and live with. however, more recently the impacts of disasters have increased substantially, partly because of the exacerbating effects of climate change, but also due to the growing complexity of socio-ecological systems in a highly connected and globalized world (becken, mahon, rennie, & shakeela, ) . for instance, the year recorded a series of hurricanes (harvey, irma and maria) in the caribbean and a severe earthquake in mexico, amongst other events, and these resulted in the highest incurred losses ever recorded (us$ billion) (munich, ) . disasters constitute abrupt changes that shock the system in which tourism is embedded (shondell miller, ) . the nature and extent of impacts depend on the type of shock and the resilience of the affected system (oecd, ) . most disasters have profound impacts on individuals, organizations and communities, and consequently on tourism activities. the repercussions of a disaster are likely to affect tourism directly at a destination country, but indirect consequences for travel to and from the affected region are also conceivable (jin, qu & bap. ; ruan, quan & liu, ) . understanding, managing and responding to these risks, therefore, has to be an integral component of sustainable tourism management (shakeela & becken, ) . consequently, it is not surprising that the topic of risk management and disaster mitigation is attracting increasing attention in tourism research. an emerging body of literature has provided both theoretical and empirical insights into multiple aspects of disasters and tourism. research to date has largely focused on crisis management and disaster risk reduction (becken & hughey, ; faulkner, ; ritchie, ) . in particular, academics and practitioners have been interested in how sustainable development and marketing strategies should include plans to prepare, protect and rebuild a destination after a disaster, both in terms of physical assets and destination image (aljerf & choukaife, ; okuyama, ) . the perceptions of safety is an important aspect of destination image, and different types of risks and events have been studied in the context of visitor travel information seeking and decision making (sharifpour, walters, ritchie, & winter, ; trumbo et al., ; williams & bal� a� z, ) . re-establishing public perceptions of safety and attractiveness following a disaster is crucial to attract and reassure potential visitors to travel to the destination and, by doing so, assisting the affected area to regain functionality and economic recovery (wttc, ) . in addition to understanding visitor perceptions, it has been found that addressing risk perceptions and behaviours of relevant tourism stakeholder is critical for effective disaster response and recovery (kozak, crotts, & law, ; park & reisinger, ) . tourism is exposed and vulnerable to multiple types of hazards (becken, zammit, & hendrikx, ) , and disasters have the potential to deter visitors from travelling to affected destinations (bhati, upadhayaya, & sharma, ) . however, empirical research that confirms or quantifies the relationship between disasters and tourism activity is scant. existing studies have taken a case study approach (e.g. for chinese outbound tourism, see jin, qu, & bao, ) , but a global analysis is missing (ghaderi, mat som, & henderson, ; j� onsd� ottir, ; mazzocchi & montini, ; ruci� nska & lechowicz, ) . it is therefore timely to undertake a global study that uses a consistent approach to measuring the impact of disasters on international tourism movements. to increase the value of such a study for tourism managers, it needs to be designed in a way that includes a wide range of disaster types and magnitudes in the same model (ghimire, ) . consequently, the aim of this research is to explore the effect of various types of natural and man-made disasters on international tourism movements. to that end, this research integrates two different global datasets, namely one on disasters and another one on bilateral international tourist flows. a gravity model for international tourism flows is defined to quantify the effects of different disaster events on international tourist arrivals to the affected country. more precisely, we analyze the impact of droughts, earthquakes (ground movements and tsunamis), epidemics, cold and heat waves, floods, industrial accidents, landslides, wildfires, storms and volcanic activities. moreover, we use three different proxies to measure the impact of disasters; namely the number of deaths, affected people and economic costs. results will support the tourism sector and other key players (e.g. international insurance companies) in developing adequate responses to managing risk and recovery. to the best of our knowledge, the present research is the first attempt to undertake such an integrated analysis at a global scale. the rest of this article is organized as follows: the next section contains a literature review of the arguments behind the expected relationship between disaster events and tourism demand. the third section explains the methodology, data and the research design. the fourth section presents the empirical application. finally, a concluding discussion is presented that provides recommendations and an outlook on future research. the general perception might point towards an increase in the frequency of natural disasters over time, but this assumption needs to be verified. in fact, it has been suggested that, in some cases, the definition of disasters can become too fluid for statistical time series consideration (horlick-jones, fortune, & peters, ) . neumayer and barthel ( ) analyzed the economic damage from climate-related disasters and they found no significant upward trends in normalized data over the last years globally. however, the same study acknowledged that the frequency of weather-related natural disasters indicates an upward trend. other research suggests that the combination of climate change, industrialization and urbanization has accelerated the magnitude and occurrence of natural disasters around the world and the extent of the resulting damage park & reisinger, ) . population growth (often occurring in exposed areas such as coastal environments) is recognized as a key driver to explain why natural disasters affect more and more people (berke, ; wachinger, renn, begg, & kuhlicke, ) . aside from natural disasters, richardson ( ) notes that man-made disasters are becoming more severe because of the increasingly more powerful technology that is being used. perceptions of the frequency and extent of disasters are just as important as statistical facts. a key factor in this growing risk perception is the media (gierlach, belsher, & beutler, ) . for a the general public, who is exposed to mass media, it may appear that we live in an increasingly disaster prone world (faulkner, ) . the saying 'perceptions are reality' is nowhere more pertinent than in tourism, where potential visitors chose their destinations based on a mix of objective and subjective factors. destination (risk) perception has emerged as one of the critical factors in the decision-making process (becken, jin, chen, & gao, ) . disasters and other forms of crises (e.g. epidemics, conflict, pollution) can lead to a reduction in visitation to the affected area (bhati et al., ) . several examples in the literature provide empirical evidence of reductions in tourist arrivals following major events. for instance, mazzocchi and montini ( ) evaluated the impact on visitation to the umbria region in central italy, following a major earthquake in september . the data showed that arrivals fell drastically the first month after the main shock, with ongoing loss in tourism activity being recorded until june . a case study of a volcanic eruption at the eyjafjallaj€ okull glacier in iceland on th march showed that tourism numbers to iceland reduced by % until th april (j� onsd� ottir, ). huang and min ( ) analyzed the taiwan earthquake in september , using an integrated moving average model to explore the recovery process. their study revealed that the island's inbound arrivals had not yet fully recovered from the earthquake's devastation after months. kuo, chen, tseng, ju, and huang ( ) also used a time series model to investigate the impacts of infectious diseases, including avian flu and severe acute respiratory syndrome, on international tourist arrivals in asia. the empirical results indicated that the numbers of affected cases had a significant impact in the case of sars (see also mao, ding, & lee, ; mcaleer, huang, kuo, chen, & chang, ) , but for avian flu. man-made crises, such as the bp oil spill in the mexican gulf in , have also been found to reduce demand for travel to the affected area (ritchie, crotts, zehrer, & volsky, ) . often, declines in visitation spread to neighboring areas, even when they are not impacted by the event. a recent example has been the dramatic down turn in tourism in the caribbean region, following the devastating hurricane season in (wttc, ) . events within one country or a region can lead to notable structural breaks in international tourism arrivals, which was demonstrated by cr� o and martins ( a) in a recent study on various forms of crises in countries. there are several reasons why visitation to disaster areas declines in the immediate aftermath of an event. the most direct inhibitor relates to the damage inflicted by a disaster that prevents the affected areas from engaging in tourism activity. secondly, the decline in tourist arrivals is due to people's risk perceptions and avoidance of regions that are deemed unsafe (kozak et al., ; s€ onmez, apostolopoulos, & tarlow, ) . thirdly, and related to the second issue, is that potential travelers may feel uncomfortable or have ethical concerns about travelling to a disaster region. these underlying factors are discussed in more detail. in many cases, disasters pose significant physical constraints on the delivery of tourism services, thus severely limiting the supply side of tourism (shaw, saayman, & saayman, ) . depending on the type and extent of the disaster, critical infrastructure could be compromised or dysfunctional. prominent examples include airports and ports, land transport infrastructure, and electricity and telecommunication networks (ghobarah, saatcioglu, & nistor, ; parajuli & haynes, ) . in addition, core tourism assets could be damaged and not ready for business, such as accommodation establishments and key attractions. for instance, the earthquake in kathmandu, nepal, resulted in wide-spread destruction of unesco listed world heritage sites, and several trekking routes were deemed unsafe due to risks of rock fall and movements following further aftershocks or heavy rain events (becken, ) . even longer-term and insidious disasters, such as a drought, may impede the ability of a destination to cater for tourism. a recent example was the water shortage in cape town, south africa, that led to a reduction in tourism and a notable loss in income for local businesses. the decline was possibly influenced by requests to conserve waters, but also due to perceptions by visitors that the destination is not able to host tourists (wendell, ) . in addition to uncertainty around whether the destination is safe or tourism-ready, there are other psychological factors that influence tourists' decision making. frequently, media coverage of disasters conveys the resulting loss of life, human suffering, public and private property damage, and economic and social disruption. the ensuing negative publicity often characterizes the period after a disaster, lasting until full recovery is achieved and pre-disaster conditions resume (s€ onmez et al., ) . for instance, cohen ( ) points out that religious beliefs relating to the bodies of the tsunami victims trapped in sediment and rubble were behind a group of asian tourists deciding to abandon their plans to visit thailand after the tsunami. others may simply consider it inappropriate to visit a disaster zone. apart from religious or ethical concerns, some travelers do not wish to impede the recovery effort and place additional burden on the destination's resources and infrastructure (e.g. becken, ) . in some cases, the delayed recovery towards previously tourism figures is deliberate and led by the local tourism organizations. this was the case for the christchurch (new zealand) earthquake ( ), where extensive destruction of the city made tourism impossible, or at best would have led to unsatisfactory tourist experiences, leading christchurch canterbury marketing to de-market christchurch but promote surrounding regions instead (orchiston & higham, ) . optimal timing and stages of recovery were examined by okuyama ( ) for the case of avian flu in japan. whilst both theory and empirical evidence point to a decline in tourism following a disaster, several factors might promote travel to an affected area. providing information about hazards and their effects draws human attention and may even cause a level of fascination (e.g. the 'ring of fire', referring to tectonic activities around the edges of the pacific ocean). in this way, the number of tourists might be influenced by the coverage that media devote to natural disasters in other countries. media often use extreme natural phenomena as material for captivating stories, and travel bloggers, tourism campaigners and social media multiply the lure of these. an example of a disaster turning into a tourist attraction is the eyjafjallajokull volcano in iceland, with "the prospect of a new eruption bring[ing] a mix of trepidation and anticipation" (lawless, , p. ) . media coverage about a natural, or perhaps also man-made, phenomenon plays an informative role as a motivating factor to visit a region. ruci� nska and lechowicz ( ) argue that mass media and marketing are influential factors in the development of various forms of disaster-related tourism, as information on catastrophes popularizes the host location and the type of the phenomenon. such coverage could be both educational and simultaneously stimulate the interest of the audience. additionally, natural disasters and unexpected events can cause the arrival of people from other countries for humanitarian reasons but also for visiting friends and relatives who have been victims of those events. according to the statistical framework used by the united nations world tourism organization, these arrivals are captured as international tourists. finally, the decision to visit a disaster area for a range of motivations has been conceptualized as dark tourism (ruci� nska & lechowicz, ). this type of tourism involves travelling to places historically associated with death and tragedy (foley & lennon, ) . according to ruci� nska ( ), tourists might decide to travel to a region that has experienced a disaster because they want to feel emotions, risk, and the dynamics of natural hazards. overall, the present research hypothesizes a negative relationship between national disasters and inbound tourism; however, it also considers the motivating factors pointed out by ruci� nska ( ) that might lead to an increase in visitation after a disaster. the model developed in the following section will capture the cumulative impact of both effects. this research develops a gravity model for international tourism flows to quantify the effects of different types of natural and man-made disasters on tourist arrivals to the affected countries. gravity models are commonly used in the trade literature (anderson, ) , and increasingly in tourism research (fourie, rossell� o-nadal, & santana-gallego, ; khadaroo & seetanah, ; santeramo & morelli, ) . these models consider that international flows between two countries are directly proportional to their economic size, and inversely proportional to the distance between them. consequently, the level of bilateral tourism flows can be explained by a set of determining variables as in a demand equation. morley et al., have shown that gravity models to explain bilateral tourism can be derived from consumer choice theory. accordingly, the formulation of a gravity model can also be interpreted as a tourism demand equation. analytically: where, the dependent variable lntou ijt is the logarithm of tourist arrivals from country i, to destination country j, at year t; x d jt is a set of d destination-specific time-variant variables such as income level or population while x k ijt is a set of k country-pair time-variant determinants such as belonging to the same regional trade agreement. the variables of interests for this research are included in y l jt which is the set of l variables capturing the effect of l different disasters typologies (e.g. earthquake, tsunami, volcano, etc.) occurred in destination j during year t. this research uses three alternative proxies to measure the effect of disasters; namely number of deaths (d) in thousands, people affected (a) in millions and economic costs (c) in billions of us$. finally, β ; β k and β l are parameters to be estimated. due to the panel nature of data used in these kinds of models, and since our variables of interest are destination-country time variant, country pairs fixed effects λ ij and origin-year fixed effects λ it are also considered for estimation purposes. one of the consequences of this choice is that time-invariant country pair characteristics (such as distance or common borders) and time-variant origin country characteristics (such as income or population in the origin countries) are not explicitly included in the model. specific consideration is not necessary, because all these variables are captured by these fixed effects, as also suggested by balli, ghassan, and jeefri ( ), fourie et al. ( ) or giambona, dreassi, and magrini ( ) . this is a common practice in the development of gravity models in order to avoid omitted factor bias, and instead focus on the variables of interest for the particular research question. as dependent variable, lntou ijt , we consider the natural logarithm of international tourist arrivals from country i to country j in year t. this dataset originates from the compendium of tourism statistics compiled by the united nations world tourism organization (unwto, ) . this database contains tourism movements between countries for the period - , with missing data for some years and countries. in reference to the d variables determining tourism flows (x d jt ), and according to the considerations mentioned above about the no inclusion of time-invariant country pair characteristics and time-variant origin country characteristics, we consider the logarithm of the real gdp per capita (lngdppc jt ) as a proxy for the development level at each destination, and the logarithm of population (lnpop jt ) to control for the size of the destination country (lim, ; yap & saha, ) . both variables were taken from the world development indicators (wdi) elaborated by the world bank. third, we also consider an instability indicator that concerns safety and security of visitors when they travel to a destination. whilst there are different ways for evaluating safety and security at international level (see cr� o & martins, b; cr� o, martins, simões, & calisto, ; fourie et al., or santana-gallego, fourie, & rossell� o, in this case, and due to data coverage reasons, we use a proxy of the crime rate defined as the number of homicides per , inhabitants in the destination country (crime jt ). data also stem from the wdi. on the other hand, vector x k ijt includes a variable to control for the intensity of the economic relationship between a pair of countries, which is also time varying. the idea is to capture the presence of trade agreements between country pairs as an indicator of bilateral relationships that could boost tourism. this variable (rta ijt ) is a dummy variable for being a signatory to the same regional trade agreement and stems from the regional trade agreements information system compiled by the world trade organization. data for the occurrence and impact of disasters were retrieved from the centre for research on the epidemiology of disasters (cred), which makes data available through the emergency events database (em-dat). em-dat was created with the initial support of the world health organization (who) and the belgian government. the main objective of the database is to inform humanitarian action at national and international levels. the initiative aims to rationalize decision making for disaster preparedness, as well as provide an objective base for vulnerability assessment and priority setting. em-dat contains core data on the occurrence and effects of over , mass disasters in the world from to the present day. the database is compiled from various sources, including un agencies, non-governmental organizations, insurance companies, research institutes and press agencies. according to the objectives of this present research, the disaster types included in em-dat and considered in our analysis are presented in tables and . for the gravity equation estimation we are limited by the availability of the tourist database ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . all other datasets provide data for this timeframe as well, leading to a database that covers a total number of events from the period of - . these are described using three types of impact metrics (table ) . more specifically, of all events, . % report information on the number of deaths, . % report the extent of affected people (beyond deaths) and . % state an estimated amount of damage measured in economic terms. with regards to people killed by different disaster types, table shows that ground movements emerge as the most fatal type of disaster, with a reported number of . deaths during the period - . tsunamis and storms accounted for almost , deaths in the same period. in terms of affected people, floods and droughts have the greatest impact, with about , and billion of people impacted upon, respectively. concerning the economic costs of disasters, storms rank first, with a total amount of , billion dollars of damage recorded in the database. storms make up % of total economic costs for the selected disasters in the em-dat during the period - . the distribution of disasters across different regions, indicates considerable variation both in terms of event type and resulting impacts. for instance, in the case of storms, although only . % take place in the americas, the impact in terms of deaths, affected people and costs is comparatively high ( . %, . % and . %, respectively) than in other regions. a similar result is obtained for earthquakes in the asia-pacific regions ( . % of events), with disproportionally high impacts in relation to the number of deaths ( . %), affected people ( . %) and costs ( . %). europe, with some exception, is characterized by a lower incidence of deaths and affected people, but a higher occurrence of costs. table shows the most important events for each type of disaster in the database. for example, it can be observed that the earthquake of haiti in january , which led to , deaths, was the worst event in terms of fatalities. the major storm (cyclone nargis) that occurred in myanmar during may resulted in , deaths, the second largest number in the records. in terms of affected people, the drought affecting india during and was the most significant event reported in the database ( million people impacted). disasters also cause substantial economic damage. the highest economic loss recorded was tropical hurricane katrina that made landfall in new orleans, usa. it caused a total amount of damage of $ billion. although the disaster database includes the exact day of the event, for the purpose of this analysis we are limited by the yearly nature of tourism data. following guidance from the previous literature another important issue to be considered is the multicollinearity that can arise between the different types of impacts related to the same specific disaster. thus, it is expected (and found) that the consequences of a certain disaster in terms of deaths will be correlated to other impacts measured in terms of affected people and economic costs. the increase in the variance of the coefficient estimates could drive them to be unstable and difficult to interpret. consequently, our first strategy is to consider the three impact metrics (i.e. deaths, affected people and cost) separately in different equations. additionally, for each of the three metrics, we evaluate the possibility to distribute the effects within and months. this results in specifications: three for each of the impacts, times the two evaluation periods ( and months). importantly, according to the theoretical argumentation, the relationship between disasters and arrivals is not unidirectional and necessarily negative, but an increase in tourist arrivals could be observed in certain circumstances. for this reason, a second research strategy considers the inclusion of all the variables in a general regression that is reduced using statistical testing strategies in order to get a specific regression encompassing every other parsimonious regression that is a table disaster typology and main descriptive magnitudes ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) notes: cold waves include severe winter conditions. epidemic episodes are not characterized by economic costs. valid restriction of the general regression perez, and ) . in other words, we integrate the three impact metrics into a single equation. through this strategy, it is possible to explore in detail if effects arise that counteract the initially expected negative relationship between disaster impacts and tourism flows. again, two impact timeframes are considered. the gravity model for bilateral tourism flows as defined in equation [ ] is estimated by using the correia ( ) procedure to estimate linear models with many levels of fixed effects. this procedure is a generalization of the panel-fixed effects estimator with both country-pair and origin-year fixed effects. database includes countries for the period - . table presents the results of estimating equation [ ] for the bilateral tourist arrivals (lntou ijt ) as dependent variable and including each disaster impact measure separately. as previously mentioned, because our variable of interest is destination-country time variant, country pairs fixed effects and origin-year fixed effects are included in the model to control for any type of determinant at origin or country-pair level. therefore, only time variant country-pair and destination-specific determinants are required. each column shows the estimate of different disaster consequences (d ¼ deaths, a ¼ affected people, and c ¼ economic costs) and the two alternatives for distributing the effects across the following and months. it is important to mention that we are interested in estimating the short-run effect of the natural disaster on inbound tourism. exploring how the tourism sector at the destination country recovers in the long-run is beyond the objective of the paper. in general, for all the estimates, control variables considered as de-terminants of tourism flows are statistically significant and with the expected sign. the coefficients for both lngdppc jt and lnpop jt are significantly positive and slightly higher that unity, implying that a % increase in the destination gdp per capita and population will lead to an increase higher than % on tourist arrivals to the country. the coefficient for the rta ijt , that controls for the existence of a trade agreement between country pairs during specific years, is also significant and positive. in this case, due to the binary nature of the explanatory variable used, the estimated coefficient (slightly higher that . ) implies that the existence of a trade agreement increases the number of tourists to a destination by more than %. finally, and as expected, the variable related to low levels of security and safety at the destination country (crime jt ) shows a negative effect, indicating that an increase in the number of homicides (per , inhabitants) reduces tourist arrivals. in reference to the different types of disasters, for events associated with tsunamis, floods and volcanoes, all the significant parameters are found to be negative, indicating that these three types of disasters constitute substantial negative motivators for prospective visitors. a more detailed examination of coefficients highlights that volcanic eruptions appear most deterring to international tourists. this circumstance could be related to the severity of the damage caused by volcanic eruptions, including potentially irreversible damage to infrastructure or the complete loss of a natural asset. for the occurrence of an eruption, and for every increase in the number of deaths (for every people), affected (in millions of people) and costs (in millions of us$), there will be a decrease in international tourists to the destination between . % and . %, . %- . % and . %- . %, respectively (according to whether the or months delay is considered). wildfires, earthquakes, industrial accidents, and storms present mixed effects on international tourist arrivals. for all types of disasters, and note: ***p < . , **p < . , *p < . . dyadic and origin-year fixed effects are included in the model but estimates are not reported. robust standard errors clustered by pairs. when economic costs are considered, a negative and significant relationship is found. in other words, the economic damage from these events, for example to infrastructure, is likely to reduce tourist arrivals. wildfires appear as the second most detrimental type of disaster when measured in economic damage, leading to an expected fall of . % of tourist arrivals for every million us$ cost associated with the disaster. interestingly and perhaps paradoxically, a significant positive relationship is evident between the number of people affected by wildfires and tourist arrivals. for every million affected people, an increase between . % and . % is expected. consequently, and considering the negative effect of economic damage mentioned above, the net effect of wildfires on tourism should consider the two different types of disaster impact measures. earthquakes show a similar negative impact compared with tsunamis (see above) in terms of the economic costs of the disaster, with falls around . % for every million us$ cost. however, the other impact metrics do not show a negative relationship. in terms of number of fatalities, there is even an increase in tourism for the number of deaths per people by . %. thus, the overall impact of an earthquake is a combination of decreases in response to economic damage and number of deaths. industrial accidents and storms show similar patterns in that there is a positive relationship between the number of fatalities and affected people, but a negative relationship between the economic impact of the disaster and tourism arrivals. for example, for storms there is a decrease in arrivals by . % for every million us$ cost but increases between . % and . % for every death/ people and between . %- . % and . - . % for every million people affected. droughts emerged as the only type of disaster that did not show a significantly negative relationship between disaster cost and tourism, but instead arrivals were significantly linked to the two other disaster impact metrics. more specifically, for every death/ people an increase higher than % is obtained, while for every million people affected a decrease of . % is estimated. it is perhaps not surprising that the relationship between disaster costs and tourism is not significant for drought. overall, it is less likely that drought conditions produce direct impacts on tourism-relevant infrastructures and supplies, as tourism businesses might absorb the extra costs of supplying water during water constrained times. there could be indirect costs, for example due to more expensive food supplies, but such effects do not seem to result in significant changes in visitation. epidemics, landslides, cold waves, and heat waves do not achieve significant results for any of the six regressions considered, and for this reason they were not considered in the final estimation presented in table . in the case of epidemics, and landslides we should note that these two variables have a strong structural component. for instance, epidemic episodes, such as cholera, dengue, and ebola, as well as land movements with consequences on people are recurrent in the same types of countries at different times, but rarely are these factors extended to other countries. in a similar way rossell� o, santana-gallego, and waqas ( ) evaluated the effects of dengue, ebola, malaria, and yellow fever on international tourism flows showing how these diseases have a strong structural component and are often recurrent in the same countries. the case of cold and heat waves is different. it should be noted how travel booking decisions (especially in international travel) are often taken months in advance, when no reliable weather predictions exist. although it is possible to cancel travel plans in case of extreme temperatures, tourist might assume the conditions are temporary and unlikely to impact their trip. in terms of longer lasting risk perceptions of a destination, heat or cold waves might not be seen as particularly threatening, and hence easily forgotten. visitors might expect that their tourism service provider is dealing with adverse conditions, for example by providing air conditioning or heating. instead, extreme temperatures are more likely to impact local people (e.g., farmers) leading to wider economic damage (but not attributed to tourism). regarding the distribution of the potential effects of each one of the disasters during the next months (columns from one to three) and during the next months (columns from four to six) no significant but only minor differences are found. additionally, different attempts to discriminate disaster by geographical regions did not yield significantly different conclusions. as mentioned earlier and in order to explore the bidirectional effects between disaster events and tourism flows, a second research strategy is implemented. based on two initial general regressions (one for each of the delay periods considered), including all the considered variables, a reduction is undertaken in order to get the specific regressions presented in table . regarding the distribution of the potential consequences of each type of disaster during the next months (columns one to three) and during the next months (columns four to six), in general, no significant differences are found. with the exception of floods and storms, the coefficients for the remaining disasters (in absolute terms) are higher for the month impact regressions than for the months ones, thus, indicating that effects are probably better captured by longer time lags. in contrast, the effects of floods and storms seem to have a shorter life span, since the month timeframe captures a higher impact. the analysis of the different disaster impacts reveals how, on the one hand, costs always present a negative relationship with international tourist arrivals. this confirms that the economic costs of a disaster are an important measure for tourism managers, probably because of the inherent damage to local infrastructure that is captured. on the other hand, the impact of some types of disaster evaluated in terms of deaths shows a positive relationship with tourist arrivals. this does not mean that the occurrence of these disasters will have a net positive effect on the arrival of tourists, since the negative effect of the associated costs must be taken into account when deriving an overall estimate of impact. as outlined earlier, the number of deaths could be related with the arrival of people for humanitarian reasons, or with a flow of people who travel to see (and support) friends and relatives affected by the event. this could present a significant effect in relative terms for those countries with a low base level of arrivals. the total effect also should note: ***p < . , **p < . , *p < . . dyadic and origin-year fixed effects are included in the model but estimates are not reported. robust standard errors clustered by pairs. consider the impacts of the number of affected people that for some disasters have a reducing effect (droughts, tsunamis and volcanoes), while for others there seems to be an increase in the number of tourists (industrial accidents, wildfires and storms). natural disasters and unexpected events have wide reaching effects on all spheres of life, including tourism. from a theoretical point of view, it has been assumed that a negative relationship between disasters and inbound tourism dominates (e.g. a cr� o & martins, a). however, because of some motivating factors identified in the literature, and due to the methodology and definition used by the unwto in collecting international tourist arrivals, an increase in visitation after a disaster seems also plausible. the number of inbound tourism arrivals directly impacts the performance of the national tourism industry, and ultimately the government, especially in countries where tourism is a major contributor to the national economy and fiscal revenue (massidda & mattana, ) . it is therefore of great importance for policymakers to improve their understanding of how disaster events affect visitor demand. this research highlights the need to consider different types of disasters and their varied consequences when assessing the consequences for tourism. the empirical research presented in this paper draws on two sets of data to explore in depth the relationship between international tourist arrivals and global disasters, measured through three different impact metrics (costs, deaths and affected people). the effects that these different disasters might have on inbound flows at a national level were investigated though a gravity model, estimated by panel data with destination-fixed effects and using yearly data. by doing so, spurious potential determinants related to the destination but not the disaster can be avoided. as a result, however, recurrent disasters affecting the same destination and those with a very short-run effect have not been captured. findings of this analysis provide evidence that the economic consequences of a disaster in a particular country generally affect international tourism arrivals negatively. this is likely due to damages to infrastructure, key attractions and a wider weakening of the economy in the host country. all of these reduce the destination ability to cater for tourism, undermine investment into tourism supply, and reduce destination attractiveness, at least in the short-term. at the same time, the analysis reveals that evaluating the tourism impacts of a disaster in terms of deaths and affected people is more ambiguous. our research found a dominance of positive effects in the case of deaths related to a disaster. thus, whilst disaster damage seems to prevent tourists to visit the affected destination, the number of fatalities and affected people seem to be less of a deterrent. tourists may not see a risk to their own safety. also, there could be an increase in tourism for some disasters due to the arrival of humanitarian 'tourists' and people visiting friends and relatives. whilst generally, this observation might be testimony to tourism resilience, and indeed reassuring for destination managers, there may be situations where continuous tourism demand after a disaster is hindering recovery works or impacting the well-being of residents. more research on 'optimum' recovery timeframes that take into account resident needs, would be useful (e.g. okuyama, ) . it is useful for decision makers to understand that not all disasters cause similar impacts. the comparison of different disaster types showed, for example, that volcanic eruptions typically cause the most significant and substantial negative impact on tourism. specifically, for every million people affected by an eruption a fall between . % and . % in the international tourism arrivals is expected, if a six-month period or a twelve -month period is considered, respectively. other disasters have smaller and shorter-term impacts (e.g. floods and storms). furthermore, floods and tsunamis are detrimental without nuance, although it is difficult to discerne whether the negative effect is due to the possible destruction or disablement of infrastructure or to the negative image of the destination generated by these types of event. when a destination is affected by a wildfire, an earthquake, an industrial accident, a storm or a drought, mixed effects may be expected. for example, when these types of disasters result in economic damage, a negative and significant relationship can be established, indicating that damage to infrastructure and built assets, and maybe business capability, is likely to reduce tourist arrivals. finally, this research revealed that some types of events are unlikely to have a major effect on arrivals, for example an unexpected epidemic, a landslide, a cold wave and a heat wave. it should be noted how these natural disasters are characterized by little or no impact on infrastructure and no long-term risk to tourists after the event has finished. natural disasters and unexpected events are traumatic experiences for the resident population and may cause lasting damage to destination infrastructures, which requires adequate and adaptive tourism management (hystad & keller, ) . strategies used to predict natural disasters and mitigate hazard risks in the first place need to be deployed to minimize the impacts. examples include the implementation of appropriate building codes, zoning regulations, and emergency training and preparedness for key stakeholders. new policies and practices may require additional resources, but investments into preparedness are likely to generate positive returns in the long term. in general, the empirical results in this paper confirm that disaster events are challenging news for tourism managers who need to deal with an unexpected fall in tourism demand. clearly, economic damage from an unexpected event leads to some reductions in tourist arrivals. in those cases, efforts by destination managers should focus on the recovery of necessary infrastructure and business capability. proactive planning, for example around business continuity, business support networks, and recovery assistance programs, could accelerate this effort (hystad & keller, ) . leadership may come from government agencies, destination management organizations, or businesses themselves. related research in new zealand revealed that leadership is "mainly provided by tourism stakeholders with a community-value orientation, and to a lesser extent by those who are mainly business-driven" (hughey & becken, , p. ) . in other words, response and recovery is often led by individuals who have a strong commitment to, and engagement with, the affected community. for some events, it is not necessarily the economic damage that is the most significant impact, but it could be the number of people affected or killed. for some disaster types, for example wildfires and storms, this research even established a positive impact. the positive relationship between number of tourists and affected people of fatalities by some disasters implies that these can attract visitors to the destination, a circumstance that should be taken into account by the managers of the destination. there are many different reasons why visitors might want to visit a destination that had been affected by a disaster (e.g. ruci� nska & lechowicz, on dark tourism), and understanding this non-orthodox typology of visitor types could be useful for destination managers. regardless, marketing activities have to be designed with great care to attract the right types of visitors at the right time, considering potentially ongoing limitations around tourism capacity (okuyama, ; orchiston & higham, ) . marketing campaigns implemented by businesses, local tourist destinations or national tourism bureaus should ideally align in their messaging and magnitude, implying a particular need for vertical integration following a disaster (hughey & becken, ) . this research has several limitations, including the availability, accuracy and granularity of data, which is outside the control of the research team. it could be argued that some impacts on tourism are significant, yet short-lived. given that the data used here is provided on an annual basis, short-term effects are likely to be missed or underestimated in this research. besides the limitations about the estimation method and the nature of the data of the unwto we have imposed a homogenization for each disaster. that means that a specific disaster in a developed country has the same effect than in an less developed one. in reality, this might not be the case. consequently, results obtained in this paper should be considered as average responses. future research should further explore this matter and investigate if differences among countries in reference to their level of development exist. our attempt to discriminate the different disaster by region did not obtain significant results. future research on the positive impacts of certain types of disaster consequences would also be beneficial in developing a potential tourist typology consisting of 'dark tourism' segments, humanitarian arrivals or other presently unidentified markets. jaume rossell� o-nadal as an expert in tourism demand modelling and the quantitative analysis of tourism has contributed with the knowledge of the specific literature of demand modelling and the identification of the gap in the literature. susanne becken as an expert in sustainable tourism and climatic change issues has contributed with the knowledge of the specific literature of natural hazards and potential effects on tourism and maria santana gallego as an expert within the fields of gravity models in a special way in the design of the methodology and in the exploitation of the results. he has also been responsible for the first model estimations. jaume rossell� o-nadal has a phd in business and economics, is full professor at the universitat de les illes balears (spain) and adjunct professor at griffith institute for tourism (australia). his research interests include tourism demand modelling and environmental issues with special interest in climatic change issues. jaume has led different research projects in spain and europe. dr susanne becken is a professor of sustainable tourism at griffith university, australia. susanne has led a large number of research programmes and consulting projects in asia pacific in the area of climate change, risk management and sustainable tourism. she contributes through various industry and government advisory roles and panels, and is on the editorial boards of nine tourism journals. professor in the department of applied economics, university of the balearic islands, spain. she teaches tourism economics and macroeconomics. her research interests include quantitative analysis of tourism and gravity models. sustainable development in damascus university: a survey of internal stakeholder views the gravity model towards understanding gcc outbound international tourism what can 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- - - sha: doc_id: cord_uid: gcduh u civil protection and disaster risk specific agencies legally responsible to enhance individual and community resilience, still utilize in their risk and crisis communication efforts, the “deficit model” even though its basic assumption and approach have been criticized. recent studies indicate that information seeking behavior is not necessarily a measure of enhanced individual preparedness. a qualitative change from “blindly” following directions to practicing emergency planning and becoming your own disaster risk manager is required. for pandemics, the challenge is even more complicated due to their unique characteristics. community based exercises (cbex), a framework concept encompassing a variety of interactive activities, have recently started being utilized to develop resilience amongst citizens. existing models of resilience can pinpoint to the required knowledge, skills and attitude. research in the factors influencing behavioral change could offer new understanding of the interplay between cognitive and demographic drivers/factors of resilience. such knowledge could be utilized for setting targeted objectives, developing appropriate activities and the corresponding training for the cbex facilitators. despite the importance of preparation, the current covid- crisis indicates that high levels of adaptive resilience can be displayed even in the absence of any risk communication effort beforehand by utilizing a pre-existing collective understanding of the system situation. one of the fundamental principles of emergency planning, that every student has been taught, is that it takes place in an environment of apathy, even resistance, and with limited resources (fema ) . this is even more valid for risk communication also termed "public preparedness education" in the emergency management field. governments and citizens (both faced with limited resources and attention) tend to consider prudent to focus on "frequently" occurring disaster risks at the national and/or local level, as these risks are naturally presumed to be of the highest priority (wilkinson et al. ) . it is an issue of risk assessment and management. the countries participating in the union civil protection mechanism regularly submit to the european commission (ec) their national risk assessment. in the latest report available (european commission ), one finds listed as priority risk along earthquakes, floods, and forest fires, the biological threat/pandemics risk as well. only nine countries (cyprus, france, greece, italy, montenegro, north macedonia, portugal, spain, and turkey) have not included the latter. the risk and crisis communication mandate rests predominantly on civil protection authorities and disaster risk specific agencies (e.g. responsible for earthquakes, floods, public health, etc.) at central, regional, and local level. to fulfill their mandate they provide information about various disaster risks in order to enhance individual and community disaster preparedness. the staff of these organizations has, in general, limited knowledge of the state of the art in the relevant to risk communication scientific fields and lacks the necessary links with academia that could inform their effort (haddow et al. ) . as a result, the approach has been and is still based on the so-called "deficit model" even though its basic assumption (the public is an empty vessel to be filled with information) has been criticized (nisbet and mooney ; boersma et al. ) . a number of alternative two-way interaction models (also called engagement models) have been proposed (boersma et al. ). ec has funded relatively few programs to experiment with the so-called engagement models (boersma et al. ; musacchio and solarino ; yovkov et al. ) . in europe and the usa the assessment is that despite more use of various two-way communication approaches, the efforts still fall short of inducing the necessary changes in behavior (boersma et al. ; national academies of sciences, engineering, and medicine ). the conclusion is that more research is needed to determine how to motivate behavior change, as well as to identify what other factors contribute to successful public disaster education campaigns. the information provided to the public usually covers facts for a) basic understanding of specific disaster risks (e.g. earthquakes, floods, etc.), and b) directions to strengthen prevention, inform and educate about the actions and behavior to decrease personal exposure to each specific risk [e.g. for earthquakes: "stop, drop under or beside, and cover" against the natural tendency to flight -evacuate the building during shaking, for severe weather phenomena: having a stock of emergency supplies (water, canned food, etc)], and how to make an individual and/or household emergency plan. it is commonplace to specifically address certain vulnerable populations, like school students. the websites of the responsible authorities and of other organizations (ngos, professional associations, civil society) are full with information of that sort. nevertheless, the effectiveness of the means used (traditional, like pamphlets and contemporary, like social media) has not really been the subject of serious study. recent studies (maduz et al. ; kohn et al. ) have indicated that information seeking behavior is not necessarily a measure of enhanced preparedness. the actual challenge is to make the transition from the so-called "weak preparation" (like storing emergency supplies) to "hard preparation" (e.g. establishing an individual and/or household emergency plan). in a sense, what is required is a qualitative change from "blindly" following some directions to cooperating with others to practice emergency planning and even further, become your own emergency or even disaster risk manager. the concept of resilience with the abundance of definitions (alexander ) and the various numbers of dimensions (called domains, properties, or stages) that have been proposed to operationalize it, can be useful in informing that goal. especially, the definition of resilience as "the ability to prepare and plan for, absorb, recover from, or more successfully adapt to actual or potential adverse events" (national research council ), the proposition that it encompasses the properties of robustness, redundancy, resourcefulness, and rapidity (bruneau et al. ; tierney and bruneau ) , and the view (cutter et al. ) that it consists of inherent resilience and adaptive resilience (through improvisation and learning), when applied to individuals and groups can guide us. they help pinpoint to the knowledge, skills and attitude we need to focus on and communicate to the public in order to enhance its resilience level. in conjunction with individual disaster preparedness surveys that could help identify barriers and possible triggers for its enhancement, they can provide paths to research that could offer some interesting and useful insights for effective risk and crisis communication. depending on the application unit, we can talk about resilience of individuals, infrastructures, institutions, ecosystems and communities (kahan ) . it is important to realize that there is inherent, not well understood, interaction between them, e.g. when citizens know what to expect from the authorities then the latter's emergency plans have an increased effectiveness and efficiency and vice versa. pandemics risk, like covid- , displays a number of characteristics differentiating it from natural disasters, namely: • relatively infrequent occurrence that "deprives" the public from firsthand experience (recent epidemics sars, mers were contained fairly easily). • pandemics risk and its management are surrounded by lots of unknowns and uncertainty, including variable positions by experts, sometimes even seemingly changing over time [adams ( ) considers that it belongs to the so-called "virtual risks"]. • early recognition of the forthcoming crisis is not (always) obvious, resulting in challenges in sense-making. • the guidelines (social distancing, wearing gloves, washing hands frequently, avoiding vulnerable friends and family, staying at home, not going to work, etc.) the public is "advised" -"ordered" to follow are "unnatural". they oppose people's tendency of wanting to spend even more time together when confront-ing a disaster situation. it is this very closeness and camaraderie that have been observed to build people's adaptive resilience in natural disasters. • emergency response lasts much longer (many months) as compared to natural disasters (days to weeks). in addition, as by definition emergency response ends when the situation stabilizes i.e. threat to life and property has fallen down to the pre-emergency level (fema ) , even the end is not straightforward but a matter of debate in pandemics. • in pandemics the public has an apparently passive role contrary to natural disasters where the public actively participates in response and recovery activities. it should also be pointed out that pandemics is probably the only disaster risk, that the protective measures bear the potential to cause individual and community resilience decreases in the future, as they negatively influence community competence factors (psychopathologies, health & wellness (brooks et al. ) ) of the population and especially of vulnerable groups (elderly, people with chronic sickness, etc.) as well as economic factors (cutter et al. ) . therefore, the main question is "how do you protect now, without negatively affecting long term resilience at the individual and community level?" more specifically, what should be the characteristics of the risk and crisis communication campaigns as far as message content and frequency of repetition, how is the effect of the unknowns on the message content managed, what are the possible shortcomings of "the war against an invisible enemy" model (adopted in many countries), what is an effective and viable mixture of coercion and persuasion, etc. all these together form a quite different and more complicated environment for the risk and crisis communication than the one we are used to in natural disasters. they superimpose on the general risk communication challenges referred to previously. besides specific disaster risk communication, risk communication efforts should be targeted to instilling to the public the emergency planning toolbox of knowledge, skills, and attitude, i.e. identifying and assessing disaster risks and vulnerabilities, understanding that preparation is key, and that key to preparation is planning together with others (family members, co-workers, neighbors, etc.), and finally acquiring the mindset for the implementation of a plan and the need to improvise if necessary. the traditional one-way communication approach is not an effective way to achieve these objectives. a framework concept encompassing a variety of two-way communication interactive activities on the above topics altogether in one event, is the so-called community based exercise (cbex). cbex have recently started being utilized with main objective to develop resilience amongst citizens (yovkov et al. ) . a cbex uses as trainers/facilitators experts and personnel of organizations that are part of the civil protection system and utilizes the participation of other stakeholders that are part of a community. the choice of the specific objectives, topics and the design of activities (facilitated work sessions, workshops, competitions, demonstrations, short exercises, games, etc.) for the various target groups of a community, are of great importance for the effectiveness of the effort. research in the factors that influence behavioral change could offer new and practical understanding of the interplay between cognitive and demographic drivers/factors of preparedness/resilience. subsequently, such knowledge could be utilized for setting clearly targeted objectives, developing appropriate activities and the corresponding training for the trainers/facilitators. in particular regarding the pandemics risk, it is necessary to understand how the specific characteristics listed before, affect and shape the risk communication effort regarding "hard preparations" as it is of a quite different nature as compared to natural disaster risks. it is also interesting to study the interplay between risk and crisis communication in pandemics as it is also defined by the pandemics' very characteristics. as a final point, we turn to the actual reason we care about all that, which is to see how individual, community, societal resilience is realized in time of crisis and identify ways to enhance it. for an effective crisis management effort, stern ( ) has emphasized the importance of early recognition of a forthcoming crisis, expedient sense-making and use of an appropriate narrative to guide crisis communication by the crisis management team. the distinguishing features of risk communication and crisis communication have been stated by reynolds and seeger ( ) . an underlying assumption is that the latter builds on the former. we would like to claim that, in the presence of early recognition and expedient sense-making, it is possible to display high levels of adaptive resilience even in the absence of any risk communication campaign beforehand by utilizing a pre-existing collective understanding of the system situation. specifically a, well known to all (crisis managers and public), weakness (e.g. the quite limited capacity of the health system) can, almost explicitly, serve as the critical element in the persuasion of the public to adhere to strict measures (movement restriction, etc.). in that way, a weakness is turned around, becoming instead an enabler for crisis communication success. unexpected allies can arise in dire situations. one should not rely on this possibility but it exists and sometimes can save even the ones that have not prepared but showed a particular type of vigilance in crisis. eur en, publications office of the european union the psychological impact of quarantine and how to reduce it: rapid review of the evidence a framework to quantitatively assess and enhance the seismic resilience of communities a place-based model for understanding community resilience to natural disasters commission staff working document, overview of natural and manmade disaster risks the european union may face, swd( ) final fema ( ) fundamentals of emergency management online textbook. fema higher education project introduction to emergency management resilience redux: buzzword or basis for homeland security. homeland security affairs personal disaster preparedness: an integrative review of the literature individual disaster preparedness: explaining disaster-related information-seeking and preparedness behaviour in switzerland, risk and resilience report emergency alert and warning systems: current knowledge and future research directions. the national academies press, washington disaster resilience: a national imperative framing science crisis and emergency risk communication as an integrative model from warning to sense-making: understanding, identifying and responding to strategic crises conceptualizing and measuring resilience. a key to disaster loss reduction science for disaster risk management : knowing better and losing less community-based emergency preparedness exercise (cbe) guide, funded by the eu civil protection financial instrument the author would like to acknowledge colleagues and students over the years and especially th. sfetsos (ncsr demokritos) and p. dimitropoulou (univ. of crete) for fruitful discussions. conflict of interest the author declares that he has no conflict of interest. key: cord- -f xja v authors: castner, jessica title: special disaster issue date: - - journal: j emerg nurs doi: . /j.jen. . . sha: doc_id: cord_uid: f xja v nan control and prevention report that more than health care personnel have died from covid- in the united states alone, and there are likely many more owing to missing data. as a professional community, we deeply grieve these tremendous losses of our valued and beloved colleagues and lift up their families in the us and around the globe. we pause to honor their lives, commitment, and sacrifice ( figure ). in addition to offering a sincere and heartfelt tribute to emergency nurses and other health care personnel who have lost their lives to covid- , the purpose of this editorial is to briefly relay a surge planning model and the collection of all-hazard disaster manuscripts published in this issue of jen. as the number of covid- cases continues to rise with no approved or effective vaccine, we face unprecedented uncertainty on the continued impact of covid- on our health care systems. respiratory virus transmission and health care surges frequently occur in the fall after school-aged children typically return to classrooms and weather pattern changes result in more time congregated together indoors. , although extensive preventative measures for the general public such as face masks, physical distancing, and limiting the number of individuals congregated together can limit virus transmission, it is prudent and reasonable to prepare for continued surges in covid- infection presentations to the emergency department. effective continued ed pandemic disaster response depends on the preparedness and competency of every member of the team at every level and in every role as we care for patients and for each other. anesi et al published the framework entitled "an adaptable model for hospital preparedness and surge planning for emerging infectious diseases" in ( figure ). the framework is briefly summarized here in this editorial, and the original manuscript is available as an open access publication for readers who wish to have more detail. the figure is reprinted here as an important and timely tool for every member of the emergency care team to incorporate into their own professional preparedness, habits, teamwork, and mental or physical drills and reminders. because patient crowding is a major and protracted problem in the emergency care specialty, emergency nurses are extensively familiar with the causes of health care capacity strain depicted in the framework as one or more of the following: increased patient volume, increased acuity, special care requirements, and resource reduction. , the framework provides a clever and easily memorized " ss" of surge preparation for ( ) space, ( ) staff, ( ) stuff, and ( ) systems. specific to staff, one of the key components of preparedness requires that staff are appropriately trained and have the needed competencies. the major theme of this jen special disaster issue is all-hazard disaster competency and training for emergency nurses around the globe. imagine how preparedness would increase if every member of the emergency care team, at every level and in every role, reviewed the domains of focus ( figure , right column) and contributed to or felt ownership of disaster preparedness problemsolving ideas and actions within their scope of practice: case definitions, testing capability and logistics, personal protective equipment and isolation precautions, triage and cohorting, clinical protocols, staff health concerns and optout, clinician well-being, communication/coordination, surge planning, and scarce resource allocation. the framework provides a useful mental model to address all of the listed domains of focus during acute surge (right column of figure ) to effectively respond to a patient volume surge of covid- or other emerging infectious diseases. the editorial team is honored to contribute to supporting and elevating the specialty of emergency nursing in the midst of the covid- pandemic with a special collection of all-hazard disaster content. this issue also contains a broad range of nondisaster manuscript topics. here, i'd like to call the reader's attention to the manuscripts that address frontline nursing staff disaster preparedness and disaster competencies. amberson et al successfully delivered a -module ed-specific disaster preparedness curriculum. rather than a didactic classroom approach alone, the authors used a creative, flexible, and pragmatic approach to deliver the educational material integrated into clinical workflow through daily huddles, staff meetings, staff emails, and a designated education board. the authors generously provided the curriculum and materials as online supplemental material for use in other settings. disaster response in the emergency setting includes stressful incidents that can threaten mental health and well-being. addressing a low-frequency, high-impact event in the trauma notebook section, mccall explored the experiences of emergency nurses who cared for victims of a multiple casualty school shooting, psychosocial aftereffects, and lessons learned. pallas provided a new idea for professional peer social support by combining technical team debriefing and after-action with psychosocial peer support and referral interventions. the newly developed program was well received at the author's practice site and provides a promising novel emergency clinician peer support idea for further development and rigorous testing. the program manual is included as online supplemental content for replication in other emergency departments. nicholas et al refocus us on the mental health of patients and a contemporary disaster with an even broader scope and scale than the current pandemic-climate change. the authors provided an overview of the key concepts for mental health impacts of climate change as an update for emergency nursing practice. patient and clinician mental health and well-being are also major considerations in preparedness for infectious disease surges, and we welcome emergency clinician psychosocial intervention testing manuscripts in jen. an accurate baseline assessment of nurse disaster competency is essential to planning interventions that improve knowledge, skills, and perceptions on the topic. marin et al developed and tested a survey tool to measure general nursing disaster response competency. readers can find references to pre-existing surveys to measure nurses' knowledge, attitudes, and training in the manuscript's introduction. the newly developed survey was tested with nurses in southern brazil on the basis of the international council of nursing's framework of disaster nursing competencies. further research and development are needed to address the limited perceptions of the disaster nurse's role in providing psychosocial support in addition to physical care. extending our global perspective on disaster preparedness, setyawati et al assessed the knowledge, skills, and preparedness in nurses in indonesia. their results replicated findings from similar studies around the globe, demonstrating only moderate disaster preparedness and a need for further preparation. the study by setyawati et al provides a special insight about the implications for interspecialty disaster preparedness professional development as the authors found no difference in preparedness among emergency, intensive care, and surgical unit nurses. nursing competency to respond to radiological or nuclear incidents includes distinct knowledge of disaster case identification, countermeasures, clinical protocols, infection control, decontamination, and further irradiation and contamination prevention. a study of emergency nurses by bowen et al reveals sobering knowledge gaps and a demonstrated need for specialty-wide professional development and training in radiological and nuclear incident response. the authors have provided the test they used in the study as part of the manuscript for readers to review, as well as a table of resources and links for independent professional development. one of the coauthors of this manuscript, dr goodwin veenema, has also authored and edited the definitive textbook for disaster nursing, which provides an excellent educational resource for nurse educators and emergency nurses seeking further information. as emergency clinicians prioritize developing and improving their own preparedness for nuclear and radiologic events, there is also a need for injury prevention and discharge education to address the lack of household preparedness. in an annual survey conducted by the us federal emergency management agency in , nuclear explosive events were listed as the lowest levels of household emergency planning ( %), followed by earthquake ( %) and flood ( %). emergency nurses are well poised to address this planning and knowledge deficit through injury prevention programs, community outreach work, and patient education. only % of us households have all recommended supplies, evacuation plans, and communication modalities recommended for all-hazard disaster preparedness. ready.gov, a us homeland security website provides allhazard education and household disaster plans that can be provided to patients as part of patient education. the information is also useful for emergency clinicians to develop their personal household readiness plans and obtain supplies. the covid- pandemic resulted in rapid adoption and expansion of telehealth to improve social distancing figure a conceptual and adaptable approach to hospital preparedness for acute surge events caused by emerging infectious diseases. health care capacity strain occurs owing to increased patient volume, increased patient acuity, special patient care demands, and/or resource reduction. preparedness and response strategies to combat acute surge events must address the " ss": space (beds), staff (clinicians and operations), stuff (physical equipment), and system (coordination). icu, intensive care unit; pui, patient under investigation; ppe, personal protective equipment. reprinted with permission from wolters kluwer. and reduce viral transmission risks for nonurgent patients. a systematic review of the published literature by nejadshafiee et al reveals a surprising gap in evidence about telenursing in incidents and disasters. the authors highlight the priority need to disseminate novel telenursing models and feasibility, as well as research the efficacy and comparative effectiveness of telenursing compared with usual emergency care. jen continues to welcome manuscripts on general telehealth and telenursing interventions. furthermore, pandemic planning must include the potential to administer covid- vaccines in the emergency department, once a vaccine is available. although ozog et al did not study attitudes toward covid vaccination, their study on health care provider attitudes toward an influenza vaccination in the emergency department has important and timely implications for the current pandemic. most clinicians supported nurse-initiated protocols to enhance the efficiency of vaccine administration, as most were vaccinated themselves ( %) and were in favor of providing vaccination interventions ( %) when staffing and resources were sufficient for overall ed flow and function. in summary, i wrote this editorial to honor the lives of our health care provider colleagues who have, sadly, succumbed to covid- , provide a brief overview of a surge planning framework with immediate clinical implications, and briefly introduce the collection of all-hazard disaster manuscripts in this issue of jen. in addition to individual household preparedness resources at ready.gov, several of the manuscripts and online supplemental content include resources that can be immediately translated into education and practice. , it is a distinct privilege to disseminate this and all the material in this issue to support and lift up the specialty of emergency nursing as we confront, draw together, and overcome in these challenging pandemic times. centers for disease control and prevention. coronavirus disease : cases in the u.s a conceptual and adaptable approach to hospital preparedness for acute surge events due to emerging infectious diseases ambient air pollution and emergency department visits for asthma in erie county respiratory virus transmission dynamics determine timing of asthma exacerbation peaks: evidence from a population-level model ena position statement committee. crowding, boarding, and patient throughput increasing disaster preparedness in emergency nurses: a quality improvement initiative caring for patients from a school shooting: a qualitative case series in emergency nursing the acute incident response program: a framework guiding multidisciplinary responses to acutely traumatic or stress-inducing incidents in the ed setting mental health impacts of climate change: perspectives for the ed clinician development and psychometric testing of a tool measuring nurses' competence for disaster response world health organization, international council of nurses. icn framework of disaster nursing competencies disaster knowledge, skills, and preparedness among nurses in bengkulu, indonesia: a descriptive correlational study exploring national nursing readiness for radiological or nuclear incident: a crosssectional study disaster nursing and emergency preparedness for chemical, biological, and radiological terrorism, and other hazards preparedness perceptions, sociodemographic characteristics, and level of household preparedness for public health emergencies: behavioral risk factor surveillance system telenursing in incidents and disasters: a systematic review of the literature attitudes toward influenza vaccination administration in the emergency department among health care providers: a cross-sectional survey key: cord- -nbkvd le authors: ashcroft, james; byrne, matthew h v; brennan, peter a; davies, richard justin title: preparing medical students for a pandemic: a systematic review of student disaster training programmes date: - - journal: postgrad med j doi: . /postgradmedj- - sha: doc_id: cord_uid: nbkvd le objective: to identify pandemic and disaster medicine-themed training programmes aimed at medical students and to assess whether these interventions had an effect on objective measures of disaster preparedness and clinical outcomes. to suggest a training approach that can be used to train medical students for the current covid- pandemic. results: studies met inclusion criteria assessing knowledge (n= , . %), attitude (n= , . %) or skill (n= , . %) following medical student disaster training. no studies assessed clinical improvement. the length of studies ranged from day to days, and the median length of training was days (iqr= – ). overall, medical student disaster training programmes improved student disaster and pandemic preparedness and resulted in improved attitude, knowledge and skills. studies used pretest and post-test measures which demonstrated an improvement in all outcomes from all studies. conclusions: implementing disaster training programmes for medical students improves preparedness, knowledge and skills that are important for medical students during times of pandemic. if medical students are recruited to assist in the covid- pandemic, there needs to be a specific training programme for them. this review demonstrates that medical students undergoing appropriate training could play an essential role in pandemic management and suggests a course and assessment structure for medical student covid- training. registration: the search strategy was not registered on prospero—the international prospective register of systematic reviews—to prevent unnecessary delay. global disasters, such as a pandemics or warfare, are events that cause a major disruption to health and social care, industry and economy, and community and education. disasters on this scale result in substantial loss of life, and an immeasurable burden is placed on healthcare services to deliver core medical care. disaster healthcare provision requires a collaborative approach that uses the expertise and skills of as many people as possible. much of what is formally taught in medical school is around the knowledge, skills and behaviours required of a physician for patients at the bedside. however, the broad training medical students receive could be applied to disaster scenarios especially if supported with adjunct specialist training. the current medical student curriculum already covers a wide range of specialties, and some may argue it is stretched. however, the rising incidence of worldwide disasters and the impact of the current coronavirus (covid- ) pandemic has justified the need for disaster preparation training in medical students. in some respects, students with disaster training may be better suited to assist in both clinical and non-clinical roles in disaster scenarios than redeployment of senior physicians with super-specialist skills and knowledge. curricula using multidisciplinary methods of simulation and human factors training have been proposed for implementation by the usa (association of american medical colleges ) and europe (government of the federal republic of germany computer science applied to medical practice, italy ). however, at present, it is recognised that there is a brief or non-existent exposure to disaster training within current medical training curricula across the world, which may leave students unprepared for an intimidating and unfamiliar setting if assisting in the healthcare workforce. the current covid- pandemic is rapidly driving the need for healthcare workers in the uk. on march , the uk health secretary, matt hancock announced plans to introduce medical students as volunteers to the nhs in order to assist in this pandemic. in response, the british medical association and medical schools council issued clear advice regarding medical students joining the uk healthcare workforce including ensuring correct induction, training and supervision. the aim of this study was to systematically review disaster training courses for medical students. we describe the educational structure and methodology employed, and evaluate both preparedness for disaster medicine and learning outcomes to inform the development of covid- -specific training programmes. we adhered to prisma (preferred reporting items for systematic reviews and meta-analyses) guidelines and recommendations for systematic reviews of observational studies. we searched embase, medline and cochrane central from for all articles published until march evaluating training that medical students receive to prepare them for pandemics and disasters, with no language restriction. we identified articles, which we then screened for inclusion. the search was conducted using the following medical search headings: 'coronavirus', 'covid- ', 'sars virus', 'disasters', 'natural disaster', 'major catastrophe', 'mass casualties', 'crisis event', 'extreme weather', 'disease outbreaks', 'infectious disease transmission', 'epidemics', 'pandemics', 'mass drug administration', 'warfare', 'biohazard release', 'chemical hazard release', 'radioactive hazard release', 'radiation exposure', 'radiation injuries', 'hazardous', 'waste', 'chemical water pollution', 'radioactive water pollution', 'medical students', 'medical schools', 'education' with terms exploded as appropriate. the search strategy was not registered on prospero-the international prospective register of systematic reviews-to prevent unnecessary delay. we selected randomised controlled trials, case-control studies and cohort studies that measured medical student training outcomes in the context of pandemics and disasters. studies were selected only if they contained a detailed report of the training implementation and used objective precourse and/or postcourse assessments related to medical student knowledge, attitude, skills or clinical care outcomes. importantly, if medical student outcomes were grouped with other healthcare students or professionals and not reported separately, the study was excluded. we excluded non-english language articles in order to ensure data quality, logistical training process evaluations, literature reviews, case reports, clinical trial proposals, conference abstracts, editorials, letters and articles evaluating non-medical student populations only. pandemic infections that may be secondary issues to a disaster, but were not the primary cause, were also excluded, for example, hiv, dengue, malaria; situations where medical students were unlikely to be required to volunteer en masse, for example, active shooter situations; and interventions that were not in a disaster setting, for example, basic life support and routine clinical infection control procedures were excluded. duplicates were removed and two reviewers (ja and mhvb) independently screened titles and abstracts using rayyan, an online software to aid blinded abstract screening. any discrepancies were resolved by consensus. of the citations screened, we identified articles for full text and reference review, of which final studies met the inclusion criteria for data synthesis (figure ). two reviewers (ja and mhvb) independently extracted relevant information from each training report using standardised data extraction proforma in keeping with best evidence medical education recommendations and one author with medical training expertise (rjd) reviewed all extracted data. we recorded administrative information including authorship, institution and year of publication; training-related data including details and duration of intervention, participants and teaching methods; and quantitative and qualitative outcome measures. the quality of training intervention and risk of bias in reporting of results was assessed using the robins- for non-randomised controlled trials. meta-analysis was not performed on the training outcomes assessed due to the wide heterogeneity in training interventions and reporting of results. descriptive analysis was performed instead. interventions were assessed against kirkpatrick criteria and kirkpatrick's levels were assigned: impact on learners' satisfaction (level ), changes in learners' attitudes (level a), measures of learners' knowledge and skills (level b), change in learners' behaviour (level ), changes to clinical processes/organisational practice (level a) and benefits to patients (level b). twenty-three studies met the inclusion criteria, and their characteristics are displayed in table . the majority of studies (n= , . %) were from the usa, and other countries were germany (n= ), israel (n= ), italy (n= ), saudi arabia (n= ) and south korea (n= ). five studies ( . %) involved a multidisciplinary cohort and reported outcomes for other healthcare students and professionals, as well as outcomes for medical students individually without pooling of results. the course structures and learning objectives were grouped into three categories: broad concepts in disaster medicine (n= , . %), trauma or haemorrhage mass casualty management (n= , . %), or influenza pandemic management, airborne viral management or personal protection (n= , %). the length of studies ranged from single day teaching to -week boot camps, and the median length of training was days (iqr= - ). the majority of training interventions used traditional didactic lectures with simulative or experiential teaching methods, with courses ( . %) containing lectures and simulation. of the simulation experiences, four courses ( . %) contained outdoor actor-based mass casualty simulation. multimedia approaches were used in eight courses ( . %) as an adjunct to training, often precourse, in order to efficiently provide material to attendees. problem-based learning or casebased learning was used as a predominant feature in five courses ( . %) in a classroom setting with or without other teaching methods. no courses involved only didactic teaching methods, all included studies were prospective cohort studies measuring the impact of their training intervention postcourse evaluation, with using precourse evaluation for comparison as displayed in table . the majority used subjective assessments of knowledge or preparedness in disaster medicine (n= , . %) with nine studies ( . %) using objective measures. there was a wide range in number of medical students attending the courses, with the median number of participants being (iqr - ). however, five studies did not clearly describe their medical student population, either omitting total number of participants or seniority of students. only two studies reported data that assessed longitudinal learning beyond the year of course implementation. common limitations of study design included training being limited to a single institution, studies which were excluded due to being randomised controlled trials evaluating the efficacy of different teaching methods or simulation technology, or studies excluded due to reporting medical student outcomes pooled with outcomes of other healthcare student or professionals. of the studies included in this review, studies in total measured precourse and postcourse outcomes. of these studies, knowledge was measured in ( . %), of which undertook objective knowledge measurements, making this the most measured outcome. however, none of the subjective or objective measures of knowledge were previously described or undertaken with validated measures. a total of four studies measured attitude-either preparedness for disaster (n= ) or confidence in approaching a disaster (n= ) by precourse and postcourse assessment. disaster medicine skills were subjectively measured in four studies and objectively measured in two, one being pass rates in personal protective equipment fitting and the second being accuracy of disaster triage. in these studies, validated measures were used to create scores or pass rates. of the five studies inviting a multi-disciplinary participant group, none trainee satisfaction was assessed in ( . %) studies and most commonly assessed using likert type scales. medical students were asked to rate the overall quality of the courses in addition to whether they would recommend courses to colleagues for disaster preparedness. course satisfaction was generally very high and appeared to be enhanced by multimodal approaches to curriculum design including the incorporation of simulation and technology. however, one group discussion and interactive activity-based study did report mixed reviews with postcourse overall ratings of positive ( %), undecided ( %) and negative ( %). this is reflective of overburdening medical students with work, with one student stating, "this was way more work than it should have been. i would rather have an hour lecture on the flu than do all that group stuff. this was just frustrating to have at the end of the year when finals are right around the corner". attitudes and perceptions of knowledge in medical students were assessed in studies ( . %). attitudes were broadly assessed as level a following courses measuring either a simple change such as interest in disaster medicine, a measurement of a medical student's willingness to volunteer in or preparedness to practice disaster medicine, or by mapping trainee responses to learning objectives. level b was measured by a total of studies ( . %) which assessed medical student knowledge or skill acquisition, with assessing knowledge and assessing skills, either alone or in combination. in courses training students in mass casualty scenarios, discrete and measurable skills were easily assessed including tourniquet application and triage skills. as behavioural change is a difficult area to measure in nonpracticing medical students, only one study was deemed to adequately assess behavioural change. this study assessed confidence and perceived stress handling emergencies once the medical students had graduated . years following the course. no studies investigated the impact of disaster training on clinical performance (level a) or organisational delivery of care (level b). all included studies were cohort studies and risk of bias was assessed using robins- (figure ). risk of bias was low to goolsby, , university of the health sciences, usa postcourse questionnaire assessing perceived confidence at assessment and procedures in a combat casualty situation and perceived preparedness at managing combat casualties. the majority of students feel more confident and better prepared to assess and perform procedures in a combat casualty situation after course. the majority of students preferred the high-fidelity simulation to their normal learning environment. attitude, skill to a ingrassia, crimedim, italy precourse and postcourse examination assessing disaster medicine knowledge. triage accuracy was measured in a disaster simulation assessed by an examiner. there was a significant improvement in knowledge of disaster medicine after course from % to % (p< . ), and a significant improvement in triage accuracy in the disaster medicine simulation after course from % to % (p< . ). the majority of students felt that disaster medicine should be part of their curriculum and evaluated the course highly. knowledge and assess learning of the didactic material immediately before the min case-based lecture, and the posttest immediately after the lectures. the class could take their pretest via an e-learning tool up to several days before the class, and the post-test was available online for weeks after completion of the course. over a -year assessment period the first year cohort's post-test knowledge scored improved from . / (below average to average) compared with . / (average to above average) and the second year's post-test scores improved from . / (average) before and . / (above average). in the first year cohort he average overall rating for the experience was . / , and % of the respondents recommended the class for next year's students allowing it to continue. knowledge, attitude to b scott, , medical university of south carolina, usa participants undertook precourse and postcourse assessment developed to meet learning objectives of the course. selfassessment of personal capability and comfort to handle a disaster and multiple choice questions of knowledge and subjective skill were undertaken. most ( %) of the trainees considered their emergency preparedness knowledge and skill as average or below average before the training experience. after the curriculum, % of trainees considered their emergency preparedness knowledge and skill above average, and % would recommend the course to other healthcare workers. knowledge, skill to b scott, , medical university of south carolina, usa participants undertook an online precourse and postcourse assessment developed to meet the learning objectives and competencies of the course in addition to giving post-test feedback on the implementation of the course. in discrete knowledge, subjective knowledge and skills all participants demonstrated significant improvements in their postcourse test results when compared with pre-test. course evaluation was performed, and it was found that students would recommend this course (median . %), whether the course was feasible (median . %) and overall evaluation ( . %). knowledge, skill to b silenas, , the texas a&m college of medicine, usa students answered likert type scales to assess the extent to which the objectives and understanding of key concepts had been accomplished. written and verbal comments from the students and facilitators about their experience were gathered. sixty-six medical students completed the knowledge test before and again days after the avian influenza exercise. the lowest scores for knowledge were best and all tested knowledge areas except one (endemic influenza as a public health issue) decreased postcourse. the course received mixed ratings which overall were positive ( %), undecided ( %) and negative ( %). knowledge. knowledge, skill b table continued figure individual risk of bias for non-randomised control trials determined by robins- . overall risk of bias for non-randomised control trials determined by robins- . critical ( figure ). confounding bias was serious overall as many studies did not present pretest control data. there was critical overall bias in the selection of participants as courses were often not open to all students, for example, self-selected recruitment from student emergency medicine interest groups. classification bias and bias due to deviation from intended interventions was low. a single study had a classification bias because they did not adequately describe their educational intervention-as all other studies had low bias, this domain was classified as having low overall bias. overall missing data bias was moderate as three studies had some form of missing data and were not able to adjust for this in their analysis. measurement of outcomes had serious bias overall, as many questionnaire evaluations were subjective without any objective measures. selection and report of results had serious bias overall. while some studies did note ethical approval there was no priori registration of the results and some studies had limited reporting of results. this systematic review identified approaches used to train medical students in disaster medicine in order to suggest training approaches for medical students in the current covid- pandemic. we identified studies published between and march . overall, medical student disaster training programmes improved student disaster and pandemic preparedness and resulted in improved attitude, knowledge and skills. there was an improvement in all studies that measured precourse and postcourse outcomes. we found that all interventions ranging from simple classroombased interactive discussion to complex multimodal simulative experiences resulted in improved knowledge, skill and attitudes towards participation in disaster medicine. the main outcomes of the courses reviewed were subjective; however, there was evidence to suggest that disaster medicine training does improve objective knowledge and can teach skills which can be used by medical students, relevant to a pandemic. the majority of courses were just day in duration, indicating that short courses can still be impactful. the courses identified in this review required expert faculty or high-fidelity equipment and were implemented alongside an already busy medical school curriculum. these barriers prevented the majority of courses in this review from reaching longitudinal integration into medical school training. however, this may be overcome in the current covid- pandemic by collaboration and coordination, particularly when many medical students have had their studies either postponed or converted to telemedicine/online teaching. the main limitations of this review are related to study design, as the majority of studies were single centre and often focused on very specific aspects of disaster medicine. the overall reporting of both participant factors and outcome factors was generally poor, and the educational methodology was very heterogeneous-this was represented by critical risk of bias in selection of participants, and serious risk of bias in measurement of outcomes. this bias inevitably weakens the strength of the conclusions drawn, but given that all studies demonstrated a positive benefit, it can still be concluded that there will be benefit to students who undertake disaster preparedness courses. another limitation was the kirkpatrick levels that were evaluated. only one study evaluated change in behaviour (level ) and no studies evaluated change in clinical performance (level a) or organisational patient benefit (level b). furthermore, only three studies focused solely on pandemic influenza, airborne viral management or personal protective equipment (n= , %), and only a single study assessed resuscitation in a disaster setting. this is of particular importance for the covid- pandemic, where respiratory personal protective equipment is a necessity and there are specific resuscitation guidelines. clinical impact and clinical utility must be taken into account when making suggestions for training during the covid- pandemic. although medical students working during the covid- pandemic will likely be deployed to non-infectious areas of work, there is no guarantee that medical students will not be exposed to the virus. furthermore, a strain will be placed on healthcare services and contingency care may need to be provided in place of a traditional care service. here, students may be essential in ► medical students could play a crucial role in the sars-cov- healthcare response. ► disaster medicine programmes using multimodal techniques improve knowledge, skills and attitudes which are imperative for medical practice in a pandemic. ► training programmes incorporating previously successful techniques could ensure the successful integration of disaster training into global medical school curricula. ► do disaster training programmes aimed at medical students demonstrate direct patient benefit? ► can disaster training programmes improve the integration of medical students into the healthcare workforce during the sars-cov- pandemic? ► how can disaster training programmes be adapted to manage future pandemics? preserving the resilience of hospitals and community healthcare systems. there will ultimately be more pressure on medical students to work than previous cohorts and this review suggests that disaster medicine training as a part of medical school's curriculum is not common practice. therefore, medical students may require a very different set of competencies than those acquired during medical school. unsurprisingly, some final year medical students do not feel ready to start as a newly qualified doctor, due to worries they are not well prepared for clinical placements, or feeling under prepared for covid- . moreover, the medical schools council have advised that medical students from any year should not take on roles that will impact on their studies. this review suggests that early mobilisation of medical students into the workforce could be accompanied by disaster medicine training. all courses reviewed in this study were positively evaluated by medical students, and if a similar programme was offered to current medical students, it would likely be well received improving willingness and preparedness to work in the healthcare service. this is of particular importance as medical students are already being asked to join the workforce as volunteers, or to graduate early in order to join healthcare systems as physicians. there is great concern that students who give assistance during a disaster without training are at an increased risk of both harm to themselves and psychological consequences. there is therefore a need to create novel courses to teach medical students pandemic skills in these unprecedented circumstances. this review suggests that the most beneficial medical student disaster medicine courses should consist of mixed modalities of didactic sessions, case-studies, practical hands on training and simulation experiences. these training methods could be used to train medical students in covid- specific knowledge and skills and prepare them for clinical practice. table shows a proposed covid- course and assessment based on the findings of this systematic review. the course structure includes the variety of elements found in other studies. didactic lectures on covid- could be delivered in a lecture hall with social distancing measures in place, or perhaps more appropriately as a distance learning component consisting of video, podcast and computer activities. practical activities could include fitting of respiratory personal equipment as well as donning and doffing. the simulated element could consist of a patient with covid- who requires cardiopulmonary resuscitation. in resource-limited scenarios, this could be undertaken using computer-based tutorials or video tutorials. as new doctors and medical students may have a substantial volume of information to learn in addition to this course, handouts and online refresher courses should be offered. the proposed assessment aims to cover all kirkpatrick levels and criteria. it is also important to teach and train human factors awareness, particularly in relation to team dynamics, lowering authority gradients and empowering anyone to speak up if concerned. maintaining both individual and team situational awareness is also important during any clinical duty, and even more so during a crisis setting. it may be useful to incorporate a credentialing process for medical students undergoing disaster training, thereby allowing students to demonstrate a background of competency and separating this cohort from unskilled volunteers when aiding a disaster medicine response. the successful implementation of these suggested disaster training techniques will require the encouragement of people-centred training, the development of peer-learning, coordination and funding of training systems, and regular disaster preparedness exercises of multimodality format. the covid- pandemic has caused unprecedented disruption to healthcare services in peacetime. medical students may play a crucial role in the healthcare response. there is an imminent demand for educational interventions to train medical students to better assist in this response. the disaster medicine courses reviewed in this article improved knowledge, skills and attitudes through multimodal techniques and were well received original research by learners. although no studies in this review demonstrated direct patient benefit, the courses increased student preparedness and similar courses should be implemented prior to medical students joining the healthcare workforce during the covid- pandemic. future courses should note the methodological and longitudinal flaws demonstrated in previous studies so that direct patient benefit can be demonstrated in the covid- pandemic. future work should be undertaken to ensure the successful integration of disaster training into global medical school curricula. twitter james ashcroft @jamesashcroftmd, matthew h v byrne @mhvbyrne, peter a brennan @brennansurgeon and richard justin davies @jdcamcolorectal contributors ja and rjd undertook conceptualisation of this article. ja and mhvb undertook data collection, analysed the data, and drafted and revised the manuscript. rjd and pb undertook critical review of all data collection and analysis and guided critical revisions. rjd approved final manuscript for submission. funding the authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. 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program for medical students with quantitative and qualitative fit test for respiratory protective equipment simulation training for in-flight medical emergencies improves provider knowledge and confidence a short medical school course on responding to bioterrorism and other disasters disaster preparedness medical school elective combating terror: a new paradigm in student trauma education disaster : a novel approach to disaster medicine training for health professionals high-fidelity multiactor emergency preparedness training for patient care providers teaching mass casualty triage skills using immersive three-dimensional virtual reality teaching mass casualty triage skills using iterative multimanikin simulations disaster training in hours: evaluation of a novel medical student curriculum in disaster medicine competing interests none declared. provenance and peer review not commissioned; externally peer reviewed. this article is made freely available for use in accordance with bmj's website terms and conditions for the duration of the covid- pandemic or until otherwise determined by bmj. you may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained. james ashcroft http:// orcid. org/ - - - matthew h v byrne http:// orcid. org/ - - - x key: cord- -p l bpqi authors: keenan, jesse m. title: covid, resilience, and the built environment date: - - journal: environ syst decis doi: . /s - - - sha: doc_id: cord_uid: p l bpqi this article provides a perspective on the reciprocal relationships between public and private sector resilience planning activities and the ongoing covid responses in the u.s. through the lens of the built environment, this article provides selected insights into how various disaster, organizational, and engineering resilience activities have likely positively shaped covid responses within the healthcare sector. these positive influences are contextualized within extensive efforts within public health and healthcare management to calibrate community resilience frameworks and practices for utilization in everything from advancing community health to the continuity of facilities operations. thereafter, the article shifts focus to speculate on how ongoing experiences under covid might yield positive impacts for future resilience designs, plans and policies within housing and the built environment. through this perspective, the article hopes to explore those often overlooked aspects of the physical and social parameters of the built environment that may be understood as providing opportunities to inform future disaster, public health, and climate change preparations and responses. climate change and the novel coronavirus ("covid") have much in common. like climate change, the covid pandemic was widely anticipated among public health officials and medical scientists for decades (kleinman and watson ; yang et al. ). among climate change experts, the risks of infectious disease and pandemics have long been on the list of multi-hazards to anticipate (semenza and menne ) and to observe (caminade et al. ) . indeed, some of the planning associated with the next anticipated coronavirus pandemic has laid the foundation for ongoing treatment and vaccine advancements being made on a near weekly basis. yet, for the most part, the risks from any number of potential-and even likely-pandemics have been broadly ignored by the general public and policy makers for decades-despite the science, despite the warnings. there is nothing new here-it's the same old story from precautionary principles (or lack thereof) to the behavioral and cognitive limitations to risk assessment and prioritization (sunstein ) . in this regard, covid and climate change are societal outcasts too ugly to standout and too deadly to ignore. yet, in our responses to both, they share a common linkage that offers an opportunity to reflect on where we have been and we are going within the allied fields of resilience and adaptation. this article provides a perspective on the reciprocal relationships between public and private sector resilience planning activities and the ongoing covid responses in the u.s. through the lens of the built environment, this article provides selected insights into how various disaster, organizational, and engineering resilience activities have likely positively shaped covid responses within the healthcare sector. these positive influences are contextualized within extensive efforts within public health and healthcare management to calibrate community resilience frameworks and practices for utilization in everything from advancing community health to the continuity of facilities operations. thereafter, the article shifts focus to speculate on how ongoing experiences under covid might yield positive impacts for future resilience designs, plans and policies within housing and the built environment. through this perspective, the article hopes to explore those often overlooked aspects of the physical and social parameters of the built environment that may be understood as providing opportunities to inform future disaster, public health, and climate change preparations and responses. there a number of primary categories associated with different variants of resilience that have their own independent conceptual and analytical frameworks-there is no one type of 'resilience' (davidson et al. ; moser et al. ). among the categorical variants of resilience, it is 'disaster' and 'engineering' resilience that are most widely utilized in domestic multi-hazard and climate change planning in the u.s. (keenan ) . within these planning activities there is increasing sophistication in separating 'risk' and 'resilience' as independent, but related, domains of management and policy (linkov et al. a, b) . while there is not a uniform consensus across fields of scholarship and practice, as a general matter, risk is relegated to responding and preparing (i.e., mitigation, transfer, etc.,) for known phenomena based on a relatively stationary probabilistic outcomes, and resilience is primarily oriented to capacities that address both known and unknown phenomena representing a broad spectrum of probability and uncertainty in comparatively fluid and dynamic conditions and responses (linkov et al. a, b) . in this sense, resilience is critically important for filling the void left by risk management that is limited to probability-particularly as it relates to low probability or highly uncertain, high impact events such as covid. in its most simplified distillation, 'engineering' resilience (and to a large extent 'disaster' resilience) speaks to the elastic and reversionary capacities of a system to return to pre-stimulus level of operational performance and material quality, which may ultimately lead to adaptive and maladaptive outcomes depending on aging effects and the associated costs of time and money in supporting such performance (hosseini et al. ; kurth et al. ) . engineering resilience is descriptive and may be readily designed and observed in a variety of engineered systems, including a variety of infrastructure systems and sectors (bostick et al. ). on the other end of the spectrum of categorical resilience is 'community' resilience, which speaks to the capacity of communities-a collection of individuals and among social organizations-to respond, recover and accommodate external shocks and stresses (matarrita-cascante et al. ) . by contrast to engineering resilience, the measurement of community resilience is still at an early-stage (sharifi ; cutter ) and current practices in community resilience at largely normative in favor of subject judgements about how communities ought to prepare for and respond to ongoing challenges (patel et al. ) . although there are other important categories, such as 'ecological' and 'organizational' resilience, engineering and community resilience have been the primary drivers in u.s. resilience planning activities in the built environment in the past decade. while advancements in the framing and measurement of community resilience have been popular in the literature as a free-standing largely normative exercise, in practice, much of this work has operated to provide a social and human dimension to the operations of disaster and engineering resilience among emergency management institutions (nist ; koliou et al. ) . while there are known limitations to emergency management's ability to challenge structural institutions that define long-term vulnerabilities to climate change (gillard ) , covid is the type of shock that fits within emergency management's multi-hazard framework (djalante et al. ). in the past decade, multi-hazard disaster and engineering resilience planning has had significant impacts in shaping the design and management of the built environment in everything from supporting the business continuity of private enterprise (keenan ) to the sustainable provision of critical public services (humphries ) . over the past decade, public health officials have actively participated in the diffusion of disaster and community resilience planning practices alongside their colleagues in emergency management, urban planning, and civil engineering. mass casualty preparations in recent years in the u.s. have largely centered on gun violence under a different policy regime within homeland security in the age of terrorism and mass shootings (melmer et al. ). however, disaster resilience planning activities have more broadly engaged both public and private health systems to look inward in terms of internal communications and business continuity; critical facilities and operations assessments; and multi-network contingency planning (zhong et al. ; verheul and dückers ) . the urgency of this work was well amplified with the high-profile loss and evacuation of nyu langone medical center in new york city during hurricane sandy in -a major center of healthcare for much of manhattan (powell et al. ; seltenrich ) . in the years that followed, healthcare systems from across the country have been actively preparing for a variety of hazards, including those associated with climate change impacts (uscrt ). by the time hurricane harvey hit houston in , the sector had a new champion in the texas medical center, which has served as the quintessential case study for engineering and operational resilience capacities (flynn ) . it is worth recognizing that the motivation for such resilience investments is partially driven by the potential for superior health outcomes, but it is also a function of the economic losses that resonate well beyond facilities repair and replacement (desai et al. ). engineering resilience models and techniques have informed nearly every aspect of facilities design and management from dry flood proofing of critical equipment (chand and loosemore a, b; bignami et al. ) to real-time intelligence of surface transportation for managing vehicle traffic (tariverdi et al. ) . beyond facilities, healthcare firms have also benefited from organizational resilience efforts to prepare for alternative supply chains and procurements models (mandal ) . but, disaster resilience 'thinking' also forced hospital and healthcare networks to evaluate the adaptive capacity of their building designs to handle multiple types of programs and alternative configurations (aghapour et al. ) . we see the benefits of this today with the expansion of intensive care units ("icu") into other parts of hospital facilities, as well as the coordination between in-hospital care and the utilization of portable mass care facilities. by another measure, the rapid deployment of telemedicine may very well challenge the future utility of some medical facilities, even if that ultimately means something like smaller waiting rooms in family practice offices (aldossary et al. ). in the broader national effort to cut healthcare costs, every square foot counts. in addition, as healthcare networks have expanded into a hub and spoke model for outpatient care, these outpatient facilities have turned into what used to be the purpose of neighborhood public health facilities-they have become, in some cases, a critical access points for covid testing and triaging (elrod and fortenberry ) . in some cases, a cvs pharmacy is doing what a county public health facility used to do (repko ) . while a replacement of public health facilities with private healthcare facilities is not a particularly defensible model, this ad hoc utilization amplifies the proposition of several u.s. cities, including miami, for the development of local 'resilience hubs' that can serve as a physical platform for deploying public health, food, information and other resources for communities in good times and in bad (city of miami ). unfortunately, such 'hubs' are not currently considered critical facilities under u.s. department of homeland security ("dhs") rules and are therefore ineligible for funding under a number of programs. perhaps moving forward, reinvestment in community public health facilities through dhs programs could serve a variety of public health and disaster and community resilience co-benefits. indeed, public health scholars and practitioners have made considerable advances in operationalizing community resilience. in a post-cutter landscape of indeterminate quantitative socioeconomic resilience indicators (burton ) that are limited in their replicability and scalability within existing policy pathways (cutter and derakhshan ), public health has stepped-up to advance a mix of quantitative and qualitative community resilience indicators that tell a broader story of community health that is central to our physical and mental capacity to endure climate change and other public health crises (who ). indeed, public health has squarely captured the attention of public policy makers by arguing that community resilience is central to offsetting existing inequitable disparities in accessing the u.s. healthcare system (lichtveld ) . but, these advancements have come in all sorts of shapes and sizes. at a truly community scale, there is little doubt that community gardens started by public health and civic ecology advocates in the name of community resilience will be providing fresh, healthy food for families struggling with covid this summer (shimpo et al. ) . perhaps community gardens and resilience hubs should both be added to the dhs critical facilities list-along with pharmacies, grocery stores and other facilities that are truly critical for social welfare and life-safety. aside from an expanded list of critical facilities, the covid crisis offers insights into a variety of vulnerabilities, coping strategies, and an ad hoc interventions that offer insight into future resilience planning and design activities. it is widely acknowledge that resilience is generally advanced in institutional terms each time that a government or a community has an experience with a disaster-there is always something to be learned (young ; henly-shepard et al. ) . another recent disaster-the foreclosure crisis ( - ) during the great recession-led to a number of legislative reforms that identified financial risks at the household level and across the housing financing system. these reforms sought to mitigate and manage a variety of risks that are yielding benefits today. one could argue that they have advanced the specific resilience of the housing economy. beyond risk transfer mechanisms in the capital markets and the elimination of highly risky loans, banks and mortgage servicers are much more reluctant to foreclosure recognizing that the weight of the empirical evidence suggests that alternative work-outs are far more effective in maintaining the asset value of mortgages and housing collateral. whether it is loan forbearance or debt reduction, these lessons have since helped local housing markets stabilize following countless hurricanes and forest fires in the past decade (gallagher and hartley ) . in the coming years, we will likely also have a much better sense of what works and what does not work in light of current congressionally allocated emergency subsidies and their effect in stabilizing local economies and housing markets. in particular, we are currently undergoing the most widespread set of experiments in rental housing stabilization every undertaken and the lessons from this will likely shape future resilience and post-disaster recovery efforts that engage housing stabilization for generations to come. so, the question remains: what are we learning about our use and design of the built environment today in the midst of the covid crisis that might shape future resilience efforts? the intimacy of social isolation has afforded us the luxury of seeing and experiencing our built environment in a very different way. from the lower occupancy rates of grocery stores to the social spaces partitioned within even a single room, there is much to be explored. most immediately, building managers are actively developing infectious disease control protocols for operating and cleaning buildings. they are thinking about weak links in hvac systems, filtration standards, and the prospects for transmission in common areas (nmhc ). these emerging practices are also likely to advance greater attentiveness to indoor air quality as people spend significantly more time inside than usual. other adaptations are perhaps less applicable, such as new signage requiring single occupancy elevator rides. yet, other mundane challenges associated with providing access to quarters for coin operated laundry serving tens of millions of american renters may be a key preparation in the future. while resilience techniques for multi-family buildings are comparatively mature, additional operational and performance standards are likely to originate from covid (schoeman ) . the design of residential housing is a reflection of our cultural construction of home and its domestic attributes. the domestic realities-good and bad-are compressed in time and spaces over the course of disasters. what happens when long periods of isolation leads to domestic violence? perhaps a resilience standard might require the installation of locks on interior doors. ensuring safe spaces might actually require the design of safe spaces. the intimacy of social relationships also plays out for families who are remotely working in spaces designed almost exclusively for entertainment, leisure and domestic pursuits. this requires new forms of multi-purpose furniture and adaptive swing spaces where eating, working and study spaces overlap. while consumer design preferences are unlikely to overcorrect to the covid experience, there are subtle adaptations that are likely to be positive. people are more sensitive to storage and their overall consumption. they are finding ways to recycle materials and fix things that they might have otherwise simply replaced. this economization of material speaks to social learning that is likely to have a positive impact on the resilience of the built environment when the next disaster strikes. just in terms of disaster preparedness, many families will now not only have stockpiles of food and medicine, they will also have things like home medical diagnostic equipment (e.g., iphone compatible portables ekg devices) and home school education materials. all of these preparations are critically important, especially at a time when covid is significantly weakening our national emergency response capacities for hurricanes, floods, forest fires and other labor intensive disasters. beyond the household, the novel experiences with the built environment are extending into streetscapes, parks and other forms of public space. times of disaster do intensify out biophilic behaviors, but they also highlight the fundamental values associated with investments in public space and the natural environment (tidball ) . with many fewer cars on the streets, a new civic realm may be envisioned that supports a more sustainable worldview of the built environment, including what it means to have a reduction in health impacts associated with air pollution (dutheil et al. ) . these renewed landscapes are the grounds where people are mobilizing new commitments for physical exercise-once speculated to be a major indicator of community resilience by the u.s. government (fema ) . like new year's resolutions, these behaviors are likely to fade in a post-covid recovery. yet, they offer valuable insight into where priorities for resilience should be defined and the role that the built environment plays in supporting those priorities. learning from disasters is critical. in the heat of the moment, we have the opportunity to observe what is working and what is not working-and for whom. as this article has highlights, existing covid responses have likely benefited from recent resilience planning efforts largely advanced in the name of addressing climate change and disaster mitigation. in particular, public health and healthcare management contributions to a broader interdisciplinary field of inquiry associated with community resilience have likely translated into meaningful action that could very well reciprocally advance resilience activities in other sectors. specific to the healthcare sector, considerations relating to the resilience and adaptive capacity of the built environment are central to managing of the existing challenges associated with supply constraints, alternative forms of service delivery, and the broader continuity of operations. in the linkage between prior disaster experience-some of which are attributable to climate change impacts-and covid, we find a measure of maturity in the human health and healthcare sectors that provides hope for the progressive development of core practices and strategies associated with disaster, organizational and engineering resilience. the covid experience has also imposed new perspectives on the role housing and the built environment in shaping resilience interventions and capacities as viewed through the lens of domiciliaries, consumers, and civic actors. from the management of social space to disaster preparedness, the built form is a conduit for shaping positive behaviors that are the heart of any frame for community resilience. while some ad hoc covid responses will soon fade, others will sustain as part of our collective adaptive capacity for addressing future social and environmental shocks and stresses. in 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been developed to measure health-related community resilience at a national and local level. world health organization the deadly coronaviruses: the sars pandemic and the novel coronavirus epidemic in china institutional dynamics: resilience, vulnerability and adaptation in environmental and resource regimes validation of a framework for measuring hospital disaster resilience using factor analysis key: cord- -m uvh zn authors: fabbricatti, katia; boissenin, lucie; citoni, michele title: heritage community resilience: towards new approaches for urban resilience and sustainability date: - - journal: city territ archit doi: . /s - - - sha: doc_id: cord_uid: m uvh zn the value of cultural heritage and its transmission for “making cities and human settlements inclusive, safe, resilient and sustainable” is an integral part of the un agenda and the new international policy for disaster risk reduction – . nonetheless, the role of culture for these important challenges is an issue that current scientific literature on resilience has not yet sufficiently investigated. starting from the concept of heritage community, elaborated in the council of europe's framework convention on the value of cultural heritage for society (framework convention on the value of cultural heritage for society, ), along with the hypothesis of its role for community resilience, this study elaborates a conceptual framework in which “heritage community resilience” is defined. it is both a target and a process in which cultural heritage supports the building of a community able to prevent, cope with and recover from disturbances and/ or disasters. through a survey of several case studies on heritage-driven practices in italian inner peripheral areas, the research aims to define the specific characteristics of heritage community resilience as well as identify any critical actors and variables, strategies and governance mechanisms, which influence both heritage community and community resilience. it predicts the challenges and highlights the potential that culture and heritage can develop for community resilience, towards further perspectives of resilient circular city. cities now have to face various types of risks, including frequent or infrequent events, with either sudden or slow-onset natural or man-made hazards, that can occur both globally (climate crisis, scarcity of resources, migrations, etc.) and locally (earthquakes, depopulation, erosion of cultural capital, etc.). urban resilience is an international topic of discussion (pu and qiu ) in global policy frameworks (unesco (unesco , undrr a; undrr b) . nonetheless, urban resilience still has a low profile in some policy arenas (chmutina et al. ) , with cities being far from reaching the goals set by international programmes or standards, as the current covid- pandemic seems to confirm at a global scale, even though the available data are still partial and contradictory. in the governance debate, community resilience is developing into an autonomous theme (coaffee ; mulligan et al. ; chelleri et al. ) . it is becoming a target for society development for both scientific literature (berkes and ross ; chaskin ; cutter et al. ; maguire and cartwright ; etc.) and national security policies (uk community resilience programme, us community resilience taskforce, australian national strategy for disaster resilience, etc.) . in recent years, communities are demanding and gaining autonomy to address deficiencies in development policies. the community is an integral part of social-urban and socio-ecological systems, with it represents the most dynamic part fabbricatti et al. city territ archit ( ) : of them. therefore, resilience must be pursued on the community scale (longstaff et al. ) . recent global policy documents (unesco (unesco , undrr a; undrr b) link community resilience to the strengthening of culture and cultural heritage. for the first time in , cultural heritage was recognised as an important "actor" in addressing global risks, especially for its role in strengthening cr (unesco , action ) . the session "resilient cultural heritage" of the third united nations world conference on disaster risk reduction (wcdrr) (undrr b) stressed how any disaster risk reduction policies and programmes should consider the cultural context, including cultural heritage as its most symbolic manifestation, if it is to be effective and sustainable. in resilience debates, however, this is an issue that current literature has largely failed to contemplate (beel et al. ) . the council of europe's framework convention on the value of cultural heritage for society (council of europe , art. b) shifts attention from the cultural heritage in itself towards people and their active participation in the process of recognizing the values held in it and their transmission to future generations (council of europe ). it defines "heritage community" as a community that "values specific aspects of cultural heritage which it wishes, within the framework of public action, to sustain and transmit to future generations" (council of europe , art. b). a heritage community is characterized by awareness of the resource value of its cultural heritage, a sense of belonging, inclusiveness, collaboration at all levels, a common interest in heritage-led actions, shared civic responsibility towards cultural heritage. based on the role of culture and cultural heritage in relation to community resilience, this study elaborates a conceptual framework in which "heritage community resilience" is considered as being both a target and a process in which cultural heritage supports the building of a community able to prevent, cope with and recover from disturbances. in an evolutionary vision of resilience, in which communities do not return to an initial state but evolve (davoudi et al. ; pink and lewis ; hillier ; etc.) , culture and cultural heritage can be the key to citizen engagement (idea of common good), as well as to social, environmental, economic and governance innovation. through a survey of several case studies on heritagedriven practices, the research aims to: define the specific characteristics of heritage community resilience; identify the effects of the practices for building heritage community and community resilience processes; define critical actors and variables, strategies and governance mechanisms, which influence both hc and cr. european peripheral areas, with particular attention to alta irpinia in southern italy, represent the research context. here, recognition and promotion of culture and creativity are particularly critical challenges. in these contexts, culture and creativity can help maximise economic returns from the production of place-specific and high-value-added products, favouring citizen engagement and community building (european commission ) . from the lessons learned in the case studies in alta irpinia, the research predicts the challenges and highlights the potential that culture and heritage can develop for community resilience. the paper is articulated as follows: first, the concept of cr is discussed within the international debate on resilience, with a focus on culture and cultural heritage; then the conceptual framework of the research is presented; in the second section, the survey method of the case studies is defined and then the research context is presented; finally, the cases are described and discussed. community resilience is an increasing target for social and urban development, as scientific literature (berkes and ross ; chaskin ; cutter et al. ; maguire and cartwright ; sharma and verma ; etc.) , international documents (unesco (unesco , undrr a; undrr b) and some agency and state strategies declare (bach ; mulligan et al. ) . the assumption of a social component, within the original ecological resilience approach, started in the late s, with a progressive enrichment of both social and ecological domains. "the social-ecological understanding of resilience emerged with the assumption that social and ecological systems were inextricably interconnected and that local communities could be made more resilient to unexpected shocks if efforts were made to increase their adaptive capacity" (mulligan et al. , p. ) . the latter is a property of the social-ecological system, with it distinguishing humans from animals and plants; the former can anticipate change and together with social, political and cultural experiences influence resilience (folke et al. ). communities do not control all of the conditions that affect them, but they can change some of the conditions that can increase their resilience (berkes and ross ) . as some authors have pointed out (mulligan et al. ; berkes and ross ; etc.) , although the approach to resilience significantly benefited from social-ecological cross-fertilization, the word "community" continued to be used rather uncritically. the causes highlighted by the authors are related to the socio-ecological approach, developed in fields such as biophysical or environmental sciences and resource economics rather than in sociological or cultural studies. a significant contribution to the evolution of the concept of community resilience comes from the field of psychology. in berkes and ross' research on the mental health and developmental psychology (berkes and ross ) , resilience is defined as a process of dynamic personal development in the face of adversity and adaptation, rather than as a stable outcome that is achieved and then retained (luthar and cicchetti ; almedom et al. ) . the extension of this study to the community scale focuses on identifying the strengths of a community, and how they contribute, in a collective process, to facing challenges and developing resilience (kulig et al. ; berkes and ross ; norris et al. ; buikstra et al. ; etc.) . several studies agree that the main strengths of a community are: individual psychological components-social networks, social inclusions, sense of belonging, leadership, outlook on life, learning (norris et al. ; kulig et al. ; buikstra et al. ; etc.) , the natural and built environment they are aware of, the lifestyles and livelihoods, where the role of infrastructure and support services are particularly important in disaster recovery (kulig et al. ) . in applied uses of psychological resilience thinking, it is important to highlight how human beings can train resilience through their responses to shocks and stresses, and actively develop resilience through capacity building and social learning (goldstein ). in the evolution of the issue of community resilience, scholars agree that some of the greatest progress has been made in urban planning, bringing together community and resilience in a meaningful way. in the urban context, as a complex adaptive social-ecological system, "a sophisticated understanding of both socio-ecological systems and the more cultural and political conceptions of the community" emerge (mulligan et al. , p. ) . in the field of urban studies, the evolutionary perspective of resilience (davoudi et al. ; pink and lewis ; hillier ) is "understood not as a fixed asset, but as a continually changing process; not as a being but as a becoming" (davoudi et al. , p. ) . to the interpretation of resilience as "dynamic interaction of persistence, adaptability and transformability on multiple scales" introduced by folke et al. ( ) a fourth component "preparation", based on learning ability has been added, which reflects "the intentionality of human action and intervention" (davoudi et al. ) . this is typical of social systems, enhancing the key role of social capital and institutions in the building up of resilient cities (galderisi ) . the ability of people to learn from experience, to increase their abilities to prepare, cope with and recover from disturbances is therefore the basis for community resilience. bulley ( ) noted that communities need to be 'produced' before they can be mobilized. rather than a static and vulnerable entity, communities are therefore as complex assemblages 'making' resilience at, across and between local and global scales (pink and lewis ) . community resilience is therefore not a target but a dynamic process based on continuous learning (cutter et al. ; wilson ) . in recent years, strengthening community resilience has emerged as an essential element of national security policies to address climate change and risks (bach ; mulligan et al. ) . in , the uk government launched in a cr programme and published in the strategic national framework on cr, which "is intended to provide the national statement for how individual and community resilience can work", and "should be relevant to all hazards and threats, and all communities" (uk cabinet office ). in the usa, the federal emergency management agency considers community resilience as one of the "core capabilities" needed to achieve the "preparedness" for all types of disasters and emergencies (fema ) . the entire strategy is based on a "whole community" approach (fema ) , which aims to engage society at all levels: "the core value proposition of this whole community approach is that by strengthening the assets, capacities, relationships and institutions within a community before disasters strike the community will prepare more effectively, better withstand the initial impacts of an emergency, recover more quickly, and adapt to become better off than before the disaster hit" (kaufman et al. , p. ) . some other examples are worth mentioning, like the australian national strategy for disaster reduction, , that of new zealand after christchurch earthquake, and the netherlands which experimented a "living with the water" approach that involved a publicprivate cooperation to face the growing climate threats (goemans et al. ) . as mulligan noted, these national community resilience policies and programmes assume that more resilient local communities will make for a more resilient national community (mulligan et al. ) . some of the above mentioned strategies, such as the australian and us, point to cultural heritage as one of the assets that people prepare to protect in a disaster resilient community. however, there is still little reference in these programs to the role of cultural heritage in building community resilience. indeed, only recently, the debate on resilience has been enriched by the emerging issues related to culture and cultural heritage. in particular, the topic is addressed in some global policy documents (unesco (unesco , undrr a) and is being discussed in further detail in current scientific literature (jigyasu ; holtorf ) . in , for the first time in international documents, cultural heritage was recognized as playing a role in addressing global risks, especially for its ability to strengthen community resilience (unesco ). in the hangzhou declaration, placing culture at the heart of sustainable development policies, "the appropriate conservation of the historic environment, including cultural landscapes, and the safeguarding of relevant traditional knowledge, values and practices, in synergy with other scientific knowledge, enhances the resilience of communities to disasters and climate change" (unesco , action ). later, during the third united nations world conference disaster risk reduction (wcdrr), in which the sendai framework for drr - was adopted, it was recognized that "cultural heritage provides important insights and opportunities for enhancing disaster risk reduction, post-disaster rehabilitation and recovery, building back better and for stimulating local economic and social development» (undrr a). the session on "resilient cultural heritage" highlighted how any disaster risk reduction policies and programmes should consider the cultural context, including cultural heritage as its most symbolic manifestation, to be effective and sustainable (undrr b). in the agenda for sustainable development (unesco ) and the new urban agenda (un ), culture emerges as a transversal driver, both as a knowledge capital and source of creativity and innovation, as well as a resource to face challenges and find appropriate solutions. "culture is who we are, and what shapes our identity. placing culture at the heart of development policies is the only way to ensure a human-centred, inclusive and equitable development" (hosagrahar et al. ). in the document of the un conference on housing and sustainable urban development habitat iii (un ), it is stated that culture allows to revitalize urban areas, strengthens social participation (point ) and contributes to developing vibrant, sustainable and inclusive urban economies (points and ). in scientific debates, the question of the relationship between heritage and resilience is spreading and evolving, although the debate is still sectoral (beel et al. ) . in most cases, the issue is addressed starting from the need to safeguard cultural heritage, recognizing its important role for the well-being and quality of life of people (azadeh et al. ; etc.) . some studies carried out as a result of the analysis of the processes that occurred before and after the disasters, have highlighted the contribution of the local material culture in prevention and recovery from risks. in the prevention phase, for example, the role of knowledge of traditional construction techniques or traditional prevention strategies resulting from subsequent trial and error in the management of known and expected risks is underlined (jigyasu ; d' amico and currà ; boccardi ; etc.) . a recent paper by holtorf ( ) , unesco chair on heritage futures in sweden, suggests an approach to cultural resilience (crane ) in which cultural heritage promotes resilience "precisely through the way, often highly evident, in which it has been able to adapt and develop in the past" (holtorf , p. ) . in this article, the author suggests that cultural resilience, risk preparedness, post-disaster recovery and mutual understanding between people will be better enhanced by a greater capacity to accept loss and transformation. in the author's view, the visible changes in cultural heritage over time can inspire people to embrace uncertainty and absorb adversity in times of change, thus increasing their cultural resilience (holtorf ) . the present research proposes new elements for the debate on the role of cultural heritage for resilience, and in particular for community resilience, with the concept of "heritage community resilience". the paper focuses on the capacity of cultural heritage to make and innovate communities (council of europe ), in a proactive process aimed at preventing, coping with and recovering from disturbances and/ or disasters. the framework convention on the value of cultural heritage for society (council of europe ) marks a revolution in the meaning of cultural heritage, shifting the attention from objects and places to people: "cultural heritage is a group of resources inherited from the past which people identify, independently of ownership, as a reflection and expression of their constantly evolving values, beliefs, knowledge and traditions. it includes all the aspects of the environment resulting from the interaction between people and places through time" (art. a). this new way of looking at heritage lays the foundations for redesigning relations between all the involved stakeholders. it stresses the crucial role of inhabitants and, as suggested by the convention, of a real "heritage community" (art. b). the faro convention approach empowers communities to take an operational role in decision-making towards direct democracy as well as contribute to the defining of policies and strategies regarding their local resources. heritage communities are defined as "people who value specific aspects of cultural heritage which they wish, within the framework of public action, to sustain and transmit to future generations" (art. b). in the aim of the convention, heritage communities are self-organized and self-managed groups of individuals interested in a progressive social transformation of relations between peoples, places and histories. they have an inclusive approach based on a better definition of heritage. fabbricatti et al. city territ archit ( ) : the principles upon which the convention is based are listed in the action plan: -"connection to a community and territory determines a sense of belonging; -social cohesion is founded on various levels of cooperation and commitment; -democracy is practised through the engagement of civil society in dialogue and action, through shared responsibilities based on capacities" (council of europe , p. ). the convention thus marks a definitive passage from the "right of cultural heritage" to the "right to cultural heritage", progressing from a static idea of the "value in itself " of cultural heritage towards a proposition of "relational value", which links in an interactive, dynamic and complex way "people and places through time" (art. b). heritage communities are the testimony and vehicle of local identity values to preserve and transmit to future generations. they are also "cultural" laboratories, drivers of inclusive actions, collaboration at all levels, of heritage-led actions, shared civic responsibility towards cultural heritage. for the purposes of this research, the attributes of a hc can be summed up in: awareness of the value of its cultural heritage resources, sense of belonging, inclusiveness, collaboration at all levels, common interest in heritage-driven actions, shared civic responsibility towards cultural heritage (council of europe ). the research hypothesises that these attributes can support community resilience at different stages of its life (asprone and manfredi ) , and in particular in disaster risk reduction. in this hypothesis, the research develops a conceptual framework in which it defines "heritage community resilience". it represents both an objective and a process in which the community builds, through cultural heritage, its capacity to anticipate and adapt to the challenges and stress factors encountered before, during and after a disaster and/or disruption. in the prevention and protection phase, heritage community resilience is characterized by strength in terms of identity and recognisability, ethics, knowledge; it acts in reducing vulnerabilities through community care and maintenance of cultural heritage; it is also characterized by creative and innovative strategies and policies for disaster risk reduction. in the reaction and recovery/adaptation phases, hcr is characterized by a sense of belonging that is a powerful catalyst for the involvement of the local population; it allows for rapid recovery through income generated in the informal sector and in tourism activities, through creative and innovative cultural adaptation solutions. this new vision of community entrusts a shared responsibility of all the actors towards heritage, implicitly imposing shared policies among institutions, sector experts, national authorities (d' alessandro ). this is a fundamental principle of "cultural democracy" (ibidem, p. ), which transfers responsibility to the same subjects that determine the meaning and value of the patrimonial elements with which they identify. recent global policy frameworks underline that the assumption of cultural heritage in disaster risk reduction requires enlargement and differentiation of the arena of actors, towards innovative partnerships between the heritage sector, on one hand, and the wide range of drr stakeholders, including local governments, humanitarian organizations and the private sector (undrr a). it is underlined also the role of educational and research institutions in supporting the various actors in the different phases (undrr a, art. b). on these bases, this paper aims to identify the critical actors and variables, strategies and governance mechanisms that influence heritage community resilience, in a self-sustaining circuit in which heritage community care actions can reduce the vulnerability of cultural heritage and community, and at the same time increase its capacity to prevent, cope with and recover from disturbances and/or disasters. the research method was a case study survey. the objectives of the survey were to elaborate in greater detail the characteristics of heritage community resilience, to define the effects of the practices for building related heritage community and community resilience processes, identify the critical actors and variables, strategies and governance mechanisms influencing hcr. for these purposes, the research analysed heritage-driven as well as both bottom-up or mixed bottom-up and top-down practices. the method was based on direct surveys, carried out through widely distributed questionnaires and interviews with selected stakeholders. these surveys were conducted through a previous definition of the heritage community resilience indicators that guided the collection and interpretation of data. the research methodology was based on the following steps ( fig. ) : -definition of hcr attributes and indicators, based on sector literature about heritage community and community resilience, and their explanation in the form of questions to answer with "yes", "no", "maybe"; -selection of heritage-driven practices; fabbricatti et al. city territ archit ( ) : -diffusion of the questionnaire, based on the previous indicators, and its submission to the "community" of the practices through mailing list and paper distribution; -selection of the stakeholders involved in the practices and their direct interview; -elaboration of the results, subsequent dissemination and verification. the first phase defining the heritage community resilience attributes and indicators was carried out analysing, in literature, assessment tools of both the issues heritage community and community resilience. regarding the first issue, the faro convention action plan - (council of europe ) defines the attributes of what makes a hc. in particular, the action plan formulates criteria to self-assess, self-monitor and self-evaluate the activities of the faro convention network good practices. these criteria are inspired by values of social inclusion, human rights and community well-being (council of europe ). unlike the heritage community, many scientific studies develop the characteristics of community resilience (maguire and hagan ; cutter et al. ; berkes and ross ; chelleri et al. ; rapaport et al. ; etc.) . some of them develop real evaluation systems (magis ; longstaff et al. ; wilding ; maclean et al. ; etc.) that vary in relation to the objectives and risks faced by the community. to provide a framework for the survey, we started from the six attributes of community resilience proposed by maclean et al. ( ) , previously tested in berkes and ross ( ) . these attributes emerge from a collective research in which the authors analysed a series of communities that successfully adapted to rapid and oftentimes crises-driven changes, deducing the key factors for the success. based on these six attributes, indicators of heritage community resilience were formulated for the construction of a survey questionnaire (fig. ) . in our research, these indicators are able to assess the resilience of a heritage community, so as defined in our conceptual framework, i.e. both an objective and a process in which the community builds, through cultural heritage, its capacity to anticipate and adapt to the challenges and stress factors encountered before, during and after a disaster and/ or disruption. the first attribute concerns "knowledge, skills and learning" defined as "individual and group capacity to respond to local needs and issues" (maclean et al. , p. ) . these can include practical knowledge but also soft skills like management and communication. in our hypothesis, culture can support and consolidate the process of developing this individual and collective capacity (fig. ) . the second attribute is about either "community networks" or the existence of collective activities and projects in which community members participate, thus strengthening the links between themselves and creating common interests. in our hypothesis, the diversification of networks and actors is critical in the construction of social capital. at the same time, cultural associations can play a central role inside and outside the heritage community. the third attribute is called "people-place connections". in order to become more resilient, community members must have a "close connection to their biophysical environment" (ibidem, p. ), which means they can take advantage of their resources, but they also have to stand for their protection and care. in our hypothesis, heritage community resilience combines adaptive capacity with a strong identity and sense of belonging; cultural heritage can sustain this process in creative and innovative ways. the fourth attribute relates to "community infrastructure". inhabitants should have access to a set of services that guarantee their basic needs (water, food, health care, mobility, education, entertainment, etc.). in particular, lifestyles and livelihoods, infrastructure and support services are crucial for the recovery from disturbances and/or disasters (kulig et al. ). in our hypothesis, when measuring this attribute, cultural services as well as tourism services and green infrastructures must be taken into account. the fifth attribute concerns the ability of the community to build a "diversified and innovative economy". it considers that the survival of the community depends not on a single but rather on multiple resources. at the same time, it recognises the need to keep up with changing market needs, as well as change in general, as an opportunity for new and diverse jobs. finally, the last attribute concerns the existence of an "engaged governance" with a "genuine participation from relevant private, public and community sector stakeholders" (maclean et al. , p. ) in problem solving and in decision-making. in our hypothesis, it implies that the governance systems include both all the actors who wish to be involved as well as those who are directly impacted by the decisions. moreover, since one of the characteristics of a heritage community is the commitment to principles of human rights in local development processes, it has been included among the indicators (fig. ) . after a phase of selection of heritage-driven practices, a questionnaire was elaborated, based on the previous indicators, and disseminated to the "community" of each practice. each question was formulated as follows: "do you think the practice contributed to…" and completed by each indicator. three possible answers were offered: "yes", "no" and "maybe". the questionnaire was distributed to about people through a general mailing list and paper distribution in places of aggregation. in addition, during the dissemination of the questionnaire, a series of semi-structured interviews were conducted with the stakeholders. they were representatives of the institutions and the main actors involved in the practices. the interviews lasted between and min, and focused on six main open themes: the origin of the project and the reason of their involvement, the project timeline, the role the interviewee play in the event, the stakeholders with whom the interviewee cooperated, the management of the event, and the results on the territory and on community everyday life. they represented a necessary support for the interpretation of the results obtained through the questionnaire. for the data analysis concerning the questionnaire, the answers were classified according to the five categories of respondents: institutions (also including administration, trade associations, etc.), actors involved in the event management (creators, organizers, designers, artists, volunteers), partners, such as entrepreneurs and traders, residents in the municipality of the event, residents in the region or occasional tourists. the classification was necessary since not all the actors have equal information about the event. the actors involved in the management of the event have a detailed knowledge of its functioning and experience in decision-making systems, while residents and tourists are better able to express themselves on the sustainable improvements generated by the events on the community. for data interpretation, graphs were made that show the contribution of each practice to the six attributes, by category of actor (figs. , and ). a final graph (fig. ) summarizes and compares the results of the three previous tables through a prior weighting of the sample, according to the number of responses contained in each category of actors. the research context is that of the internal european peripheral areas, with particular attention to an area of southern italy: alta irpinia (in the region of campania, italy). this area is composed of municipalities covering . sq.km., with a population of approximately . inhabitants. it was selected as one of the pilot areas of the italian strategy for internal areas (snai), launched in by the italian minister for territorial cohesion with the main aim of reversing demographic trends. in the classification of the strategy, this area is composed by peripheries and ultra-peripheries, defined as areas "very diversified within themselves, far from large agglomeration and service centres and with unstable development trajectories but nevertheless with resources that are lacking in central areas, with demographic problems but also highly polycentric and with strong potential for attraction" (territorial cohesion agency ). this definition tends to overcome the traditional dichotomy between cities and countryside or between mountain and coastal cities, to underline, in accordance with the european definition of peripheral inner areas, "the degree of disconnection of these areas with neighbouring territories and the network, and not (or not only) their geographical position with respect to the centres" (espon ) (fig. ) . the resilience approach for these areas allows to interpret the dynamics of reaction and adaptation to local and global risks (depopulation, reduction of employment and sustainable land use, landscape degradation-caused, in turn, by hydrogeological, seismic, anthropogenic, environmental risk conditions); at the same time, it allows to define factors, endogenous and exogenous, that can influence these dynamics and can enable and facilitate changes. in addition, this approach makes it possible to define the thresholds of the variables that guide these processes, which in contexts for different aspects very vulnerable -built environment with "simple" qualities, collective memory entrusted to an aged population, natural and agricultural landscape unprofitable, etc.-can lead to trade-offs and cause irreversible changes. for the purposes of our research, inner peripheral areas represent an interesting laboratory to investigate the role of heritage communities for community resilience, and more generally to study in greater detail the characteristics of the resilience process, along with the role that the community and institutions can play in it (pike et al. ) . european peripheral areas share a set of common characteristics that are both the cause and result of their remote nature (pezzi and urso ) ; poor access to services of general interest and to job and education opportunities, limited market access of local actors, emigration of skilled people, ageing population with the need of appropriate infrastructures and services, low accessibility in terms of both transport and communication systems (digital divide), high socio-cultural capital linked to peculiar material and immaterial heritage, high air and water quality. in this context, which has been characterised by high state intervention and exclusion from networks and political power in the decision-making process, the issue of governance is crucial (herrschel ; pezzi and urso ). therefore, remoteness generated both the conditions that have determined the ability of these areas to adapt, which today represent the potential conditions for increasing their resilience. european peripheral areas preserve almost intact their material culture (robustness) and have a "latent territorial capacity", also linked to their immaterial culture, that offers high potential for innovation (adaptive capacity) (pinto et al. ) . in this cultural context, in recent years, either bottomup or mixed bottom-up and top-down experiences have been developed and intensified. many of these, starting from the rediscovery of values of local heritage have experimented the creation of opportunities for work, leisure, networking, research, etc. these experiences are carried out by different actors-residents, returnees, new inhabitants, tourists, volunteers, etc.-who have designed from time to time new community formations; at the same time these are characterized by innovative decision-making and management processes and new interactions with traditional institutions (magnaghi ; pinto et al. ). this research analyses three cases of cultural and creative practices in the single territorial context of alta irpinia (in campania, italy). several issues are weakening this area. first of all, the depopulation process: between and , the population decreased by . %, exceeding both the regional ( . %) and the national ( . %) average for non-core areas (elaboration of istat data, istat ). the main cause is the out-migration: people leave the territory to find working opportunities somewhere else. the second weakness, which is connected to the first one, is the ageing of the population. the 'over ' represents about % of the population of the area (istat ). the third main weakness is the erosion of the cultural capital and the territorial identity, which are mainly challenged by external pressures on local resources: the landscape is frequently threatened by wind turbines, oil drilling and landfill projects. the change in agricultural land use represents for the resilience theory a so-called trade-off, caused precisely by the loss of value of agricultural land. the first practice analysed is the sponz festival (fig. ) , which is held every august since , in the municipality of calitri. the artistic direction is provided by the singer and composer vinicio capossela, who works closely with a local association called "sponziamoci" to organize the festival. together with the municipality, they are the main protagonists of the management of the event. their shared objective is to draw attention to this small village while creating community empowerment. they rely on an original reinterpretation of the local intangible cultural heritage, such as rituals, traditions and narratives. in addition, the program is dense and varied with musical concerts, conferences, film screenings, and artistic performances. it is organized in the oldest part of the village, reusing semi-abandoned public spaces. part of the programme takes place in five other municipalities in alta irpinia. the audience is about people per day, with peaks that in reached about , presences at the final concert (growing from ). this is an international audience, even if % of the participants come from the campania region (data provided by the organizers, who each year elaborate a self-assessment). the economic support is provided by local institutions (municipalities and local action groups), but also in a large part by the campania region through european funds. the second case is the translations workshop (fig. ) , which takes place in the municipality of aquilonia. it is an experimentation of a larger project called "e.colonia", which aims to create a training and artisanal district, where designers and makers can work together innovating the local artisan knowledge. the organizing group is composed of local architects and academics, who manage the event together with the local action group (lag), offering financial support. they form groups composed of about people, including local craftsmen, designers, artists and students, who produce prototypes of "rural design" objects in two weeks, inspired by local traditions and skills. the project required the workshop to be annual, so as to create a new artisan network, which could better connect designers to regional traditions, while also opening up new markets for local artisans (fabbricatti ) . however, the lack of political support prevented this from happening. the format, which was probably highly ambitious, clashed with the visions of the municipal administration and with a moment of political redesign of the local action groups in alta irpinia. as a result, an exhibition of the prototypes and conceptual ideas was organized at the end of the event. in addition, several professionals who had met during the event, held in , have continued to collaborate. the third case is the cairano x festival (fig. ) . this is also an annual event, organized every summer since . it takes place in the municipality of cairano, which is one of the smallest in the territory with only inhabitants. the organizers are both the village association (pro loco) and a group of creatives and artists living elsewhere in the province, who create their own association (called "temporary communities" and then "irpinia x"). the objective is to publicize the case of a small village trying to survive by repopulating it for week each year. they also want to reveal the qualities of rural villages, such as air quality, tranquillity and creative inspiration. during this one week, participants can take part in construction workshops, short film and gardening competitions, theatrical performances and activities for children. they can also sleep in the vacant houses of the village. temporary repopulation brings some years around visitors to the village (boissenin , p. ) . the series of cultural events fulfil meet the project of the municipality to restore and enhance its built heritage. the economic support was first sourced by local associations and the municipality with the help of a private sponsor, then sustained by european funds. the event management system here is more informal, most of the decisions are taken during the general meetings of the association "irpinia x", which are moments of conviviality open to both the community and stakeholders. the questionnaire intercepted about people and received responses: for sponz fest, which involves a larger audience; for translations and for cairano x. the "mortality rate" of the questionnaire (about %) can be justified primarily by the type of tools that were adopted for its dissemination (email and paper distribution at aggregation points). moreover, the questionnaire required a commitment in terms of time and concentration, due to the number of questions and their content. the main positive outcome of the festival regards the "people-place connection" (fig. ) . the respondents were particularly unanimous about the ability of the event to reuse places and buildings ( % replied yes) and about its contribution to initiate a broader vision of cultural heritage ( % replied yes), including the oral traditions. the opinions about the "community infrastructure" attribute are more divided. we still obtained % of "yes" for the improvement of cultural services and % for the touristic ones. the interviews made it possible to understand that the indecision was due to the fact that the positive results linked to the event are temporary and the residents are deprived of these services for the rest of the year. a slight majority of "no" votes prevailed for the indicator about transport services. however, the interviews shed a larger perspective: sponz fest was a strong supporter of the local association which has managed to reopen the avellino-rocchetta railway line (suspended a few years before due to the lack of users and maintenance). every year during the festival, a train service was implemented to take participants from other villages to boissenin ( ) the event, and that contributed to highlighting how the railway line has a touristic potential. better results were achieved for the "knowledge, skills and learning" attribute, with a large majority of "yes" ( %) being given by the actors involved in the event organisation. the festival provides significant experience for the volunteers in team management, public reception, communication, both in terms of skills acquired and curricular experience. the sponz fest seems to help build a "diverse and innovative economy" increasing the cultural sector. half of the respondents believe that the event has reinforced the tendency to develop heritage-led projects, although they question the capacity of these projects to generate new and innovative job opportunities. finally, we noticed the strengthening of "community networks" and the building of an "engaged governance". a diversity of stakeholders were involved, with the participation of six municipalities to the event-which is rare in alta irpinia. the organisers, institutions and partners agreed that all the relevant actors were present and played their part in setting up sponz fest, with respectively , and % of the votes. according to the answers of the questionnaire, the main positive outcome of the translations workshop was the enhancement of "knowledge, skills and learning" of the involved actors: % of the institutions, organisers and participants, and residents said "yes" (fig. ) . the on the contrary, the event seemed particularly powerless in relation to the improving of "community infrastructure" with a majority of "no" for of the indicators. the workshop is part of a larger project to reuse the ancient abandoned area of the village of aquilonia as a design academy. the project for political and financial reasons has yet to be realized. it would have represented an important cultural infrastructure. this result leads to the issue of "engaged governance". the stakeholders seemed unanimous about the collaborative approach of the event (from % for tourists to % for the institutions and residents) and generally agreed on its capacity to involve all the relevant actors (from % for the partners to % for the organizers), but the interviews revealed a more mixed view: the involved actors were mainly from the private sector and we could also notice the reluctance of the municipality of aquilonia, which led the project promoters to seek the support of other institutions, such as local action groups. the results of the survey about the cairano x festival (fig. ) were elaborated considering all the interviewees as a single category of actors, due to the small number of answers obtained from the questionnaire ( ). like sponz festival, the interviewed actors particularly agreed on the ability of the cairano x to reuse the abandoned houses. we have to precise that the cultural practice met with the plan of the municipality to restore its built heritage, a theatre school and new services were created in some abandoned buildings. this nevertheless, the respondents found it difficult to assess the ability of cairano x to generate a "diverse and innovative economy" ( % replied "maybe"). the interviews helped to note that the opening of the theatre academy brings new career opportunities for the young people from the area; they have access to an education program that did not exist before. when it comes to the existence of an "engaged governance", % of the respondents agreed on the collaborative approach of the event. however, we need to report some conflicts between the external actors (irpinia x association) and inhabitants, along with their own cultural committee (pro loco). only after a few editions, the inhabitants realized the particular value of their village, but they did not agree with the way it was valued, with the activities responding more to the expectations of tourists than to their own. so, they decided to separate from the first association and create their own events. this conflict allowed the locals to move from a passive behaviour to an active construction of a cultural offer that corresponded to their interests and expectations. the cultural and creative practices examined have in common the strengthening of "people-place connection" (fig. ) . moreover, the respondents particularly agreed on the attribute of "knowledge, skills and learning" for the ability of the practices to develop educational actions and to enable dissemination of culture ( % on average over the three events). on the contrary, no real impact was noted on "community infrastructures", with a majority of "no" answers, in particular regarding the mobility infrastructure ( %) and social or health services ( %). only the cultural infrastructures seemed to be improved in two of the three cases, but most were activated occasionally. then, respondents were not able to express themselves on the capacity of the events to generate "diverse and innovative economy": a majority of "maybe" prevails, caused above all by the seasonality of the events. a similar situation arises for the indicators related to "community networks". the responses still converge on the capacity to strengthen existing networks ( %). with the help of the interviews, we know that the three practices did not generate new associations but better articulated the existing ones. finally, the apparent consensus on the existence of an "engaged governance" needs to be revisited. for cairano x, a "maybe" majority wins for of the indicators, while all three indicators are green for sponz fest and translations: "development of a collaborative approach to event management" even reaches % of "yes" on average over the three practices. the interviews revealed a more mixed picture. while some of the institutions seemed willing to cooperate, others were still very reluctant to engage with the community-a situation shared by the different case studies. the cross-reference of the results highlights some useful topics for discussion. first, the indicators developed proved effective for the survey and provided a complex view of not only community resilience, but also the contribution that the heritage community concept can make in its pursuit. concerning the effects of the practices examined on building heritage community resilience, the results of the survey demonstrate that a hc is actually emerging in irpinia, but that the road to building a more resilient community is still long. the practices initiated the community towards a process of acquisition and/or consolidation of knowledge, competence and awareness of its biophysical environment and the care it requires. moreover, thanks to their involvement in heritage-led practices, the inhabitants discovered that cultural heritage can be a source to build new and creative job opportunities. the examined practices suggested new approaches (innovation of craft knowledge, creation of educational centres, etc.) that diversify the solutions traditionally foreseen for the relaunch of these territories (such as tourism, industrial settlement, etc.), and encourage new economies (sponzfest), start-ups (translation) and cooperative businesses (cairano x). in addition, through the involvement of different actors and community networks, the practices gave the opportunity to address actions towards building community infrastructures (the reopening of the avellino-rocchetta railway line for tourism purposes, the rediscovery of old transhumance routes and green infrastructures, enhancement of cultural and tourist services, of digital technologies, etc.). with regard to engaged governance, a good cooperation between different types of actors was noted, as well as the participation of a wide and differentiated range of actors. moreover, some institutions showed a good ability to cooperate in the general interest (sponz fest together with six municipalities). however, the poor propensity of some local administrations to engage in a more democratic approach and in vertical collaboration persisted (translations workshop), as did the existence of conflictual situations between residents and non-residents, due to different interests (cairano x) or to the reluctance of some inhabitants to an innovative approach. it is also necessary to underline data from the interviews that the indicators did not reveal. the administration of the municipality of calitri highlighted that following the sponzfest sales of properties for holiday homes of italian and foreign visitors were recorded in the historic centre. in addition, to support the survey, quantitative data were collected for some sample indicators. analyzing the requests for building maintenance and rehabilitation in the municipalities examined, the data show a slight increase since . although in these municipalities of a few inhabitants, the numbers of requests are low, the data show a constant trend, particularly positive in the municipality of calitri, which from shows an almost exponential growth. this data can be referred both to the indicator "development of actions for the care of cultural heritage" of the "people-place connection" attribute, as well as to the "development of interest in heritage-led actions" related to the "diverse and innovative economy" attribute. the latter was also verified by collecting data on the number of the employed population (between and years of age). they are not easy to interpret because of the multiple economic categories they include. starting from , in fact, calitri records a negative trend ( . % in ; . % in ), while a positive trend is recorded in the municipalities of aquilonia ( . % in ; . % in ) and cairano ( . % in ; . % in ) (istat ; infodata ). direct surveys show, however, for calitri as well as aquilonia the creation of some new and innovative jobs, which also reveal synergies between inhabitants of different municipalities. a further survey, through archival data, concerned the number of accommodation facilities, the relative number of stay, and the presence in tourist offices (pro-loco) outside the week or period of the events, which can be referred to the attribute of "community infrastructure". also in this case, since there is a positive trend for calitri. aquilonia and cairano shows a constant trend during the year, that in august sees the population double for the return of natives living abroad, and peak in the days of the festival. finally, data on the trend of the real estate market since show an irregular performance with maximum house sales values that remain constant in the municipalities of calitri and aquilonia (https ://www.agenz iaent rate.gov.it). it is useful to underline that this last data excludes, or reduces, the risk of trade-offs, such as the cases of gentrification, that some authors detect by analysing the dynamics of cultural and creative processes (duxbury and campbell ; kebir and crevoisier ; mitchell and de waal ) other types of trade-offs are pointed out by some authors such as: the risk that the commodification of certain components within the culture could turn a community into 'a folkloric spectacle' , contributing to the destruction of the very image of rural heritage and to the reproduction of a 'leisure-scape' (mitchell and de waal ) ; the possibility that certain temporary events can create a gap in the economic and political situation by interrupting the regularity of a virtuous circuit established between the social, economic and political components during the year. to avoid these risks, it is recommended to monitor data over a longer period of time and, as pointed out by evans ( ) , to evaluate the sustainability and distributive equity of cultural and creative practices "seeking better engagement/consultation with local communities to improve ownership of the (cultural) project and (local) benefits" (dcms , p. ) . starting from these findings, it is possible to identify some elements that could positively influence heritage community and community resilience, in a self-sustaining circuit. a plurality of actors and competences has proved to be a fertile element for all practices. the involvement of the local community, internal and external organizers, of external people who had never before visited those places, of both local and external heritage experts was observed in each practice. in this process, the encountering of these different actors helped the unveiling, decoding and enhancing of values to be attributed to cultural heritage, triggering a virtuous circuit of awareness and care. building a shared project between the inhabitants and their elected representatives is strategic to achieving cr. cultural heritage plays its role as a "federation" in each of the three case studies. several actors put aside their reticence and personal interests to contribute to a project of collective interest. by learning to work together, many actors begun to rebuild relationships, which are essential for cr. heritage thus has become a dimension that 'unites' and allows for the fertile confrontation among multiple identities. it also allows to highlight the skills and talents of the community, mediating among different points of view and interests, in a perspective of common interest (fusco girard et al. ) . building a proactive and responsible role of the inhabitants supports community resilience. from the interviews, we learned that after the event people usually try to continue working on other cultural and creative practices or initiatives. since the early s and the spread of a cultural movement in irpinia (boissenin , p. ), a succession of cultural practices have led to a growing proportion of local people and new inhabitants becoming active. the community raised its voice, gradually forcing the institutions to take its demands into account. the relationship that exists between the community and place becomes, in turn, a prerequisite for its care and conservation, with direct effects on the reduction of the physical and social vulnerability of the territory. recognition of a complementarity between community and institutions is useful for the success of heritage-led practices, and for the objective of heritage community resilience. the positive results achieved in the objectives of heritage community and community resilience were made possible due to one category of actors taking a step towards the other. the events happened because the creative and management skills of the community met the ability of the institutions to have access to sources of funding and networking. in the case of the translations workshop, precisely the lack of support from the administration was one of the main reasons for its short duration. this paper explored the issue of community resilience with the objective of helping to reduce emerging gaps between theory and practice (stumpp ) and at the same time enrich the debate on the contribution of cultural heritage to cr. the paper elaborates a conceptual framework from which to define the perspective of heritage community resilience. this original concept, described in the paper through indicators, can act both as a new target and a process in which cultural heritage supports the building of a community able to prevent, cope with and recover from disturbances. in an evolutionary vision of resilience, culture and cultural heritage can be the key to citizen engagement (idea of common good), as well as to social, environmental, economic and governance innovation. through a survey of several heritage-driven case studies, either bottom-up or mixed bottom-up and top-down, based on direct analysis tools, the research tests the heritage community resilience indicators and highlights the characteristics and potential of the concept. the research context is that of italian inner peripheral areas, proved to be an interesting laboratory for the crucial challenges facing these territories. the practices analysed demonstrate that although a heritage community is actually emerging in alta irpinia, and despite the relevance of the issue in these areas, there is a lack of strategies and operational tools aimed at community resilience. from the lessons learned from the case studies, the concept of heritage community resilience imposes shared policies among institutions, residents, sector experts, entrepreneurship, researchers, facilitators, and humanitarian organizations, requiring to equip themselves with participatory management tools and defining a shared framework of governance of cultural policies. in this regard, the further perspectives of this study are to understand the relationship between hcr and community based disaster risk management (cbdrm). it is a process in which at-risk communities are actively engaged in the identification, analysis, treatment, monitoring and evaluation of disaster risks, contributing to the reduction of their vulnerabilities and the improvement of their capacities (adpc ; abarquez and zubair ) . in this direction, a contribution could emerge from the definition of heritage community (council of europe art. b). it implies collaborative actions of care and maintenance of cultural heritage, affecting both its vulnerability and that of the community. this can trigger a virtuous circuit in which actions on cultural heritage strengthen community cohesion, reduce urban degradation, start urban regeneration actions and employment opportunities. the process for heritage community resilience thus becomes a circular path (fusco girard et al. ; de medici et al. 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institutional affiliations diarc, univ. of naples; idex univ. grenoble alpes/labex ae&cc. department of architecture diarc , university of naples "federico ii", via tarsia , naples, italy. labex architecture, environment and building cultures, grenoble school of architecture, univ. grenoble alpes, avenue de constantine, grenoble, france. act antropologia cultura territorio, via festo avieno , rome, italy.received: june accepted: october each author has made substantial contributions to the conception and design of the work; or the acquisition, analysis, or interpretation of data; or the drafting of the work or its revision; and has approved the submitted version; and agrees to be personally accountable for the author's own contributions and for ensuring that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved and documented in the literature. kf: literature review, conceptualization, methodology, discussion, conclusions; lb: data curation, findings, writing-original draft preparation; mc: literature review, investigation, writing-reviewing and editing. all authors read and approved the final manuscript. not applicable. the datasets used during the current study are available from the corresponding author on reasonable request. the authors declare that they have no competing interests. key: cord- -g hx xa authors: miller, elaine title: dealing with uncertainty: lessons learned from covid- date: - - journal: pain manag nurs doi: . /j.pmn. . . sha: doc_id: cord_uid: g hx xa nan the covid pandemic turned our world upside down and altered routines and priorities. we took many things for granted and now suddenly faced a new situation that changed how we performed customary activities such as going to the grocery store, going to work, keeping scheduled doctors' visits, going to the dentist, and socializing with family, colleagues and friends. framed within this new set of circumstances have been increased stress, anxieties, and for some, loss of family, friends, income, and home. on the other hand, several positives have emerged such as the expanded use of telemedicine and many of us becoming more adept in using technology to participate in online school activities, church services, work related and civic meetings, and family events. as a result of social isolation, altered connectivity, and disruption of normalcy, we now have greater insights into how the lives and circumstances of individuals with chronic or acute pain may be temporarily or permanently altered. even in normal circumstances, chronic pain management affects over million us adults (iom ), is the most frequent reason individuals seek healthcare, and is challenging to treat even in the best of circumstances (daubresse et al., ) . although there are many factors to consider as we provide care during disaster or emergency situations, several critical elements must remain in the forefront of our thinking: • in large scale disasters or emergency situations, whether natural (e.g., pandemic, hurricanes), environmental (e.g., deepwater horizon oil spill) or traumatic (e.g., mass shootings, world trade center attack), there are increases in depression, loneliness, anxiety, posttraumatic stress disorders, substance abuse, along with behavioral disorders such as child abuse and domestic violence (neria, nandi, & galea, ; galea, merchany, & lurie, ) . unfortunately, the impact of these events often affects mental health in the short-term and general quality of life in the long-term (galea, merchany, & lurie, ) . as a result, mechanisms must be put in place to address the signs/symptoms of mental health disorders while monitoring the successes of our interventions. • during the covid pandemic, numerous individuals experienced difficulties obtaining the necessary resources to survive such as prescribed and over-the-counter medications, supplies and food. for those with limited transportation, economic hardships, and reduced social support systems, there were even greater difficulties obtaining basic necessities. these sudden new challenges contributed to the deterioration of the physical, mental and pain status of individuals experiencing pain. • another stressor exhibited by many was fear of seeking professional care and if admitted to a facility, of being isolated from family and friends. as we look to the future of similar situations, how can we creatively address these concerns? • research further indicates that community dwelling adults with more severe or poorly managed pain often have impaired attention capacity, diminished decision-making capabilities and memory impairment (nadar, jasem, & manee, ; van der leeuw, eggermont, shi, millerg, gross et al. ) . in conditions such as a pandemic or other disaster/emergency situations, consistently monitoring these individuals and finding ways to provide care are critical. what have we learned that will help clients experiencing pain survive pandemics or other disaster or emergency situations? it is evident that planning for potential disaster/emergency situations is essential. moreover, planning is critical for persons with chronic and disabling conditions including pain, mobility, sensory, or cognitive issues (barth, ; owens, stidham, & owens, ; fema, · disaster and emergency supplies must be ready and in one place prior to an actual disaster or emergency. supplies should last at least days and be placed in easy to carry containers (e.g., backpack) with id tags displaying name and contact information. label all equipment such as wheelchairs, canes, walkers with the client's name, address, phone number and significant others. make sure the disaster kit is up-to-date, and review contents every months. it is vital that individuals have disaster or emergency plans, escape routes, and designated meeting places. in addition, it is important to keep in the forefront how vision, hearing, mobility, and cognitive or emotional impairments may affect preparation and outcomes. families should have their own communication plans and carry information in their wallets, listing out-of-town contact persons as a main contact, and these out-of-town contact persons must be aware of these plans. keep emergency contact numbers near the telephone or in phone number listings, make plans for those with disabilities, as well as for pets or service animals. know what the community warning system is for disaster or emergencies and what services are offered. determine if smart is available in your community and sign up so emergency responders are aware of the clients' location and specific needs. for more information about the types of disaster or emergencies (e.g., hurricanes, earthquakes, tornadoes, floods, chemical spills) possible in your community, visit www.ready.gov (http://www.ready.gov) or call -be-ready. once this information is obtained, it is essential to adapt this information to an individual's personal circumstances and make every effort to follow instructions given by local authorities. adults with disabilities should know the community warning system and how residents are to be notified of a potential disaster or emergency situation. disaster and/or emergencies situations are never ending. in , there have already been disaster declarations made by fema ( ). it is imperative that we are prepared for the next disaster and work with our clients to take action now. meeting the needs of people with physical disabilities in crisis settings ambulatory diagnosis and treatment of nonmalignant pain in the united states fema disaster declarations preparing for disaster for people with disabilities and other special needs the mental health consequences of covid- and physical distancing: the need for prevention and early intervention relieving pain in america: a blueprint for transforming prevention, care, education and research the cognitive functions in adults with chronic pain: a comparative study post-traumatic stress disorder following disasters: systematic review disaster evacuation for persons with special needs: a content analysis of information on youtube pain and cognitive function among older adults living in the community preparedness for natural disasters among older us adults: a nationwide survey key: cord- -ftkoxzz authors: grossman, valerie aarne title: catastrophe in radiology: considerations beyond common emergencies date: - - journal: j radiol nurs doi: . /j.jradnu. . . sha: doc_id: cord_uid: ftkoxzz abstract disasters often occur without warning and have the potential to affect large numbers of people. those in the radiology environment experience unique effects on them, their equipment, and their ability to provide quality patient care. lessons can be learned by reviewing events and their impact on imaging departments around the world. radiology departments need to be actively involved in the disaster planning and the management of disasters when they occur. common themes emerge regardless of the type of disaster and these themes should be included in all planning. organizations around the world, increasingly prepare for the "what ifs" of our environments. regulating and certifying agencies mandate organizational plans for threat management to include risk factor identification, threat mitigation, prevention (when possible), response to, and recovery from the event. the world health organization (who) estimates that natural disasters kill approximately , people annually and affect an additional million people worldwide (who, ; who, ) . the disaster recovery reform act of developed improvements to the federal emergency management agency (fema) by establishing a clearer framework for disaster management in both the preparation for and response to each event; pre-staging now occurs with incident command centers, resource mobilization, and search/recovery teams on standby, ready to act (fema, ; reynolds & knox, ) . the joint commission continually updates their expectations for organizations, uses information obtained through their post disaster organizational debriefing, and supports organizations by providing informational resources (joint commission, ) . the occupational safety and health administration (osha) provides a number of resources to assist organizations in the creation of their individual disaster management plans (osha, ) . in , a policy directive was developed to deal with all natural and manmade disasters, which evolved into the hartford consensus that addresses the loss of life and has a chief principle that no one should die from uncontrolled bleeding (jacobs, burns, pons, & gestring, ) . while disasters of every kind have occurred throughout history, the number and severity continue to increase. society demands to be kept safer … demands that are at times, difficult to achieve. even with an ever-increasing amount of information available and regulations to comply with, radiology departments are still often excluded from a hospital's disaster management plan and drills. it often isn't until an organization experiences a catastrophic event that the catastrophes in radiology identification of a plan for radiology's role during a disaster, comes to mind. regardless of the event type, radiology will be affected in some manner. while no amount of preplanning can fully prepare any organization for the unpredictability of a catastrophic event, having a plan in place will provide for better response and care during any mass casualty incident (mci), regardless of the type of catastrophe. many radiology departments are now creating their own disaster management plan within their department: while the hospital may have an organizational plan, individual departments should be aware of the role they will need to play when a catastrophe occurs (dargan, ; haygood, ) . anecdotal reports from events around the world are valuable to consider when creating an organization's disaster response plan. firsthand lessons learned by others should be considered when organizations create their own disaster management plan, inclusive of considerations for the imaging departments. whether external or internal in origin, many similar considerations apply to nearly all mci events. while catastrophic events may vary in type, length, recovery time, number of victims/relief workers, and a host of other important details, radiology departments should consider all types and create disaster plans accordingly. redundancy and back up plans are essential to also have in place, as established disaster plans do at times, fail (dargan, ) the following chart lists types of disasters which could be catastrophic to any healthcare facility, its imaging department including some historical examples. (insert table (schoeberl, ; snair, ; berger, ; sen, ; cdc, b; flammarion, : richmond enquirer, torok, ; goodwin veenema, ; trevisanato, ; grojec, ; opcw, n.d.; sutherland, ; haygood, ; aarne grossman, ) hospitals are seen as part of the solution to any catastrophic event in the community, however, hospitals can also be the problematic during mass casualty incidents (mci) as people often flock to a local hospital to seek safety and to look for loved ones, which creates additional issues for the healthcare team. the who describes an mci as any event that results in a greater number of people seeking assistance and support than what a local system can provide (who ) . mcis are usually a sudden and dramatic event that cause a surge in patients or a change in normal business. whether an act of violence or a natural disaster, the healthcare community must have an action plan that can be immediately implemented to provide safety and recovery to all people affected. healthcare personnel by nature, are dedicated to responding to any event they are faced with: it is this dedication that drives them to figure out a back-up plan when the original disaster plan doesn't or can't work. the who outlines guiding principles which all disaster management plans should incorporate. clear lines of responsibility should define roles, responsibilities and assigned activities to all dealing with the event. the plan should have scalability and be flexible to meet the needs of any mci which could occur. it should address whole health and be prepared to deal with: injuries and death, environmental issues (water, sanitation, housing, food, transportation), disease management (communicable and non-communicable), health care delivery, and mental health services. the evidence based plans should include case reviews of historical events and consider lessons learned from past events worldwide when developing their own plan. all plans must be multisectoral in order to be successful, with the inclusion of different organizations which will need to work together in a professional manner. these will often include but not be limited to: communication providers, transportation, law enforcement, security forces, military, water/sanitation departments, social services, health care providers, emergency service personnel, local industry/businesses, and emergency response teams (red cross, governmental agencies, etc.) (who, ) . it is essential for organizations and communities to drill repeatedly, looking for potential flaws in any disaster management response plan (haygood, ) these acts can be difficult to predict or understand. the goals of these individuals who intentionally inflict harm and fear towards others are usually intended to impact the greatest number of victims possible. sometimes, the goal is more about maximum disruption (hysteria) than maximum damage (injury, death, environmental destruction). the aggressor(s) may be a single individual, a small group of people, "homegrown" violent extremists, international terrorist groups, or transnational criminals. (breslin, ; williams, ) . the purpose of their destructive actions may be based on perceptions and beliefs and can be quite difficult for others to understand and explain. these could include beliefs or goals such as: unfairness in social, racial, economic or political arenas; spiritual or religious ideology; personal revenge towards another person or group; a statement in support of or against a person, group, nation, ideological; some may have a mental illness however, there is no clear proof that all people who commit aggressive acts towards others, are mentally ill. (gotzsche-astrup & lindekilde, ). when a violent act occurs, initial response focuses on neutralizing the threat and minimizing any additional damage. this is most successful when responding services have preplanned and carried out robust, ongoing training and practice drills. partnerships must be formed and maintained between all agencies that may be involved. ongoing monitoring of activity that may appear suspicious can pre-empt some attacks. it is difficult to smuggle bombs into a country or to transport them, so some terror groups are sending their bomb making recipes to home grown terrorists in locations where an attack is scheduled to occur, and the bomb can be crafted close to where the attack will occur. to help combat this, the new york city metropolitan transportation authority's security awareness campaign introduced "if you see something, say something" in , as a method to be able to report suspicious behavior or packages. in , the department of homeland security expanded this to be a nationwide campaign. (dhs, n.d.) in , a terrorist drove a truck into a crowd of people in nice, france. people died, were injured, and people received care at local hospitals. challenges included being able to properly identify patients as many were unconscious or did not speak french. one hospital that normally performed ct scans during an average night, performed ct scans on patients in hours. (dargan, ; amoretti, ) mass shootings: these events can occur anywhere, at any time. mass shooting events externally to a hospital can result in a surge of injured patients coming to a hospital. shooting events which happen inside of a hospital pose their own risks for a number of reasons. a person can plan their assault within a hospital by conducting surveillance ahead of the event, planning entrance and exits, identifying departments or offices to target, and studying the habits of security and other staff. hospitals are open to the public, and the aggressor optimizes the sudden chaos and fear to their own advantage. staff may be confused between saving themselves, or someone near them. some key facts about shooting events and hospitals include: ♦ active shooting events often begin spontaneously and end quickly (average is less than minutes) ♦ since over healthcare facility related shootings in the us with % occurring inside of hospitals and % occurring outside of buildings on hospital property ♦ hospitals are high stress environments where individuals may have weakened coping skills, experience fear, aggression, anger and seek retaliation ♦ there are large concentrations of potential victims ♦ % of healthcare facility-based shootings occur before police arrive ♦ smaller hospitals may be more vulnerable due to easier maneuverability, less security, (blair, ; schwerin, ; bjelopera, ; borchers, ) to be best prepared in the event of a mass shooting, disaster plans must include threat assessment and frequent training and drills. each department, including radiology, should have their own threat assessment conducted including a map of the department, location of staff, patients, and visitors. staff should be inserviced on policies, procedures, methods of communication, and behaviors that can preserve lives during such an emergency. staff may be trained in the following for use during an active shooter event: ♦ run (escape route, leave belongings behind, save self not others) ♦ hide (out of shooter's view, block/lock the door, silence electronics, turn off lights) • while waiting for help to arrive, administer first aid to those who are hurt (jacobs, ) in las vegas, nevada experienced a mass shooting that killed people, injured people ( of them sustaining gunshot wounds). the shooter was positioned on the nd floor of a nearby building, fired , + rounds in less than minutes into a crowd of , concert attendees. many victims self-transported to area hospitals, "carloads" of gunshot wound victims appeared at unsuspecting hospitals. ♦ most victims were cared for at three of the over hospitals in the area ♦ a national shortage of intravenous (iv) fluids complicated the care of the patients: it is estimated that + intravenous lines were started that night and supplies of iv fluids ran short ♦ it is estimated that ~ units of blood components were transfused in the first hours post incident. (lozada, ) in at the fairfield air force base hospital in spokane, washington a mass shooting event killed people and wounded . one of those wounded was months pregnant and miscarried a day after the shooting. ♦ the shooter was a former airman who was diagnosed with schizophrenia and recommended for military discharge by two psychiatrists. these two physicians were among those murdered by the shooter. after killing two psychiatrists, the gunman walked through the facility, firing randomly until he exited the building. theft of radiopharmaceuticals may occur for use in making "dirty bombs" (radiological dispersion device = rdd). these would typically result in "weapons of mass disruption" instead of "weapons of mass destruction". victims of a dirty bomb may have radioactive shrapnel embedded in their bodies, respiratory injury from inhaled radioactive dust, or wounds with radioactive contamination but not likely have injury or illness directly related to the exposure to radiation. these attacks could occur inside of a hospital or in a community with the contaminated injured patients transferred to the hospital. blast related injuries are meant to cause massive injury to a large number of people with the most common injuries including blunt, penetrating, burn, amputation, and emotional trauma. the most common injury locations include: brain, ear, eye, lung, cardiac, abdominal, limbs in , the boston marathon bombing occurred when pressure cookers, packed with shrapnel (nails, metal pellets, etc.), exploded, killing and injuring + people. of the patients were treated at hospitals (patients were cared for by a total of hospitals). hospital emergency response teams were immediately alerted, outpatient schedules were cleared, and additional radiology teams were called in to work. ct scans and x-rays were able to quickly identify the scope of injuries caused by the shrapnel contained in the explosive devices (ready.gov, ; goodwin, ; singh, goralnick, velmahos, biddinger, gates & sodickson, ) cyber attacks: cyber-attacks can happen to individuals, businesses, governments, and hospitals. fraudulent access enters a computer system with goals to steal, dismantle, alter, extort, or take part in other criminal activity. these actions can be conducted by one individual or from an international criminal enterprise in , a ransomware attack occurred at the erie county medical center (ecmc) in buffalo, ny. it locked down , computers by encrypting files, and severely affected the bed hospital and bed nursing home. ecmc did not pay the $ , + ransom, however, it did spend $ million to recover from the attack. the hospital was forced to revert to paper charting for weeks while they recovered from this event. earthquakes can occur suddenly and without warning. those who live in earthquake prone zones, know that damage occurs quickly to infrastructure, buildings, and equipment. to minimize personal injury, it is important for people to get low to the ground, cover the head and neck, and avoid windows, doorways, falling furniture/equipment. imaging departments in elevators were inoperable. during the first hours post initial earthquake, only portable x-rays and ultrasound imaging were available to the ed patients. without generator power available, radiologists relied on flashlights and headlamps for light. nuclear medicine department received no damage, computed tomography was up after the initial hours. while this hospital was built with seismic upgrades, geotechnical failures did occur and lead to widespread damage to the hospital (walls/ceilings/floors cracked, tunnels flooded, damage to the roof/boiler stack/medical equipment, etc.). (gregan, ; mitrani-reiser, kirsch, jacques, giovinazzi, mcintosh, & wilson, ; haygood, ) hurricanes/tornadoes/flooding: powerful and at times, unpredictable storm systems which can include strong winds, heavy rainfall, storm surges, rip currents, flooding, and landslides. most areas have emergency communications and alerts which should be listened to carefully and directions followed. emergency crews will be mobilized, emergency supplies will be on standby (ready to infiltrate the disaster area), and individuals as well as businesses will make necessary arrangements and preparations (reynolds, ) . hospitals can be best prepared by: ♦ frequent training drills that are comprehensive ♦ ensuring a - day supply of emergency power, water, medication, food, linen, and other essential supplies ♦ the more emergency power a hospital has available, the more successful they can be during a catastrophic event ♦ hospitals located near known threats, should be built to expect the worst (flooding, earthquake, tornadoes, etc.). this includes: special windows that protect against flying debris (withstand up to mph); underground wiring to guard against power outages with different wiring pathways; a reinforced roof, safe interior rooms to protect against wind, rain, and flooding; watertight barrier storm doors; and equipment with extra battery backup (ventilators, bassinets, specialty equipment, etc.) (lallanilla, a) (hayes, ) when a severe storm system attacks a hospital, care consideration and planning must occur that includes care of those within the structure (food, safe shelter, medical care) as well evacuation. care of the equipment should be considered as loss of electrical power, flooding, or wind damage can severely damage equipment and hinder the ability to care for patients. tornado prone areas may have sirens that alert the community of an approaching tornado. other indications of an approaching tornado include: a dark or green colored sky; large, dark, low-lying cloud; large hail; or loud roar that sounds like a freight train. not all tornadoes will present with the characteristic funnel cloud. danger exists from extremely high winds, flying debris, falling objects, etc. people should seek protection during a tornado, including: underground shelter, interior part of a basement or the lowest floor of a building away from windows and doorways. it is never safe to stay in a mobile home, car, bus, long-span building (i.e. mall). regardless of the type of weather event, flooding is a potential danger. fast flowing water or standing water, pose a dangerous risk. flood waters commonly test positive for waterborne and/or sewage contamination including: (haygood, ; lallanilla, b; schubert & busciolano, ; grossman, ) mudslide/landslide/avalanche: these disasters can occur without warning and create a sudden loosening of earth from a mountain side, that travels quickly down the slopes. there is great danger to structures in the path of this disaster as the moving landslide carries with it any structure in its path, which increases the danger to those below. roads can be disrupted which increase danger to motorists, emergency vehicles, and may hinder evacuation routes (cdc, ). victims suffer from crush injuries from rock, soil, mud, snow, ice and debris (trees, cars, etc.). drowning can occur from swift moving flood waters. many victims also sustain ocular injuries due to infiltration of mud into the eyes, and must be treated emergently to limit traumatic blindness. in a sudden, heavy downpour resulted in a mudslide in leh, india sending mud, rocks, and boulders cascading down the barren mountains to the communities below. the closest hospital became inoperable due to overwhelming sludge and flooding. this disaster occurs as a result of a series of enormous waves (known as seismic sea waves) caused by displaced water following underwater earthquakes, volcanic eruptions, landslides, or meteorite. tsunamis are not preventable nor entirely predictable other than a few warning signs that may include: ♦ the ocean may appear to be "boiling" as large quantities of gas bubble up from far below the ocean surface ♦ the ocean water may smell of rotten eggs, be hot, and/or sting the skin ♦ a loud thunder boom may be heard, followed by a roar or whistle ♦ the ocean shoreline may recede a large distance from the coastline ♦ the horizon may appear red in color ♦ animals often are seen running to higher ground in advance of the receding water line tsunami damage is often catastrophic in nature as powerful waves destroy structures in its path, injure or kill living beings, destroy basic infrastructure (transportation, communication, public water/sewage, etc.), cause widespread chemical contamination and debris to be washed over land. resulting health risks occur from contaminated water, destruction of safe housing, food supply, healthcare services, etc. there is a usually a high death toll from drowning, resulting in fewer victims seeking emergency health care. in , the great east japan earthquake (magnitude . ) and resulting tsunami caused the evacuation of , people claimed the lives of over , people ( % of those deaths were from drowning), , + people missing, damaged over , structures, and cost over $ billion in damages. (mccurry, ; ehara, ; fuse, ; goodwin veenema, ; nohara, ; oskin, ) volcanoes: volcanoes are an opening in the earth that allows molten rock, gases, and debris to erupt and flow across land at up to mph. volcanic ash can travel hundreds of miles and cause respiratory difficulties, skin/eye/nose/throat irritation for all living beings. volcanic activity can be monitored, and be somewhat predictable however, they are also quite unpredictable. areas that would be affected by a volcanic eruption have emergency alert systems that announce instructions for those in danger. volcanic eruptions can additionally cause flooding, mudslides, and loss of infrastructure (roads, power, communication, clean water, etc.) . common injuries and diseases include multiple trauma, burns, infectious disease, respiratory compromise/suffocation, ocular injuries, etc. in , the nevado del ruiz volcano erupted in south america. the enormous lahar of molten lava and mudslides buried the small town of armero, killing , people (the deadliest lahar in history). the entire town was submerged in lava and mud. all buildings and infrastructure were completely destroyed, and the town was eventually declared a 'national cemetery' ♦ for those few who were able to be rescued, they suffered abrasive burns and other injuries from the caustic substances mixed in with the mud ♦ the loss from this disaster included schools, hospitals (including all equipment), roads, railroad tracks, bridges, water/sewer systems, pipelines, , acres of farmland and livestock. (nrc, ; cdc, ) wildfires: wildfires are often fast moving and unpredictable. a raging fire can travel . mph through a forest, mph in open fields, and these speeds can be higher if there is an upward slope involved (siegel, ) . those areas in the danger zone, should heed evacuation orders, ♦ due to the high cost of repairs, the hospital was closed and + employees laid off. (sutherland, ; gabbert, ) preparing for the "what ifs" and the "worst case scenarios" in our world can be very difficult. disasters are difficult to anticipate and properly plan for perfectly. by listening to the experts in the field of disaster management and learning from those who have lived through catastrophes, we can better evaluate our own environment and strengthen the disaster management plan that we create. community services, emergency response organizations, industries, businesses, and governmental agencies must work together when responding to a crisis in a community. intelligence and law enforcement agencies must work together with effective communication and role delineation. during the initial event and response, competition should be set to the side and the focus placed on the safety of all members of the community. from a review of case studies looking at disasters that have occurred, there is a repeated recommendation to have a "back up plan" in case the original disaster management plan fails. (reynolds, ) each healthcare organization must have an individualized plan that is fitting of the facility, the size, the patient populations, layout, security (onsite and also municipal). in addition to the organization's plan, each imaging department should have their own disaster management plan that works in concert with the organization's overall plan. investing large amounts of capital into resilient infrastructure can be difficult to justify when there are competing projects that need to be completed in the immediate future. until an organization has endured great hardship and loss as the result of a catastrophe, investing money into a project that may never be needed, is often pushed to the side. (grain, ; lau, ) the events listed earlier, are examples of what can happen during a disastrous event. hospitals in earthquake zones, should invest in appropriate foundations and watertight rooms to protect their expensive equipment. radiology reading rooms should always be on a back-up generator and remote reading capability should always be in place. regional businesses should be included in the responsibility for disaster plans and their back up: the financial district of new york city, the oil/gas industry in texas, or the shipping industry in southern california are essential to the well-being of not just their local communities but also the nation as a whole. including key players in the preparation for catastrophic events for the entire area, should be a priority for all involved. (lau, ) . communities and organizations that have experienced catastrophic events, can offer valuable first-hand accounts of the lessons learned and offer suggestions for others to consider when creating their own disaster management plan. precise needs for each individual catastrophe may differ, however, there are many common considerations that should be included in all plans. electrical considerations: ♦ guard against flooding of the generators, have ample fuel available to run generators ♦ if there is a loss of power to industry, water treatment stations, etc. may negatively impact the hospital ♦ the more emergency power a hospital has available, the more successful they can be during a catastrophic event ♦ incident command centers must be deployable and not fixed ♦ organizations must keep up-to-date phone lists (employees, local business, vendors, fuel companies, utility companies, medical equipment companies, etc.) ♦ portable wi-fi units can be used if it down or power outages occur ♦ satellite telephones, wireless radios, amateur radios, and other forms of communication may be used if cellular telephones and/or landlines fail ♦ organizational leadership must be visible around the building, calm, optimistic, and ready to respond to issues (bluth, ) ◊ communication must be honest, transparent, and frequent in order to counter the spread of inaccurate rumors and contain mounting fear among staff, patients, visitors (jones, ) ♦ when calling for emergency assistance (" ") or reporting suspicious activity, essential facts should include: gray, ; doh, ) patient transport to/from radiology (berger, ) ♦ if the disaster is an approaching storm, all studies should be dictated, rooms stocked with supplies, phone numbers updated, disaster management plan reviewed with team ◊ extra staff should be called in ◊ consider moving some portable equipment to essential upper floors (in case elevators fail during the storm event). (bluth, ) ♦ the role of imaging in a mci is to increase triage accuracy, identify injuries, and more precisely assign resources ◊ whole body ct scans using an mci protocol can increase the number of ct scans per hour and also detect indirect injuries that could otherwise be missed. a disadvantage is the large number of images generated that the technologists then need to reconstruct, and the radiologists need to read (korner, ) ♦ if technology is intact, remote radiologists may be able to assist in reading exams ♦ all steps of imaging may be affected by a catastrophic event: orders from referring physicians, patient transport, images (acquisition, coding, worklist, storage, retrieval, viewing, reporting, etc.) . ◊ communication may need to be flexible (face to face, paper notes, etc.) if telephones, computers, etc. are inoperable ♦ some hospitals have found that having a radiologist go to the ed with the technologists to perform bedside x-rays and ultrasounds, allows for immediate reading of images ... which allows for immediate identification of injuries, streamlines communication between radiologist and emergency physician, reduces the risk of errors from high volume and miscommunication or lost information, incorrect patient id, etc. elevate any equipment that could be water damaged if flooding occurs such as coils, control consoles, and mri quench duct • mri suites should close until threat of quench passes. (gregan, ) o risk of quench if the quench pipe is damaged, loss of temperature regulation of the liquid helium, movement of the helium inside cryostat vessel, o mri rooms should be designed to be watertight, with an additional stabilizing foundation construction. (hayes, ) ♦ staff: ◊ staff shortages (staff can't come to work, those who can't leave will face exhaustion) ◊ plan for % of normal staffing levels with enough food and water ◊ care of the staff must include risk protection and: • physical needs must be met • protection from chemical, biological, infectious, and radiologic exposure • psychological and behavioral health should be provided for ◊ staff coming into work should bring own supplies (water, food, medicines, etc.) and waterproof clothing for both hot/cold temperatures ◊ staff must stay, until replacements have arrived. consider staffing up, in case future replacements can't get into the hospital and those on duty, must work elongated shifts ◊ maintain employees on payroll … need to have adequate staff for disaster recovery periods ◊ staff should be encouraged to create a family emergency plan in advance, that covers all possible disasters. plans should cover a minimum of days (best if week supply on hand) and should include: • phone numbers (family, legal, medical, community, etc) • bottled water ( gallon/day for each person and each pet) there is no perfect plan, when preparing for a catastrophic event. the best preparation includes an evidence based plan, consideration of past events (case reviews, lessons learned, etc), ongoing education, frequent drills, and stock piling of essential supplies. considerations need to be designed for the individual (person, patient, staff, etc), the departments that could be affected, the organizations that could be involved, and the community as a whole. fast facts for the radiology nurse massive influx of patients to a radiology department emergency imaging after a mass casualty incident: role of the radiology department during training for and activation of a disaster management plan public mass shootings in the united states a study of active shooter incidents managing in a catastrophe: radiology during hurricane katrina accessed / / the squishy definition of 'mass shooting' complicates media coverage core principles of threat management units natural disasters and severe weather preparedness and safety messaging for hurricanes, flooding, and similar disasters past pandemics center for disease control and prevention: rabies natural disasters and severe weather: infectious disease after a disaster including radiology in emergency plans is critical nationwide suspicious activity reporting (sar) initiative (nsi) if you see something, say something campaign in a radiology department during an earthquake, tsunami, and nuclear power plant accident raw sewage released by hurricane harvey disaster recovery reform act the necrology of aeronautics". wonderful balloon ascents; or, the conquest of the skies lessons learned from the japan earthquake and tsunami feather river hospital evacuated patients and staff as camp fire approaches. wildfire today the initial response to the boston marathon bombing: lessons learned to prepare for the next disaster disaster nursing and emergency preparedness either or? reconciling findings on mental health and extremism using a dimensional rather than categorical paradigm after katrina: hospitals in hurricane katrina challenges facing custodial institutions in a disaster. the urban institute critical infrastructure security and resilience national research and development plan. national infrastructure advisory council radiology in the christchurch earthquake of february : challenges, interim processes and clinical priorities chemical weapons: a deadly history. radio free europe disaster management hurricanes test radiology's disaster preparedness including radiology in discussion paper: health and medical response to active shooter and bombing events active-shooter events in the workplace: findings and policy implications initial steps in training the public about catastrophes in radiology bleeding control: surgeon participation and evaluation emergency management resources -general references 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health systems in iwate prefecture worker safety in hospitals: caring for our caregivers what's your plan? radiology today organisation for the prohibition of chemical weapons japan earthquake & tsunami of : facts and information. live science radiological dispersion device. department of homeland security preparing for and responding to disaster: a the joplin tornado: the hospital story and lessons learned developing a hospital disaster preparedness plan for mass casualty incidents: lessons learned from the downtown beirut bombing. disaster medicine and public health preparedness cbrne weapons & islamic state -a bad combination analysis of storm-tide impacts from hurricane sandy active shooter response usns comfort arrives in puerto rico to aid maria relief efforts sewage, fecal bacteria in hurricane harvey floodwaters coping in a calamity the terrifying physics of how wildfires spread so fast radiologic features of injuries from the boston marathon bombing at three hospitals cloud burst in leh: pattern of casualties; challenges faced and recommendations based on the management of such natural disaster at multi-specialty hospital improving local health department cybersecurity minutes. national fire protection association journal. february catastrophes in radiology a large community outbreak of salmonellosis caused by intentional contamination of restaurant salad bars the 'hittite plague', an epidemic of tularemia and the first record of biological warfare fecal bacteria contaminated surface water after hurricane harvey: hurricane harvey delivered five consistent days of flooding and storms to texas last august the hillsborough tragedy biologic, chemical, and radiation terrorism review mass casualty management systems: strategies and guidelines for building health sector capacity who: disasters and emergencies world health organization ( ) flooding and communicable disease facts sheet environmental health in emergencies planning for catastrophes affecting imaging departments ♦ disaster management plans rarely include radiology ♦ million people worldwide are affected by a disaster each year ♦ lessons can be learned from those who lived through one key: cord- -cvdne ks authors: kim, yong-kyun; sohn, hong-gyoo title: disaster response policy change in the wake of major disasters, labeled focusing events date: - - journal: disaster risk management in the republic of korea doi: . / - - - - _ sha: doc_id: cord_uid: cvdne ks responding to the will of the people or the will of the government after a focusing event is complex and fraught with perils; this is none more so than after a major disaster that has brought on the sudden death of many people or the initial incalculable destruction of property or the environment. korea has experienced several of these types of focusing events that have had major social and policy implications between the years and . we analyzed them to glean their impact on disaster response policy, organizational and law reform, and first response and national countermeasures – and presented them in a clear and logical array so that the information could lead to a new type of disaster management model. additionally, we look at how these focusing events altered the political, policy alternative and problem streams, as well as media coverage and policy change in the wake of the focusing event. and finally, we analyze disaster-triggered policy change in korea to find out if the relation between the focusing event and institutional reforms for disaster response is path-dependent. the water resources bureau was reorganized as the disaster prevention planning division and established the disaster prevention facilities division by the presidential decree no. , on december , , which strengthened the functioning of the disaster prevention administration. however, since there were no disasters for two years-from to -the disaster prevention planning division and the disaster prevention facilities division were integrated and downsized to the disaster prevention division by the presidential decree no. on march , . on december , , the government organization act (act no. ) and the countermeasures against typhoons and floods act (act no. ) were amended. on april , , the decree on the organizations of the moi was amended to abolish the department of disaster prevention in accordance with the revised the government organization act. as a result of the amended decree, the disaster management office was abolished, and the river management division and the underwater resource bureau were established. also, the deputy director-general's office for disaster management planning and the disaster management division were established under the civil defense bureau to transfer disaster management tasks from the moc to the moi. the collapse of the levee in the ilsan region, downstream of the han river due to a downpour in the central region (september ~ , ) served as a momentum to amend the government organization act by act no. on december , , which revised the countermeasures against typhoons and floods act as an additional clause. this transferred the work of disaster response measures from the moc to the ministry of home affairs (moha) on april , . due to the gupo station train overturn accident, the instructions of the prime minister, "instructions on the settlements of the disasters due to accidents" (instructions of the prime minister no. , april , ) was issued. this instruction was the result of political responsibility on the aspect of overcoming the risks of severe accidents. it came about after the inauguration of the civilian government and rise in public opinion on the necessity for institutionalization of disaster response measures. after the seohae ferry sinking accident, the coast guard founded a coherent command system on maritime rescue. in , the rescue and aid at sea and river act was amended unifying the rescue system by replacing the position from the chief of the korean coast guard to the chief of the national rescue coordination center. for prompt accident registration and broadcasting, a salvage radio station and a satellite early warning receiving system were constructed and operated. also, to prevent casualties, safety management work of passenger liners and excursion ships and ferries was taken over from the moha in . the special act on the safety control of public structures was established after the seongsu bridge collapse in . due to the sampoong department store collapse on june , , the disaster control act was established on july , . the act includes response, recovery, and relief centered around human-caused disasters. also, a national rescue service was established on october , , which started to perform rescue work by sending rescue resources directly to the fields of major accidents both inside and outside the country. in november of the same year, the disaster control department (the disaster coordination division, disaster management division, and safety instruction division) and the equipment and communication division from the fire department were merged as the office of civil defense. it expanded and reorganized as the headquarters of civil defense and disaster management in the moha. disaster risk management (drm) agencies were established in local areas thereby starting a standard to systematically manage human-caused disasters. also, in the office of the prime minister (the safety management office), the ministry of trade and industry (the gas safety division), and the ministry of construction and transportation (moct, the facilities safety division, the construction safety division), departments and divisions dealing with human-caused disasters were established. to improve disaster management capability of local governments, the civil defense bureau was reorganized into the civil defense and the disaster management bureau in the metropolitan and provincial governments, and the civil defense division was reorganized into the civil defense and the disaster management division in local governments in december of the same year. according to the reorganization, a safety inspection team was established in all metropolitan and provincial governments. on december , , the countermeasures against typhoons and floods act (act no. ) was amended to the countermeasures against natural disasters act (act no. ). as the act was revised, earthquake and drought were added to the category of natural disasters, the disaster countermeasure committee was established under the moi, and the central and local disaster countermeasure headquarters were installed and became operational. in , the roh, tae-woo administration amended the government organization act, which merged the ministry of government administration and the moha and made the ministry of the interior. from this event, disaster management was managed through individual laws integrated into a unified system. that is, systematic disaster management was systematically initiated. this was a shift of disaster management from what was mainly controlled by the central government to what works along with local governments. also, a subordinate organization of the ministry of the interior was established (presidential decree no. ) on february , ; organization enforcement rules were also established by decree of the ministry of the interior no. on march , as a follow-up (lee ) . as the ministry of the interior initiated, the disaster management department merged into the civil defense department and this integrated into the civil defense and the disaster management department on may , . thereafter, as the restructuring of the public sector accelerated, the disaster prevention department shrank to the deputy direct-general's office for disaster management under the fire department before being abolished. president kim, dae-jung instructed to establish korean-styled countermeasures against flood damage, which can be trusted by the public at a cabinet meeting on august , . also, he expressed his strong determination by saying, "we will not repeat the problems which lead to damage of lives and economy through strengthening fundamental measures to prevent flood damage and disasters," at the congratulatory speech on national liberation day on august , . accordingly, he launched a task force for the countermeasure of flood damage headed by cho won-cheol, professor of yonsei university, as a subordinate body of the presidential secretary on september , . after the hwaseong sealand youth training center fire, a task force for the enhancement of safety management under the prime minister's office was established. in , a task force for the countermeasure of flood damage analyzed and evaluated the past measures on flood damage and collected extensive opinions from all citizens, thereby developing a comprehensive plan that would be implemented in the following ten years. for the follow-up to the specialization and research reinforcement of disaster prevention organizations in planning and for reforms in the implementation system of the natural disaster relief work, the deputy direct-general's office for disaster management was redirected from under the bureau of civil defense and disaster management to under the head of headquarter of civil defense and disaster management, so that natural disaster work was separated from the work of the director of the civil-defense disaster prevention bureau. also, the "structure of the ministry of the interior" was amended (presidential decree no. , june , ) to change the name from the civil defense disaster prevention bureau to the civil defense disaster management bureau. for the follow-up, the departments under the director of the civil defense disaster management bureau and the director-general of the natural disaster management of headquarter of civil defense and disaster management and the enforcement rules that facilitate the installation of agencies and work of the director-general were amended (decree of the ministry of the interior no. ). as typhoon rusa in caused unprecedented massive damages in the whole country, the countermeasures against natural disasters act (act no. ) was amended and a special disaster area was established in article . for urgent recovery and support. the roh, moo-hyun administration adopted the improvement of the national disaster management system as one of the major government projects. so exclusive organizations for disaster management to effectively manage disasters were created at the first cabinet meeting after the inauguration. on february , , at the inauguration, president roh, moo-hyun stated: "i will improve the national disaster management system innovatively to realize a safe society." it could be realized from the announcement that the government had a large interest in disaster management. therefore, the national disaster management system planning group was installed and the disasters and safety act was announced. also, the national emergency management agency (nema), the first independent disaster management agency, was established by expanding and reorganizing the headquarter of the civil defense and disaster management. in addition to the establishment of the nema, the disasters and safety act integrated legal systems were dualized by the natural disaster countermeasures act and the disaster management act, and social disaster such as the lack of a national critical infrastructure was added to the concept of disaster. in , prevention-centered systems like the preliminary disaster inspection and consultation system, and the comprehensive plans for the reduction of damage from storm and flood were introduced, which amended the countermeasures against natural disasters act. on march , , the special act on the safety control of publicly used establishments was enacted to demand compulsory fire safety training for employers and employees of publicly used establishments and evacuation guidance and screening of videos on evacuation. on september of the same year, coordination of civil defense and support of the prime minister were transferred from the moi to the nema in accordance with the amendment of the framework act on civil defense (act no. ). on july , , the act on assistance to the autonomous activities of enterprises for disaster mitigation (act no. ) was enacted. the act contained contents for the adaptation of the certification system for enterprises with outstanding performance in disaster mitigation and the establishment of standards for disaster mitigation activities of enterprises. on july of the same year, the prevention of the steep slope disasters act (act no. ) was enacted. a safety inspection had become mandatory for steep slopes, collapsing hazardous areas were designated, and it was decided to remedy collapsing hazardous areas after consultation. on september , the disaster prevention standards team was established in the nema by the revision of the nema and affiliated organizations (enforcement rule of moi no. ). in , the lee, myung-bak administration took over, and the moi was reorganized into the ministry of public administration and security (mopas) through the general revision of the government organization act (act no. ) to oversee the integrated management of the central personnel management and the disaster and safety management at the national level. in accordance with the amendment of the government organization act, the framework act on civil defense (act no. ), the nema and its affiliated agency (presidential decree no. ) were amended. the moi is responsible for ensuring that the government's safety management policy and emergency preparedness, civil defense, and disaster management system are continuously carried out by the mopas. the function of generalizing and coordinating civil defense and acting as the prime minister's assistant was also transferred from the nema to the mopas. on march of the same year, act on the preparation for earthquake and volcanic eruption (act no. ) was enacted. with this enactment, the nema's responsibility as a national disaster management authority for earthquake mitigation was established. also, an earthquake and tsunami observation facility was installed and a basic plan for seismic reinforcement for existing facilities was established. on december , , countermeasures against natural disaster act (act no. ) and framework act on the management of disasters and safety (act no. ) were amended to include lightning strikes as a natural disaster. on february , , the safety culture-related functions were transferred from the nema to the mopas to unify the safety function. on march , , the special act on management of disasters in super highrise buildings and complex buildings with underground connections was enacted to conduct the predisaster impact assessment on high-rise buildings to be carried out. as a result, the establishment and implementation of disaster prevention and damage reduction plan for high-rise buildings and the integrated safety inspection for high-rise buildings became mandatory. on february , , pedestrian safety and convenience enhancement act (act no. ) was enacted, in which ensuring the right to walk and establishing basic plan for pedestrian safety and convenience are included. after the gumi city hydrofluoric acid leak accident in september of the same year, the government installed an integrated chemical disaster prevention center on november , . in , park guen-hye administration reformed the mopas to the ministry of security and public administration (mospa) in order to strengthen the comprehensive safety management by the revision of government organization act (act no. ) . the disaster and safety act was partly revised on august , in order to integrate human-caused disaster with social disaster. the human-caused disaster management responsibility was moved from the nema to the mospa on april , . the act on the prevention of coastal disaster was enacted on may , , which regulates the development of the regulations for safety management in coastal disasters and the establishment of a basic plan for the prevention of coastal disasters. after the sewol ferry sinking accident on april , , the need for a reshuffle of the government's disaster response system intensified. therefore, the government organization act (act no. ) was enacted and the mospa was reorganized and divided into the moi and the ministry of public safety and security (mpss). additionally, disaster management tasks were transferred from the nema to the mpss. the act on safety management of small scale public facilities (act no. ) was enacted on july , , which regulates the mandatory regular inspection of small-scale public facilities and designation of at-risk facilities in order to prevent disaster in those facilities. the background of the enactment is that those smallscale public facilities suffer repeated damage every year because the management responsibility of the facilities is not clear. the center for disease control and prevention was upgraded to vice-ministerial level through the revision of the government organization act (act no. , . in march , , the fire services act was established to protect life and assets by preventing, bordering, and suppressing fires in buildings, ships, etc. used for work or residence and in october , , the firefighting division was established in the police bureau according to the enactment of the organization of the new moi (cabinet order no. ). in march , , the disaster relief act (act no. ) was enacted to protect the victims and recover from disasters by providing emergency relief during emergency situations, and the firefighting task was transferred from the moi to the autonomous community in august , . in june , fire departments were installed in seoul and busan to take charge of fire services. with the establishment of fire departments in seoul and busan, systematic fire service started. also in february , the local officials act was passed, which dualized the position of firefighting officers. national public officials became police officers and local public officials became local fire officers. there was a big change in the firefighting administration system because of the local public official institution. on february , , the law no. act on the indemnification for firecaused loss and the purchase of insurance policies was enacted to prevent damage caused by fire and to provide prompt recovery and appropriate compensation. the police bureau was reorganized as the police headquarter, and the firefighting division in the second division of the police headquarter was responsible for firefighting tasks through the revision of the organization of the moi (presidential decree no. ) on december , . in , the civil defense headquarter was established and the firefighting division in the police bureau was expanded to the firefighting bureau in the civil defense headquarter through the revision of the government organization act (act no. ) on july , the enactment of the framework act on civil defense (act no. ) on july , and the revision of the organization of the moi on august . in july , fire service education began at a fire service academy, which was established for systematic disaster management. a firefighting division, a fire service division, and a fire prevention division were established under the firefighting bureau according to the revision of the decree on the organization of the moi in april , . the government merged the city and county fire service, and the regulations on installation of firefighting systems, and established the regulations on installation of firefighting institutions and quota by presidential decree no. in december . the next year, in january , dualized firefighting systems of national firefighting and autonomous firefighting were converted into local autonomous firefighting systems. special local administrative agencies under article of the "government organization act," were formed as the disaster management systems, which unified the responsibility to city mayors and provincial governors. by installing the special local administrative agencies as subordinate organizations of the local government and by installing fire departments in nine provinces on the basis of article of the local autonomy act, the government formed disaster management systems, which unified the responsibility to the city mayors and provincial governors because it had converted to local and autonomous firefighting units from january , . this was possible by converting firefighting joint facilities tax, which was originally city and municipality tax, to provincial tax and by permitting provincial governors to rent all the firefighting properties from city mayors and municipal governors without compensation, and to manage them by amending the local subsidy act and the enforcement decree. on april , , civilian and military labor and equipment could be mobilized in the event of a major accident through the enactment for disaster relief in accidents (instructions of the prime minister no. ). the head of the korean coast guard was appointed as the head of the central rescue coordination center to unify the rescue system through the revision of the rescue and aid at sea and in the river act (act no. ) on december , . on may , , the government organization act was amended to restore the firefighting work to the ministry of the interior, which gave the state certain responsibilities in the firefighting administration. therefore, disaster management had become a dual system of the state and the local autonomous firefighting administrations. in the s, the type of major disasters moved discernibly from natural disasters to social disasters and there was a big change in state disaster management. in the wake of the seohae ferry sinking accident in , the coast guard founded a coherent command system on maritime rescue. in , the rescue and aid at sea and river act was amended, unifying the rescue system by making the chief of the national rescue coordination center as its head. for prompt accident registration and broadcasting, a salvage radio station and a satellite early warning receiving system were constructed and became operational. also, to prevent casualties, safety management work of passenger liners and excursion ships and ferries were taken over from the moha in . due to the sampoong department store collapse on june , , the disaster control act was established on july , . the act includes provisions by which firefighting organizations play a leading role in emergency rescue and salvage function of the government as it gives the command and control of emergency rescue and salvage function to the head of the fire department. also, the national rescue service was established on october , , and it started to perform rescue work by sending rescue personnel directly to the field of major accidents both within and outside the country. in november of the same year, the equipment and communication division within the fire department was established, as the office of civil defense expanded and reorganized as the headquarter of civil defense and disaster management within the moha. also, in the same year, on december , , the position fire commander (current position: fire chief) was established, which provided a new position to disaster management. on december , , the structure of the moha and the subordinate organizations were reorganized, and the position of the head of fire department was promoted as the fire commander (current position: fire chief) or fire chief (current position: fire deputy chief). on may , , the central rescue team was reorganized as an affiliated organization in the moi through the amendment of the decree on the organization of the moi. the framework act on fire services was enacted to provide the basis for the organization and operation of international rescue teams by law act no. on may , . on may , , decree of nema and affiliated organizations, president decree no. , was enacted and nema and its affiliated organization requirements were defined. the special act on the safety control of publicly used establishments was enacted to establish and maintain firefighting and safety facilities for multiuse facilities and to provide the necessary information on safety management and risk assessment by act no. on march , . on september , , the second center was established in the central firefighting school by the revision of nema and affiliated organizations (enforcement rule of moi no. ) and national rescue team was promoted to national center on january , . on march , , rescue and emergency medical services was established by act no. , and regulations and emergency services were specified for efficient operation in the emergency situation. on february , , the framework act on health, safety and welfare of fire officers was enacted by act no. to improve the health and safety of fire officers and their working conditions. on july , , the rescue and first-aid bureau was established. on january , , the firefighting manpower was supplemented to suppress a fire at the scene of the disaster, and to support emergency and rescue activities and fire prevention activities through the enactment of the volunteer fire services (act no. ). organizations and laws scrutinizing the major disasters and the change of disaster response organizations and laws shows that there is a high correlation of before-after relations. for the analysis, historical records and related documents, such as a -year history of disaster management (nema ) and related documents (lee et al. ; kwon ; ryu ) , will be analyzed in order to identify major disasters and disaster response policy change. in this research, policy change means the change in disaster response organizations and enactments or major revisions of response-related acts. the index to analyze the change in disaster response organization is the change in organization operating with natural and social disaster, and safety management headquarters and the change of organization dealing with rescue. the reason the index only targets disaster and safety management headquarters and rescue organization is that it is almost impossible to deal with all related disaster response organizations and laws because, according to types of crisis management standard manuals, most government agencies are related to disaster response in korea. the organizational changes will be divided into direct and indirect changes. direct changes will include large-scale change and middle-scale change: largescale change is the establishment of a new agency or the transfer to another ministry, and middle-scale change means the establishment of a bureau or a division to deal with disaster response. indirect change means the change of an organization that supports disaster response: e.g. the establishment of a fire academy, a flood recovery office, or a river management division, etc. this book will focus on direct change. however, indirect change will be reviewed and included as useful information for future research. table . shows the change in disaster response organizations and laws from to . this section will analyze how disaster response organizations and laws were changed in the wake of major disasters, called focusing events. the disaster-triggered policy change model, developed on the basis of kingdon's policy stream framework (psf) and birkland's event-related policy learning (erpl) model, will be used for the analysis. policy has been defined diversely according to scholars. dye ( ) defined a policy as "everything which the government has decided to do or not to do" and considered it as the government's selection. on the other hand, jenkins ( ) defined a policy as "a series of mutual-related decision-making of a doer who has authority to achieve a purpose under specific situations to select purposes and measures to realize such purposes" and considered a policy as a series of decision-making processes. yang ( ) defined policy change as "the modification and conclusion of a policy alternative generated from the previous policy decision by recognizing changes regarding the policy issue after drawing up a policy alternative in the policy decision process and returning to the policy agenda establishment process again (yang ) ." factors promoting a policy change include changes in the environment of policy, changes in public demand, and unexpected incidents. on the contrary, factors hindering a policy change include psychological resistance, political allies that oppose changes, political burden, and high costs. among various types of policy change, the strongest form is the amendment of the constitution or formulation and full-text amendment of major laws while a slightly weaker form of policy change include changes in the behavior of streetlevel bureaucrats or modification of regulations (lipsky ). the pocf is generally used to explain policy output process, but can be used for the policy change model. in pocf, hofferbert noted that five elements-historicgeographic conditions, socioeconomic composition, mass political behavior, governmental institutions, and elite behavior-affect the policy output directly and indirectly (hofferbert ) . his view is that these five factors undergo the process of "passing through the tunnel" in consecutive order, thereby directly and indirectly affecting policy output. he considered historic-geographic conditions and socioeconomic composition as different elements because two states having similar environment and natural resources often have a different socioeconomic composition, and put historic-geographic conditions before socioeconomic composition because the former tends to change less than the latter. the third element of mass political behavior affects the decision of government institutions and the behavior of elites independent of socioeconomic composition. the last step to formal policy change is elite behavior, which is a part of a residual category to explain undiscovered reasons of policy change (hofferbert ). sabatier's acf is a policy decision model developed to deal with public policy issues. the key elements of the acf include external parameters, belief system, advocacy coalition, policy mediator, policy learning, policy output, and policy change (weible and sabatier ). according to the acf view, a policy process is not a linear process in which critical decision is made at each phase consecutively, but as a dynamic process in which struggles for policy formation, execution, and reformation are continuously repeated (jeong and jeong ) . there are two types of external parameters affecting the policy subsystem in the acf model: relatively stable parameters and dynamic ones. relatively stable parameters include the basic attributes of the problem area, basic distribution of natural resources, fundamental sociocultural values and social structure, and basic legal structures; in general, the parameters do not change often. on the other hand, socioeconomic conditions, changes in public opinion, changes in governing coalition, and impacts from other subsystems are dynamic external parameters, which affect policy subsystem dynamically. mediator and policy learning are other important elements for policy change (weible and sabatier ). policy advocacy coalition always appear in the process of policy-making and implementation, and their activities always affect policy change (jeong et al. ) . the acf can be best used in understanding and explaining belief system and policy change where there are goal disagreements and technical controversies among complex agents including various levels of government, interest groups, research institutes, and mass media (weible and sabatier ). hall emphasizes the importance of policy learning in the process of policy change, and regards policy formation as the process that includes three variables: policy goal, policy output, and technology/policy environment. moreover, the pcf model conceptualized policy change, which brings rapid change to policy goal and means as paradigm change (lee ) . the pcf classified the process of policy change into three steps according to the concept of policy paradigm and scale of change. the first change is gradual, and it is a decision-making method commonly encountered in a general policy process. the second change indicates development of a new policy tool. the third change refers to rapid changes that bring a paradigm shift. the first and second changes do not necessarily lead to the third change (hall ). kingdon's psf, also referred to as a "multi-stream framework" or "window of policy model," was originally developed as a policy agenda setting model, but now has extended to the model for explaining policy change, policy formation, policy implementation, and policy evaluation (oh ). psf's three streams, the problem stream, the politics stream and the policy alternative stream, independently flow according to their roles and are suddenly combined when a dramatic event or a political event occurs, resulting in policy change driven by the triggering device (jeong et al. ) . the scheme of psf is shown in fig. . . in other words, when three streams progress independently and are combined at critical junctures, this combination creates an opportunity for agenda change. the problem stream means that policy decision-makers become interested in a specific policy problem among various problems. the stream of politics consists of the national mood, public opinion, election results, replacement of administration, lopsided or ideological distribution in a council, and pressure of interest groups. the political stream has a strong influence on setting a new agenda. the policy stream is the procedure to set various policy alternatives through the policy community including researchers, council workers, workers in planning, evaluating, and budgeting, and interest group analysts. kingdon emphasized the importance of the political stream and policy entrepreneurs (kingdon ) . the policy window opens for a short period of time when the requirements for presenting given topics to the policy agenda are fulfilled. major changes in public policy occur following the opening of this policy window (kingdon ). kingdon's psf was developed from cohen et al. ( ) 's garbage can model that appeared as an alternative to the old rational model, and it is useful for explaining the role according to the interest of various participants based on the dynamic policy formation process (kim and lee ). kingdon's psf focuses on problem stream, policy stream, and politics stream while the garbage can model focuses on four streams including the problem stream, the solution stream, the choice opportunity stream, and the participant stream. among various policy change models, we chose kingdon's psf for the analysis on disaster response policy change in the wake of disasters in korea. etkin ( ) studied the garbage can model in order to understand complicated processes of policy change that resulted from interactions among various factors, such as increased attention from the citizens, press, and politicians and numerous policy recommendations. kingdon's psf, evolving from the garbage can model, has more strength in explaining the interactions of various factors compared to other policy change models. therefore, kingdon's psf is the most appropriate model for the analysis of simultaneous interactions among various factors in the wake of disasters. this section will analyze the process of changes in disaster response organizations and laws after large natural and social disasters occurred in korea from to . kingdon modified the garbage can model in a study targeting the transportation and health policy fields and presented the policy stream model while birkland specialized in the natural disaster and terrorism fields and emphasized the focusing event (kwon ). a modified model combining kingdon's psf and birkland's erpl model will be presented and the process of change in disaster response organizations and laws after a large-scale disaster in korea will be analyzed. the reasons to use the modified model combining two models are as follows: first, kingdon's psf, among various policy change models, is the most appropriate model, which explains changes in the disaster response organizations and laws that occurred due to the simultaneous reaction of various factors after a largescale disaster. however, the kingdon's model regards an unexpected large accident just as one element in the problem stream. therefore, the psf cannot fully explain the national interest and requirements that start to increase rapidly from the occurrence of large-scale disasters and increasing demand on consequent agenda. owing to this, there are few research studies on the change of disaster response organizations and laws after a large-scale disaster by using kingdon's psf. second, birkland's erpl model can supplement kingdon's model. birkland explained how large-scale disasters brought changes in the disaster response organizations through the studies on the establishment of department of homeland security (dhs) and the improvement of aviation security policy after september terror attack in and changes in disaster management organizations in the usa after hurricane katrina. however, birkland's model considers increase in social interests on policy agenda, unification of interest groups, discussion on ideas, adoption of new policy, and social learning process as the processes carried out linearly so that this model has a limit to explain various situations occurring simultaneously after a large-scale disaster. therefore, a disaster-triggered policy change model that modifies kingdon's psf by taking the occurrence of a focusing event and increase in social interests on policy agenda and birkland's erpl model by inputting political, policy, and problem streams simultaneously, will be proposed in this book. the disaster-triggered policy change model is shown in fig. . . in other words, the focusing event is considered as the beginning point of policy change and the relation between the three streams that occurred due to an increased interest on the agenda will be analyzed. and, it will be analyzed to see which of the three streams gives the most significant influence on changes in disaster response organizations and laws. as the form of policy change for this research, the establishment and revision of disaster response-related laws, which is the most certain form of policy change suggested by lipsky ( ) and the consequent changes in the disaster response organization, are selected. for the disaster response organizations, the organization operating the central disaster and safety countermeasures headquarters, which was the final decisionmaking organization among natural and social disaster-related government agencies and the organization handling emergency relief that had the core function of field response were examined. this is because most central government agencies and all cities and towns take charge of unique disaster response functions for each function including situation report and distribution, emergency facility restoration, communication of disaster information, and emergency relief, and it is almost impossible to secure relevant material for all these organizations. also, core change factors in organizations, such as an establishment of a charging department and the transfer of function to another department, were only defined as changes in organization in this book. after major disasters, there are four dynamic activities: media, political stream, policy alternative stream, and problem stream. the time period for this analysis is from to . the disaster-triggered policy change model is composed of the following elements: media: media represents the increased attention after a disaster. political stream: the president's political will would be reflected in the statement after disaster, official order to the administration, and statement in the national assembly. national assembly's political will would be reflected in the special committee regarding the disaster and agenda in the assembly plenary session. policy alternative stream: policy alternative stream will be reflected in the activities of the prime minister or the line minister and the announcement of countermeasures by the government. problem stream: problem stream will be reflected in the cause analysis report by national audit office, academia, or research institutes. torrential downpour in the nakdong river basin in there were various articles reporting the large calamities and displaced people due to the torrential downpour of . in addition, newspapers reported the announcement by president rhee syng-man to console the people affected by the calamities and displaced people and to insist a public-private partnership to overcome the damage due to the disaster. typhoon sarah landed and affected the korean peninsula on september , , and the press release on the eighteenth was mostly on the path of typhoon sarah, the power of the typhoon and the report of damage. from november to , the press release was mostly on recovery after the disaster. according to the general news page of the dong-a daily news on september , the title of the article is "serious nationwide damage of , displaced from the typhoon at beginning of chuseok." it was implicated that because the typhoon led to one of the longest holidays in korea, it resulted in greater damage. also, it was stated that the government requested for the displaced emergency assistance by the red cross of various countries such as the usa, australia, united kingdom, france, west germany, and italy for the relief of the unprecedented damage by typhoon sarah (september , dong-a daily news). also, during the cabinet meeting, there was an effort made to recover from the disaster with various methods like collecting contributions for the relief (september , dong-a daily news). flood in jeollabuk-do namwon-eup, gyeongsangbuk-do yeongju-gun in articles related to a countrywide continuous heavy rain in july were reported as the banks in the yeongju-gun and the namwon-eup collapsed, and articles related to the damage situation and recovery of the flooded area were reported on july . starting on august , , when the flooding began in the area, to september , there were about news articles in the dong-a daily news and the kyunghyang daily news. from september until april , there were articles reported. the articles were mostly about the damage situation, situation of the displaced, and the recovery. on july , , there were articles reported in the dong-a daily news, the kyunghyang daily news, and the maeil business news. they were mostly focusing on the weather-related reports and damage situation. the articles compared the water level of the first bridge on the han river on the sixteenth at : p.m., which was m cm, with that on july , , which was m cm. in all there were articles on the wow apartment collapse. five of the articles were reported on the day of the accident, and articles, more than half of the articles, were reported four days after the accident. the contents were mainly on the cause of the accident, the analysis of the causes, the relief, and the punishment of the persons in charge. the number of articles related to the namyoung ferry sinking accident in the dong-a daily news, the kyunghyang daily news, and the maeil business news was . among these, the number of articles reported in five days from december to was , and those reported until the end of december was . on the day of the accident, the articles were focusing on the accident process, damage situation, and the cause analysis. by the nineteenth, the articles were mostly on rescue operations and the situations of the bereaved, while after the rescue operations, they were mostly on the punishment of the persons in charge. the seoul daeyeonggak hotel fire on december , , was broadcast live, and the number of articles reported in the dong-a daily news, the kyunghyang daily news, and the maeil business news was . on december , a christmas holiday, articles of the accident that happened at p.m. were published. considering that it happened on a holiday and the time of the accident was late, it is not an insignificant number of articles. also, the cause analysis of the accident was published through articles for five days after the accident (december ). this led to an inspection of the fire-extinguishing facilities in seoul. the number of articles published in the dong-a daily news, the kyunghyang daily news, and the maeil business news on the explosion at iri station where there were casualties was . the day after the accident, which happened at : p.m. on a friday, articles were released about the report of the accident, the control of the accident, the relief, and the government's measures. the next week, from the fourteenth to the nineteenth, articles were published. the contents of the articles were mostly on cause analysis of the accident by inspectors, punishment of the persons in charge, and compensation for the accident. the number of articles on typhoon agnes, which caused casualties and , displaced was in the dong-a daily news, the kyunghyang daily news and the maeil business news. among these, articles provided full coverage from september when the typhoon led to the biggest damage to the fourth when the typhoon went extinct. the articles were mostly on the path of the typhoon, scale of damage, method to minimize the damage, and the report of the situation in the affected areas. after the extinction, they were mostly about the extent of damage and recovery. twelve articles were published from september to related to the great flood in in the dong-a daily news, the kyunghyang daily news, and the maeil business news, and they were mostly on the weather situation and the degree of damage. also, there were an additional seven articles until october , and among them three were on the damage situation, which were published every time after the great flood in when there was a torrential downpour. the number of articles related to typhoon judy, which damaged the republic of korea at the end of july , was in the dong-a daily news, the kyunghyang daily news and the maeil business news. on july and , before the typhoon was downgraded to a tropical depression, the articles reported on the expected path and power of typhoon judy, and the damage situation. from the twenty-ninth, the articles focused on the damage situation and the cause analysis. according to the article on august in the kyunghyang daily news (page , general news), the busan local government insisted it was a natural disaster, while citizens argued it was a human-caused disaster due to the lack of countermeasures like water supply supplementation in areas prone to floods, insisting the government's proactive actions against natural disasters. fifty-four articles related to the collapse of levee in ilsan region were reported in the dong-a daily news. four of the articles were reported on the day of the accident about the cause of the collapse and the damage situation, and related articles were reported for a week after the accident. train overturn accident at gupo station in news regarding the gupo station train overturn, which was caused by the sinking of a train track, began to be published on the twenty-ninth (monday); the accident had occurred the previous day. there were news articles from the dong-a daily news, the kyunghyang daily news, the maeil business news, and the hankyoreh. among them, half of the articles were announced within one week from the accident. the news in the early period focused on reporting and analyzed the causes, and the latter articles were about recovery status, compensation and bereaved families, and punishment to those who were in charge. asiana airlines boeing crash in there were a total of news articles from the dong-a daily news, the kyunghyang daily news, the maeil business news, and the hankyoreh regarding the asiana airlines boeing crash near ungeo mountain of masan-ri, hwawonmyeon, mokpo-si, jeollanam-do. among them, were reported from the day of accident to five days afterward, and they mostly discussed accident process and cause, damage followed by the accident, and compensation. there were news articles regarding the sinking of the seohae ferry sinking accident from the dong-a daily news, the kyunghyang daily news, the maeil business news, and the hankyoreh. the news continued until december as the boat was salvaged and sunk again. news regarding compensation given to victims and bereaved families and the salvage continued for three years until june, . the collapse of seongsu bridge happened during the morning rush hours. this case showed that a social disaster is one that can happen not only on someone's way to work but also without any warning. accordingly, the media reports mainly focused on individuals in the accident and their families. at that time, the press contributed to people's right to know by live reporting the shocking moment to the people, but did not focus on the fundamental problems as it focused on punishing related officers found responsible; such as seoul city officers, builders, and managers. for example, the dong-a and the kyunghyang daily news newspapers gave the collapse of the seongsu bridge front-page prominence on october . the kyunghyang, the next day on the twenty-second, such as "a bridge that even taxi drivers refused to go," "mom crying over the dead body of her son on his birthday" were published, and "the head office of korean japanese community called and said it was embarrassing." additionally, the korean media focused on the bereaved families emotionally attacking anyone they perceived to be responsible or sobbing over the bodies of loved ones, while pushing for the punishment of the involved construction companies or "people in charge" rather than demanding more intense rescue attempts or enhanced disaster policy improvements. in contrast, american or japanese media focused on rescue images while advocating for improved disaster policies (korea press and foundation/reporter association of korea th reporter forum ). recently, there is much progress in the way of media approach to disaster events by emphasizing the root cause of the problem and improvement of policies, which still needs to be further enhanced for resilience building in korea. there were reports regarding the gas explosion in daegu city in from the dong-a daily news, the kyunghyang daily news, the maeil business news, and the hankyoreh. this accident took place when people were on their way to work in the morning just like the seongsu bridge collapse, which happened a year earlier in . the accident caused casualties. for the three days since the occurrence, there were a total of articles issued and articles issued until may , which was the seventh day after the accident. sampoong department store collapse in the sampoong department store collapse occurred in gangnam, a rich municipality of korea. when talking about "wealth," people not only think of being well-off but also safe from disaster. thus, the collapse in the wealthiest district in korea, worked as a factor for creating an air of anxiety that any kind of building in any region could fall, and affected people's safety awareness. to that extent, the accident was in the center of the media from the accident occurrence to the investigation periods for the cause of the accident. for two months after the accident, the chosun ilbo and the hankyoreh published and news articles respectively. also, taking a look at the articles by subject area, chosun ilbo published articles in the social section, which was the highest. this made up % of the total news articles, and the accident was reported times in the politics, commentary, and opinion sections; times in the general section; times in the economy section; and times in others. the hankyoreh on the other hand, published articles in the society section, which was the highest. this made up % of the total news articles, and the accident was reported times in the politics, commentary, and opinion sections; times in the general section; times in the economy section; and times in others. through the number of reporting by subject area in the newspapers, it can be confirmed that a social disaster does not simply end as a disaster. a disaster that had an impact on the society also influences politics and policy; in case of the collapse of the sampoong department store, it can be inferred that it had a huge impact on the economy of a country. there were news articles regarding typhoon janis from the dong-a daily news, the kyunghyang daily news, the maeil business news, and the hankyoreh. typhoon janis began to be broadcasted as it came up north on august , and there were in all reports regarding its track, weather forecasting, and damage condition until the twenty-eighth when the power of the typhoon subsided, and it left the korean peninsula. later, flood victims, damage from flood, and recovery were reported. korean air boeing crash in there were news articles regarding the korean air boeing crash near guam hagåtña airport from the dong-a daily news, the kyunghyang daily news, the maeil business news, and the hankyoreh. since the accident took place outside of korea, the media covered the accident starting the next day, on august , and there were newscasts within one day. there were in all news articles from the dong-a, the kyunghyang, the mail business, and the hankyoreh regarding the torrential downpour in august, , which caused casualties as a natural disaster. the rainfall came during summer holiday season so the damage was massive. not only that, it flooded homes and roads by sweeping the central region area without any notice, and it cut parts of a train track and the gyeongbu line road. in case of seoul, subway line flooded and was out of service as also major sections of subway lines and causing great inconvenience to commuters. this natural disaster called localized heavy rainfall had an impact on people's daily lives and economic activities, and there were news articles issued in the society section and in the economy section. the following highlights how the media covered the disaster: the munhwa ilbo article on september , (page , social section, words) titled, "fishermen anxiety over hurricane waste," described how only tons of waste had been collected out of a total of , tons along youngdong's (gangwon province) sandy beaches, which damaged various fishing gear and nets. the dong-a daily news on september (page , edition, social section, words) also dealt with the damage by the typhoon and criticized the delayed restoration by the government: it described how emergency provisions like rice and water had been delivered through military helicopters; yet victims struggled to get sleep from the cold without heaters. on september , the segye daily news featured an article titled "impact of typhoon rusa's-vegetable prices surge." the news conveyed how heavy rain along with the damage from typhoon rusa caused the price of agricultural goods like cabbage, lettuce, and other vegetables to surge. this could be considered as an economic crisis caused by the linkage between the chuseok holiday (korean thanksgiving) and damage of agricultural goods from the typhoon. in addition, the seoul newspaper (page , edition, political section, words) criticized the poor response and recovery performance by the government. it highlighted that the national government failed to decide a timely disaster recovery plan for the damaged areas due to a poor damage investigation and assessment, which was caused by the inaccessibility to the damaged areas because of the delayed recovery of damaged roads. it also pointed out the inappropriate disaster relief to vulnerable groups, such as senior citizens, many of whom had to subsist on instant meals during the crisis. apart from the three national broadcasting channels, the press featured articles on the event for two months after the incident. the chosun ilbo published articles, hankyoreh newspaper published articles, and the maeil business news published articles. the incident was featured as headline news by various newspapers as follows: five days in the chosun ilbo, six days in the hankyoreh, and over two months in the maeil business news as the main local media in daegu and the north gyeongsang provinces. in addition, the news was covered times in the general section of the chosun ilbo, times in the social section of the hankyoreh, and times in the social section of the maeil business news. from february to , , the maeil business news reported the incident times and the chosun ilbo and maeil business news released over articles respectively on a daily basis (lee ) . in the television and press coverage of the daegu subway fire incident, there had been timely analysis and reporting of incidents covering dramatic situations, responses, causes, and countermeasures. there was a continuous coverage of the incident on topics including the absence of a train-operation management system; details of materials that the passengers had carried, which were vulnerable to fire; poor safety measures at the train station; the weak disaster management capacity of the government (lee and sohn ) ; and the importance of assessing overall safety measures in all the areas served by trains. the mayor of daegu and the director of the fire department held six press conferences and interviews concerning the family members of the deceased and made three formal statements including one official statement of apology. media coverage of typhoon maemi from its occurrence near guam island to its movement out the uljin east sea and restoration activities afterward were times in all. in the dong-a daily news on september , , the power of typhoon maemi was reported to have a maximum wind speed of m/s, which was the highest since weather observation began in . it retained its destructive power until it arrived on the korean peninsula, and the size and danger of the typhoon was also reported to be unusual for early autumn. on september , the chosun ilbo reported the extent of the physical and financial losses caused by the typhoon. the masan fish market area, containing approximately sushi restaurants, lost tens of billions of won and to people were missing due to pieces of wood debris flooding in from an open storage at : p.m. on march in the masan city shipping plaza. on september , the dong-a daily news featured articles on how approximately members of a community service group were voluntarily conducting rescue activities with equipment provided by provincial governments. it also reported that about % of roads and bridges and % of electrical and telecommunication resources were recovered for use and described how the cdschq provided necessary equipment to the southern gyeongsang province by requesting all local government entities to support its recovery. furthermore, there was news on restoration involving plans to reduce telecommunication service charges, make low-interest loans available, and extend deadlines from banks. on september , , the chosun ilbo featured an article on the "hazard map," which is widely used in japan to prevent damages from floods and contains evacuation guidelines. it emphasized how the korean government can adopt japanese measures by setting up an emergency management center in the central government and implementing rapid responses to multiple disasters. on september , , the dong-a daily news reported that areas affected by typhoon maemi had been marked as a "special disaster area." on september , , the construction of debris barriers around dams in the northern gyeongsang province had prevented erosion of hundreds of tons of soil being held against potential landslides. torrential downpour in the nakdong river basin in on september , , president syngman rhee spoke about the severe torrential downpour in the nakdong river basin, one of the worst disasters in recent years. twenty-nine people were instantly killed when all the homes in yangsan-si in gyeongsangnam-do were suddenly washed away (presidential archives n.d.-d). he mentioned that in total, there were about deaths and injuries. also, it was announced that all the public should help and support the displaced wholeheartedly. on september , , president syngman rhee announced that the government would do its best to return citizens back to their normal routines after typhoon sarah had wreaked havoc with their lives while consoling those who had been physically harmed by the typhoon (national assembly ). also, the vice-president inspected the damage situation of the miryang area in gyeongsangnam-do on september , and expressed sympathy for the displaced who were accommodated in the sericulture school in miryang-si and given a gift of money. the national assembly called a disaster relief control committee meeting on october and , with a question and answer session, reported on the typhoon disaster, and made a recommendation to the government at the assembly plenary session on the seventh. the next day, on the eighth, there was a preliminary discussion among members of the committee on the recovery of the affected region by typhoon sarah and the compensation at disaster relief control committee meeting. flood in jeollabuk-do namwon-eup, gyeongsangbuk-do yeongju-gun in president yun bo-seon visited the flood-damaged area due to the collapse of the embankment in yeongju-gun of gyeongsangbuk-do and namwon-eup of jeollabuk-do and consoled the displaced in july . as a flood in suncheon occurred on august , , park chung-hee, the chair of the supreme council, announced a special statement and instructed the related departments to fully strengthen the relief measures for the flood displaced on august (kyunghyang daily news a). on the thirtieth, he received reports on the situation of the suncheon flood damage and instructed the related authorities to do their best to recover and take preventive measures for the displaced people's health (dong-a daily news ) . in the morning of september , he visited suncheon and instructed the persons in charge to supply rescue, preventive measures, preparations for the winter, emergency relief works, and systematic restoration (kyunghyang daily news b). at noon, he announced a special statement that the government would do its best to rescue the displaced and recover the flooded area. after two months, on october , he inspected the recovery situation of the flooded area in suncheon city with kim yong-soon, head of the culture and society committee, park lim-hang, minister of moc, and lee hu-rak, head of the public relation agency and instructed kim dong-bin, head of the flood countermeasure committee, to prepare for winter for the displaced. after a day of the accident, on august , hong jong-cheol, a member of the culture and society committee, visited the flooded area and asked for the recovery cost, the change on the budget, recovery projects, and the countermeasures for avoiding future damage by floods. on september , the committee approved the flood damage recovery plan in suncheon, jeollanam-do, gyeongsangnam-do and other areas, which was suggested during a cabinet meeting. as there were a lot of loss of lives and property from the torrential downpour on july , in the central region, president park chung-hee made an administrative-policy speech on the revised supplementary budget at national assembly. park said, "the government appropriated a budget of million korean won (krw) ( . billion krw of ) for the countermeasures against disasters in , but due to the unprecedented extreme drought, the reserved fund ran out. even though the government implemented a beforehand evacuation and emergency relief action against the torrential downpour from july to , there were , displaced, . billion krw ( . billion krw of ) in property damage and hundreds of casualties. therefore, the government used the established budget to supply temporary accommodations and grain relief for the displaced, while compiling and submitting a revised supplementary budget to the national assembly." further, at the national assembly plenary session on august , , parliamentarians requested the government to implement the countermeasures for the flood disaster and relief of the displaced. the day after the wow citizens apartments collapse (april ), president park chung-hee demanded the dead to be promptly found and brought to their families; recovery work to begin immediately afterwards; a field survey of other wow citizens apartment complexes around the country; a look into future safety technologies; and finally he demanded that the rest of the apartments of the wow citizens apartments complex be demolished before they too collapsed (maeil business news ) . the government and the ruling party opened a joint meeting at the republican's meeting room to discuss the countermeasures of the wow apartment collapse. the new democratic party opened an extended emergency meeting at their central party headquarters at : a.m.; they discussed the wow apartment collapse, inquired into the truth of the accident, and set a measure to reprimand the persons in charge in the national assembly at : p.m. the committee of interior and construction made the related officials on the wow apartment collapse like jeong il-kwon, prime minister, and lee han-lim, minister of moc, to be present at an emergency meeting on april , listen to the truth of the accident, and answer questions about countermeasures and responsibilities. also, the committee of interior and construction had a respective meeting and organized a lieutenant for an inquiry into the truth of the wow apartment collapse on the fourteenth. on may , a month after the accident, there was an interrogation on the wow apartment collapse at the assembly plenary session, and on the fifteenth and the sixteenth, there were questions about the disorder and the problems associated with the construction administration, the building act and the construction of the wow apartment complex at the assembly plenary session. president park chung-hee announced at a press conference on january , that the cause of the namyoung ferry sinking accident, which happened on december , , was due to an overload of passengers and loading (presidential archives n.d.-a). also, he announced that the belated response of the sos on the sinking led to a great disaster. president park chung-hee immediately ordered the fire to be brought under control at the scene of the seoul daeyeonggak hotel fire in chungmu street on december , . at the new year press conference on january , , he mentioned the seoul daeyeonggak hotel fire and pointed out that careless fire management of the buildings and the building materials were the reasons. he also pointed out the problem that the staff members of the hotel were not trained in handling fires, and instructed the related organizations to check and prepare for precautionary measures. president park chung-hee ordered the reconstruction of the iksan iri station, which was destroyed by the explosion accident on the november , four days after the accident. after he was debriefed on the recovery situation from second-chief secretary jung sang-cheon of the blue house, who was sent out to the scene to find out the situation on recovery. the president instructed the government to pay for the public officials who were doing the relief and recovery activities at fixed daily wages. also, he expressed gratitude to the iri citizens for their hard work and the public for its fraternity and warm support (maeil buisness news ). on november , ten days after the accident in , he instructed the related authorities to amend the legislation following complaints on the frequent occurrences of accidents at the trade promotion and expansion meeting (dong-a daily news ) . also during the december speech in and new year press conference on january , , the president mentioned the gunpowder freight train explosion at iri station and insisted the importance of preventing large-scale accidents and the responsibilities of particular organizations and positions. president chun doo-hwan inspected the measures against the flooding of seoul and ordered the related organizations to make full preparation on flood control for the whole han river area in case of a heavy rainfall, which could be brought on by typhoon agnes on august . on september , two days after the accident, he checked the readiness for flooding of the han river; where water levels had reached alarming rates (kyunghyang daily news ). as the whole country, including jeollanam-do and gyeongsangnam-do provinces, was seriously damaged by the typhoon, president chun doo-hwan facilitated a disaster recovery meeting in the blue house on september , , and insisted the necessity of government support and the increase of the budget for the recovery during the administrative policy speech around the submission of the revised supplementary budget on october . therefore, the expenditure of the disaster response reserve fund of the general account was decided at the cabinet meeting on november , . as the great flood in caused severe damage, president chun doo-hwan prayed for the repose of the deceased and expressed consolation to the bereaved before the speech for the formal visit to japan on september , (presidential archives n.d.-b). also, he expressed gratitude to the public for the hard work to recover from the damage. he mentioned the necessity of government support for the recovery of the flood damage at the administrative policy speech around the first submission of the revised supplementary budget of october , . president roh tae-woo visited the central disaster relief center in the central government complex in gwacheon-si on july , . he received reports of the situation of typhoon judy and the flood damage in yeongnam and honam area by director kim young-hwan of the department of water resources of the central disaster relief center. he voiced his appreciation of the hard work of the public officials working on disaster relief, and ordered to do their best for relief to the displaced and emergency recovery (dong-a daily news ). on july , president roh tae-woo mentioned the situation on relief and emergency recovery and the plan on strengthening flood-control facilities through a radio address for disaster recovery and insisted that it was important to stand as one to overcome the difficulty. the next day, on august , , he visited the flooded areas including gwangju city, naju-si, gimhae-si, and busan city and consoled the displaced (maeil buisness news korea ). at : p.m., president roh tae-woo called for the embankment to be immediately fixed and the finishing of the yeongsangang flood-control project to be finished by instead of by (kyunghyang daily news ). the home affairs committee of the national assembly opened an administrative commission to identify the analysis of the cause and the responsibility on september , and opened the committee of construction and welfare to discuss the measures on the countermeasures on the recovery of the flooded area and the medical services for displaced on the eighteenth. the korean national assembly opened two standing committees with public affairs and replacement (interior, education, and sport) on march , three days after the accident, and discussed the circumstances surrounding the accident and compensation for the victims' families. at the standing committees, members of the ruling and opposition parties pressed hard upon the minister of moi lee hae-gu, the minister of mot lee gye-si, and korea electric power corporation (kepco) officials about the need for ex-ante safety plans, ex-post plans and recurrence prevention measures, which were lacking (maeil buisness news korea a). a day after the asiana airlines boeing crash, on july , people, including the vice-minister of ministry of health and social affairs, director of the parliamentary government, and members of the assembly, visited the site. president kim young-sam received reports of the seohae ferry sinking accident from prime minister hwang in-sung right after the accident, directed life-saving works with urgency, and asked for everyone involved to do their best (hankyoreh ) . also, the president himself visited wido-myeon on the twelfth and publicly announced that the government would offer compensation, as per the law, to the victims and their families. at : p.m., hours after the collapse of seongsu bridge, the mayor of seoul city, lee won-jong, was replaced by choi byung-ryeol. also, while the investigation of the cause of the accident was proceeding, president kim young-sam held a chief secretary meeting on october , and directed poor construction companies to be eliminated from the construction industry and called for construction-related laws to be revised so that maintenance and safety management periods of buildings could be extended. also, he emphasized a continual check-up by establishing a thorough check-up system regarding roads, tunnels, and bridges as he noted that the risk of accident was everywhere (dong-a daily news ) . the next day, on october , the president made a special public statement through a national telecast. the statement contained several important issues. first, for the last years of economic development, since , there had been a positive outcome; but at the same time, there were negative outcomes such as the collapse of the seongsu bridge. there was risk everywhere of similar types of accidents and incidents. second, the government would like to promise to take all kinds of measures to minimize all risks existing in korea. third, the president gave an apology to the people with a mark that he would try hard to improve the maintenance and the innovation of the country as he recognized problems in the management system through the accident. the national assembly investigated the cause of the collapse of the seongsu bridge and sought measures to prevent reoccurrence. also, the prime minister, lee young-duk, was invited to the plenary meeting on november to discuss the cause of the accident and crisis management of the government. president kim young-sam received a report from the director of administration park sung-dal on the morning of the accident, and in the afternoon he promised he would try his best for dealing with the aftermath, and directed an investigation of the cause of the accident, preparation plans, and a basic plan for the construction and management of underground facilities. the prime minister lee hong-gu who visited the accident site submitted his report (maeil buisness news a). in spite of efforts to prevent large-scale accidents through activities at the national assembly and the government, after the collapse of seongsu bridge, another largescale disaster occurred when the sampoong department store collapsed on june , . after the accident, prime minister lee hong-gu visited the site and directed the seoul city mayor to do his best for the rescue, to lead the site, and to hold a press conference to inform the people. on the same day, the prime minister's office opened the first central disaster measure headquarters committee to prepare government-level response support measures and to seek for each ministry and administration's support plans (seoul metropolitan government ) . five days after the accident on july , , the government focused on discussions on the prevention plans surrounding sampoong department store through a cabinet meeting. in the meeting, the ministry of public affairs reported that it would introduce a special disaster area announcement system to disaster management laws, establish a safety measures committee between the central and local government agencies, and authorize the local director to be the fire defense authority. the ministry of law reported it would strengthen punishment for those in charge of large-scale disasters, and the amendment in the law was passed in the provisional session of the national assembly. the government turned in the following bill to the provisional session of the national assembly after deciding it in the provisional cabinet meeting. also, president kim, young-sam announced a statement related to a special disaster area announcement (presidential archives n.d.-c). the statement read as follows: first, the government has organized a disaster management law to enable the prevention and response activities for large-scale disasters. second, the accident site area will become a special disaster area. also, according to the announcement of the special disaster area, the government would seek special support in terms of administration, finance, and tax when it is necessary for rescue, relief activities, and disaster recovery. third, in order to eradicate poor construction and stabilize the safety culture in the korean society, the government promises to revise construction-related laws and get rid of corruption so that public officers would not commit corruption which leads to poor construction. the national assembly held a special committee on the investigation of the sampoong department store collapse two weeks after the accident on july , and adopted an investigation plan on the sampoong department store collapse as it related to the government. the investigation lasted for days from july to august . the investigation methods required reports related to the investigation, requiring documents, witness testifier appraiser, and evidence. if necessary, a sub-committee or a group would be organized to provide additional investigation. also, on september , the national assembly adopted a report on the sampoong department store collapse in relation to the government, by holding a special investigation committee and open plenary sessions regarding the accident. the chairman park woo-byung of the "sampoong department store collapse special committee," summarized the report thus, "the accident was the result of poor management caused by a lack of construction, building, inspection, maintenance, and management, and a lack of supervision from the administrative office." the collapse began on the fifth floor, and the shock of the collapse caused a consecutive collapse to the whole building due to its weak superstructure. also, through the investigation of the state administration, several problems were identified. first, there were problems in the progress of the construction such as lack of construction consistency, frequent construction changes, poor construction, and perfunctory inspections. second, a lack of public officer's professionalism ignoring manuals, corruption, a lack of management and supervision of an administrative office, were the problems. the third problem was related to the control of the accident such as a lack of a command and control system, a failure of accident-site control, a lack of rescue equipment, a delay in rescue, poor first-aid treatment, confusion in counting missing people, and a weak management of dead bodies and debris. fourth was about safety frigidity and a trend to make light of human life, which had spread in the society. regarding the problems, several suggestions were made, such as an effective and smooth control of accidents, which would be including an increase in disaster response in ordinary days, improving disaster management capacity, such as the establishment and operation of a disaster control body under the prime minister's office, and the establishment of an emergency rescue system, improvement in construction administration, such as improving construction administration's professionalism, securing safety of multiuse facilities, strengthening punishment against poor construction companies, and the legislation of construction laws, and preparing damage compensation after disasters, expanding national budget support, appropriate response to the missing people and unidentified bodies, the establishment of a massive safety accident exclusive research group, thorough investigation on public officers' corruption, and improving management capacity for missing people. on february , , president kim, young-sam emphasized disaster prevention again by mentioning efforts regarding strengthening legislation, manpower and equipment expansion, efforts to prevent accidents and incident by continual checking up and the supplementation of risk factors, and accident prevention safety checks such as embankment security, road health, and plumb blocks. typhoon janis in president kim young-sam received reports of the flood damage due to typhoon janis and localized heavy rainfall in the situation room at the central disaster control headquarters in the first government buildings for minutes from : a.m. on august . he directed that trains, planes, and ships would not be allowed to move unless a preliminary safety checkup result was carried out by mentioning the need for prevention efforts. president kim young-sam received a call from ban ki-moon, senior secretary to the president for foreign affairs and national security and a chief secretary, who gave the details of the accident and the thorough accident control plans. an hour and a half later at : a.m., he received the second report from his chief secretary, kim young-tae, and directed everyone to do their best for the rescue and for accident control to collaborate with the us government (dong-a daily news ) . also at : a.m., the president promised to do his best for accident control and directed a government-wide plan for the victims' families. two days later, he directed the vice-president to monitor the need for medical treatment at the accident site, investigation of the cause of the accident, and preparation of recovery plans at a council meeting. president kim dae-joong directed each minister to have all public officers actively participate in relief and to have flood damage measures be quickly implemented at a cabinet meeting on august , as the localized heavy rainfall continued. on the fourteenth, he directed the budget for the august celebration street march to be used for flood damage and an extra budget to be reflected in the second revised supplementary budget. additionally, on the seventeenth, he called for each institution to focus on flood damage recovery, a cooperation between federal and local governments to reduce the chance of a similar disaster from occurring, and a fundamental effort to reduce great floods from happening (office for government policy coordination ). president kim dae-joong directed flood damage measures at a ministerial level meeting for emergent flood damage control on the morning of september , , before typhoon rusa disappeared near km away from the sokcho-si seacoast at : p.m. and, he announced plans to expand and initiate government support by designating special disaster areas on severely damaged regions through a speech on "disaster revised supplementary budget" on the eleventh. also, the government turned in a revised supplementary budget plan to calculate local grant and to support damage recovery from the biggest natural disaster of all time. he promised to implement rehabilitation projects with fast damage recovery by establishing an effective damage recovery scheduling as soon as the revised supplementary budget plan was confirmed. also, on march , , president roh, in his first cabinet meeting, directed the establishment of a governmental institution at an administrative level that would fully take charge of disaster management tasks to efficiently manage all kinds of disaster. at the construction and transportation committee of the national assembly on september , , president kim received reports about the damage from typhoon rusa and about recovery measures including extra support to special disaster areas and support to flood damage recovery. he also heard reports on measures and supporting status on typhoon rusa from each ministry and administration at a disaster measure special committee. the next day, on october , a list of questions and answer on disaster recovery plans in youngdong, chungbuk where received at the national assembly regular meeting. also, in the next year on august , , the national assembly agricultural and fisheries committee received a petition on compensation to indirect damage from typhoon rusa. on february , at : p.m., there was a director-and chief-level meeting under the chairmanship of the daegu city mayor in the situation room to discuss subway fire control measures. two hours later, daegu's mayor asked the moct to announce jungang street station as a special disaster area. the next day at : p.m., the central government with central disaster control headquarter located in the moct held a support measure committee meeting to discuss supporting measures. it accepted the request of the mayor and announced areas of jungang street of the daegu subway line as a special disaster area. the prime minister and related ministers were immediately dispatched to the accident site by president kim dae-joong, who also directed the mobilization of all the national available assets, offered condolences to victims and their families, and announced the area as a special disaster area (presidential announcement no. ) . at that time, a newly elected president roh directed a recurrence of similar measures and actively participated in the response by establishing a specialized organization for disasters after visiting the accident site with lim chae-jung, the chief of committee, on february . also, president roh in his inaugural speech, comforted victims of the daegu subway fire accident and promised to make a safer society by checking and improving disaster management systems innovatively. the national assembly pointed out and discussed the existing problems and measures that had caused the accident, as the accident was mentioned in the construction and transportation committee and the home affairs committee meeting on february , which was the day after the accident. also, a comprehensive plan demanding establishment of safety measures for national disaster and hazard prevention was received at the disaster measure special committee; the bill was passed at the eighth regular meeting of the th national assembly on february . besides that, several plans were recommended, such as having the daegu region as a special disaster area, strengthening the standard of safety on city subway trains, strengthening safety education, and the establishment of an accident management coordination organization (lee ) . the committee defined the accident as a human disaster, pressed the government for an investigation and hearing, suggested various policy tools for problem-solving, urgently asked for an establishment of a disaster management organization and a special audit of the board of audit and inspection, and formed an investigation group. on september or four days before typhoon maemi was scheduled to hit korea, a special disaster area announcement was revised through a cabinet meeting chaired by the president. on the twenty-second, the revision included cities, counties and districts, excluding seoul and incheon, and eup, myeon, and dong were announced as special disaster areas (presidential announcement no. ) . through the temporary cabinet meeting on october , it was decided to draw up a second supplementary budget with trillion krw ( . trillion krw of ) in order to recover public facilities damaged by typhoon maemi in the early stages. about billion krw ( . billion krw of ) of reserve fund was secured for relief of victims and damage recovery of private facilities. also at a special committee on budget and accounts at the national assembly, reports were heard on damage and recovery measures from typhoon maemi on october , , and , . at the cabinet meeting on september , , "the agenda on collection of contributions for relief of damage from typhoon sarah" was decided. "the agenda on collection of contributions for relief of damage from typhoon sarah" was suggested because there were casualties, , damaged houses, and , displaced throughout jeollanam-do, gyeongsangnam-do, gyeongsangbuk-do, gangwon-do, and jeju island due to typhoon sarah which struck in the country on september ; so it was necessary to cope with the typhoon and devise a recovery measure as soon as possible, but it was hard to cover and afford with the government budget. therefore, to make a full preparation for the relief and recovery measure against natural disasters, the government requested contributions from the public. the contribution period was one month, from october to , , and the goal of the contribution was billion krw ( . billion krw of ) from fund raising in theaters, student donation, street fund raising, public official donation, and others (financial syndicates, corporate employees). on december , , the moha submitted "a statement on the relief of displaced from the typhoon (proposal)" as an agenda to the cabinet meeting (secretariat of state council ). the content included a gratitude to the public for accomplishing more than the goal of "the collection of contributions for relief of damage from typhoon sarah," which was implemented in october and the suggestion to use the collection for the recovery of the damage and the relief for the displaced. as the embankment collapsed on july , after continuous heavy rain in july , seven cabinet members including prime minister song yo-chan inspected the flooded area to identify the damage and assess the situation, and the government opened an emergency cabinet meeting to set up emergency relief countermeasures for the flooded area on the thirteenth. on the fifteenth, two days after the accident, the government installed emergency headquarters for flood countermeasures and its local centers and decided to provide relief and recovery in the yeongju-gun of gyeongsangbuk-do and namwon-eup of jeollabuk-do from flood damage as soon as possible. on the sixteenth, the government opened a meeting that was composed of representatives from the moha and ministry of agriculture and forestry and related officials to decide the operation policy on the installation of emergency headquarters for flood countermeasures and its local centers. on august or a month after the accident, the moha took over the recovery efforts in namwon-eup from the emergency headquarters for flood countermeasures, designating a construction agency to lead the work. the yeongju flood damage recovery office opened in the construction agency, which was an affiliated organization of the economic planning board (kyunghyang daily news ). during the suncheon deluge and subsequent embankment collapse, the moha, on august , , opened the "relief headquarters for flood damage" in the assembly hall of the ministry. the headquarters immediately started relief measures with the army chief of staff urgently mobilizing personnel and equipment from the troops near the accident to control the flood damage (dong-a daily news ) . the day after, on twenty-ninth, the government called an emergency temporary cabinet meeting to consider a countermeasure on the flood damage of the suncheon-si and established emergency and recovery countermeasures, including emergency relief. the ministry of transportation (mot) and the ministry of communication (moc) identified the damage and recovery situation of suncheon-si respectively, and kim, hyun-cheol visited suncheon-si. also, the government decided to use emergency expenses at the emergency cabinet meeting, and to install a flood damage recovery office to help in recovery of the suncheon district from the flood damage. on september , the national countermeasures committee announced the countrywide damage situation, including suncheon-si seungju-eup where there were damages due to heavy rain after august , and on september , the government established the flood damage recovery plan for the suncheon-si and jeollanam-do and gyeongsangnam-do, and decided on the cost for the recovery at the third revised supplementary budget at the temporary cabinet meeting. on the sixth, the ministry of education obtained the supreme council's approval to appropriate recovery cost for the education facilities of the flooded areas and the ministry of agriculture and forestry released the reserved rice to the flooded areas including suncheon district. also, on december , the suncheon flood damage recovery headquarters was disbanded on the decision of the cabinet meeting. prime minister chung il-kwon instructed related departments at a cabinet meeting to inspect the situations of flood disasters of each region and make a contingency plan on july , , and discharge the rice in government stock to gangwon-do where the traffic was cut off as to relieve the displaced. also, he made the ministry of national defense (mond) provide army vehicles to seoul city on july . the moc decided to investigate the condition on the entire wow apartments around the country and to sort out the poor constructions on april , , the day after the wow apartment collapse. the countermeasure committee of the wow apartment collapse of seoul city, headed by director-general kim eung-jun, decided to provide condolence money of thousand krw ( . million krw of ) per death and provide the compensation after obtaining government approval. from december to , , the special committee for inspection on the namyoung ferry sinking accident was held six times. at the second committee, there were reports of response situations from four related ministries ( prime minister kim jong-pil went to the scene of the accident right after he received news of the seoul daeyeongak hotel fire, and was debriefed on the rescue work and the situation on the accident from a related official (kyunghyang daily news a). on the scene of the accident, the minister of moha, kim hyun-ok, and seoul city mayor, yang tak-sik, took command of the operations. also at the scene of the fire, yang tak-sik ordered the establishing of a temporary rescue headquarters for the injured in seoul city hall and to place the corpses in morgues. he also made general hospitals promptly give the injured emergency treatment (maeil buisness news korea a). the ministry of foreign affairs consulted with the related embassies and authorities for the compensation of the foreigners who were injured in the accident and took actions to provide the highest compensation according to international practice (kyunghyang daily news b; maeil buisness news korea b) . four days after the accident, on the twenty-ninth, the moha provided and made the cities and provinces implement comprehensive countermeasures. this made the related authorities have special fire prevention diagnosis and fire prevention facilities for corporations that had more than employees and for high-rise buildings that had more than stories; both had to implement individual fire drills more than once a month (kyunghyang daily news c). prime minister choi kyu-hah instructed each ministry to make and implement a countermeasure to prevent severe accidents, including fire accident, to revise and supplement related regulations on safety control, and to legislate new regulations if needed after the iri station gunpowder freight train explosion as some lessons were learnt from the explosion and the jangsung-gun coal mining accident. at the same time, in accordance with measures to prevent negligent accidents, he ordered to punish persons who caused an accident due to neglect of duties and to strictly make the persons accountable, and made each ministry announce to the state enterprises and major companies that it is necessary to follow the safety regulations as to prevent negligent accidents and confirm the result of the measures (dong-a daily news ) . also, on december , , ministers and vice-ministers from ministries excluding the ministry of post office, the ministry of national unification, the ministry of finance, and the ministry of foreign affairs, the director of administrative structure reform and the seoul deputy mayor discussed measures together to prevent severe accidents at the precautionary measure meeting, which was facilitated by the prime minister. from september to , , seven ministries organized a joint investigation party and confirmed the amount of the damage after typhoon agnes. at the same time, the moha instructed the whole country to implement the "synthesis measures to support recovery of typhoon damage" on september , and announced that the government would support the farming families whose agricultural land was swept away by the typhoon with tax privileges, including farmland tax and property tax exemption for a maximum of five years and other measures for damage recovery (maeil buisness news a). also, the central disaster relief center confirmed a plan for the recovery on september , and announced a recovery project plan costing . billion krw ( . billion krw of ) for "recovery of damage from torrential downpour in the central region in august," and the "recovery of damage from typhoon agnes in september" on october (maeil buisness news b). in addition, the joint technology force including personnel from the moc, the industrial base development public corporation, the korea expressway corporation, and the agriculture development public corporation was established and operated for one month from october to , , and the members of the force were dispatched to jeollanam-do and gyeongsangnam-do provinces. the central joint investigation party, which consisted of agents, investigated the damage by typhoon judy in cities and provinces including busan from august to , . on september , the central disaster relief center meeting was held and a . billion krw ( . billion krw of ) recovery plan was determined. on september or two days after the collapse of the ilsan region levee, the moc released a plan to fundamentally reinforce and strengthen the han river embankment (dong-a daily news ). after the accident, which took place in buk-gu, busan on march , , all the officers in the busan station, busan city, the busan national railroad, and the police were mobilized, and an emergency headquarters was established. also about people, including public officers, soldiers, police officers, fire-fighters, and civil defense members, gathered to begin recovery works. the next day, on the twenty-ninth, a related ministerial committee, headed by the prime minister, and a working-level committee with the vice-minister of mot as the chairman were formed. also, the prime minister, the minister of mot, and the minister of ministry of health and social affairs visited the accident site and consoled the victims. also, on the thirtieth, the prime minister, hwang in-sung, announced a statement to the nation. the minister of moi, lee hae-gu, established an emergency headquarters at the accident site regarding the asiana plane crash in the afternoon on the day of the accident occurrence, and directed the governors of jeollanam-do and of haenamgun to take steps to search for survivors and medical plans for the injured. also, the minister of ministry of national defense, young-hae, sent uh h helicopters for troops carrying of the second army command at the accident site. the prime minister, hwang in-sung, visited the emergency headquarters located at the tongbu situation room that night to direct officers to make a correct investigation into the cause of the accident and relief for the injured (maeil buisness news b). the next morning, the prime minister himself visited the local emergency headquarters to comfort the victims. the ministers of public affairs and of transportation too visited the site and directed control of the accident themselves and comforted the injured. two days later, prime minister hwang called an emergency meeting at the central disaster measure headquarters to discuss control of the asiana airlines boeing crash and prevention measures of recurrence of large-scale accidents such as a plane crash (maeil buisness news c). prime minister hwang in-sung, after giving a report to president kim young-sam about the seohae ferry sinking accident, deployed the minister of moi, lee hae-gu, the minister of mot, lee gye-ik, the administrator of korea maritime and port administration, yeom tae-sup, and of the national maritime policy agency, park il-yong, to the accident site according to a presidential order. also, he directed related ministries and administrations to do the best for rescue and an investigation of the cause of the accident. at the same time, he directed to quickly seek response measures to victims by establishing an emergency headquarters at the central and local maritime and port administrations. also, regarding compensation, at first he announced that there was no government-level compensation at the central disaster measure headquarters meeting of which the prime minister was in charge, but on the fifteenth, he directed to the ministers of public affairs and of transportation to take legal and administrative measures to offer compensation to their best abilities (dong-a daily news ) . after the collapse of seongsu bridge, the government took various efforts to rectify legal and institutional causes of poor construction by construction companies. as a result, the government initiated "the prevention measure on poor construction and the ensurement of building safety" (ministry of construction ). this was a measure to strengthen safety on private buildings by recognizing the limit of the past poor construction prevention measures after the collapse, and was connected to "the prevention measure on poor construction and strengthening competitiveness of construction industry" announced the following year by the moc on february , , as a measure to strengthen safety on private buildings. this measure earned a positive evaluation as it promoted an institutional advancement for private buildings safety and security by strengthening multiuse buildings related systems. however, the basis of the institutional measures was focused on strengthening the construction industry such as internationalization of the construction system, building a basis for competition, nurturing construction manpower, employment stabilization, specialization and improving responsibility of construction institutions, building quality management systems at construction sites, and strengthening support for construction companies. however, these were felt insufficient for solving the fundamental problem of structural safety improvements, and many of the detailed contents were irrelevant for prevention of poor construction. as a result, the moct in started to view the problem of poor construction from a construction company's stages of planning, design, construction, and maintenance management by announcing the "comprehensive measure on prevention on poor construction of construction company." on the day of accident, april , , the prime minister, lee hong-gu, canceled an executive council meeting, directed a local emergency rescue team headquarters with the mayor of daegu city in charge, and directed prosecutors and the police to conduct a thorough investigation of the cause of the accident by establishing a central disaster measure headquarters with the minister of moci, park jae-yoon, as the chairman. also the head of ministers called an emergency measurement committee with executive members of the prime minister's office, to address the circumstances surrounding the accident and damage and to implement measures such as building a central safety checkup control group, and the minister of ministry of finance and economy, hong jae-hyung, directed a necessary budget review (maeil business news b). three days later, on may , prime minister lee opened the fifth central safety checkup control committee and prepared measures for improving gas safety management systems. after president kim young-sam's statement on special disaster area announcement and the national assembly's report on the resulting investigation with the sampoong department store collapse investigation committee, the government held a cabinet meeting on september , submitted a bill on governmental recommendations made after the sampoong department store collapse investigation and passed a resolution without changes (national assembly ). accordingly, prime minister lee hong-gu asked related ministries and administrations to analyze recommendations by the national assembly and actively reflect them into policy. also, he made sure to proceed a safety culture movement so that each individual would promote a sense of safety and to stabilize an administrative feature that prioritized safety. the central disaster control headquarters announced a temporary total of casualties, property loss, and flooded farming area caused by typhoon janis (dong-a daily news ) . also, the government decided to direct to billion krw ( . to . billion krw of ) of flood damage recovery to the revised supplementary budget as there was more severe damage from typhoon janis and the localized torrential rain in the latter part of the previous month than what was expected (maeil buisness news b). on the day of the accident, prime minister ko gun called an emergency ministerial level meeting at his office at : a.m. to discuss the number of survivors, cause of the accident, whether or not the black box was found, and response of the local control tower at the moment of the accident. at : a.m., the second ministerial level meeting was held at the welfare officer at the government buildings. in the second meeting, what had been discussed during the first meeting was inspected by each ministry and administration, and the prime minister directed the minister of ministry of foreign affairs, yoo jong-ha, about the deployment of doctors (kyunghyang daily news ) . the third meeting for accident control checkup and future-plan discussion was held at : a.m. on the seventh, and meetings under the chairmanship of the prime minister continued for an additional times for an effective response to the disaster. the minister of ministry of foreign affairs, yoo jong-ha, took an emergency call in the early morning, arrived at an information situation room, directed an emergency order on response measures such as a local public investigation on the accident and survivors, as well as medical treatment to the injured. the ministry of national defense activated a hotline between the rok-us combined forces command and the military base in guam for smooth rescue at the site. also the moct formed a central disaster control headquarters of which minister lee hwang-kyun became the head and the head of aviation department, son soonyong, became lee's aide to assess the situation and proceed with the response measures for the accident. also the moct established the aviation safety comprehensive plan and traffic accident reduction comprehensive plan in december and opened a meeting of rok-us combined investigation team into the korean air accident site supplementary investigation team (january - , ) on december (ministry of construction and transportation ). also the moct wrapped up the rok-uk combined investigation and held a combined meeting from january to . the acting premier, kim jong-pil, held a press conference on flood damage on august , and announced a comprehensive flood-damage recovery plan. also, the minister of moi, kim jung-gil, and the minister of ministry of finance and economy, lee kyu-sung, announced the necessary budget for recovery. the government confirmed an individual support fund for those who died and were lost during the localized heavy rainfall in , and billion krw ( . billion krw of ) was given to a householder and billion krw ( . billion krw of ) was given to a member of a household of the bereaved family (dong-a daily news ) . after the new prime minister's inauguration, on february , he went to daegu to pay his respect at a memorial altar at the daegu citizen's hall for the people who perished during the daegu subway fire. the prime minister heard from the people during the service that they didn't trust the daegu city officials to conduct an impartial and thorough investigation into the accident. they asked the prime minister to help them raise safety standards and figure out what really occurred. the prime minister promised to take an active role by deploying a special committee chaired by a vice-minister (board of audit and inspection of korea b). also on march , a special support group under the chairmanship of kim jungyang, the chief of appeals commission, was sent to daegu and was given the mission to deal with the central special group tasks from the victim's perspective to re-establish mutual trust through talking with the families of victims. a head of an administrative department who chaired each presidential meeting of the accident control headquarters, delivered the contents of conversation between the families of victims and the chair of the central special supporting group. it was instructed to each representative that a channel of communication with the bereaved families would be unified to a central special supporting group. thus, regarding the relationship between daegu accident control headquarters and the central special support group, the chair of the central special supporting group would lead the accident control headquarters and the central special supporting group had a final decision-making authority by first hearing the opinions of daegu stakeholders. at the th central safety-measure committee meeting, under the chairmanship of the prime minister on august , , billion krw ( . billion krw of was confirmed for required materials related to the daegu subway fire accident (reserve fund ; special grants ; increased grants ; daegu ). as typhoon maemi hit the peninsula at : a.m. on september , , a disaster measure committee with ministers and head administrators from ministries and administrations such as the ministry of education, the mond, the ministry for food, the moct, and the ministry of maritime affairs and fisheries was held under the chairmanship of the ministry of government administration and home affairs, and a ministerial-level damage recovery meeting took place under the chairmanship of the prime minister at : a.m. the meeting was to vote for urgent support plans, such as reserve funds for disaster emergency recovery and immediate recovery measures of livelihoods and related facilities, such as power, communication, roads, and railroads. the next day, september , the ministers of the ministries related to flood damage such as the ministry of planning and budget, the ministry of government administration and home affairs, ministry of commerce, the ministry of information and communication, the moct, and the ministry of maritime affairs and fisheries visited busan city, gyeogsangnam-do, gwangwon-do, and gyeongsangbuk-do to assess and direct damage recovery. on the same day, the prime minister visited the central disaster control situation room, directed quick estimation of damage costs, emergency recovery planning, early emergency recovery of livelihoods and related facilities, such as power, communication, roads, and railroads, and sought for immediate support plans, such as reserve fund for disaster emergency recovery. a government coordination officer opened a vice-ministerial level damagerecovery measure meeting on september , , to review damage recovery status, measures, and recommendations, and on the next day, the eighteenth, the prime minister held a damage-recovery measure meeting to discuss fast tracking of recovery measures to the damaged facilities as an agenda item (nidp ) . the prosecution set up a policy to expose fraudulent constructions, slapdash constructions, and constructions based on personal considerations of the entire cooperative apartments in seoul, and carried out overall investigation, taking the wow apartment collapse on april as an opportunity. the prosecution team investigated the problems and causes of the accident and interrogated officials in charge of the apartment construction in the district office, workers from the construction company, and subcontractors. the prosecution investigation found the following: (a) wow apartments were constructed without footing beams, (b) instead of -mm rebars in a beam only were used, (c) cement was not blended as specified, and (d) the weight of the buildings was supposed to be kg per m as per the plan, but the real weight was around kg per m . the more than kg per m excessive weight was partially due to individual homes adding stone floors, and bringing in heavy furniture such as pianos and briquettes. the planning engineers had taken such action by residents into account; however, they had significantly underestimated the additional weight that would be added to the superstructure. the excessive weight was found to be the fundamental catalyst for the collapse (seoul city ) . the cause of the namyoung ferry sinking accident was the overload of passengers and loadings, and the belated response of the government authority on the sos led to the great disaster. many complex factors contributed to the fire: (a) no implementation of a predelivery inspection, (b) the deviation from the blueprint by omitting an external emergency staircase, (c) omission of sprinklers, (d) poorly installed air conditioning units on all floors, (e) the omission of a "smoke tower," and (f) no heliport (lee ) . additionally, the built staircase acted as a fire conduit and the material used during construction and interior furnishing accelerated the fire (korea fire safety association ). also, the following could also be pointed out: omission of fire-extinguishing facilities and smoke prevention facilities in elevator shafts, no fire safety training for workers, neglecting safety management of fire-extinguishing facilities and fire protection facilities from the person-incharge and so forth. an investigation team into the cause of the "gunpowder freight train explosion at iri station" on november , assigned by the national assembly special committee on budget and accounts, found a staff supervising deliveries during the loading of dangerous products, neglected to secure personal belongings, did not consider safety measures as important and therefore neglected many safety protocols (national rescue headquarter ). in order to investigate the asiana airlines boeing crash near mokpo airport on july , , public officers from the mot were mobilized for days from august to , to initiate a special safety checkup on asiana's flight maintenance and safety management. a disaster control committee established by the minister of moi on september looked into whether special disaster areas should be announced. in the mot's department of aviation's september investigative report, the "result on the special safety check-up on asiana," was that asiana was woefully suffering from many insufficient safety measures. the investigation found that asiana had forgone such things as a safe-flight management system, high-tech support for mechanics, or nurturing a culture of excellence in order to focus on expanding the business abroad and meet the high demand for flight travel. the report included glaring issues that needed remedying: in-flight management problems, equipment and maintenance management concerns and safety management issues. an investigation by public affairs against the national police was conducted on october , as there was a criticism that the structure of the national maritime police agency, with a focus on security, should be revised to focus on public maritime safety systems. during the construction of the seongsu bridge, the political and social environment was more concerned about time than quality. this led to contracts being won by companies that would promise to finish a project as quickly as possible instead of regarding the construction of a safe or quality product. this phenomenon was nationwide as also a lack of a technical supervising system to oversee construction or a mandatory budget to conduct maintenance by the winning construction company (seoul district prosecutor's office ) . the causes of the collapse in terms of design, construction, and maintenance management based on "seongsu bridge thorough safety checkup report" by the korea society of civil engineers and "collapse cause investigation appraisal report" by seoul district public prosecutor's office were as follows: • design all the dead loads and live loads loaded to the suspension truss where the collapse occurred were connected to anchor truss by only six vertical members. at the bottom of the hinge part, which link the suspension and anchor truss, a transverse bracing was divided. though there was a structural systematical mismatch since a transverse load such as wind load and suspension load are asymmetric, after the three-dimensional interpretation, even regarding the total load, the vertical members did not exceed the maximum capacity, so there was no direct cause in design. the direct cause of the collapse was poor welding of vertical members, which were the core elements to connect suspension truss to anchor truss. after radiographic investigation tests, among connections of the bridge, were identified with defects. compared to the mm thickness of vertical member, the actual depth of penetration was only mm, and the available depth of penetration of some was merely mm. though the bridge was designed with db- and dl design loading, the design loading increased to db- and overloaded trucks rapidly increased. in spite of this situation, a practical maintenance management such as a thorough safety checkup was not done due to lack of a maintenance management budget and a rigid budget operation system, which became a cause that failed to prevent the accident. after the accident was taken care of, seoul city announced to reopen traffic after three months by repairing the intact parts but citizens were against the idea. therefore, the policy was retracted and it was decided to newly construct the bridge. from april , hyundai engineering and construction began to rebuild the seongsu bridge and completed it on july , , and the traffic was reopened on the same day. on the other hand, the dangsan bridge for trains, which was built with a similar truss method after the collapse of seongsu bridge, became a subject of safety checkup and was reopened on november , after demolition and reconstruction. on april , , the day of the accident, the president ordered an investigation of the entire seoul subway lines. the new order strengthened an earlier plan to inspect the lines for pending disasters by the board of audit (maeil business news a, april ). the cause and problems of the collapse were investigated in terms of design, construction, and supervision: originally, the principle was that a building should be constructed following design documents that were accepted by an approval administrative office, and if design was to be changed, a design change should be approved in advance. however, sampoong department store ignored such design-change procedures, and constructed by applying another design document rather than approved design documents. after completion, it was revealed that public officers were given bribes and the sampoong department store received a design change approval, which was an expedient. in fact, the actual design documents severely lacked pillar diameter, steel bar diameter, and its number compared to a structural bill. also, employees were not fully equipped to calculate construction and had to use a poor design document that was randomly written by the construction company. this became one of the reasons the structure was left vulnerable. in addition, design documents were supposed to be completed before construction began; but in case of the sampoong department store, there was no systematic construction management since the building owner frequently asked for design changes, and the construction company had to often turn in a design document by production process and by floor. along with poor design, poor construction practices were widespread, such as poor connection in slab reinforcement where the collapse began in the pillars, iron bars between bearing wall and slab, and other places. also, the collapsed rooftop of building a's thickness of concrete was constructed thicker than the design, and as restaurants entered in the fifth floor unlike the design, a severe overload occurred due to large refrigerators, masonry walls, and rock gardens. similarly, four cooling towers (about tons) were placed at the back side of the rooftop of building a and were moved to the front side afterward which severely damaged the slabs. even after completion, the bearing walls were disturbed in order to install a ventilation duct in the kitchens of the restaurants. the architect and engineering office that won the design contract along with the supervision contract did not carry out daily supervision of construction until the frame construction was finished because the owner, the sampoong construction company, did not pay the daily supervision cost. also, after the frame construction was completed, an employee who was not qualified to supervise was sent to the construction site to execute supervision and directing tasks, and he turned in a falsely written local investigation to the public office in charge. the final announcement of the investigation on the korean air boeing crash occurred on august , , and was opened to the public on november , , at the board meeting of the us national transportation safety board (ntsb). the reason for the two-year delay was the process of investigation by the ntsb that needed a longer time since it went through a complex procedure for massive disasters such as local investigation, truth investigation, public hearings, technical review, and final investigation report review. the ntsb found that a flight captain could not perform all the required tasks during approach adequately after investigating the flight, the communication with the control tower, and the rescue team, looking at the approach procedures, and consulting with the korean commercial arbitration board (kcab) of moct, and the federal aviation administration (faa). additionally, the ntsb found that the copilot and the flight engineer did not check their monitors and each other when the captain was trying the approach, the captain was fatigued, and the korean air flight attendants were inappropriately trained. also, the faa found that the minimum safe altitude warning mechanism malfunctioned (ministry of construction and transportation ). an october investigation into the damage caused by typhoon rusa ( ) found the precipitation caused by the typhoon to be . mm, which was % of the yearly average of rainfall in the gangneung-si region. although the heavy rain was the fundamental cause of the damage by the record-breaking typhoon, other factors such as a lack of appropriate response measures to disaster and a lack of awareness also led to intensifying the damage (nidp ) . according to a result of inspection on natural disaster preparedness status done by the board of audit and inspection in april , several problems were pointed out, such as in the management of slope and cutting area caused by road construction and not considering heavy rain in terms of design and management of stream facilities (board of audit and inspection a). in the aftermath, the natural disaster preparedness status inspection report showed similar problems, such as a lack of safe securement in dams and measures against climate change, mismatch in basin unit flood control and stream area-related regulation, mismatch in national stream assignment and inappropriate management. also many causes for natural disasters were identified, such as an absence of disaster and hazard management task control and coordination system, lack of investigation system for establishing the reasons for the casualties, absence of adequate local finance for alleviation measures by local public management facilities during damage recovery, inappropriate installation and management of weather radar, inappropriateness of long-term plan for dam construction, and lack of an automatic rainfall alarm system. in september , the board of audit and inspection's supervision board found that the moct's "rule on city subway train safety standard," was lacking in details when it came to regulating inflammable materials in the interiors of the trains.. additionally, train-purchase institutions such as the daegu metropolitan subway corporation did not consider specifying interior panels, seat covers, seat cushions, or flooring's resistance to fire, which allowed the manufacturers to use material based on cost and not fire resistance (board of audit and inspection of korea b). along with this, train manufacturers approved a resistance to flame test of interior materials only to newly manufactured trains. furthermore, corporations that executed inspection tasks did not obtain a report from an official examination organization for a test of interior materials, but rather had manufacturers provide those reports. additionally, when a train manufacturer first turned in a test result, nothing was claimed for interior materials manufactured by subcontractors without an approval of the ordering body. in addition, there was no necessary corrective action that took place regarding individual businesses passing the test and other interior materials being manufactured and delivered. after all, the lack of institutional tools and the absence of morality of those who manufacture, manage, and direct train worked as a complex cause and created a material that was not resistant to flame and emitted toxic gas according to the board of audit and inspection. the national institute for disaster prevention's october report on typhoon maemi found that the main cause of the damage was due to several overlapping factors as follows: (a) an intense hailstorm, (b) the typhoon landing during high tide, and (c) ten deaths occurring in an underground karaoke club in masan-si. the typhoon had a maximum wind speed of m/s, released mm of precipitation in the korean interior over hours (youngdong area, gangwon-do and gyeongsangnam-do), snapped electrical poles and steel towers, and left , , households without power (nidp ) . as the korean government was established in , the division of water resources, which took charge of damage from storm and flood, and the division of fire service, which took charge of fire, were established as basic organizations for the response to the disasters under the moha, and the coast guard team, which took charge of the disaster work at sea was also established. the organizations were established, but the level of the response to the disaster was not high enough, and if there was damage from storm and flood, the main measure was rescuing the displaced, which depended on international aid. since the five-year economic development plan was implemented in the s, the countermeasures on storm and flood damage were systematized. as the moc, which was expanded, took charge of the disaster work in , structural measures like embankment construction and river refurbishment were implemented. in addition, fundamental acts on disaster management were passed in the s. in , rescue and aid at sea and in the river act was passed, and in , countermeasures against storm and flood act was passed, and in , fire service act was passed. storms and floods were continuous in the s and the s, so the government invested continuously to construct infrastructure to prevent storm and flood disasters. regardless of the effort of the government, due to rapid urbanization and industrialization, the risk of storms and floods in the urban areas continuously increased as lowlands were developed. in such situations, the rain, which poured intensively for five days in the gyeonggi-do on september , greatly damaged the area including the ilsan-si, and this worked as an opportunity of the change the history of disaster management in korea. the torrential downpour from september , , recorded mm of average precipitation and caused big and small damages throughout the country. as there was a flood risk situation at the ilsan levee on the eleventh, emergency reinforcement work was implemented. goyang-gu officials and soldiers were mobilized to pile up sandbags on the levee. however, at : a.m. of the twelfth, a patrol team found a symptom that the levee could collapse, reported the crisis to the superior authority, and requisitioned emergency support. the related officials were mobilized urgently at the site while asking the residents to evacuate, but before the supporting labor and materials arrived, the lower part of the levee started to collapse at around : a.m., and around : a.m., as the lost width of the levee reached m, goyang-gu was flooded. this great disaster is called the "collapse of levee in ilsan region." on the day of the collapse, there were four news articles, and on the day after, there were articles reporting in the social column, political column, and economic column of the hankyoreh, the dong-a daily news, and the kyunghyang daily news. some titles were "collapse of levee in ilsan region is man-made disaster (social column of dong-a daily news on the thirteenth)," "shocked by the collapse of levee in ilsan region . . . belated countermeasures (social column of dong-a daily news on the fourteenth)," "ignoring the reinforcement work on ilsan levee was a delinquency of duties (political column of dong-a daily news on the thirteenth)," " -year-old worn out levee . . . seoul city gets only interested in demonstrative administration (social column of dong-a daily news on the thirteenth)," the cause of the accident was considered as a man-made disaster and not a natural disaster. the recovery of the "collapse of levee in ilsan region," which caused deaths and , casualties started one hour after the collapse with the instructions by president roh tae-woo at : p.m. the president instructed the cabinet to devote all energy to recover the destroyed and washed away levee, roads, bridges, railroads, and houses and to mobilize authority power and officials to minimize the damage to the crops, and instructed particularly the ministers of home affairs, construction, and the national defense to mobilize equipment and military strength and to support as much as possible. also, after two days, on the fourteenth, the moc announced the han river bank reinforcement plan, which stated the start and completion of the bank from haengjudaegyo to the goyang-gu isanpo section ( km) of jayu st section, which is located from the northern han river to tongildongsan, by the end of to fundamentally reinforce the collapsed han river bank. also, the home affairs committee of the national assembly set up an administrative commission to identify the cause of the chungju dam overflow with the collapse of the han river embankment. the problems identified were as follows: first, the conventional stream management was a dual system where the responsibilities were separated into the moha in charge of management and maintenance work and the moc in charge of improvement and repair work of the stream. second, there was an improper management and lack of risk management capacity at the moha. therefore, the countermeasures against storm and flood act was revised with additional articles since the government organization act was amended by the act no. on december , , and the work on disaster prevention measures moved from the moc to the moha. the "collapse of levee in ilsan region" was an accident, which demonstrated that the disaster work done mainly by the moc after was improper, where there was rapid urbanization and industrialization. as a result, the work on measures against damage from storm and flood that focused on the construction of solid infrastructure due to the characteristics of the moc moved to the moha that focused on disaster management by cooperation with the local governments. meanwhile, the cooperation of the local governments meant the cooperation of citizens at the local governments. therefore, it can be interpreted that there was a transformation of the disaster management from one-way management where there was only the government to a two-way management where there was cooperation between the government and the citizens. from the amendment of the government organization act on december , , the work on disaster prevention measures was managed by the moha. from the s, korea went through various social disasters. there was a fire accident in a night club in october , a bus plunge accident on honam expressway in april , a fire accident at uam apartment in cheongju-si in january, , the gupo station train overturn accident in march , seoul neurosurgery clinic fire accident in buchang-dong, nonsan-si in april , asiana airlines boeing crash in july , the seohae ferry sinking accident in october, , the seongsu bridge collapse in october , ahyun gas explosion accident in december, , and the sampoong department store collapse in june . particularly, the seongsu bridge collapse and the sampoong department store collapse were the disasters that shocked the public. the reasons were as follows: first, a bridge and a department store are places open to everyone, where anyone can be the victim of an accident. second, a bridge and a department store are places where a large number of people flock, and everyone is vulnerable. lastly, a bridge and a department store are not considered as structures that can collapse. this can be noticed from the articles in the press. for example, most of the major newspapers covered the catastrophic events as a front-page story, while opinion columns criticized the government's failure to prevent the accidents and requested the development of comprehensive countermeasures. the shock of the public and the various ripple effects on society were reflected immediately in politics and policies. in case of seongsu bridge, president kim young-sam mentioned the expulsion of the companies that have done weak constructions and directed the amendment of the acts related with construction the day after the accident. three days after the accident, on october , he announced a special statement to the nation that covered an apology through national television. at the national assembly, the cause of the collapse was identified, the countermeasures were considered to prevent the recurrence, and the cause of the collapse and the responsive attitude of the government were discussed with prime minister lee yung-dug at a regular session on november . a year after, on january , , the special act on the safety control of public structures (act no. ) was passed to protect lives and properties of the public and improve the utility of public structures through safety inspection and proper maintenance. after the sampoong department store collapse, president kim young-sam announced a statement on proclamation on special disaster areas on july . it included the following measures: first, the government established the disaster control act so as to make the actions on prevention and countermeasures systematic and smooth for severe accidents due to disasters. second, the government proclaimed the site of the sampoong department store collapse as a "special disaster area." according to the proclamation of "special disaster area," the government announced that it will provide special support in terms of finance, banking, and tax relief for the rescue and relief actions and disaster recovery. third, the government promised to amend acts related with construction as to expel weak constructions and set up a culture of safety in korean society, and eradicate corruption so as not to make public officials commit corruption and irregularities. the national assembly opened a special committee on the inspection of the sampoong department store collapse and adopted the plan on investigation of the state administration of the sampoong department store two weeks after the accident, on july , and carried out the investigation of the state administration for days from july to august , . the disaster control act (act no. ) was passed on july , . it aimed to establish disaster management systems for the national and local governments and to build emergency rescue recovery systems, which are needed to prevent and resolve a disaster like severe accidents, which can greatly damage lives and properties of the public. this was to make life of the people secure from various social disasters, like the collapse of the seongsu bridge and the sampoong department store, which greatly shocked the public in the early s. also on october , there was a reorganization of the moha and the affiliated organizations (presidential decree no. ) to strengthen the disaster management organizations of the moha. as a result, the office of civil defense of the moha was reorganized as the headquarter of civil defense and disaster management; an internal disaster management division was also established; and the national rescue service was also established under the central fire academy of the moha. also in the office of the prime minister, the coordination office for safety management and the director-general's office for gas safety management in the moci, and the director-general's office for construction safety management in the moct were established, and in december, in terms of reinforcing the local disaster management organizations, the civil defense bureau in the metropolitan and provincial governments were expanded and reorganized to the civil defense and disaster management bureau. in addition, the disaster management division was established in all local governments. in august , typhoon rusa, which damaged the country the most after typhoon sarah in , occurred, and typhoon maemi occurred, which recorded hpa which was the lowest central pressure after weather observations began in korea. also, a catastrophic fire accident happened in a daegu subway station on february , , due to arson, and the crisis plunged the society into sadness and chaos. the social interest surrounding typhoon rusa in and typhoon maemi in can be noticed by the amount of the articles reported by the press. a closer look at the press releases related to typhoon rusa show that there were articles before the disaster, and articles during the disaster, and after the disaster. also, in case of typhoon maemi, there were articles where of them were released during the typhoon and of them were released for days after the disaster. that there are a lot of articles released means the increase of social interest, and this brought changes in politics and policies. at the emergency meeting on flood control measures of the concerned officials, president kim dae-jung directed a flood control measure in the morning before typhoon rusa dissipated around : p.m. on september , , km away from sokcho sea. on the eleventh, he designated the areas where there were severe damages as special disaster areas through the speech for revised supplementary budget for disaster recovery, expanded the government support, and announced the plans to be implemented. president roh moo-hyun examined the designation of special disaster areas through a cabinet meeting on september it was four days later that typhoon maemi struck, september . on the twenty-second, he designated cities, counties and districts, and eup, myeon, and dong, excluding seoul and incheon, as special disaster areas. on october , he drew up the second revised supplementary budget of trillion krw ( . trillion krw of ) to recover public facilities from damage of typhoon maemi in the early stages through a temporary cabinet meeting. he ordered release of billion krw ( billion krw of ) of emergency fund to relieve the displaced people and recover private facilities. this kind of response strategies of the presidents, due to the two severe typhoons, impacted the policies on damage recovery, established "special disaster areas" through countermeasures against natural disasters act (act no. ) in september after typhoon rusa, and the task force for the countermeasure of flood damage was installed (presidential decree no. ) on november , . these changes related not only to natural disasters but also to social disasters. highlevel officials' meetings were held under the leadership of the daegu city mayor and discussed countermeasures on metro fire accidents at : p.m. on february , , in the situation room on the second floor of the daegu city office hours after the daegu subway fire accident in february . also, after two hours, daegu city mayor suggested to the moct that the damaged area near jungang st station to be designated as a special disaster area. and the day after the accident, at : p.m., the central government discussed the support plan by opening the support measure committee under central accident countermeasure headquarters that was formed in the moct, and accepted the suggestion of daegu city mayor to designate the jungang st station area of the daegu subway line number as a special disaster area. president kim dae-jung urgently sent the prime minister and ministers of related government departments, instructed to mobilize available national assets, expressed his condolences to the bereaved families, and designated the accident district as a special disaster area. as the president-elect roh moo-hyun received the situation report on february , he aggressively intervened by directing countermeasures to prevent recurrence and visited the accident site with the chairman of the committee, lim chae-jung, on february ; he promised to install an organization exclusively for disaster management. from the occurrence to response, recovery, and identification of the daegu subway fire accident, the president, the national assembly, and the government coordinated continuously for effective implementation. in this is not just the establishment of a new agency, but it is the establishment of the organization in charge of natural disaster and human-caused disaster as an independent agency for the first time in the republic of korea. and on january , the entire special act on the safety control of publicly used establishments was amended, drastically strengthening preventive measures as to fundamentally cope with the risk of natural disasters increased by climate change. the dynamics of policy change through the policy window is summarized in fig. . . the result of applying the disaster-triggered policy change model to the korean case indicates that the relation between the focusing event and institutional reforms for disaster response is path dependent. disaster-triggered policy change happens when the policy window opens with the interactions of the political streams, policy alternatives stream, and problem stream triggered by increased attention in the wake of major disasters. among the three streams in kingdon's model, the political stream plays the most important role in policy change: the president is the leading power for policy change, while the national assembly plays as the pushing power. government actions to resolve the crisis and coming up with countermeasures plays as a driving power to follow up the president's political will, and problem stream with the cause analysis by the audit office or research institute lays the foundation for the policy change. in addition, abruptly increased press release pulls the gear for policy change by sparking public attention. figure . explains well the dynamic process in the wake of disasters from to in korea with the disaster-triggered policy change model. the most important finding in the analysis is that the president's political will plays as a leading power for disaster response policy change in the wake of disasters. the president's political will can be classified into three grades: announcement on the innovation of disaster management system; apology statement or order in cabinet meeting; and statement in the national assembly. as analyzed above, disaster response policy change after focusing events in korea is closely related with the president's political will. particularly, after , . disaster-triggered policy change in korea strong political will of the president to improve the disaster response system is reflected in the disaster response policy change in the wake of major disasters having large death tolls. the relationship among the impact of events, political will, and probability of disaster response policy change can be expressed in the form of the graph below. figure . shows the disaster-triggered policy change model in korea. in summary, the korean case model for disaster-triggered policy change shows that the disaster with high impact will drive the institutional reforms for effective disaster response when it is combined with high political will. maeil business news ( , april ) mayor kim's resignation seems to be repaired. government pays full attention to restoration and relief maeil buisness news ( a, december ) relief headquarters installation maeil buisness news ( b, december ) ministry of foreign affairs, foreign casualties relief and close cooperation with the embassies concerned maeil buisness news ( , november ) construction of iri station under president park's instruction maeil buisness news ( a, september ) farmers who had more than % crop damage will be exempt from the land, property tax maeil buisness news ( b, october ) billion-won will be spent on flood, hurricane restoration billion spent by the end of the year maeil buisness news ( , august ) finish flood control of the youngsan river until maeil buisness news ( a, march ) resumption of discussion of the train accident compensation maeil buisness news ( b, july ) the plane broke in two, and the passengers were shouting for help maeil buisness news ( c, july ) government gave consideration to private transfer of military airport maeil buisness news ( a, april ) political and official world extremely alarmed and make every effort to control the situation maeil buisness news ( b, september report on the accident of daegu subway fire cohen md, march jg, olsen jp ( ) a garbage can model of organizational choice ) rok ii corps was mobilized every effort to prevent major accidents president roh urging the authorities to do their best for relief of victims jayu-road in ilsan will begin construction as a bank of han-river in the year the cabinet tried to read the president's face dong-a daily news august ) dawn emergency meeting. emergency control group dispatched, request personnel and equipment mobilization to the disaster theory: an interdisciplinary approach to concepts and causes. butterworth-heinemann hall pa ( ) policy paradigms, social learning, and the state: the case of economic policymaking in britain the study of public policy policy analysis: a political and organizational perspective analysis of super supermarket regulation and policy changes based on advocacy coalition framework (acf) a study on the disasters broadcast by tv : a case study on daegu subway fire study for the policy evaluation and conflict analysis of the reserve rental housing policy by kingdon's "policy window" model agenda, alternatives and public policies, update edition, with an epilogue on health care development of fire safety standard for high-rise buildings korea press and foundation/reporter association of korea th reporter forum ( ) problem of disaster reporting and proposed disaster reporting standards flood restoration project of yeongju-eup and namwon-gun kyunghyang daily news december ) ministry of the interior indicated that companies employing over people need to receive fire drills more than four stories tall september ) pay full attention to prevention of han river flood the sad news of korean air flight disaster was reported, and related departments ran emergency systems exploratory study on the policy process after catastrophes events the lessons of the daeyeonggak hotel fire a study on learning process and policy change by analyzing the case of sungraemun fire event : using birkland's policy learning model a study on the major disaster reports of newspapers : case studies on sanpoong department store collapse in and daegu subway fire in disaster management, life and power press lipsky m ( ) standing the study of public policy implementation on its head seoul district prosecutor's office ( ) white book of investigation activities for the cause of seongsu bridge collapse october ) emergency instructions for lifesaving and ministers sent weible cm, sabatier pa ( ) handbook of public policy analysis: a guide to the advocacy coalition framework key: cord- -hslnkv p authors: ke, kai-yuan; lin, yong-jun; tan, yih-chi; pan, tsung-yi; tai, li-li; lee, ching-an title: enhancing local disaster management network through developing resilient community in new taipei city, taiwan date: - - journal: int j environ res public health doi: . /ijerph sha: doc_id: cord_uid: hslnkv p large-scaled disaster events had increasingly occurred worldwide due to global and environmental change. evidently, disaster response cannot rely merely on the public force. in the golden hour of crisis, not only the individuals should learn to react, protect themselves, and try to help each other, but also the local school, enterprise, non-government organization (ngo), nonprofit organization (npo), and volunteer groups should collaborate to effectively deal with disaster events. new taipei city (ntpc), taiwan, was aware of the need for non-public force response and therefore developed the process of enhancing local disaster management networks through promoting the resilient community since . the concept of a resilient community is to build community-based capacity for mitigation, preparedness, response, and recovery in an all-hazards manner. this study organized the ntpc experience and presented the standard operation procedure (sop) to promote the resilient community, key obstacles, maintenance mechanism, and the successful formulation of the local disaster management network. the performance of the promotion was evaluated through a questionnaire survey and found that participants affirmed the positive effect of building community capacity through the entire process. in general, the resilient community as the center of the local disaster management work is shown promising to holistically bridge the inner/outer resources and systematically respond to disaster events. global warming and environmental changes have led to more frequent and extreme weather events and resulted in disasters of a greater magnitude worldwide. serious disaster events accompanied by significant casualties repeatedly occurred, such as the great hanshin earthquake in japan, the chi-chi earthquake in taiwan, the indian ocean earthquake and tsunami, hurricane katrina in the usa, sichuan earthquake in china, typhoon morakot in taiwan, as well as tohoku earthquake and tsunami in japan. exposure of persons and assets in all countries has increased faster than vulnerability has decreased, thus generating new risks and a steady rise in disaster-related losses, especially at the local and community level. the impact could be short, medium, and long term and appears in terms of economic, social, health, cultural, and environmental aspects [ ] . in the great hanshin earthquake, during the early stage, . % of those in danger survived by themselves, . % escaped with assistance by family members, . % by neighbors/friends, and . % by passerby [ ] . only less than . % of those in need of help were saved by the public in the great hanshin earthquake, during the early stage, . % of those in danger survived by themselves, . % escaped with assistance by family members, . % by neighbors/friends, and . % by passerby [ ] . only less than . % of those in need of help were saved by the public force. this investigation indicated that, in such a great-scaled disaster, public force usually could not timely reach all the affected areas. therefore, the community must be resilient enough to respond by themselves and help each other in the golden hour of crisis events. community resilience refers to the capacities and capabilities of a human community to "prevent, withstand, or mitigate" any traumatic event [ ] . to strengthen community resilience, not only the residents but also neighboring stakeholders, no matter the public sector or private sector, units, or individuals, should join together to form a local disaster management network. it is not easy for the community to organize such a network by itself; hence, the government must invest funding and resources to accomplish this goal. many studies have shown that to deal with disasters, whether pre-disaster [ , ] , in-disaster [ ] , or post-disaster [ ] , awareness raising [ ] and capacity building [ ] are of significant importance, especially at the community level. this study aims to present how new taipei city (ntpc) government, taiwan, integrated the resources at the local government level and enhance the local disaster management by building a significant amount of resilient community, and begins with why the promotion of resilient community is necessary and how the promotion links to the local disaster management network. the performance is assessed through a questionnaire survey. two successful cases of community operation are introduced. from the ntpc government's angle, its experience from nowhere to somewhere is investigated and key obstacles, as well as solutions, are finally identified. new taipei city, taiwan, covers an area of km with a population of million. there are districts and villages under ntpc authority. districts can be categorized into types, i.e., in the urban areas, in the rural areas, and in urban-rural areas. geologically, ntpc is extremely vulnerable to earthquakes due to the direct pass-through of active shanchiao fault from the southwest to the north-east. from a topographical perspective, % of ntpc is the mountainous area (partly covered by tatun volcano), and the entire coastline is km long, which means ntpc is prone to geohazards such as debris flows, landslides, volcano eruptions, and tsunamis. flooding is another disaster event happening frequently due to annual typhoon and torrential rain. furthermore, two nuclear power plants are situated in ntpc, implying possible nuclear hazards ( figure ). according to the report by the national fire agency, ministry of interior, taiwan [ ] , a total of , (partly) collapsed buildings, , casualties, and , citizens in need of shelter are likely to happen if a large earthquake of scale . occurred in the center of taipei basin. with such kind of catastrophic damage, the public force is unlikely to give support for all affected areas fully and timely. more assistance from private sectors or citizens is necessary, especially those in or nearby the disaster hotspots. ntpc's disaster management system can be divided into three levels, i.e., local government, district office, and community, from the top down. ntpc government was aware of the complex and hazard-prone environment, as well as the abovementioned potential damage which cannot rely on merely the government's capacity. therefore, the government thought of enhancing the local disaster management network through matching cooperation between the local units and individuals. to do so, the promotion of the resilient community was considered as the cornerstone. seven standardized steps were taken to develop a resilient community in ntpc as follows [ ] . stakeholders in the resilient community include the public sector, community residents, and at least one expert in the disaster management field. to coordinate the resilient community promotion, the start-up meeting is hosted. in the meeting, it is vital to make sure the key person in the community, usually the village chief or community committee chairman, understands the benefit of the resilient community and has the willingness to cooperate in the future activities to be hosted. to encourage community participation, it is necessary to arouse public interest through the activation workshop in which the invited expert would give the lecture on the resilient community. because not all the community had experienced a serious disaster event, the lecture material usually includes not only the concept of the resilient community but also some case studies about disaster scenarios and associated casualties in taiwan or worldwide. successful cases of resilient community operation were also delivered to construct the vision and inspire the residents' participation in future activities. all lecture materials are prepared for the layperson rather than for an expert in order to ensure the lecturer and participants are on the same page. there has to be a broader and more people-centered preventive approach to disaster risk. disaster risk reduction practices need to be multi-hazard and multi-sectoral, inclusive, and accessible to be efficient and effective [ ] . therefore, community residents are invited to jointly investigate the environment. accompanied by experts, residents learn to identify potential/historical disaster hotspots and resources, such as shelter, convenience stores, and public facilities, useful for responding to the disaster event. after the site survey, all participants will furtherly discuss associated strategies through following minor steps ( figure ): sorting photo: during the site survey, photos are taken and printed. participants are asked to sort out the photos into two categories, i.e., disasters hotspot and resource points. mapping photo: those photos sorted in the previous step are pasted on the aero map with stickers near the photo. if the photo is a disaster hotspot, its condition, such as the location and cause/effect of the potential disaster is written down on the stickers; if the photo is a resource point, its function is described. strategy discussion: with possible disaster conditions and resource points at hand, the expert will help participants discuss strategies to deal with issues from the perspective of the individual, the community, and the local government level. for example, trash sometimes jams the gutter and causes flooding; therefore at the individual level, every resident should be made aware of not dropping trashes in the gutter; at the community level, residents should team up to clean the gutter regularly especially before the flooding season; at the local government level, district office can ask the cleaning contractors to dredge the cutter or provide the community with equipment needed to clean it. local enterprises and schools can be invited to discuss their role as outer resources to help the community respond to disasters. . experience sharing: the goal of this workshop is to finalize valid strategies mainly by the community; therefore, resident representatives are asked to report the discussed strategies to all the participants and try to reach consensus. aware of not dropping trashes in the gutter; at the community level, residents should team up to clean the gutter regularly especially before the flooding season; at the local government level, district office can ask the cleaning contractors to dredge the cutter or provide the community with equipment needed to clean it. local enterprises and schools can be invited to discuss their role as outer resources to help the community respond to disasters. . experience sharing: the goal of this workshop is to finalize valid strategies mainly by the community; therefore, resident representatives are asked to report the discussed strategies to all the participants and try to reach consensus. to efficiently carry out strategies in the previous step, the resilient community response team is organized. the typical structure of the response team is shown in figure . it contains five divisions, namely, patrol, evacuation, rescue, medical, and logistics, with their general function as table . the commander, usually the village chief or community committee chairman, supervises the deputy commander and executive secretary, as well as oversees outsourcing and leads the team. the deputy commander supervises the heads of every division and the executive secretary assists the commander and the deputy commander. to efficiently carry out strategies in the previous step, the resilient community response team is organized. the typical structure of the response team is shown in figure . it contains five divisions, namely, patrol, evacuation, rescue, medical, and logistics, with their general function as table . the commander, usually the village chief or community committee chairman, supervises the deputy commander and executive secretary, as well as oversees outsourcing and leads the team. the deputy commander supervises the heads of every division and the executive secretary assists the commander and the deputy commander. aware of not dropping trashes in the gutter; at the community level, residents should team up to clean the gutter regularly especially before the flooding season; at the local government level, district office can ask the cleaning contractors to dredge the cutter or provide the community with equipment needed to clean it. local enterprises and schools can be invited to discuss their role as outer resources to help the community respond to disasters. . experience sharing: the goal of this workshop is to finalize valid strategies mainly by the community; therefore, resident representatives are asked to report the discussed strategies to all the participants and try to reach consensus. to efficiently carry out strategies in the previous step, the resilient community response team is organized. the typical structure of the response team is shown in figure . it contains five divisions, namely, patrol, evacuation, rescue, medical, and logistics, with their general function as table . the commander, usually the village chief or community committee chairman, supervises the deputy commander and executive secretary, as well as oversees outsourcing and leads the team. the deputy commander supervises the heads of every division and the executive secretary assists the commander and the deputy commander. pre-disaster in-disaster and post-disaster patrol . understanding and periodically patrolling the disaster potential area and hotspot. eliminating disaster factors in advance, such as cleaning gutters. monitoring weather and patrolling disaster potential area. if a disaster condition is spotted, send messages to the community command center and make records. setting up a cordon around a disaster point and prevent from a passerby in. tabulating and periodically updating the vulnerable residents, such as elderly, incapable people and those living in disaster potential areas. planning evacuation route. making and periodically updating the evacuation map. reminding and assisting the residents, especially the vulnerable residents, to evacuate in an emergency. making sure the evacuation route is safe and not blocked. helping traffic control in vital traffic intersection and direct the evacuating people. maintaining existing equipment and assess the need for additional equipment based on disaster type and potential in the community. being familiar with the equipment operation through periodically training. keeping smooth telecommunication by preparing walkie-talkie. preparing the equipment and applying it in a small-scaled disaster event, such as putting out a small fire with a fire extinguisher or sawing a fallen tree into pieces and removing it to avoid traffic congestion. if residents were trapped due to serious events, trying to identify their location and asking support from the authority concerned. being proficient in first aid and caring skills . periodically training residents with those medical skills. preparing items for medical purposes, such as first-aid kit and stretcher. helping injuries in need of first aid. guide outside medical resources to people in need. helping local governments open shelters and prepare living supplies. mentally comforting the refugees scared by disasters. assessing the living material, such as drinking water, food, and medical needs, required during a disaster event. tabulating and periodically updating the community response team members. helping the local government maintain shelters. helping local governments open shelters and prepare living supplies. helping refugees register when they arrive at the shelters and distributing living supplies. supporting the other four response team divisions. based on the characteristics of the potential disaster, the community action plan is suggested to include but not limited to the following items. environmental and disaster risk assessment the environmental assessment should cover the location of the community, its neighboring geography, social condition, and historical disaster hotspots. the disaster risk assessment must include disaster type the community is facing and associated risk map drawing. the community usually has no capacity of drawing such kind of risk map; therefore, it is advised to utilize some government resources. in taiwan, the national science and technology center for disaster reduction (ncdr) developed the risk map platform (https://dmap.ncdr.nat.gov.tw/) for the public to have access to risk maps of earthquake, landslide, debris flow, flooding, tsunami, and nuclear event nationwide. community response team and local disaster management network the community response team is the frontline force to deal with the disaster. according to the experience of all resilient communities promoted by the ntpc government, the general functions of the team were organized as in table . in addition to the community's strength, outer resources, such as district office, fire department, police department, school, enterprise, volunteers, ngo, and npo could be invited to formulate a local disaster management network and cooperate pre-disaster, in-disaster, and post-disaster. community resources mean the equipment such as pump, power generator, fire extinguisher, and power saw owned by the community or facility such as activity center, shelter, and community office managed by the community. however, those existent resources might not fully meet the need in terms of disaster response. the community should periodically update resources inventory and proactively assess the extra demand for resources to deal with the possible disaster. all the resources must have someone be appointed to manage. some of the duties could be assigned to the community response team member as a suggested division task in table . after the resilient community is established, the top issue is that the community sometimes does not keep on its work due to not having a sustainable operation mechanism to follow. the standard sustainable operation mechanism for the resilient community in ntpc includes the following items: ( ) regular training: it defines the courses and skill training to behold and its frequency; ( ) community disaster management database update: it includes the response team member recruitment/retirement, vulnerable residents list update, and equipment maintenance frequency; ( ) disaster processing record: the community should record the action taken pre-disaster, in-disaster, and post-disaster. it helps review the community action as well as identify defects and weak points of the plan. the community action plan was discussed and instituted by the residents and the community response team. stakeholders, such as the school, enterprise, or vulnerable individual/groups in the neighboring area, were welcome to join the discussion. the role of each stakeholder was be identified, e.g., community response team as helpers; residents and vulnerable individuals/groups as help receivers; enterprise as helpers and living material supplier; school as shelter accommodators. education and training aim to develop the knowledge and basic skills for community residents responding to disasters and specifically enhance the response team's capacity to execute their tasks. for the basic knowledge, the courses include disaster response concepts according to the community disaster characteristics. the required skills include basic first aid, such as cpr (cardiopulmonary resuscitation), heimlich maneuver, and aed (automated external defibrillator) and operation of equipment such as fire extinguishers, pumps, power saws, etc. this course is suggested to be hosted at least once per year. the community response team members could practice their tasks and skills through the war game or drill. war game helps test the validity of the action plan established in step , and the drill can further test the skills learned from step . in ntpc, not only the community response team but also stakeholders in the neighboring area, such as staff from the district office, the local fire department, school staffs, and enterprise partners are role players. table is the typical scenario designed for an earthquake drill in ntpc. a few key principles are suggested as follows: . scenarios must correspond to community characteristics in terms of single disaster or complex disaster. . self-protection skills of individuals could be exercised, such as "drop", "cover", "hold on" during the earthquake. the disaster scale should be designed properly so that the community must and could react. if the scale is too small, then no significant damage will highlight the necessity for community response; if the scale is too large, most community members might lose their capability due to casualties resulting in malfunction of the team. every division in the community response team should have the chance to familiarize themselves with their tasks and required skills. coordination and communication among the response team, stakeholders, and public/private agencies should be tested. . the community should understand the evacuation routes to the shelter as well as arrange and test the transportation for evacuation. . collaboration between the district office and the community team to open the shelter should be exercised. scenario self-protection, such as "drop", "cover", "hold on" exercise at the time of an earthquake. community response team mobilization and preparedness. preparedness for opening shelter by logistic division. the assistance of refugee evacuation to the shelter by evacuation division. patrol division surveys the area and calls for help from the rescue division upon locating damage. assistance by logistics division in shelter opening, such as registration, food sharing, and related operations. living supply may come from the enterprise. first-aiding the physically wounded people or caring for the traumatized people by medical division. rescue division puts out small-scaled fire induced by the earthquake scenario recovering the environment by the entire response team and community residents. upon completion of resilient community development, posters and videos are made showing the annual activities and joint efforts achieved by the community, government, school, and enterprise. the community response team member share experiences with those from other communities/villages who have never joined the resilient community workshop. the purpose is to not only encourage the ongoing involvement in this developed resilient community but also inspire other villages' participation shortly. to evaluate the effect and performance of promoting a resilient community, an anonymous physical questionnaire survey was conducted after we finished each resilient community for that year. the participants were informed that participation was voluntary and the participants' willingness to return the completed questionnaire indicated their consent to participate in this study. eight key questions were asked as follows: q : do you understand the disaster risk of your community after the workshop? q : do you feel developing a resilient community and building capacity is necessary? q : has your community built a feasible action plan after the workshop? q : do you understand the tasks of the response team? q : are you willing to become a member of the response team? q : have you learned basic medical skills and been capable of performing it when necessary? q : have you learned the fire-fighting skills and been capable of performing it when necessary? q : is retraining necessary for the community? q and q checked if the participants were aware of the disaster risk and management; q checked if the community action plan was built and valid; q and q checked if the participants understood the tasks they should perform while they became response team members; q and q checked if basic skills were well taught; q checked the necessity of hosting retraining courses, and is linked to the maintenance mechanism in section . . despite the eight key questions, only age and gender information were collected; therefore, no personal information of any specific individual could be exposed. table shows the age distribution of respondents who joined the workshops hosted by the ntpc government in . we kindly asked every participant to do the questionnaire for us right after the workshop; therefore, the response rate was %. from a total of participants, including males and females from communities, more than % of them were over years old, and more than % were over years old. the aging population phenomenon is very common in rural areas of ntpc which are usually prone to high disaster risks. it implies that their mobility to react to disaster events is relatively low before the promotion of a resilient community. the questionnaire was designed to confirm the contribution of promotion, and results are shown in figure . the survey has shown that, after -steps of promotion as described in section . , % of the participants realize the risks they are facing and % agree with the necessity to develop a resilient community; % believe that the action plan we helped them build is feasible; % understand the tasks of the response team and % are willing to serve the community as a team member; % and % think that they had well learned and were ready to perform basic medical skills and fire-fighting, respectively; % also thinks retraining is important for the community. overall, about % of the participants' awareness was raised and the capacity to deal with community-based disaster events the survey has shown that, after -steps of promotion as described in section . , % of the participants realize the risks they are facing and % agree with the necessity to develop a resilient community; % believe that the action plan we helped them build is feasible; % understand the tasks of the response team and % are willing to serve the community as a team member; % and % think that they had well learned and were ready to perform basic medical skills and fire-fighting, respectively; % also thinks retraining is important for the community. overall, about % of the participants' awareness was raised and the capacity to deal with community-based disaster events was established. it indicates the triumph of resilient community promotion and implies its contribution to the successful community operation introduced in the next section. two case studies are introduced to demonstrate how the established resilient community reacts pre-disaster, in-disaster, and post-disaster. those cases may not have been catastrophic events but showed how the community spontaneously mobilized after the training received through building community resilience. jiaqing village, an urban village located in zhonghe district, is the resilient community that started in . this village was prone to flooding, earthquake, and fire. after the village was trained and the community response team was organized, it progressively operates whenever there is a typhoon coming ( figure ). the village chief, as the response team commander will host a preparedness meeting and assign tasks for the team. the biggest concern is to prevent the low-lying area from flooding; therefore, team members were sent to the gutter and drainage outlet where garbage is easily accumulated. once waste was found stuck in the drainage system, the team notified the district cleaning contractor and cleaned the site together. occasionally, if the cleaning of the drainage system could not prevent the flooding from happening, the team recorded the situation for the village chief to discuss improvement measures thereafter. respectively; % also thinks retraining is important for the community. overall, about % of the participants' awareness was raised and the capacity to deal with community-based disaster events was established. it indicates the triumph of resilient community promotion and implies its contribution to the successful community operation introduced in the next section. two case studies are introduced to demonstrate how the established resilient community reacts pre-disaster, in-disaster, and post-disaster. those cases may not have been catastrophic events but showed how the community spontaneously mobilized after the training received through building community resilience. jiaqing village, an urban village located in zhonghe district, is the resilient community that started in . this village was prone to flooding, earthquake, and fire. after the village was trained and the community response team was organized, it progressively operates whenever there is a typhoon coming ( figure ). the village chief, as the response team commander will host a preparedness meeting and assign tasks for the team. the biggest concern is to prevent the low-lying area from flooding; therefore, team members were sent to the gutter and drainage outlet where garbage is easily accumulated. once waste was found stuck in the drainage system, the team notified the district cleaning contractor and cleaned the site together. occasionally, if the cleaning of the drainage system could not prevent the flooding from happening, the team recorded the situation for the village chief to discuss improvement measures thereafter. baiyun village, a mountainous village located in xizhi district, is a resilient community stated in . after six months of solid training and immediately after the community drill was performed on october , a landslide event occurred due to typhoon aere in the early morning of october. the village chief, jun-di chen, immediately assembled the community response team as well as reported the situation to the xizhi district office and ntpc fire department as soon as he was notified by the residents who spotted the event. eight team members were called in and approached baiyun village, a mountainous village located in xizhi district, is a resilient community stated in . after six months of solid training and immediately after the community drill was performed on october , a landslide event occurred due to typhoon aere in the early morning of october. the village chief, jun-di chen, immediately assembled the community response team as well as reported the situation to the xizhi district office and ntpc fire department as soon as he was notified by the residents who spotted the event. eight team members were called in and approached the disaster site to evacuate people by knocking on doors one after another. once the government forces arrived and took over the frontline, the community response team helped set up the cordon to prevent residents from entering the disaster site. the team also helped the public force establish the command post in the nearby area to monitor disaster development and timely response. finally, when the situation was under control, the response team moved to the shelters and took care of the residents who had evacuated earlier. in total, people took shelter in the baiyun activity center with no casualties reported. the resilient community developed in ntpc has by far been running for three phases as follows. most problems were identified in phase and solutions were given accordingly in phases and . ntpc has launched the resilient community since . until , only resilient communities were developed by a few ntpc departments. the speed of promotion is quite slow because the nptc government was unfamiliar with the concept of the resilient community and need help from certain universities who have associated expertise and enough manpower to host the workshops and activities described in section . . during the first phase, key factors impeding the promotion were identified as follows: in general, residents usually lack the willingness to participate in the resilient community workshop from the beginning due to three reasons. first of all, they think that if no serious disaster happened before then why would there be one in the future. next, there is already some structural protection in the community such as the dike or pumping stations/machines to prevent flooding and the retaining wall to prevent from hillslope disaster. they feel quite safe with those protection measures. finally, even if a disaster indeed happened, the government would come and help because the government must save the citizens. there are varying conditions in different communities. the community is usually prone to hillside disaster and debris flow in the rural area especially in the mountainous area; prone to earthquake and fire in the urban area especially with densely distributed old buildings; and prone to flooding in the low-lying area. therefore, there is no "one size fits all" approach for community resilience building [ ] . although the goal of the resilient community is building capacity for it, the ntpc government specifically asks the public sector such as district office and local fire department corps and branch to progressively join associated activities. therefore, a great amount of time and involvement from the community and public sectors is required. it usually takes a minimum of - months to develop a base-type resilient community and up to years to finish the complete-type resilient community. the minimum requirement for a base-type resilient community is to raise the residents' awareness and train their basic skills. for the complete-type resilient community, the steps in section . should be strictly followed and their performance tracked to ensure a fully built capacity. it would cost , to , usd to hire the expert/team to finish one complete-type resilient community. there are villages in ntpc, and the total expense would exceed million usd for all. the different authorities concerned are entitled to deal with different disaster types. for example, in ntpc, the water resources department and the agriculture department promote resilient communities prone to flooding and debris flow, respectively. it is not be a problem if the community has only a single disaster type. however, it is very common that the community has more than one disaster potential. more than one department can invest in the same community if they wanted to, resulting in the duplicate investment and waste of government resources, furthermore, harming the government's general interest. one other issue is that every department in the local government is a subordinate agency of certain authority in the central government which institute the policy to promote the resilient community. for example, the soil and water conservation bureau (swcb) under the council of agriculture supervises the agriculture department in ntpc. they focus only on debris flow and train the residents accordingly. on the other hand, the water resources agency supervises the water resources department in ntpc to build flood-proof capacity for the community. as a result, not all communities receive the same training and build the all-hazards response code. the abovementioned four obstacles account for the "integrated resilient community program" launched by the ntpc government in phase and the necessity of establishing a maintenance mechanism, as shown in the following section. the different authorities concerned are entitled to deal with different disaster types. for example, in ntpc, the water resources department and the agriculture department promote resilient communities prone to flooding and debris flow, respectively. it is not be a problem if the community has only a single disaster type. however, it is very common that the community has more than one disaster potential. more than one department can invest in the same community if they wanted to, resulting in the duplicate investment and waste of government resources, furthermore, harming the government's general interest. one other issue is that every department in the local government is a subordinate agency of certain authority in the central government which institute the policy to promote the resilient community. for example, the soil and water conservation bureau (swcb) under the council of agriculture supervises the agriculture department in ntpc. they focus only on debris flow and train the residents accordingly. on the other hand, the water resources agency supervises the water resources department in ntpc to build flood-proof capacity for the community. as a result, not all communities receive the same training and build the all-hazards response code. the abovementioned four obstacles account for the "integrated resilient community program" launched by the ntpc government in phase and the necessity of establishing a maintenance mechanism, as shown in the following section. (figure ). it ensures not only the optimal utilization of the local government's resources but also the consistent procedures for all departments to follow and promote resilient communities. in phase , the school played quite an important role in the local disaster management network. the ministry of education had initiated the campus safety program in , and the focus was on building school internal capacity until . after , schools were asked to gradually cooperate with nearby villages and communities in the context of disaster management. school and district activity centers are two major facilities in taiwan to shelter the refugees in a disaster event. the community and school must work together while opening the shelter. besides, both of them could in phase , the school played quite an important role in the local disaster management network. the ministry of education had initiated the campus safety program in , and the focus was on building school internal capacity until . after , schools were asked to gradually cooperate with nearby villages and communities in the context of disaster management. school and district activity centers are two major facilities in taiwan to shelter the refugees in a disaster event. the community and school must work together while opening the shelter. besides, both of them could collaborate in medical service, mental caring, patrolling disaster hotspots, and dealing with small-scaled disaster events if needed. such cooperation is practically valid because most students, even teachers, are from a neighboring community and therefore a tight bonding already exists. the only movement needed to enhance the link and push forward is asking both parties to attend the resilient community workshop and discuss the terms of cooperation in the context of the local disaster management network. schools, especially at the university level, can also help build resilience capacity for the community [ ] . in phases and , all of the resilient communities were promoted by the local government's departments with help from certain universities. however, building community capacity to deal with disasters is the legal duty of the district office in taiwan. to help the district office learn and promote the resilient community by itself, the community consultant team was organized by the ntpc government in . it hires experts specialized in community disaster management to train the district offices to promote the resilient community through the seven-step process. besides, the resources from enterprises were specifically introduced to the community in phase . as is well known, the key to successful enterprise disaster management is the development of business continuity planning (bcp). however, bcp functions more internally than externally. it means, with bcp, the enterprise knows how to deal with disaster by itself whether in terms of mitigation, preparedness, response, or recovery. what the ntpc government tries to achieve is to develop a cohesive local disaster management network that involves the collaboration of community, public sector, schools, and enterprises. the enterprise is the last piece to complete such a network. not all enterprises are suitable to join the network. the enterprise must meet three ntpc criteria such as positive image, enough scale, and high willingness. the ntpc government or district office will sign the mou with the enterprise after it is chosen. to build tighter bonding among stakeholders, the enterprise is invited to join the resilient community activity and discuss cooperation or action plan as mentioned in section . . . other than direct financial support to the community or public sector, there are various ways in which the enterprise can play a role in the local disaster management network. for example, the mitsui outlet park in linkou joined the drill hosted by the linkou district office and provided hot meals and medicines for nearby communities; yulon group, well known for its yulon motor co., ltd. offered xindian district office vehicles to evacuate community refugees. through helping the local government and community, the enterprise can not only fulfill corporate social responsibility (csr) but also enhance its image from the public sector's media propaganda. the maintenance of the resilient community is usually harder than its development; therefore, it is suggested to employed four measures as the ntpc government did and keep the heat on. retraining is vital as shown by the questionnaire survey (q ). various courses could be chosen from the following depending on the community's needs. tasks review of the community response team: new members will join the community response team now and then. it is of great importance to make sure each member, whether senior or newcomer, knows his/her task well. collection and reporting of disaster information: with the popularization of smartphones, more apps are available for collecting disaster information and uploading it to the cloud platform. the community should learn which technical tool is more suitable to the community and how it functions. all disaster information collected could be reserved in a community database for future review. advanced disaster response skills: basic skills such as cpr, heimlich maneuver, and fire extinguisher operation were taught while developing a resilient community. advanced skills, such as patient moving, escape from the fire scene, and responding with the tool at hand (e.g., making slippers with old newspapers; making simple toilets with paper box and plastic bag) are suggested in the retraining courses. considering the covid- pandemic in , epidemic prevention is also suggested to be included in the retraining. thereby, every trainee could be a community watcher and help spread epidemic prevention knowledge and support the government's action if necessary. the selection of skills is not limited to specific disaster types that the community is most likely to confront. the advanced skill training aims to make the community function in an all-hazards response manner. . war game: every disaster management action plan should be periodically reviewed and tested. at the community level, war game is a less costing and less time-consuming way to validate the plan compared to drill. however, the design of a proper war game is still not easy for the community. they should deeply consider the potential risk and transform it into disaster scenarios for strategy discussion. they will also have to manage inner resources and seek additional outer resources. usually, inviting experts or public sector personnel to join the war game would help the community deliver more insightful outcomes. skills training and raising awareness are compulsory for community residents to increase their chance of survival in the catastrophic disaster event. with the right tools and equipment, the core function of self-help and mutual help could be even more effective. the ntpc government supports certain funding for the community to purchase equipment upon the completion of a resilient community establishment. the community could buy the equipment according to a predefined list which includes evacuation bag, disaster prevention hood, helmet, first-aid kit, stretcher, walkie talkie, pumps, fire extinguisher, trolley, power saw, power generator, emergency ration, etc. the purchased equipment should be listed in the community action plan and be maintained regularly. the response team member must be trained to operate it. issuing the resilient community certificate to those progressively engaged in associated activities and who made solid achievements would raise the community's sense of honor and make it more likely to keep on the operation. ntpc government initiated the certificate application program in . the community receives the ntpc certificate (figure ) , and it proves the following criteria have been met: environmental risk assessment: the identification of disaster potential and associated strategies must be delivered. community disaster management database: including the identification of vulnerable people in the community, inventory of equipment, list of community residents with special skills and who can help respond to disaster, and contact list of outer resources such as police department, fire department, volunteer, school and enterprise. . community response team: including the head and crew of the five-response team divisions. it is batter if the enterprise and school can join as a support division. skill training: including basic skills introduced in section . . . drill: including the script with properly designed disaster scenarios and the actual role-playing of team divisions. ideally, after the resilient community is established, it should consistently and spontaneously operate by itself; nevertheless, this is usually not the case in reality. without the government's supervision or expert's assistance, some communities fail to keep on with the work. to avoid it, the ntpc government designed a simple performance tracking table (table ) and asks the community to fill it in whenever a disaster happens or is expected to come. the table is separated into operation types, valid not only for operation during the disaster event but also for mitigation measures on normal days. the following are some suggested actions that the community can take. . mitigation: including routine education, skill training, drill/war game, environment patrol, disaster information; . preparedness: including hosting preparedness meeting, equipment inventory, real-time weather monitoring and early warning, checking vulnerable people's condition and need, patrolling areas prone to disasters, and shelter opening preparedness; . report in: once the disaster is spotted, reporting to the community and the authority concerned for timely response, as well as to associated private sectors such as water company or power company for assistance; . response: including dealing with disasters such as removing fallen trees, fire-fighting, identifying risk area and setting up cordon; evacuating people in the high-risk area; helping public sectors such as opening shelter, traffic control, and setting up command post; taking care of wounded by first-aid, caring for, and moving patients; . recovery: including environment cleaning, recovery, and rebuilding. ideally, after the resilient community is established, it should consistently and spontaneously operate by itself; nevertheless, this is usually not the case in reality. without the government's supervision or expert's assistance, some communities fail to keep on with the work. to avoid it, the ntpc government designed a simple performance tracking table (table ) and asks the community to fill it in whenever a disaster happens or is expected to come. the table is separated into operation types, valid not only for operation during the disaster event but also for mitigation measures on normal days. the following are some suggested actions that the community can take. checking the drainage fence the water level is normal in the drainage system near jiaqing bridge as shown in table , the population is aging in ntpc rural areas. young people leave their hometown to seek more work opportunities, which leave the elders more vulnerable to disasters. the aging population is not a unique problem to taiwan. many developed countries, such as japan, italy, finland, portugal, and greece, have this kind of social problem. responding to disaster requires mobile manpower to execute the tasks as designated in table . to have more young people engage as shown in table , the population is aging in ntpc rural areas. young people leave their hometown to seek more work opportunities, which leave the elders more vulnerable to disasters. the aging population is not a unique problem to taiwan. many developed countries, such as japan, italy, finland, portugal, and greece, have this kind of social problem. responding to disaster requires mobile manpower to execute the tasks as designated in table . to have more young people engage in community-based disaster management, the government should help improve the employment market in rural areas to attract young residents' return or stay. it also implies the inseparability of disaster-related and social-economic issues in the era of public engagement in disaster management. it takes a disaster to learn a lesson. however, most people never really suffer from a medium to large scale disaster, not to mention a catastrophic one. what is taught in the resilient community workshop is the concept of self-help and mutual-help, as well as basic response skills. we never know if the residents could apply the concepts and skills perfectly during a disaster event. therefore, the retraining courses should be hosted persistently. moreover, most of the public lacks the experience of dealing with post-disaster recovery. it is time for the community to participate in pre-disaster recovery planning with the government to envision the potential damage and associated recovery work. after the entire training of a resilient community, most residents recognize its necessity and are willing to continue running it. the only problem is where the funding support comes from for consistent operation. although the ntpc government offers the community certain equipment, it is usually not enough regarding the regular operation, emergency response, and administrative works. more funding contributions from public and private sectors shall be needed. the government should put more effort into matchmaking between the needs of the communities and the resources from enterprises. extracting from ntpc experience, this research has proposed the sop to promote the resilient community, identified the key obstacles, suggested the maintenance mechanism, and shown the successful formulation of the local disaster management network. the policy to deal with disaster in ntpc is the "top-down" guidance with "bottom-up" implementation. in this manner, responsibilities and initiatives could be well balanced between residents and the government [ ] . the network involves the community, local government, district office, school, and enterprise. those network members are invited to join the workshops and associated training for collaborative learning and developing a viable joint action plan. therefore, it is expected that, during a major incident or disaster (mid), the resilient community, school and enterprise could all play a role when the local government requires flexible surge capacity (fsc). surge capacity (sc) means the ability to increase staff, stuff, structure, and system ( s) rapidly and effectively in the affected areas. fsc indicates the capability to scale up and down resources in a fast, smooth, and productive way [ ] . the community could provide manpower to help local government in many ways such as, but not limited to, evacuating vulnerable people, opening shelters, managing living supplies/materials, and identifying disaster hotspots. with that assistance, the government could focus more on addressing hardest-hit areas and situations. since this study shows a promising non-structural method to enhance the local disaster management network, any country or government willing to intensify the capacity of disaster management at the community level could follow ntpc's steps and avoid the obstacles. mitigation: including routine education, skill training, drill/war game, environment patrol, disaster information; . preparedness: including hosting preparedness meeting, equipment inventory, real-time weather monitoring and early warning, checking vulnerable people's condition and need once the disaster is spotted, reporting to the community and the authority concerned for timely response, as well as to associated private sectors such as water company or power company for assistance response: including dealing with disasters such as removing fallen trees, fire-fighting, identifying risk area and setting up cordon; evacuating people in the high-risk area; helping public sectors such as opening shelter, traffic control, and setting up command post; taking care of wounded by first-aid, caring for recovery: including environment cleaning, recovery, and rebuilding. operation process note central weather bureau issued the land waring of typhoon mitag at : garbage accumulated at the drainage fence in lane , liancheng rd. was reported to the district office, and removed by the cleaning contractor no garbage spotted in the gutter along lane the water level is normal in the drainage system near jiaqing bridge united nations office for disaster risk reduction (undrr, formally unisdr) japan association for fire science and engineering. fire investigation of southern earthquake in hyogo prefecture in , japan community capitals as community resilience to climate change: conceptual connections community advantage and individual self-efficacy promote disaster preparedness: a multilevel model among persons with disabilities applying community resilience theory to engagement with residents facing cumulative environmental exposure risks: lessons from louisiana's industrial corridor analysis of the actions and motivations of a community during the torrential rains in northern kyushu building resilience during recovery: lessons from colorado's watershed resilience pilot program. environ. manag. , , are cities aware enough? a framework for developing city awareness to climate change a typology of community flood resilience ministry of the interior. assessment of the problem and preparedness of metropolitan taipei during a large scale earthquake new taipei city fire department. resilient community operation manual understanding the operational concept of a flood-resilient urban community in jakarta, indonesia, from the perspectives of disaster risk reduction, climate change adaptation, and development agencies a case study of university involvement in community-based reconstruction: in the coventry university model. community-based reconstruction of society bottom-up citizen initiatives as emergent actors in flood risk management: mapping roles, relations and limitations flexible surge capacity-public health, public education, and disaster management this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license acknowledgments: this research was supported by the ministry of science and technology (most), taiwan, through project most - -m - . the authors declare no conflicts of interest.int. j. environ. res. public health , , garbage accumulated at the drainage fence in lane , liancheng rd. was reported to the district office, and removed by the cleaning contractor. no garbage spotted in the gutter along lane , liancheng rd. the water level is normal in the drainage system near jiaqing bridge. no flooding in the mrt construction site. the water level is normal in the drainage system near jiaqing bridge as shown in table , the population is aging in ntpc rural areas. young people leave their hometown to seek more work opportunities, which leave the elders more vulnerable to disasters. the aging population is not a unique problem to taiwan. many developed countries, such as japan, italy, finland, portugal, and greece, have this kind of social problem. responding to disaster requires mobile manpower to execute the tasks as designated in table as shown in table , the population is aging in ntpc rural areas. young people leave their hometown to seek more work opportunities, which leave the elders more vulnerable to disasters. the aging population is not a unique problem to taiwan. many developed countries, such as japan, italy, finland, portugal, and greece, have this kind of social problem. responding to disaster requires mobile manpower to execute the tasks as designated in table as shown in table , the population is aging in ntpc rural areas. young people leave their hometown to seek more work opportunities, which leave the elders more vulnerable to disasters. the aging population is not a unique problem to taiwan. many developed countries, such as japan, italy, finland, portugal, and greece, have this kind of social problem. responding to disaster requires mobile manpower to execute the tasks as designated in table key: cord- -or zzjs authors: zhou, liang; zhang, ping; zhang, zhigang; fan, lidong; tang, shuo; hu, kunpeng; xiao, nan; li, shuguang title: a bibliometric profile of disaster medicine research from to : a scientometric analysis date: - - journal: disaster med public health prep doi: . /dmp. . sha: doc_id: cord_uid: or zzjs this study analyzed and assessed publication trends in articles on “disaster medicine,” using scientometric analysis. data were obtained from the web of science core collection (woscc) of thomson reuters on march , . a total of publications on disaster medicine were identified. there was a mild increase in the number of articles on disaster medicine from (n= ) to (n= ). disaster medicine and public health preparedness published the most articles, the majority of articles were published in the united states, and the leading institute was tohoku university. f. della corte, m. d. christian, and p. l. ingrassia were the top authors on the topic, and the field of public health generated the most publications. terms analysis indicated that emergency medicine, public health, disaster preparedness, natural disasters, medicine, and management were the research hotspots, whereas hurricane katrina, mechanical ventilation, occupational medicine, intensive care, and european journals represented the frontiers of disaster medicine research. overall, our analysis revealed that disaster medicine studies are closely related to other medical fields and provides researchers and policy-makers in this area with new insight into the hotspots and dynamic directions. (disaster med public health preparedness. ; : – ) n atural disasters, biological terrorism, nuclear leakage, public health emergencies, epidemic diseases, and other disasters directly threaten the survival and development of mankind. currently, a major disaster occurs almost daily in some part of the world. most population centers are concentrated in high-risk locales like metropolitan cities, which feature very frequent and multiple person-to-person contacts. high-risk occupations, international trade, and housing construction all increase the possibility of human exposure to disasters, leading to increased casualties after each disaster. the ever-increasing spiral of human populations, the rapid growth of technology, swift world-wide travel by millions of persons, and the exponential expansion of at-risk industries and residences combine to increase human exposure to disasters. in particular, the major casualties caused by the wenchuan earthquake, the nepal earthquake, and the indian ocean tsunami pose great challenges to disaster medicine. the wenchuan earthquake was one of the most devastating disasters in the past years and caused more than , casualties; the main causes of death were trauma and crush syndrome. in addition, there was a significant increase in the number of respiratory infections, enteritis, and skin diseases in the week after the earthquake. even a full year after the earthquake, some survivors began to suffer from posttraumatic stress disorder. disaster medicine has attracted global attention gradually by implementing emergency medical treatment, disease prevention, and health care science under the conditions of disastrous damage. after the september attacks, the united states made two major adjustments to the national disaster medical system (ndms) to form a high-efficiency operating mechanism called the national disaster medical rescue system. japan has also established a national rescue medical center in tachikawa city, tokyo. as a data transmission and command center for disaster medical care, it features a disaster medical information system used to determine damage for medical institutions. in addition, japan has enhanced its disaster emergency medical rescues by launching civil and community organizations. after the outbreak of severe acute respiratory syndrome (sars) in , china likewise began to attach importance to the establishment of an emergency medical system. then, after experiencing the wenchuan, lushan, and yushu earthquakes, and observing the actual rescue experience, it built an emergency medical rescue system, including a rescue command center and a medical rescue scene and rescue information platform. disaster medicine scholars have published a substantial amount of original research based on care during disaster rescues, emergency medical treatment, and disease prevention. however, the bibliometric profile of disaster medicine in the literature is still unknown. therefore, in this study, a scientometric analysis was conducted on disaster medicine to estimate the productivity of specific journals, countries, institutions, authors, and research areas, and to identify research hotspots and trends in this field. all of the data for this study were obtained from the web of science core collection (woscc) of thomson reuters on march , (incomplete data existed in ). the woscc, which includes the social sciences citation index, current chemical reactions, and index chemicus, is the most frequently used source of scientific information. the search term "disaster medicine" was used to retrieve titles, keywords, author information, abstracts, and references published from to . the following search string was used: (ts = (disaster medicine)) and languages: (english) and document type: (article or review). the impact factor of each journal was obtained from the journal citation reports science edition, accessed on march , . citespace iii ( bits) was used to analyze publication outputs and construct knowledge maps, to analyze the extracted records for citation characteristics, and to visualize the patterns and trends in disaster medicine. [ ] [ ] [ ] [ ] [ ] a total of studies on disaster medicine, published from to , were retrieved from the woscc (incomplete data existed in ). of these, ( . %) were original articles. although the number of publications increased only mildly from (n = ) to (n = ), the number of citations increased substantially from (n = ) to (n = ) ( figure ). of studies, ( . %) were cited at least once, with an average of . citations per article for , total citations. table shows the most frequently cited articles. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] among these articles, the most common topic was disaster rescue and post-disaster health effects ( of [ %]). the top-ranking paper ( citations) was published in chest and involved critical care treatment: "definitive care for the critically ill during a disaster: a framework for allocation of scarce resources in mass critical care -from a task force for mass critical care summit meeting, january - , , chicago, il." the article provided suggestions to perform triage while allocating scarce critical care resources during a disaster. the studies were published in different journals. the top-ranked journal, which published papers, was disaster medicine and public health preparedness, followed by two other journals with more than papers each: academic emergency medicine (n = ) and american journal of preventive medicine (n = ). disaster medicine and public health preparedness also had the greatest number of total citations (n = ), again followed by academic emergency medicine (n = ) and american journal of preventive medicine (n = ) ( table in the online data supplement). these research studies were published by countries. the top countries published of the studies, accounting for . % of the total number of publications. the country with the greatest number of publications was the united states (n = ), followed by japan (n = ) and china (n = ) ( table in the online data supplement). similarly, among the sponsoring institutions, the top institutions published literatures, accounting for . % of the total number of publications. new york university had the most publications (n = ), followed by the university of washington (n = ) and johns hopkins university (n = ) (table s ). a total of authors contributed to these studies; the top authors accounted for studies, . % of the total. three authors tied for first place, each with publications: m. d. christian, f. della corte, and p. l. ingrassia ( table in the online data supplement). a total of research areas were represented, with the majority of articles focusing on public environmental/occupational health (n = ), general internal medicine (n = ), and emergency medicine (n = ) (table s ). the visualization analysis for reference citations was conducted by citespace iii. the parameters in citespace were as follows: time span = years ( - ); time slicing = ; term type = burst terms; selection criteria (c, cc, ccv) = ( , , ) ( , , ) ( , , ) . the top most cited or occurring items from each slice were selected. the pathfinder network method was used to streamline the network and to map the visualization analysis. the network revealed nodes and lines. in figure , the thicker circle indicates a higher level of between-study centrality. in general, a study with a centrality value equal to or greater than . can be considered a key study; therefore, the key studies were [subbarao i, ] ( . ), followed by [einav s, ] ( . ) and [gillett b, ] ( . ). in addition, the red circles represent burst studies which represent the frontier of a period ; among them, the key burst studies were [subbarao i, ] and [walsh l, ] , which had the highest citation rates between and . figure presents the timeline view for hot keywords. the results show that the hotspots of disaster medicine during this period were spinal cord injury, conceptual framework, health professional, occupational medicine, medical surge capacity, oleic acid, lifesaving intervention, terrorist bombing, developing country, workforce, professionalization and west africa (figure ). in addition, the research papers published in journals represent the frontiers of certain subjects, and the references cited in these papers provide the knowledge base of the papers. in figure , the nodes of clusters # , # , # , # , and # were mainly distributed before (the knowledge base), while the nodes of clusters # , # , # , # , # , # , and # were mainly distributed between and (the frontiers). a total of papers on disaster medicine research were included in this analysis. the visualization was generated by the carrot system based on the first results of a search on regenerative medicine. there were results from the lingo clustering algorithm; the first ranked cluster was practices in disaster (n = ), followed by hospital disaster (n = ), disaster events (n = ), disaster setting (n = ), and earthquake disaster (n = ) (figure ). in addition, the time interval is depicted as a blue line, whereas the time period that represents a burst cited journal is depicted as a red line, indicating the beginning and the end of the time interval of each burst. the top burst references were public health preparedness ( . ), hurricane katrina ( . ), and european journal ( . ) ( table ) . to the best of our knowledge, this is the first scientometric analysis on the topic of disaster medicine. the results indicated a significant increase in the number of publications ( and ) . this increase may be due to several major disasters. the year was the first year after the haiti earthquake, and much of the related research focused on the implementation and development of international medical rescue. [ ] [ ] it was also the third year after the wenchuan earthquake, research on which mainly focused on disease classification and patient management of the patients. [ ] [ ] finally, was the th anniversary of the / attacks; the relevant research mainly focused on post-disaster effects, including respiratory and mental health problems, among survivors and rescuers. [ ] [ ] the united states, japan, and china published the most research on disaster medicine. this may be because the frequent occurrence of disasters in these countries has caused serious casualties and property losses. , [ ] [ ] [ ] likewise, these countries have participated in international humanitarian relief efforts many times, so they have a wealth of medical rescue experience. [ ] [ ] [ ] the top studies (by number of citations) all emphasized a lightweight map of major terms on disaster medicine. burst strength: representing the intensity of the frequency of a key word suddenly increasing over a short period of time. the burst-detection algorithm can be adapted for detecting sharp increases of interest in a specialty. in citespace iii, a current research front is identified based on such burst terms extracted from titles, abstracts, descriptors, and identifiers of bibliographic records. burst-detection algorithms can identify emergent terms; centrality: evaluating the parameter of the number of lines on a certain node, the larger the value, the more the number of lines, that is, the importance of the node in the whole network. disaster medicine and public health preparedness categories of disaster medicine, except for [leaning j, ] , which summarizes the challenges and pressures posed by natural disasters to public health. these categories are disaster rescue , [ ] [ ] [ ] [ ] and post-disaster health effects. [ ] [ ] [ ] [ ] overall, the most cited article was "definitive care for the critically ill during a disaster: a framework for allocation of scarce resources in mass critical care -from a task force for mass critical care summit meeting, january - , , chicago, il," which offers guidance for allocating scarce critical care resources, drawn from a task force on mass critical care. this task force provided several suggestions for managing the triage process when medical systems are overwhelmed. in addition, [devereaux av, ] was sponsored by new york university, which sponsored the greatest number of disaster medicine publications from to . among the authors, f. della corte, m. d. christian, and p. l. ingrassia were the most productive. in their papers, the most cited articles were all associated with the "task force for mass critical care." , [ ] [ ] among the studies of post-disaster health effects, the most cited article was "trends in respiratory symptoms of firefighters exposed to the world trade center disaster: - ," which described trends in post- respiratory and gastroesophageal reflux disease symptoms in wtc-exposed fire fighters. this study also contributed to the literature on public environmental/occupational health, the discipline that produced the most disaster medicine studies from to . based on the co-citation analysis, "a consensus-based educational framework and competency set for the discipline of disaster medicine and public health preparedness" had the highest centrality; it developed a new educational framework for disaster medicine and public health preparedness, based on consensus identification from an expert working group in the american medical association. a time-view map of the co-citation activities appears to the left of the column with the clusters' labels. new clusters include cluster # on spinal cord injury, # on conceptual framework, and # on health professionals; the landmark publications include [subbarao i, ] and [walsh l, ] . they were also the newest burst strength publications, which suggests that "public health preparedness" will become a hot topic in disaster medicine. terms analysis provides a reasonable description of research hotspots (areas of focused attention by a number of scientific researchers, addressing a set of related research problems and concepts), whereas burst words represent new research frontiers (emerging trends and abrupt changes that occur in a timely manner). as shown in figure , the top hotspots of disaster medicine research were: ( ) "practices in disasters." these papers focus on the practical elements of disaster medicine, including the treatment of wounded, effect evaluation, first aid, and disaster medical education. [ ] [ ] [ ] [ ] [ ] ( ) "hospital disasters." these papers also focus on practical elements of disaster medicine, including modular management, humanitarian relief, first aid management processes, and disaster emergency departments. [ ] [ ] [ ] ( ) "disaster events." these papers summarize the casualties of disasters and their impact on public health. - ( ) "disaster settings." these papers focus on the medical needs of the disaster, including medical personnel, medical equipment, and medical technology. - ( ) "earthquake disasters." these papers focus on medical rescues during an earthquake, including the medical decision-making, the rescue process, and the treatment of the special population. [ ] [ ] [ ] [ ] in addition, several burst terms were detected by cite space iii and are considered indicators of research frontiers over time. in the results, the time interval is shown as a blue line, and the time period that represents a burst term category is shown as a red line, indicating the beginning and the end of the time interval of each burst. therefore, the three newest frontiers were: ( ) "impact." these papers focus on post-disaster effects on the physiology and mental health of survivors, including their daily behaviors, physiological indicators, and mental states. [ ] [ ] ( ) "public health preparedness." these papers focus on the establishment, evaluation, and management of medical rescue systems. - ( ) "public health emergencies." these papers focus on the training of emergency personnel, the promotion of emergency technology, and the management of emergency procedures. , [ ] [ ] limitation in this study, although the noise data can be reduced by setting up the requisite statistical parameters in citespace iii, the source of data is limited by a generic search term strategy, which is likely to lead to some noise in the selection of articles. the major findings of the present scientometric study are helpful for all those involved in worldwide disaster medicine research. indeed, this study can help researchers better understand disaster medicine research worldwide and be useful, for example, in choosing appropriate journals for publication and collaborations. fellows choosing an institution for advanced work may also be interested in such an analysis. journals can determine where they stand in relation to other journals in publishing articles related to disaster medicine. governments and policy-makers can also ascertain the most effective countries and institutions in the world in this field, and this analysis may assist them to apprehend and predict the hotspots and dynamic directions of disaster developing health information documentation in disaster update in intensive care and emergency medicine medical action and reflections on china's rescue in nepal emergency medical rescue efforts after a major earthquake: lessons from the wenchuan earthquake the pandemic and all-hazards preparedness act: its contributions and new potential to increase public health preparedness development of the japanese national disaster medical system and experiences during the great east japan earthquake emergency medical rescue major earthquakes: lessons from the wenchuan earthquake emerging trends in regenerative medicine: a scientometric 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disaster medicine among health professionals, medical students, and local residents in building community disaster resilience: perspectives from a large urban county department of public health assessing disaster preparedness among latino migrant and seasonal farm workers in eastern north carolina association of community health nursing educators: disaster preparedness white paper for community/ public health nursing educators characteristics of effective disaster responders and leaders: a survey of disaster medical practitioners national differences in regional emergency department boarding times: are us emergency departments prepared for a public health emergency this study was supported by the third military medical university military doctoral program (no. jskt ).lz and pz conceived and designed the paper. lz, nx, and sl wrote the article. zz, lf, st, kh, lz, and pz collected and analyzed the data. sl provided critical revisions. all authors approved the final version of the paper. to view supplementary material for this article, please visit https://doi.org/ . /dmp. . key: cord- - a cbuh authors: boshoff, willem h. title: south african competition policy on excessive pricing and its relation to price gouging during the covid‐ disaster period date: - - journal: s afr j econ doi: . /saje. sha: doc_id: cord_uid: a cbuh the declaration of a state of national disaster in south africa, due to the covid‐ pandemic, was followed by excessive‐pricing regulations pertaining to certain consumer and medical products and services. the regulations and their application suggest an intertemporal benchmark to judge excessive pricing, deviating from previous practice. intertemporal comparisons assume a structural shift during covid‐ that changes competitive conditions, related to changes in consumer behaviour. such comparisons must also account for demand and cost changes. while the covid‐ regulations allow for cost‐based price increases, demand‐based increases are not explicitly accounted for, suggesting that the regulations are framed more generally as price‐gouging regulations. the differences between price‐gouging and excessive‐pricing benchmarks depends on the type of disaster‐period demand shock. they are similar following a transitory demand spike, provided sufficient time is allowed for dynamic price behaviour, but differ markedly when demand is elevated for the duration of the disaster period. applying simple cost‐based comparisons in recently concluded cases against smaller retailers are consistent with excessive pricing, given the presence of a demand spike. to the extent that these involve persistently higher demand, cases against wholesalers and larger retailers will be more complicated, as such demand must be reflected in competitive prices. extreme exogenous shocks to the economic system (due to war or natural disaster) may bring surges in demand for various goods and services and disruption to supply, often producing sharp acceleration in prices. during such times, regulations against price gouging -especially in relation to basic food and other consumer items -may form part of the policy response. accordingly, following declaration of a state of national disaster due to the covid- pandemic, the south african minister of trade, industry and competition published regulations pertaining to the pricing and supply of certain consumer and medical products and services during the disaster period. this market, competition practitioners seek to understand the relative size of the firm and the extent of competition (and potential competition). consequently, the definition of the relevant market (from both a product and geographic perspective) is a critical first step in the assessment of market power. it is therefore vital to assess how the covid- disaster may affect market definition, in order to assess the extent of its expected impact on market power. the thought experiment that underlies market definition in most competition jurisdictions, including in south africa, is the hypothetical monopolist (hm) test. the hm test focuses on demand-side substitutability, i.e. the substitutes available to buyers of the product or service offered by the firm under investigation. the analyst applying the test must consider when it would be profitable for the firm to impose a "small but significant non-transitory increase in price" (ssnip), assuming that the firm acts as a hypothetical monopolist (i.e. controls an ever-growing set of substitutes for its own product). the smallest possible set of substitutes for which a ssnip is profitable is considered the relevant market (together with the firm's own product): this set of substitutes significantly constrains the market power of the firm under investigation, as they are the key alternatives available to the customers of this firm. the covid- disaster can affect how analysts define markets, because of its impact on demand-side substitutability. as discussed later, changes in consumer behaviour during the disaster period -including increased search costs and/or higher valuation of particular product characteristics -may reduce demand-side substitutes and increase the unilateral pricing power of firms -at least in certain types of market (frank, ) . this would imply narrower product and/or geographical markets and, hence, increased market power. from the supply side, limitations on business operations may also delay or prevent entry of new competitors during the disaster period, which would further support arguments that market power may rise during the disaster period. indeed, competition authorities often view a lack of entry as an important condition for prosecuting excessive pricing (jenny, ) : entry may temper excessive pricing in the medium run, limiting enforcement costs (see ezrachi and gilo, ; mncube and ngobese, ; das nair and mondliwa, on how entry and investment considerations played out in seminal excessive-pricing cases in south africa). the covid- disaster may give rise to significant, though transitory, market power with no prospect of an immediate increase in competition: the short duration of the disaster period may limit the probability of entry. changes in the behaviour of consumers and competitors during the covid- disaster period may give rise to a temporary increase in market power. conventional competition policy, both in south africa and abroad, deals with market power as a long-run structural feature: economists view market power as the ability to influence the long-run level of mark-ups, i.e. the extent to which prices exceed cost in the long run. market changes resulting in higher long-run mark-ups, rather than transitory price increases, are usually the subject of interest. a substantial and sudden increase in price does not offer sufficient evidence of market power or its abuse. even under perfectly competitive conditions, a firm can always increase its price. however, within a short period of time, such a price increase will be met with consumer substitution to other firms, forcing the firm to reduce its price or exit the market. in the case of a positive, but firm-specific, demand shift, the resultant increase in price will draw heightened competition for customers, ultimately resulting in a demand shift away from the firm to its competitors. intense competition therefore ensures that firm-specific price increases, and hence margin increases, are transitory. the question, therefore, is whether a substantial or sudden increase in price can be sustained. substantial welfare losses obtain when competitive responses to such a firm-specific price increase are muted or slow. under these circumstances, a firm may be able to implement and maintain an increased price and, hence, margin. such ability, or market power, is evident from long-run equilibrium behaviour. the typical horizon over which competition economists study price behaviour is months and beyond, as this allows an assessment of the equilibrium relationship between price and its underlying determinants, including rivalry. the hypothetical monopolist test for market definition, in which the analyst considers whether a firm can maintain a small non-transitory price increase, therefore typically relies on a period of months or longer (see bishop and walker ( ) for an overview). a -month or longer horizon is also broadly consistent with the empirical evidence on the speed with which equilibrium between price, demand and cost is established in most markets. for example, south african evidence suggests that the median frequency of price changes for consumer prices is approximately months (ruch et al., ) . the duration of the disaster period may well exceed months. given the above, under normal circumstances, persistent pricing behaviour -including excessive pricingwould attract policy interest if it was maintained over this period. yet the covid- regulations seek to do more. the recently completed cases confirm that south african competition authorities focus on particularly short time horizons in assessing pricing conduct during the disaster period. the cases completed so far, discussed later in this paper, indicate a policy concern with price changes in the immediate weeks prior to, or following, the start of the disaster period. this short horizon may partly reflect, as mentioned, a concern that a firm under investigation may enjoy significantly enhanced market power due to changes in customer behaviour and limits on new entry during the covid- disaster. yet, as argued further in this paper, policymakers must still distinguish between anti-competitive conduct due to such market power and normal market behaviour -which involves price responding to demand and supply shifts. the assessment of price responses to demand and cost changes is not necessarily quicker or easier during disasters than in other cases. as discussed later, dynamic price adjustment involves partial and lagged responses to demand and cost changes. particular care may be required when assessing price behaviour during a disaster period. a sharp increase in price immediately following a disaster is often a response to significant uncertainty about demand and cost conditions. studies of price gouging following natural disasters suggest that short-run price spikes typically occur in the days immediately following a disaster, after which price returns to levels consistent with cost increases (wilson, ) . the uncertainty associated with the disaster period suggests that a short-term horizon must at least account for those initial weeks. a policy concern with short-term pricing power and conduct bears resemblance to price-gouging laws, which do not necessarily rely on market power considerations. the enforcement of the new excessive-pricing regulations have often been aimed at smaller firms, which would not traditionally be considered dominant (see the final section for a discussion of these cases). the focus on shorter horizons to assess market power has therefore facilitated an expanded scope of south african competition policy during the covid- disaster, especially in relation to excessive pricing. historically, excessive-pricing enforcement have been limited to highly selective enforcement against large corporates, including sasol and mittal, in markets with a particular policy history. this expanded scope, while capitalising on the institutional strengths of our competition authorities, also pushes the excessive-pricing provisions towards a more general price-gouging tool. as discussed in section , by august , two contested cases, involving excessive pricing during the disaster period, had been concluded in south africa -in addition to several non-contested cases. one case involved a small wholesaler of facemasks (babelegi) and another a large pharmacy group (dischem) for the pricing of its retail mask products. it is useful to briefly note the approach taken by the competition authorities in evaluating temporary market power in these cases, given the arguments presented here. in both cases, the competition commission, as plaintiff, did not engage in a rigorous market definition exercise, but instead argued that market power can be inferred from the conduct itself -effectively, this entails an argument that it is not possible to impose a large price increase if the relevant firm does not enjoy substantial market power. while the competition tribunal appears to have accepted this approach in their judgement in the babelegi case, the tribunal did engage in a market definition exercise in the later dischem judgement. arguably, the latter approach accords with the position advocated in this paper, as it recognises both that the disaster period may affect substitutability and that fact-based analysis is required. as argued earlier, merely observing a firm-specific price increase of a substantial size order does not offer conclusive proof of market power. furthermore, as explained subsequently, the nature of demand changes during the disaster period (whether they are sustained or involve transitory spikes) are critical to determining the appropriate standard for excessive pricing. in this regard, a rigorous market definition exercise, shedding light on the features of demand, can be useful. as argued in the introduction, in addition to changes in the assessment of market power, the covid- excessive-pricing regulations raises questions about the relevant standard for excessive pricing. the emphasis on cost-based increases in the new excessive-pricing regulations affects how competition authorities evaluate demand-based price increases. the simulations presented later in this paper show that price-gouging and excessive-pricing benchmarks may differ substantially if demand remains elevated over the disaster period, but may be similar when demand experiences only an initial disaster-period spike. in terms of section ( ) of the south african competition act (act of , as amended), a dominant firm is prohibited from charging its customers a price that is excessive. in the original formulation of the act, an excessive price was to be determined by reference to "economic value," a concept which was given content in subsequent case law. the amended act removes this concept, setting out the factors that should be considered in determining a benchmark competitive price and whether a price is deemed excessive relative to such competitive price. the factors identified in the act are: (i) price-cost margins and other profitability measures; (ii) prices charged by the respondent in other markets and over time; (iii) prices and profits of comparator firms in competitive markets; (iv) duration of pricing at that level; (v) structural characteristics of the relevant market, including market share, contestability, barriers to entry and past or current advantage that is not due to the respondent's own commercial efficiency or investment; and (vi) any regulations made by the minister of trade, industry and competition, "regarding the calculation and determination of an excessive price." following the declaration of a national disaster due to covid- , the minister relied on section ( )(f ) to introduce new regulations on determining excessive pricing, in selected industries, during the period of national disaster. these regulations define an excessive price increase as a price increase that (i) does not correspond to increases in costs or (ii) results in an increased markup relative to the average markup achieved over the threemonth period from december to february . the regulations apply to four broad groups of goods and services: (i) basic food and consumer items; (ii) emergency products and services; (iii) medical and hygiene supplies; and (iv) emergency clean-up products and services. these regulations, which pertain to competition policy, are the focus of this paper. even so, the regulations were accompanied by regulations, similar in form, pertaining to the south african consumer protection act (act of , amended). this act contains provisions against "unconscionable, unfair, unreasonable and unjust" prices. the regulations rely on section ( )(d) to define, for the period of national disaster, price increases as unfair if the price increase meets the same conditions as those for excessive pricing: it does not correspond to increase in cost or results in an increased markup when compared to the -month period prior to the disaster period. in contrast to the broad groups defined for excessive pricing, these regulations apply to a specified set of household products and medical services. subsequently, the minister tasked the south african competition authorities to implement both the competition-law and the consumer-law regulations. this is arguably a pragmatic decision to capitalise on the institutional strengths of the competition authorities. even so, the benchmark triggering competition-law investigations of excessive pricing differs from the benchmark triggering investigations of price gouging, which is the focus of the consumer-law-based regulations mentioned above. this distinction receives further attention in the subsequent sections. the principal economics concern in excessive-pricing cases is the determination of the competitive benchmark price. competition policy allows for imperfect competition, implying that a perfectly competitive price does not offer an appropriate benchmark. while allowing imperfect competition to affect pricing, competition policy against excessive pricing does not permit monopoly pricing. excessive-pricing provisions are specifically aimed at preventing firms from fully exploiting consumers' willingness to pay prices that would not prevail in a more competitive market. indeed, the challenge of determining an appropriate competitive benchmark is a key reason for the circumscribed application of excessive-pricing provisions (drexl, : ) . international competition policy practice features two approaches to obtaining competitive benchmark prices in excessive-pricing cases (gilo, ) . comparative benchmarking involves comparison of the market price under investigation with prices set by the firm under investigation, or similar firms, in other markets (gilo and spiegel, ) . to the extent that demand and supply conditions are similar to the market under investigation, so that the markets are broadly comparable but for the difference in competitive conditions, the latter would offer competitive benchmarks for the market under investigation. if this condition is met, significant price differences can be attributed to differences in competition. specifically, if prices are significantly higher in the market under investigation, it may be considered evidence of excessive pricing. an alternative approach entails cost-based benchmarking, which involves assessing a firm's cost structure -to determine average cost for the product under investigation -and identifying an appropriate profit margin. as discussed below, south africa has been a front-runner in developing this approach, with several well-known cases featuring sophisticated cost-benchmarking exercises. while comparative and cost-based benchmarks offer complementary approaches to obtaining competitive reference prices, a cost-based approach faces significant practical challenge. first, the determination of a firm's cost structure requires a bottom-up approach, including translating accounting costs into economic costs and allocating such costs to the product under investigation. misallocation, including of common costs, may upwardly bias the estimated competitive price. second, a cost-based approach faces the task of determining the profit margin that would apply if the market was "competitive." there are conditions under which a cost-based approach may be preferable, notably in the absence of comparator markets or firms. apart from these select cases, comparator approaches may well be preferable. comparator approaches can provide a range of price estimates, allowing practitioners to infer an upper bound for the competitive price (gilo, ) . besides, realised price exceeding this upper bound is a sufficient condition for its also exceeding a cost-based benchmark. it is useful to distinguish between comparator benchmarks based on spatial or rival comparisons and those based on intertemporal comparisons. spatial comparisons involve as reference prices those charged by the same or other firms in more competitive markets or to other classes of consumer in the market. similarly, rival comparisons rely on prices charged by direct rivals of the firm in the market under investigation. intertemporal comparisons -the focus of this paper and of the new regulations -involve a comparison of price in the period under investigation against prices charged in a different period. intertemporal approaches can involve either before-and-during analysis, in which a preceding period is used as the reference competitive period, or a during-and-after analysis, which relies on a subsequent period. intertemporal comparisons are preferable to spatial comparisons when seeking to identify benchmark competitive prices. it is often challenging to account for idiosyncratic features of demand, supply or structure in other markets and many of these features may be unobservable. this undermines the general utility of spatial comparisons in excessive-pricing investigations. price comparisons based on the same, rather than a different, market may largely avoid this problem (akman and garrod, ) . where the same market can be observed, under periods with different competitive dynamics, price differences between the periods can be related to competitive differences with relatively high confidence. consequently, where data availability permits, the preferred benchmark in excessive-pricing investigations should be the market under investigation over an earlier or subsequent time period. during the disaster period, rival price comparisons may be even less useful, especially if rivals have also increased prices during this time (when prices are strategic complements). similarly, spatial price comparisons may ignore that prices may have increased in other geographic locations because of similar increases in market power. preliminary indications from other jurisdictions suggest cases clustering in the same type of product market (e.g. face masks). therefore, for cases involving markets of a considerable geographic scope, international price comparisons, for examples, may be problematic. where the disaster period does not raise such additional concerns (perhaps in cases featuring local geographic markets, which allow price comparisons with, for example, nearby markets), intertemporal comparisons continue to offer more appropriate benchmarks for covid- -related investigations, for the reason discussed above. the utility of an intertemporal benchmark vitally depends on the presence of an exogenous structural shift that results in significantly different competitive conditions in the period under investigation compared to the benchmark period. gilo ( ) identifies three such structural shifts for excessive pricing benchmarking. first, the entry of new competitors can materially affect ex post competitive conditions. competition authorities can prove ex ante excessive pricing by comparing pre-and post-entry prices in the market. second, changes in regulation (specifically, deregulation) or related marketing strategies can affect competitive behaviour. especially in markets with some form of price regulation, which can be taken as attempts to establish more competitive prices, the regulated period may be an appropriate benchmark period. for example, recent excessive pricing cases in pharmaceutical markets relate to price increases following changes in branding in order to avoid regulation (see the recent flynn pharma limited and pfizer limited v the competition and markets authority ( ) case in the uk court of appeal). third, changes in consumer behaviour can affect competition and pricing. gilo ( ) notes an example related to consumer boycotts of cottage cheese in israel, where higher price elasticity during the boycott period resulted in significantly lower prices. © economic society of south africa anti-cartel policy also relies on structural shifts related to competition when identifying the price overcharge of cartels. cartel overcharge models compare prices during collusion with prices prior to or following collusion and depend critically on the presence of structural changes associated with the end (or onset) of cartels. such changes may include cartel enforcement or the entry of new competitors. the structural shifts on which intertemporal benchmarking relies must be clearly linked to changes in competitive conditions. the covid- regulations suggest that the national disaster is considered a structural shift that delineates a more competitive pre-disaster and less competitive disaster period, allowing identification of price changes with changes in competition. however, we note below that this shift is difficult to disentangle from demand and cost changes during this period. a further condition for intertemporal benchmarking, to provide comparable reference prices, is that the benchmark period must involve transactions under similar demand and cost conditions to those of transactions in the period under investigation (akman and garrod, : ) . consequently, one should distinguish between unconditional (which do not correct for the impact of demand or cost changes on price) and conditional comparisons. to the extent that demand and cost conditions are broadly similar, the former may be sufficient. in most cases, however, conditional comparisons are required. a conditional intertemporal benchmark price is a constructed, or counterfactual, price. it refers to the price that would have been charged if the benchmark period was characterised by the same demand or cost conditions prevalent in the period under investigation. the competition-economics literature has built up a significant body of work around the estimation of conditional intertemporal benchmarks relying on statistical analysis, to which we return later in this paper. the conditionality requirement represent a significant challenge when relying on intertemporal benchmarking in a market that is subject to significant demand or cost shocks. if the benchmark period does not contain periods during which prices have had to respond to large demand shocks or to significant increases in cost or cost uncertainty, it may be challenging to obtain comparable conditional prices. as discussed below, this should be considered at the core of the challenge facing economic analysis in covid- excessive-pricing investigations. south african competition policy has been a leader in the prosecution of excessive pricing. a number of high-profile cases -including cases involving mittal-harmony and sasol -raised important questions about the appropriate competitive benchmark. das nair and mondliwa ( ) in the seminal excessive-pricing cases in south africa, preferring cost-based benchmarks. roberts ( ) , das nair ( ) and calcagno and walker ( ) provide in-depth analyses of cost-based benchmarks in the seminal mittal-harmony case, highlighting the variety of challenges associated with cost and profit measurement. in the earlier cases, intertemporal comparisons would have been less useful, due to the unique competition problems associated with these cases, which involved the exploitation of market power over many years, with no discernible competitive period (e.g. see mondliwa and roberts ( ) on the sasol case and the role of state support). indeed, most comparator-based methods would have faced challenges in these cases, given that underlying demand conditions may not be similar in different markets (see murgatroyd and baker ( ) ). the covid- regulations require the assessment of excessive pricing during the national disaster period to rely on an intertemporal comparison of prices. as noted earlier, the regulations consist of two parts and breaching either part is sufficient to trigger prosecution. the first part of the regulations emphasise that price increases that do not correspond to cost increases will be considered excessive. an economics interpretation of this provision is that the correlation between price and cost during the disaster period must be unchanged relative to that of a prior benchmark period. retrospective analysis is essential, especially given that price may respond differently to different cost items and given the dynamic nature of price adjustment. the second part of the regulations emphasise that profit margins must be constant between the disaster period and a -month period preceding the disaster period, which would also imply an intertemporal benchmark approach. as discussed previously, an intertemporal benchmark for excessive pricing during the disaster period must meet two conditions. first, the disaster period must be associated with a structural shift that can be linked to changes in competitive conditions. second, the comparison must control sufficiently for demand and supply conditions to ensure that transactions between the two periods are comparable. crisis conditions can imbue smaller firms with market power (as is evident in the prosecution of smaller retailers during the disaster period) and enhance the market power enjoyed by larger firm or provide incentives for currently powerful firms to raise prices. one may advance two hypotheses concerning the impact of the covid- disaster on consumer behaviour. the first hypothesis is that the disaster period may significantly raise transaction costs, including search costs, for buyers of retail goods and services, which will reduce the set of substitutes that constrain the market power of firms. in particular, transaction costs may be higher (relative to the pre-disaster period) for at least two reasons. first, lockdown and other restrictions on movement during the disaster period may reduce the mobility of customers and their associated ability and willingness to respond to price increases. second, and related, health concerns may reduce willingness to enter alternative outlets in search of substitute products. consequently, market definitions are likely to be narrower. the second hypothesis is that the disaster period may significantly alter consumers' valuation of product characteristics for selected products, reducing or otherwise limiting the set of substitutes that would constrain the market power of firms selling those © economic society of south africa products. for example, whereas hand sanitisers with lower alcohol content may have been substitutable with other soaps or sanitisers, they may now be significant less substitutable. consequently, market definitions are likely to be narrower. these hypotheses are likely of greater import in retail markets, which would that the retrospective benchmark implied by the regulations may well be easier to sustain in the context of cases against retailers. even so, the empirical support for these hypotheses will have to be considered on a case-by-case basis, as part of the market definition exercise. for example, the increase in transaction costs may be weaker in high-income retail settings. firms offering online substitutes for the products of bricks-and-mortar retailers have rapidly expanded in a few weeks during the lockdown period, which undermines the argument that retailers of food and other essentials would gain much local power. the hypothesis may enjoy stronger support in low-income settings where consumers do not have online alternatives. in upstream wholesale and input markets, the first hypothesis may enjoy less support. search costs may be less significant in markets involving business-to-business transactions, where a significant portion of which may be governed by long-term contracts and involve negotiation with powerful buyers. in any event, many south african wholesale markets for food products do include a large number of smaller buyers, which already suggest market power for sellers. in contrast, the second hypothesis would imply changes in the inputs purchased by retailers, and may be supported in markets where upstream suppliers and manufacturers face weaker competition from competing suppliers due to supply disruption during the disaster period, especially in those markets where international suppliers compete. apart from changes in consumer behaviour, competition authorities may also rely on the impact on the impact of the regulations on the extent to and speed with which firms not currently active in the defined market may enter. in this regard, one hypothesis concerning the impact of the covid- disaster would involve that, in those industries facing fixed costs, the relatively short duration of the disaster period would limit entry and, hence, supply side substitutability. a lack of entry is a core consideration in excessive pricing investigations: competition practitioners are often willing to limit enforcement to high profile cases if, in the long run, entry is considered unlikely or ineffective. the very nature of the covid- disaster may limit the potential of new competitors to enter. even so, it would appear that there is no necessary link between the regulations and changes in competitive conditions. such a link may well be likely in particular retail settings, which would support the focus of the initial enforcement efforts on retailers. apart from relying on a structural shift impacting competitive conditions, intertemporal benchmarking requires similar demand and cost conditions to hold during the two periods, i.e. before and after the structural shift. as argued, markets may well be characterised by changes in demand and supply, making conditional comparisons essential. the first part of the new regulations require price comparisons between the periods to be conditional on cost changes. the second part of the regulations (which require profit margins to remain constant) also imply this conditionality: formally, the second part may be interpreted as defining a price increase as excessive if: with t the profit margin at time t. ε is a parameter to reflect the burden of proof, which eliminates the prosecution of profit differences of an appropriately small degree. frank ( ) argues for a safe harbour if the gap between price and cost does not exceed %, consistent with south african competition authorities' reliance on a % harbour on the basis of "economic value" in previous cases. as noted earlier, the amended act has removed reference to economic value. the above profit condition can be decomposed in its price and cost components as follows: re-arranged, the condition can be stated as: consequently, the second part of the regulations permits increases in price, relative to the price prevailing during the pre-disaster period, if the price increase is consistent with an increase in cost. intertemporal price comparisons that are conditional on cost must be sensitive to changes in the cost structure of firms during the disaster period. the disaster period may bring novel cost pressures from various sources. first, interruptions to supply chains can constrain production or sales and increase costs. for example, disruptions may arise in the distribution network (due to constraints at maritime ports and airports), upstream production or a reduction in available labour (including due to constraint in operating hours and new health regulations). second, search costs may increase significantly, if supply disruptions require firms to identify new suppliers and negotiate prices. for example, in the absence of favourable contract-based terms with existing suppliers, a firm may need to pay spot prices. suppliers may also invoke force majeure clauses, allowing the pass-on of higher costs to buyers. third, surges in demand may create capacity constraints, which may cause firms to incur additional costs. finally, firms may be required to incur additional costs related to hygiene and sanitisation. while a sensitivity to higher or additional costs may appear consistent with the new regulations, it is not immediately clear how demand-based price increases are to be treated. the regulations make no explicit reference to demand conditions. by focusing exclusively on cost-based price increases, the regulations identify as anti-competitive any price response to a demand-side factor during the disaster period. this approach effectively transforms excessive-pricing regulations into price-gouging regulations, which typically treat any demand-based price increase as "unfair." indeed, the consumer protection sections in the disaster-period regulations rely, similarly, on exclusive cost-based criteria to determine "unconscionable, unfair, unreasonable and unjust" prices: the excessive-pricing provisions are therefore similar to consumer-protection provisions (with the latter focused on a somewhat broader set of products and not requiring a finding of dominance). an exclusive cost-based focus is contrary to the objective of relying on retrospective prices to provide reference prices that can be considered competitive. indeed, motta and de streel ( ) note explicitly that a competitive price "is not only determined by supply-side factors (in particular the cost of production), but also by demand side factors (demand elasticity, willingness and ability to pay)." demand shifts in consumer income, © economic society of south africa prices of substitute products and demand seasonality may affect prices, even in competitive settings. expected normal demand features as a statistically significant factor in empirical models of price (see seminal work on manufacturing industries by maccini ( ) ). competition policy practice recognises that obtaining a comparable competitive price from the benchmark period requires accounting for both cost and demand differences between the periods (gilo, ) . international practice suggest that even cost-based benchmarks for excessive pricing must at least account for demand factors. for example, in its port of helsingborg decision, the european commission explicitly considered aspects of port customers' willingness to pay in applying cost-based tests. in a prominent attheraces appeals case in the united kingdom, excessive-pricing findings were overturned based on failure on the part of the authorities to account for customer valuation when assessing excessive pricing. indeed, motta and de streel ( ) use the requirement to at least account for demand as one reason for relying on multiple excessive-pricing tests. to the extent that south african policymakers have chosen to rely on competition policy to address pricing behaviour during the national disaster period, it follows that such policy must be sensitive to demand-based price increases as indicative of normal competitive behaviour. previous excessive pricing cases in south africa have attempted to grapple with the impact of demand: in the mittal case, cost and profit comparisons accounted for global steel demand conditions. however, these cases did not involve controlling for demand in the context of intertemporal benchmarking. an intertemporal benchmarking approach sensitive to demand would be consistent with south african policy approaches to damage determination in cartel cases -indeed, the proposed econometric approach in section draws heavily on damages models which typically control for both demand and supply factors when estimating the price overcharge of a cartel. for example, boshoff and van jaarsveld ( ), when estimating overcharges by the cement cartel, control for the impact of construction demand, including the world cup construction boom. therefore, an alternative interpretation of the new regulations would be that they may be concerned with prohibiting price changes due to exogenous changes in demand or supply, rather than adopting a narrow focus on the effects of market power and its abuse during the disaster period. a narrow focus does not imply that competition policy allows rational monopolists, or firms otherwise enjoying market power, to set prices at levels that fully exploit their customers' willingness to pay. the case law recognises that such a benchmark would impair the enforcement of excessive-pricing policy, as monopoly pricing is its primary concern (gilo, ). even so, international legal practice affirms the need to account for demand-side factors when evaluating excessive pricing: even after the competition authority has decided to enforce an excessive-pricing prohibition on a dominant firm, the recent flynn pharma/pfizer case in the united kingdom confirms that a respondent must be given an opportunity to show that the price it charges is justified, at least partly in relation to the consumer benefit of the product. an intertemporal benchmark overcomes the difficult problem of accounting for demand shifts and consumer benefit, while disallowing full exploitation of willingness-to-pay. intertemporal comparisons allow for price changes due to changes in demand-shift variables between the period under investigation and the benchmark period, but not for price changes due to structural changes in demand (which are the sources of market power, as discussed earlier). this advantage of the intertemporal benchmark is even more important in the context of covid- cases, where changes in the willingness-to-pay is at the heart of excessive-pricing investigations: as argued earlier, changes in the willingness-to-pay underlies increased market power and its potential abuse during the disaster period. a consideration of the influence of demand shifts on price may also be important to an assessment of cost. "demand"-related variables, such as measures of unfilled orders and of finished-goods inventories, may be significant drivers of price, either because they shift demand or, importantly, affect the cost function of firms. the effects differ depending on the type of production in which the firm is involved. firms that produce to stock are primarily concerned with goods inventories, maintaining a particular level of stock (say, at retail outlets) depending on anticipated demand. firms involved in production to order are concerned with responding to demand, keeping delivery lags minimal. in production-to-order, a large order backlog -due to a surge in demand -may permit production smoothing (and lower costs), while larger inventories increase holding costs (including storage and insurance costs) in production-to-stock markets. case-by-case assessment of the mode of production is therefore required. treating demand-based price increases during the disaster period as necessarily anticompetitive undermines the consistency introduced by retrospective benchmarking: it is not clear why price-cost relationships in the past should be considered an appropriate guide for the present, while price-demand relationships are not. subsequent sections in this paper explore and contrast such a price-gouging view against the standard excessive-pricing view. we show that there are conditions where economists may discount demand-based price spikes, as long as average prices over a sufficient period is considered. the excessive-pricing regulations in south africa also specify the period (december to february ) applicable in determining the intertemporal benchmark. the literature on intertemporal benchmarks refrains from linking such benchmarks to particular time frames. a benchmark price is the average price over a competitive period of suitable duration, where such duration should reflect a balance between obtaining a thorough assessment of price setting and minimising the risk of structural or other factors contaminating the assessment. as far as the former requirement is concerned, an interval of sufficient duration is required in order to assess the dynamic nature of price, cost and demand as well as their respective relationships. from the perspective of the latter requirement for structural stability, an interval of sufficiently short duration is required to ensure that market conditions approximate those prevailing during the period under investigation. the trade-off between a choice © economic society of south africa of duration that enables a complete assessment and one that limits structural changes is heavily dependent on the frequency of price changes and the availability of data. lowfrequency price changes (quarterly and lower) would imply that an interval of a longer duration is required, while the availability of data may also result in a duration less than the ideal. even where price changes are of a higher frequency, it may be necessary to look further back before the december-february period, when historically subdued demand and cost increases, seasonal fluctuations or other idiosyncratic price behaviour (including special discounts) characterise the market. a short reference period may be particularly problematic in retail setting relying on promotional pricing, where a return to normal pricing coinciding with the disaster period may lead to incorrect inferences of unjustifiable price increases. furthermore, in relation to demand spikes, it may be particularly important to consider past responses to periods of unexpected and large demand (or cost) shocks. consequently, a three-month period is not necessarily appropriate for the estimation of underlying elasticities, even for prices set at a relatively high frequency. this is true whether or not actual econometric analysis is employed: even in those instances where authorities rely on a qualitative analysis of price elasticity, it is preferable to draw on the experience over a longer period to infer average behaviour. as shown in the case overview presented later in this paper, it is not clear to what extent competition authorities have limited their analysis to the three-month horizon. the covid- regulations require a conditional intertemporal benchmark, which involves a comparison of prices during the period under investigation (disaster period) with those of a benchmark period (pre-disaster period), after controlling for both demand and cost differences between the periods. the literature on cartel damages offers an econometric methodology for obtaining benchmark prices, using reduced-form regression. the following sections discuss this econometric methodology, as applied to conventional excessive-pricing and (for a comparative view) price-gouging investigations. as shown, the distinction between conventional excessive-pricing and price-gouging benchmarks matters for covid- excessive-pricing investigations. intertemporal benchmarking requires conditional comparison of prices in the benchmark period (which we have argued is considered more competitive) relative to those in the period under investigation (which, due to a structural shift, is now less competitive). in the context of covid- , conditional comparisons would be between the disaster period (the period under investigation) and the ex ante period (the competitive benchmark period). conditional comparisons discount price differences that are due to cost and demand differences. econometric modelling can assist in discounting demand and cost differences. benchmarking requires a study of reduced-form price elasticities, with respect to both demand and cost, during the benchmark period (nieberding, ; rubinfeld, ) . these elasticities, applied to demand and cost factors during the period under investigation, allows a forecast of the price that the firm would have charged if it had still faced the pre-disaster competitive conditions. the cartel damages literature has long relied on such econometric modelling to achieve benchmarking (rubinfeld, ) . price overcharge during collusion is the basis of cartel damages and is typically determined by comparing prices during the cartel period with prices during a more competitive period, preceding or following the cartel period. intertemporal benchmarking in excessive pricing investigations face a similar problem to determine the 'overcharge' relative to the price in a competitive period. as explained below, the cartel-damages literature offers a reduced-form econometric methodology for estimating competitive benchmark prices in excessive-pricing investigations. practical considerations may prevent the explicit use of econometric analysis, especially in the context of excessive pricing investigations under the new regulations (with their truncated adjudication periods). but even where econometric modelling is not possible, the exposition in this section elucidates key empirical issues in the assessment of excessive pricing. the econometric methodology provides a guide for an empirical strategy based on qualitative analysis or more rudimentary quantitative techniques. even if econometric analysis is feasible, it may be preferable to rely on multiple approaches in order to triangulate estimates. econometric analysis allows an assessment of the dynamic relationships between cost, demand and price. menu costs (including the cost of re-negotiating prices or changing list prices) may lead firms to limit the response of price to small cost changes and gradually increase prices over time. prices may also increase at different time points for different customers, depending on contractual arrangements. similarly, prices may not respond to short-term demand or cost fluctuations immediately, as firms seek to smooth production over time to avoid costs related to varying production. dynamic econometric models capture these effects. furthermore, incorporating lagged price terms in dynamic models also allows controlling for the influence of non-observable information. for these reasons, the cartel-damages literature relies on dynamic price regressions (for a recent summary, see boswijk et al. ( ) , for south african applications see govinda et al. ( ) , mncube ( ) and boshoff ( ) ). consider a reduced-form model of price during the pre-disaster period (t = , … , t , with t the end of the period): where p is the price of the product, d is a demand shifter and c is a cost shifter, with t ∼  ( , ). the autoregressive distributed lag (ardl) specification reflects the dynamic adjustment of price, cost and demand, allowing for both contemporaneous and lagged price adjustment. intertemporal benchmarking relies on the parameter estimates from ( ) to obtain dynamic price forecasts p t during the disaster period (t = t + , … , t ): see boshoff ( ) for a defence of limited-information quantitative tools in competition analysis, with applications to south african competition policy. ( ) these forecasts constitute the competitive benchmark prices, applicable to the disaster period. under this approach, price is excessive to the extent that it deviates from the benchmark level suggested by demand and cost factors. applied to the covid- disaster, the assumption is that the deviation of the actual and benchmark price during the disaster period is a reflection of a change in competitive conditions due to the crisis, the sources of which must be verified (and relate to changes in consumer behaviour and lower likelihood of new entry). conventional excessive-pricing investigations focus on pricing due to a lack of competition after controlling for non-competition factors -specifically, demand and cost factors. in contrast, price-gouging cases emphasise price responses to demand as undesirable. as noted earlier, price gouging laws differ across a variety of jurisdictions (including within the united states), but the overarching aim is to keep prices as close to their pre-disaster behaviour as possible. at the same time, it is often accepted that prices may vary for cost-related reasons. research following hurricane katrina in the united states reject a hypothesis of price gouging, with the evidence indicating that cost explains most of the price increases following the disaster, at least if one excludes the first days immediately following the disaster (see montgomery et al., ; wilson, ) . a version tolerant of market forces would also allow for a price response to "normal" demand. therefore, a generous benchmark price for the purposes of assessing price gouging would reflect cost as well as "normal" demand, i.e. demand neutral to a disaster-period surge. price-gouging counterfactual prices (p * ), neutral to a demand surge during the disaster period (t = t + , … , t ), would be: where d t is a forecast of the demand-shift variable, based on pre-disaster behaviour. as demonstrated by the following simulation example, the nature of the disaster-period demand surge will determine the extent to which a price-gouging benchmark in ( ) differs from an excessive-pricing benchmark in ( ). price-gouging laws are primarily aimed at muting price responses in the immediate runup to and aftermath of a natural disaster. demand spikes, due to panic buying, often put extreme pressure on prices. some of the initial cases investigated under the new regulations in south africa reflect such a spike in demand. these include retail cases involving an alternative approach involves estimating equation ( ) over both the pre-disaster and disaster period, but adding a disaster-period dummy variable as well as a set of variables capturing interactions between the dummy variable and the various demand and supply terms. the sum of the coefficients on these additional variables then measure the extent to which price deviates from the predicted pre-disaster level. there is an extensive literature on the conditions for equivalence between forecasting and dummy-variable approaches, with the latter potentially improving forecast accuracy by increasing sample size, but the former allowing a more flexible treatment of parameter constancy (see, for example, mccrary and rubinfeld, ) . boshoff and van jaarsveld ( ) discuss the impact of time-series properties on the equivalence of the two approaches. ( ) panic purchases of hand sanitiser and, for the smaller retailer cases, masks at the start of the lockdown period. yet not all disaster-period demand changes take this particular form. a number of cases involve consistently elevated demand, including demand for masks from manufacturers and larger retailers. a distinction between cases involving demand spikes and cases involving persistently elevated demand matter for the determination of average benchmark prices. the primary aim of the forecasts in ( ) and ( ) is to estimate an average price. average prices, calculated over a sufficiently long period, reflect long-run equilibrium prices. as argued earlier in this paper, long-run equilibrium prices are the traditional focus of competition policy. short-run fluctuations are important in relation to how they contribute to the maintenance of long-run equilibrium. for example, nieberding ( ) studies how a short-run model, specifically a reduced-form error-correction model of price, can yield insight into the long-run effect of anti-competitive behaviour. in the absence of trending behaviour in prices, as exhibited in the example below, dummy-variable methods are often used as a substitute for forecasting methods. these dummy-variable methods yield an estimate of the average price increase for the period under investigation, rather than price forecasts for each date in the period. in the presence of trending behaviour, where dummy-variable methods are less useful, one can infer an average price increase based on the individual date forecasts. a disaster-period demand spike may produce a short-term price increase that does not change the excessive-pricing benchmark significantly, resulting in a benchmark quite similar to that of price-gouging. in contrast, elevated demand may well raise the average benchmark prices obtained from ( ), resulting in a significant difference between the price-gouging and excessive-pricing benchmarks. consider a model based on ( ), with the following parameterisation for the pre-disaster period t = , …, : where cost evolves as follows: and demand as follows: the chosen parameterisation ensures trending behaviour in both costs and demand, with ( ) ensuring that demand shocks are not permanent -an important feature for the subsequent simulation exercise. suppose that cost remains unchanged. consider two possible demand processes for the disaster period. first, suppose that the disaster period, t = , …, , is characterised by a demand shock of size at the start and demand subsequently returns to its pre-disaster trajectory: ( ) this is not key to the result, but ensures that disaster-period price behaviour can be linked to demand in the particular simulation exercise presented in this paper. second, suppose that demand is elevated, by size , for the duration of the disaster period: with t = for t = , …, fig. shows prices during the pre-disaster period together with a set of benchmark prices for the disaster period. this figure does not include any realised price for the disaster period, in order to focus attention on the various benchmarks. in particular, fig. shows the benchmark price under a price-gouging law (p * , based on equation ( )). as discussed earlier, while this particular price-gouging benchmark makes no allowance for abnormal demand during the disaster period, it does reflect price-responses to the normal trajectory of demand. given that we have not allowed for cost increases in this simulation, this benchmark behaves similar to the pre-disaster price. furthermore, fig. shows two excessive-pricing benchmarks (p, based on equation ( )), when disaster-period demand follows the spike defined by ( ) and when it is elevated for the entire period, as defined by ( ). the excessive-pricing and price-gouging benchmarks are similar in the case of a disaster-period demand spike: given a period of sufficient duration, average price increases predicted by the two benchmarks are similar. the benchmarks differ substantially when demand is persistently elevated over the disaster period. in these cases, excessive pricing sets a more lenient benchmark, to allow the demand shift to be reflected in prices. without a sufficient period to account for the dynamic behaviour of price, a transitory price response to a demand spike would be easily confused with a price response to elevated demand. even for a transitory shock limited to period , the lagged response of price generates increases until period and elevated levels (relative to the price-gouging benchmark) for several periods afterwards. because of this dynamic behaviour, and the impact of idiosyncratic demand and supply shocks in any one period, interval forecastswhich involves average forecasts over a particular horizon -are superior to point forecasts. the duration of such an interval is an empirical matter based on an understanding of price-demand dynamics in the case at hand. fig. elucidates this point, focusing exclusively on a demand spike at the start of the disaster period. the graph shows two realised price series over the disaster period (denoted case and case ), together with the relevant excessive-pricing and price-gouging benchmarks. as shown , only when considering the average of the price forecasts, can case (competitively neutral) be distinguished from case (anti-competitive). to the extent that the spike in prices does not persist in case , the average price will not be in excess of the price-gouging or excessive pricing benchmarks. only in case , where it can be shown that the price was persistently higher than the benchmarks, despite the demand spike having subsided, can it be argued that excessive pricing has taken place. while a failure to rely on a longer interval in assessing excessive pricing may raise the risk of over-enforcement in some cases, it may raise the risk of under-enforcement in other cases. consider a variant of case , where the realised price increase is muted, such that it falls below the excessive pricing benchmark, but does not return to its original level. a hasty investigation, with a limited interval following the demand spike, will not flag this problematic case, implying under-enforcement. figs and suggest that an excessive-pricing and a comparatively generous price-gouging benchmark will deliver similar price forecasts in the presence of demand spikes, provided a sufficient interval of assessment. however, if demand is persistently elevated during the disaster period, fig. suggests that the benchmarks produce markedly different price forecasts. as shown below, reliance on a price-gouging benchmark would flag a further set of potentially anti-competitive cases, which would not ordinarily attract scrutiny under an excessive-pricing benchmark. similar to figs and shows two realised prices, together with the relevant excessive-pricing and price-gouging benchmarks. the first realised price (denoted the "simple case") exceeds the higher excessive-pricing benchmark and would attract an investigation under the standard approach. the second realised price (denoted the "harder case") falls between the two benchmarks. judging this price as excessive requires price responses to elevated demand during the crisis period to be judged differently to price responses to "normal" demand during the pre-disaster period. as argued, competition authorities would find it hard to justify that the elasticity of competitive prices with respect to demand must necessarily be lower during disaster periods. the simulation exercise offers two insights for enforcement against excessive pricing during the covid- disaster period. first, it is not necessarily inappropriate for excessive-pricing policy to be pursued as a price-gouging tool in the presence of cases involving demand spikes. price-gouging and excessive-pricing benchmarks produce similar price forecasts, provided that a sufficient forecast interval is allowed. competition practitioners must however (i) reach a sufficient understanding of the nature of the demand response in any particular case and (ii) ensure that an interval of appropriate duration is allowed, again based on a case-specific understanding of the dynamics of price behaviour. such an approach would be consistent with the general approach to price gouging elsewhere. wilson ( ) documents various instances over the past four hundred years where natural disasters gave rise to claims of significant price increases. older examples include increases in fish prices following the great fire in london (+ %) and increases in transport wagon prices following the san francisco earthquake in (+ %). contemporary examples include claims of gasoline price gouging following hurricane katrina (+ % on average) and several other hurricanes as well as claims of exorbitant price increases in building supplies and services following the christchurch earthquakes in new zealand. wilson ( ) documents the empirical record on these price increases, which suggests that price spikes -where confirmed -are often limited to shorter intervals. in many of these modern examples, there has been strong political support for policy action, although wilson has noted that the short time horizons have usually limited concrete interventions. second, if the demand evaluation suggests elevated demand -rather than a mere demand spike -and if price falls between the excessive-pricing and price-gouging benchmarks, it is critical to justify why price responses to abnormally high demand over a sustained period -i.e. to elevated demand beyond that predicted by its pre-disaster trajectory -must be treated differently. this justification ensures that the focus of excessive-pricing policy -even when applied in disaster periods -remains on market-powerrelated abuses and harm to competition. it is also consistent with the earlier arguments concerning changes in market power as the basis for an intertemporal benchmark. while our simulation exercise also emphasises the importance of an interval of sufficient duration, the requirement for a longer interval need not be incompatible with the covid- policy aim of rapidly prosecuting abuses of temporary market power. all that is required is a sufficient period for equilibrium adjustment, as is evident from the brief discussion of completed cases that follows. since march , south african competition authorities have been active in pursuing excessive-pricing cases based on the new regulations. to consider the extent to which enforcement has been sensitive to the distinction between demand spikes and elevated demand -and the associated need for a sufficient interval -we distinguish between cases against smaller firms in narrow geographic markets (the majority of cases) and cases against larger firms that meet the traditional requirements for dominance. settlement agreements were concluded with several small respondents in the first months of the disaster period. table shows agreements concluded until may , with subsequent settlements following similar patterns. the cases involve small retailers (mostly individual pharmacies) facing a demand spike for, or panic buying of, either hand sanitiser or face masks at the start of the national disaster period. even though market-wide demand for hand sanitiser or face masks may remain elevated for the duration cedar pharmaceuticals t/a bel-kem co may hand sanitisers mark-up not reported but found in contravention of the disaster period, the initial spike in demand at these individual retailers is likely to have subsided significantly and rapidly, as new supply became quickly available during the course of march and april. the benchmark relied upon was not always an intertemporal benchmark. a selection of the cases involve firms selling hand sanitiser or face masks for the first time. it is not clear from the limited information available in the published tribunal orders on which benchmark the competition commission had relied in these cases, given the absence of retrospective prices or margins. the remainder of the cases appear to apply an intertemporal comparison. furthermore, in these cases, the requirements set down by the simulation exercises appear to have been broadly met. based on the limited information available from the tribunal orders, it appears that price responses to demand and cost were relatively quick in these cases, implying a shorter interval for dynamic price adjustment. in addition, it would have been relatively clear in these cases that the demand spike had subsided after a few weeks. consequently, these cases involve a reasonably straightforward judgement of whether price continued to exceed the higher level justified by the initial demand spike and, hence, whether the price is excessive. in this sense, these cases appear to meet the requirements set down by the simulation exercise. in addition to the cases settled by consent agreement, the authorities have also completed a contested case, involving babelegi workwear overall manufacturers & industrial supplies cc (babelegi), a small wholesaler, for excessive pricing of its face masks (case number cr apr ). in this case, the tribunal noted price increases from january to march in comparison to prices in december (see also frank, ) , confirming its reliance on an intertemporal benchmark. in relation to the earlier arguments (see section . ) concerning the appropriate length of the benchmark period, it is noteworthy that the competition authorities and the tribunal did not consider themselves bound to rely on prices from the three months preceding the disaster period for benchmarking purposes: the babelegi complaint focused on pricing behaviour prior to the start of the disaster period. indeed, in its judgement against babelegi, the tribunal emphasised the substantial differences in calculated profit and price increases for alternative benchmark periods. the tribunal found that babelegi's price increases were not consistent with cost increases. furthermore, the tribunal noted that the price increases occurred prior to the cost increases, which suggests that it did not consider demand fluctuations as a driver of competitive pricing. given that this case involves a wholesaler supplying to various clients, demand may well have remained elevated (compared to pre-disaster levels) after the initial spike in demand, which would require further analysis, similar to the final case against dis-chem, noted below. at the time of writing, babelegi's appeal against the decision was yet to be heard by the competition appeals court. in keeping with its standard practice of prosecuting large firms, the commission also brought a case against dis-chem, a large pharmacy group in south africa, for price increases between % and % on some of its surgical face mask products (case number cr apr ). again, the implications of our earlier simulation evidence suggest that the commission should have considered whether dis-chem faced sustained higher demand for its face masks, rather than a mere spike. it is plausible that dis-chem, as a more sophisticated buyer than the individual pharmacies involved in the consent agreements, would not have acquired substantially more face masks, without judging demand to be elevated over this period. however, in its judgement, the tribunal did not consider whether demand was permanently elevated. there was significant debate during the trial about the appropriate horizon for the long run, especially in light of societal pressure for swift policy action. yet a requirement to ascertain whether increased demand is persistent does not necessarily, or always, imply a long lag for policy action. sales and sales orders, for example, may be used to determine the persistence of increased demand in a matter of weeks. if the demand increase is confirmed to be transitory, it will be comparatively easy to assess whether price increases have also been transitory, so that it would be possible to prosecute short-term price increases. eon the other hand, to the extent that the babelegi and dis-chem cases are characterised by elevated demand, rather than transitory demand spikes, the benchmark for excessive pricing in such cases cannot be a price-gouging benchmark (i.e. one predominantly based on cost). the brief overview of completed excessive-pricing cases during the disaster period suggests that the policy decision to implement a reverse legal onus (on respondents), and to accelerate adjudication of excessive pricing cases, may be merited in those cases dealing with spikes in demand. these circumstances are also closer to the ones contemplated in traditional price-gouging policy. cases involving sustained higher demand during the disaster period, however, requires an approach closer to that employed in conventional cases. in such cases, the elasticity of price, with respect to abnormal demand, must be better understood, including to what extent a different competitive reaction is to be expected. the subsequent judgements may clarify matters. during times of extreme economic disruption, prices of food and other essential goods and services may rise significantly. such price increases, and their accompanying consumer welfare effects, have often attracted policy intervention. periods of war and natural disasters are often associated with various forms of price control, as the introduction and enforcement of price-gouging laws and regulations in various jurisdictions have shown. as part of their response to the covid- disaster, south african policymakers have elected to rely -predominantly -on competition policy to deal with price increases. south african policymakers introduced excessive-pricing regulations applicable during the period of national disaster, which prohibit price increases that do not correspond to cost increases or which result in changes in profit margins compared to the pre-disaster period. a focus on competition policy, as an expansive tool to address price gouging and other pricing concerns, is novel in the international context. historically, the prosecution of excessive pricing -both in south africa and abroad -is limited to select high-profile cases, partly because of the complexity of analysis required. in contrast, the re-allocation of resources within the south african competition authorities have allowed expansive screening of complaints and prosecution during the disaster period. an expanded enforcement effort raises the question of whether covid- -related excessive-pricing investigations involve less complex analysis. the complexity of analysis in excessive-pricing investigations is, too a significant extent, determined by the relevant benchmark used in judging whether prices are excessive. in this regard, this paper delivers five key insights. first, the paper argues that the covid- excessive-pricing regulations introduce an intertemporal benchmark for the evaluation of excessive pricing. the regulations require a comparison of prices during the period under investigation (the disaster period) with prices during the pre-disaster period, which are considered to represent a more competitive period. international experience, and the associated economics literature, support intemporal benchmarks as preferable to other benchmarks, including cost-based benchmarks or comparisons against prices in other geographic markets: the data for intertemporal comparisons are easier to obtain and avoid difficult accounting cost and profit calculation exercises. second, the paper argues that the basis of an intertemporal assessment is the presence of a structural shift that causes a change in competitive conditions. in covid- cases, this structural shift must be shown to be related to either or both changes in consumer behaviour and weakened entry during the disaster period. this underlines the importance of the market power assessment, which should precede the pricing analysis. while the consent agreements listed earlier often contain references to "temporal market power" during the disaster, the extent of case-specific analysis is unclear: the consent agreements rely heavily on an approach that views the ability to implement excessive price increases a sufficient condition for possessing market power. this behavioural view of market power requires further academic scrutiny. third, and importantly, the paper highlights that the structural shift associated with the covid- crisis is also associated with a surge in demand and/or cost. the paper emphasises that price responses to demand or cost surges are not incompatible with competitive behaviour, as such surges may cause prices to rise significantly even in competitive markets. consequently, intertemporal comparisons must always be conditional on demand and cost drivers. the covid- regulations do not appear to reflect this position: while allowance is made for cost-based price increases during the disaster period, demand-based increases receive no explicit attention. in this sense, covid- excessive-pricing regulations may be interpreted as price-gouging regulations: price-gouging policy does not typically allow for demand-based price increases following a natural disaster, though it often allows for cost-based increases. fourth, the paper relies on an econometric methodology, drawn from the empirical cartel literature, to study the differences and similarities of a price-gouging and a standard excessive-pricing benchmark. using simulations, the paper shows that the nature of the disaster-period demand surge determines the extent to which a price-gouging benchmark differs from a standard excessive-pricing benchmark. provided that a sufficient period is allowed for calculating benchmark prices, the two benchmarks deliver similar average prices following a transitory demand spike: if competition authorities allow a sufficient time period for price responses to demand and cost changes, the distinction between price gouging and excessive pricing becomes less relevant. a sufficient time period allows clear distinction between cases involving a temporary upshot in price, which subsequently returns to the benchmark level, and cases involving sustained price increases over a longer period. the former are likely "normal" market reactions to uncertainty, whereas the latter should potential attract antitrust scrutiny. the two benchmarks differ substantially if demand is permanently elevated over the disaster period. again, for those cases involving sustained price increases beyond the standard benchmark, excessive pricing will be easy to identify. but, in the case of elevated demand, price increases below the standard excessive-pricing benchmark, but above the price-gouging benchmark, will present particular difficulties. viewing such prices as excessive implies that price responses to demand during the disaster period are viewed different to those in the pre-disaster period. while one portion of the literature supports an assumption that price competition may be heavier during periods of high demand, other evidence points to the contrary. this requires case-by-case evaluation. in practice, such evaluation need not involve econometric analysis, and it is preferable to employ multiple analytical approaches. but even qualitative analysis will have to pay careful attention to the impact of demand and cost drivers on price. fifth, the paper studies the extent to which the completed covid- cases in south africa (finalised in april and may ) have followed the principles elucidated by the simulation exercise. these cases all involve smaller retailers (often pharmacies) selling hand sanitiser and face masks, which would not ordinarily attract antitrust scrutiny. for those retailers that have been selling these items pre-disaster, the approach adopted (as described in the consent agreements) appears largely consistent with the guidance from the simulation results, to the extent that these cases involve retailers dealing with a demand spike. even so, the intertemporal benchmark has not been consistently applied in those cases where firms introduced a new product. furthermore, for the on-going cases involving especially larger retailers (dis-chem), ignoring elevated demand over the disaster period raises significant challenges for the economic analysis. if competition authorities treat pricing behaviour without acknowledging structurally higher demand for the duration of the disaster period they may significantly impair the functioning of markets, especially if they lead to shortages. in sum, a greater policy emphasis on intertemporal benchmarking in excessive-pricing cases is a welcome development. it is particularly useful in the context of the covid- disaster, where the disaster may provide a structural shift directly linked to market power. the challenge, however, lies with obtaining case-specific evidence of such market power and with understanding the nature of the demand shock associated with the disaster. especially the latter will be important in justifying using excessive-pricing cases as price gouging tools against smaller players. the role of a sufficient time period, even if much shorter than the traditional horizon, will be critical in this regard, to avoid both over-and under-enforcement errors. one of the critical remaining issues concerns the impact of demand spikes on vulnerable households, especially in those cases where the horizon of the price spike is too short to support competition policy intervention. the older literature on price gouging suggests that policymakers can support households (and, simultaneously, maintain functioning markets) by ensuring that supply chains remain operative. functioning supply chains ensures quicker supply responses to any demand increase. in this regard, the relatively limited price increases in food during the first months of the disaster period can be linked to pro-active management of supply chains, in part due to coordination facilitated by government. in some instances, however, supply coordination may not be sufficient and other forms of government support -such as the increased income support provided to poorer households -may be required. when are excessive prices unfair economics of e.c. competition law: concepts, application and measurement conceptual and empirical advances in antitrust market definition with application to south african competition policy recurrent collusion: cartel episodes and overcharges in the south african cement market cartel dating excessive pricing: towards clarity and economic coherence measuring excessive pricing as an abuse of dominance -an assessment of the criteria used in the harmony gold/mittal steel complaint excessive pricing under the spotlight: what is a competitive price competition law and economic regulation in southern africa on the (a)political character of 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competition policy: theory and practice excessing pricing in competition law: never say never? the pros and cons of high prices does import parity pricing constitute evidence of excessive pricing and what are the consequences of attempting to remedy it? excessive pricing regulation in china, south africa, and other brics member states estimating overcharges in antitrust cases using a reduced-form approach: methods and issues assessing excessive pricing: the case of flat steel in south africa chicago: american bar association section of antitrust law quantitative methods in antitrust litigation decomposing inflation using micro-price-level data: south africa's pricing dynamics price gouging, construction cartels or repair monopolies? competition law issues following natural disasters key: cord- - u tyszd authors: wang, chun-yuan; guo, jinyun; kuo, ming-feng title: the building of social resilience in sichuan after the wenchuan earthquake: a perspective of the socio-government interactions date: - - journal: safety science doi: . /j.ssci. . sha: doc_id: cord_uid: u tyszd abstract in november , china implemented its emergency response law to ensure national unified leadership and collaboration when responding to emergencies. in recent years, china’s main focuses for enhancing disaster management have included emergency preparation, emergency management, and legal system mechanisms. however, its well-designed management system faced a great challenge during the wenchuan earthquake in . by examining the literature on the development of disaster management, we realized that enhancing self-organization in communities can effectively resolve problems caused by collective actions and strengthen resilience to disasters. in the decade since the wenchuan earthquake, the literature has focused more on empowering communities during disaster management in china. however, literature on the compatibility of social resilience and the government-dominant model in china is still scant. this study investigates china’s current disaster management system design; specifically, it identifies ways and methods for counteracting any conflicts between disaster management under social synergies and china’s emergency management system. it further explores what factors facilitate the balance between social synergies and the emergency management system if the two concepts were fused together. using case studies, in-depth interviews, and a focus group in the field of public administration, this study collected qualitative data to understand the changes in china’s disaster management system since the wenchuan earthquake as well as provide recommendations for future reform. in the past years, disaster prevention and rescue operation systems have become an important issue discussed in related fields (buck, trainor and aguirre, ; hsiung et al. ( ) ; stumpf, ; yang, ) . in order to deal with an increasing number of disasters, the chinese government initiated research on mitigation-related programs. for example, in april , the state council promulgated and implemented the disaster reduction plan of the people's republic of china ( china ( - ; in august , the government promulgated the national comprehensive disaster reduction eleventh five-year plan. such efforts aimed to further emphasize the role and function of social participation. also in , the national people's congress officially adopted the emergency response law of the people's republic of china, which went into effect on november . articles and of this act regulate, respectively, the "establishment of an effective social mobilization mechanism by the nation" and "the people's government … immediately organize relevant departments to mobilize emergency rescue teams and social forces." related to preventing, reducing, and relieving disasters; capacity building; community involvement; and international cooperation related to the resulting analysis (ministry of civil affairs, , accessed on / / ). in , the national people's congress approved the establishment of a new agency, the ministry of emergency management, to further strengthen the overall management of emergencies and non-emergency events as well as improve the overall levels of emergency management in order to integrate various emergency rescue forces. such developments show that the non-governmental organizations' (ngos) and the government's cooperation mechanisms and responses to the public crisis have gradually gained importance in china in recent years (wang, ). however, as disagreements or contradictions occur when different units or departments cooperate in disaster management, there is an urgent need to establish a system between the public and private sectors through collaborative relationships to facilitate cooperative reciprocity (chen, , p. ) . in other words, it is important to consider how to interact with and coordinate disaster-relief ngos with inter-governmental, inter-departmental, and/or civil organizations to construct disaster resilience and implement post-disaster recovery measurements (benson et al., ; mushkatel and weschler, ; rubin and barbee, ) . this article explores the compatibility of western literature on disaster management and social resilience with china's governance structure. although the chinese government wants to be more open to public participation under the traditional administratively oriented system, the level of openness is still deeply influenced by the government system. on one hand, the government wants to open authorization to allow decentralization; however, because of institutional problems, there are still limitations. on the other hand, society also wants to contribute to or expects to expand autonomous governance. however, barriers such as a lack of resources and space have kept them from entering the disaster management network (wang, ; wang and chang, ) . the main research question of this study is: how has social resilience been built since the wenchuan earthquake? this paper adopts the viewpoint of the dynamic interaction of multiple actors to emphasize how social organizations and communities play a role in sociogovernment interactions and strengthen the resilience of the government and social organizations during disasters. the article first reviews the relevant literature on the interaction between chinese society and the government as well as disaster management, and it examines the current situation and major challenges of disaster prevention and rescue-related mechanisms in china. this study collects qualitative data through in-depth interviews and analyzes the development of disaster resilience construction in the years since the wenchuan earthquake in sichuan in . it also analyzes feasible strategies for future disaster self-organization from different perspectives. the development of disaster management in china has been highly valued in the past decade. scholars have examined the literature on disasters in china from to , which included records, as well as between and , which included records. there are articles on the wenchuan earthquake alone (wang et al., ) . since the s, china has endured several major natural disasters, such as the tangshan earthquake and yangtze river floods. knowing how to deal with natural disasters has gradually attracted the government's attention. the united nations proposed the international decade for natural disaster reduction in , which facilitated china's establishment of the national committee for disaster reduction to improve cooperation among different departments and agencies at the state level. thus, china's first generation of disaster management paid more attention to natural disasters and the role of the government at the state level (zhang, ) . in , facing the challenges of severe acute respiratory syndrome (sars) outbreaks, the chinese government reviewed its disaster management system and initiated reforms for a second generation of development (wang et al., ) . the disaster management system of this period generally focused on different types of disasters as well as coordination among various agencies and departments (lu and han, ; zhang, ) . the emergency response law of the people's republic of china, issued in , adopted the government-led model. article of this law decrees that "the state shall establish an emergency response system mainly featuring the unified leadership, comprehensive coordination, categorized management, graded responsibility and territorial management." meanwhile, article decrees that "the state shall establish an effective social mobilization mechanism to strengthen the awareness of public safety and risk prevention and control of all citizens and improve the ability of risk avoidance and rescue in the whole society." the seemingly well-designed system encountered severe challenges, particularly after the wenchuan earthquake. in zhong ( ) , zhong pointed out that "the ineffective system and political sensitivity of crisis management means that china is likely to become more vulnerable to disasters, disturbances, and other critical contingencies" (p. ). under china's one-party political system, the mobilization of various areas to persuade or even force members of political groups or other members of society to identify, obey, cooperate, and support lacks sustainability (wang, ; zhang, ) . the literature has highlighted the importance of ngos' and civil society's participation in disaster management systems (lu and xu, ; lukaszczyk and williamson, ; meier, ) . ten years after the wenchuan earthquake, systematically examining the interaction between government and ngos in the disaster management system and constructing an effective and sound resilience system have become critical and urgent issues. the one-party political system with an authoritarian regime in china has three main characteristics: it is led by the communist party of china (cpc) party, it has a high level of hierarchy, and it has a strong and robust ability to gather resources at higher levels of government (zhang, ) . in recent years, this system has been challenged in terms of its disaster response performance and effectiveness in large-scale disasters. although some scholars have pointed out the advantages of control and command systems and have considered the system a force for improving the efficiency and effectiveness of disaster response (gao, ; shan and chen, ) , others have asserted that china's organizational structure and response model should be more flexible to improve disaster management performance (guo and kapucu, ; liu and xiang, ) . comfort ( ) argued that disaster management networks can be understood as self-organizing systems, which is an important corrective action for the assumptions of central planning. with its non-linear and dynamic nature, society can produce a self-organizing process sufficient to reallocate resources and actions so that the crisis is reduced, and society thus continues to operate stably. in other words, self-organization provides a more simple and effective way to deal with complex work than the traditional mechanical view of the organization (wheatley and kellner-rogers, ) . wheatley and kellner-rogers ( ) described organizations as being adaptable, flexible, self-renewing, and self-leaning while also having clever features. these characteristics only exist in a living system. modern organizations have increasingly emphasized complex adaptive systems. a complex environment includes five characteristics: they are composed of many agents who act and interact in unpredictable ways; they are sensitive to changes in the initial state; they adapt their behavior to the environment in an unpredictable way; they swing between stability and instability; and when an imbalance is encountered, they make emergency moves, meaning the complex system is dynamic and non-linear. the concept of emergency self-organization is a complex theory of "anchor phenomenon" (plowman et al., ) . comfort ( ) pointed out that, in a rapidly changing environment, in order to assess the existence of self-organization and its performance in the social system, the concept of self-organization needs to be redefined and explained. first, self-organization is a process in a social context through continuous interaction in a scenario. through verbal, written, or electronic forms of communication involving two or more participants, these behaviors become the most common ones within the system or between the system and the environment. these actions may also include different forms of communication, such as non-verbal communication or the use of symbols. it indirectly delivers powerful information through examples and actions. communication behavior includes direct and indirect forms, and these behaviors are the foundation in the process of self-organization. the three elements of self-organization include identity, information, and relationships. additional characteristics include that the intrinsic driving force in this process of communication is the creative self-expression desire or "autopoiesis"; self-organization, along with selections, creates the system's capacity to adapt to environmental conditions; self-organization recognizes that some units exert influence and control over other units in an interdependent system; and self-organizing systems are massively parallel operational systems (comfort, ; wheatley and kellner-rogers, ) . according to the logic of collective action (olson, ) , unless there are very few members in a group or there are mandatory special designs, neither a rational nor self-interested individual will take action for public interest. in a risk-prone society, individuals will take actions and pay attention to their own interests to reduce any individual potential crises (such as the quality of buildings in which they live and the re-planning of illegally constructed areas). however, when it comes to improving collective actions to strengthen the resilience of the community, there are only a few actions, and the discussions on self-organization are effective actions to solve collective problems (jan ) . the significance and importance of self-organization in disaster management has gradually emerged from the previously discussed literature. however, when examining the system in china, it is necessary to understand that the government still plays a critical role in disaster management. in other words, ensuring good interactions between the government and society during disaster management is a key direction that any post-wenchuan earthquake reforms of the disaster management system should follow. the concept of resilience appeared earlier in the field of engineering, ecosystems, and socio-ecological studies (brand and jax, ; folke, ) . in social sciences, resilience can be defined as "capacity for collective action in the face of unexpected extreme events that shatter infrastructure and disrupt normal operating conditions" (comfort et al., , p. ) . in terms of crisis and disaster management, boin, comfort, and demchak ( , pp. - ) pointed out that, for non-routine emergencies, the so-called low-chance, high impact incident has made it difficult for the government to respond using the four stages of traditional disaster management (mitigation/prevention, preparation, response, and recovery). resilience depends on this social system, the learning of past disasters to achieve better protection in the future, and the degree of self-organization of risk reduction measurements (jan ) . in recent years, the literature has gradually developed a resilience system model from a cooperative perspective, demonstrating that a community's capabilities are important for improving disaster resilience. for example, norris et al. ( ) considered community resilience as a set of networked adaptive capacities. this network includes four major elements: economic development, social capital, information communication, and community capabilities. ronan and johnston ( ) proposed the strengthening systems r prevention model, in which system resilience means the communities affected by disaster are able to cooperate and communicate with various organizations, experts, and community groups to face disasters and crises. in the past, different levels of government units have often played the role of command and coordination in a major disaster whereas civil rescue teams from different organizations were the first responders at the front lines. however, in some cases, the government is unable to effectively control and deploy sufficient rescue organizations and related resources, resulting in overlapping resources or faults and, thus, weakened disaster relief (liu et al., ) . the interaction between government and non-government actors has become a trend in future disaster prevention and rescue, making it important to understand how to properly use ngos' resources for disaster management (huang et al., ; lin, ) . in the face of large-scale disasters, the government's disaster prevention capability is far from the threat posed by the disaster itself. therefore, determining ngos' role in the traditional government-based disaster management system has become an important issue for public governance. ngos can play at least eight roles in disaster prevention and rescue: organizers, coordinators, resource integrators, information communicators, supporters, counselors and educators, consultants, and advocates (zhou and wang, ) . however, observations of the relationship between state and society in china make it evident that the development of the country's nonprofit organizations (npos) and the search for a model for the development of chinese civil society are topics that concern many scholars. there are also some important issues worthy of discussion, such as the duality of government and the people and the dual nature of the chinese society (kang, ; sun, ) ; the three pathways-namely, from the bottom up, top down, and cooperation (jia, ) ; and the administrative absorption of society (kang et al., ) . liu ( ) identified three features of china's current npo legal system: dual control over management systems, permitting and laissez-faire approach in management processes, and restrictions on competition and inhibited development in management strategies. the interpretation of these models highlights the fact that the government still plays the dominant role when interacting with society. the government's interactions with civil society organizations, voluntary organizations, and ngos during the wenchuan earthquake have received extensive attention. wang ( , p. ) pointed out that "the government's drawbacks and deficiencies in public crisis management are mainly because it is difficult to sustain." under the propaganda and encouragement of political entities, mainly political parties, the entire political system plays the role of persuading and even forcing members of political groups or other members of the society to accept, obey, cooperate, and support the capacity of the entire political system. however, such mobilization lacks sustainability. tong and zhang ( ) demonstrated that, due to china's long-term policy restrictions, the development of chinese civil organizations still has a long way to go. although more than civil society organizations were mobilized for disaster relief following the earthquake, with more than million volunteers participating in the action (optimists even consider as china's first year of civil society), a year later, the number of ngos still within the disaster-stricken area had likely fallen below , with fewer than , total volunteers. therefore, through training and management development, ngos' involvement during emergency and social mobilization mechanisms can be conventionalized. the pre-zero draft of the post- framework for disaster risk reduction of the third un world conference on disaster risk reduction (wcdrr) stated that such efforts: [need] to be reinforced further by the post- framework for disaster risk reduction with a much stronger focus on anticipating long-term risk scenarios and concrete measures to prevent the creation of new risk, reduce the existing risk and strengthen economic and social resilience of countries and people, by addressing both people and assets' exposure and vulnerability. (unisdr, , p. ) the social resilience perspective emphasizes the social motivation and collective action ability of the people during disasters (manyena, ) . the scope includes the influence of individuals or communities on collective behavior, collective decision, and collective actions with various informal institutions. important focuses of such efforts are how local informal institutions can help overcome the difficulties of collective action and form the interaction between local organizations and the state as well as contribute to society (li and lin, ) . social resilience involves social entities-whether individuals, organizations, or communities-and their ability to tolerate, absorb, respond to, and adapt to various environmental and social threats (keck and sakdapolrak, ) . maguire and hagan ( , pp. - ) pointed out that social resilience is the capacity of a social entity (e.g., a group or community) to "bounce back" or respond positively to adversity which is understood as having three properties comprising aspects of how people respond to disasters: resistance, recovery, and creativity. the literature has suggested that an array of factors may impact social resilience, including trust (e.g., enemark, ) , social cohesion and a sense of community (e.g., poynting, ) , and communication and information (e.g., ink, ) . zolli and healy ( ) pointed out two ways to enhance resilience: enhance its ability to fend off and overcome the limitation during these major damages (even when permanent damage is caused) and maintain (or even expand) survival ability in the ever-changing environment in order to adapt to the new environment healthily, even when pushed to the limits. from economics to ecology, almost all resilience systems have a rigorous feedback mechanism to detect upcoming mutations or critical limitations. for example, in an ecosystem such as the coral reefs, some organisms may change their behavior due to environmental degradation. the same behavior also applies to human society, except that we rely heavily on various tools and techniques to strengthen our alertness to the environment. when sensing information that the system is about to cross its limitation, a system with true resilience uses dynamically reorganized efforts to ensure that the mission is continued, and the scale of operations is maintained. many systems have built-in counteracting mechanisms that start working once the crisis occurs; the counter-measure mechanism attacks like the human immune system, restoring the system to a normal state. aldrich ( ) pointed out the importance of social capital for building social resilience in post-disaster recovery, and the cultivation of trust is the key factor in accumulating social capital (newton, ) . on may , , sichuan province in mainland china experienced a magnitude . earthquake (also known as the wenchuan earthquake) that killed almost , people, injured more than , , and left almost , missing. in addition, nearly million buildings collapsed or were damaged. more than million people needed emergency resettlement, and the estimated economic losses were roughly billion rmb, making it the most severe disaster since the tangshan earthquake in (china news, / / ). from a social perspective, the relevant functions of emergency management in the past are distributed in multiple departments and at different levels of government. the function is unclear, and there is a lack of institutional mechanisms for emergency management as well as a lack of efforts by the public, the media, volunteers, and ngos. when it comes to the exchange and cooperation of external resources, there is a widespread phenomenon of mobilization and light coordination, and social organizations are slow to develop their ability to participate in disaster relief (xue and tao, ; zhang et al., ; zhang and zhang, ) . in march , china established the emergency management department, which had an important impact on the entire disaster management system. in order to understand and analyze how the government worked together with civil organizations, volunteer organizations, and community organizations in order to enhance social resilience after the wenchuan earthquake, this study collected qualitative data through in-depth interviews and focus group discussions from to . the main purpose of the in-depth interviews was to explore, realize, and understand the life experiences of others and the meanings they have given. as the core of interview research is an interest in other people's stories (seidman, ) , the research methods related to participation, observation, and narrative helped better understand the evolution of social resilience in china (especially in sichuan) after the wenchuan earthquake in . over the past two years, the research team, which consists of crossstrait scholars, has taken advantage of exchange visits and arranged for meetings and field studies in the earthquake-affected area. qualitative data were collected through a snowballing approach. after being introduced to an officer in the department of emergency management in chengdu city, sichuan province, and based on the recommendation of scholars in the university, the research team contacted participants involved in the relief or recovery efforts following the wenchuan earthquake as well as scholars in the field of disaster management. participants in the focus group discussion and in-depth interview respondents included two main targets: practitioners, who are the main persons or directors of social organizations, and scholars and researchers from universities in the public administration and disaster management fields. in order to analyze issues from different angles and include more perspectives from respondents outside of sichuan province, this study also conducted interviews in beijing and shanghai. these meetings were recorded, with the participants' permission. although no government officials agreed to participate in interviews due to the sensitive nature of socio-government interactions, with their help, the research team was able to participate in and observe the district government emergency management working forum organized by the municipal government. table presents the information about focus groups and in-depth interviews. article of the law of the people's republic of china on incident responses defines "emergency events" as natural disasters, major accidents, public health incidents, and social security incidents that occur suddenly, cause or may seriously endanger society, and require emergency measures to deal with the situation. in addition to the classification of the severity of disasters and the hierarchy of vertical systems, the law authorizes horizontal response departments to deal with different types of disasters. the law and administrative regulations stipulate that the relevant departments of the state council are responsible for responding to emergencies. different interviewees pointed out that the horizontal design of this disaster-based approach caused challenges in terms of communication and coordination. the literature also pointed out that the mechanical disaster prevention and the design of the focus exclusively on the efficiency of the system members to complete the work create a drawback in this design, making it difficult to respond quickly to environmental or sudden changes (chang, ; hatch, ; jan, ) . from the academic point of view, it may be better to establish a more comprehensive system instead of the single-hazard system, which may result in some problems, such as a lack of information sharing and communication between the different governmental agencies. if something happens today, maybe they do not know how to communicate effectively. (interviewee c) another explained: there is always a coordination problem between the departments and departments within the government, and then there is also coordination problems among the government, enterprises, and the ngos in emergency management. (interviewee h) the ministry of emergency management was established to coordinate emergency management and comprehensive disaster management, standardize and integrate social rescue forces, facilitate the connection between social organizations and the government, and enhance the synergy between government and social organizations (gao and liu, ; wang, ) . these functions can be examined in three aspects. first, the ministry accelerates the construction of social forces to participate in the disaster relief platform. for example, in march , the social emergency force participated in the online application system for disaster relief. it was officially put into operation to realize the functions of online registration and reviews of social emergency forces, disaster information releases, rescue applications, and rescue management. second, the ministry coordinates some policy issues that plague social emergency forces and prevents them from effectively participating in emergency response. for example, in january , the ministry of transport and the ministry of emergency management jointly issued the "notice on doing a good job in social traffic vehicles for inter-provincial disaster relief and highway traffic protection" 《关于做好社会力量车辆跨省抢险救灾公路通行服务保障工作的通知》 to establish a nationwide unified emergency rescue road for free passage and related service guarantee. third, the ministry improves social organizations' ability to participate in disaster relief. for example, in june , the ministry of emergency management held the first professional training of social forces that participate in disaster relief work; six months later, in december, it launched the first national social emergency strength skill competition. in addition to the integration of government departments, it is important to know how to implement emergency management into community governance-a task facing china's emergency management system reforms in the past decade. one interviewee stated: now we have a community grid management system in each district-that is, we are divided into this unit grid in this urban area. if some problem occurs in this unit grid, it will be systematic and immediately mobilize specific forces to the rescue. (interviewee h) the research team also participated in the district government emergency management working forum organized by the chengdu emergency management office, during which it acquired a better understanding of the emergency work from the perspectives of government and community safety and the setting up and operation of the community micro fire station. furthermore, the data indicate that the current chinese emergency management system has focused more on the importance of community risk awareness and capacity building. after the wenchuan earthquake, the number of social organizations involved in disaster emergency rescue and the amount of disaster relief funds invested in china continued to grow, and the rescue areas and rescue methods involved showed diversified development. meanwhile, the legal system's emergency mode relied on the emergency response law as the main body and emergency response plan system at all levels. yet disaster coordination governance continued to face challenges from the government, the light society, the inefficient operations of resource integration and emergency management, the insufficient cultivation of specialized teams, and inadequate support measures for social forces and participation (jin, ; zhou and liu, ) . to this end, the chinese government has focused on improving the laws and regulations, policy planning, and behavioral norms of social forces participating in disaster relief. its main content involves the role of market and social forces in disaster prevention, mitigation, and relief. these environmental traits can easily impact the routine operation procedures and decision-making processes of government agencies. in the past, administrative organizations emphasized the development of stability, rationality, and linearity. however, under the advent of the risk society, the concepts of chaos and non-linearity continually impact the thoughts of the traditional public sector. the factors that impact social resilience include trust and social cohesion as well as a sense of community (enemark, ; poynting, ) . the interviewees pointed out how these factors affected efforts during the wenchuan earthquake and subsequent recovery phases. one interviewee provided a vivid example: a few years ago, i went to several communities and started promoting the idea. some local representatives said, "we want to do disaster prevention and reduction…to save your time, we can have a simple plan, and everyone just follow the guidelines of this plan." i came up with a question that took him a while to figure out the answer. i asked him, "if a real disaster hit the area, do you think people around the area would still follow the plan easily?" (interviewee a) other interviewees mentioned cases about accumulating trust between government and social organizations and between social organizations and community citizens: for example, we need to report to the school and the education bureau whom we invite to participate in the program. in other words, social organizations must first form a trusting relationship with the government. (interviewee g) for ourselves, we need to grasp the characteristics, principles, and norms of being social organizations. we are partners of the government. you will find that the government needs some time and space to slowly feel and understand social organizations for a better collaboration. (interviewee e) we started to do post-disaster services after the rescue phase. we build relationships with the villagers through a large number of activities, and we need to promote residents' autonomy and some things within the community (community awareness) and discover community leaders and community cadres. (interviewee f) in addition to trust, the interviewee from academia mentioned that the sense of community and cohesion also play important roles: the community in western society usually has some grassroots or civil organizations self-organized by the community residents. however, the community in china i observed was very different from the west in substance and structure… in china, currently the idea of "community" cannot be treated as a unit alone because the public's awareness of the community is still very weak. (interviewee j) in other words, social resilience involves a common reaction of all social entities, so it is important for the government to increase its trust in ngos and strengthen community awareness. as kooiman ( ) pointed out, there is no single actor in the policy implementation process that can have enough knowledge to deal with the increasingly complex issues. therefore, governing future disasters requires the cooperation of the public and private sectors to form different networks, share responsibilities, and engage in mutual granting power and capacity in order to achieve the best policy results. as one interviewee stated: especially after the ya-an earthquake, similar disasters were very stimulating to social organizations, and social organizations were becoming more and more professional. their professional courses were approved by the government. once the government's trust in social organizations is raised, they find that this mutual cooperation will benefit all social organizations, governments, and the general public. in order to form common goals, accumulate and exert more energy in disaster management, and effectively reduce the casualties caused by disasters, the self-organization mode in community and social organizations warrants more attention in the future. an emergency regulatory system refers to a mechanism built on methods and measures of the emergency management process. in some of china's government documents, the word regulatory is replaced by mechanism (wang et al., ) , suggesting that the trend of emergency management system design among authorities is to pursue collaboration. according to the interviewee from beijing: in fact, the government's role is constantly being revised. with the development of society, this is inevitable… after , non-governmental organizations were eager to grow because of the wenchuan earthquake. within six months, these civil organizations were fully recognized. the government acknowledged that civil organizations can help solve many problems with high efficiency and good quality. since then, the importance of the rescue organization has been known, and various support policies have gradually emerged. (interviewee l) the relationship between ngos and the government varies in different situations (coston, ; najam, ; young, young, , . interviewee a pointed out that relationships with the government are also very subtle: in fact, the death rate of social organizations in china is very high because they can neither be separated from the government nor is it legal to leave the government. however, being too close to the government means that civil organizations must adapt to the government style of management, which limits civil organizations' openness-that is to say, they cannot find their position and may become temporary workers for the government. in recent years, a mechanism has gradually emerged during interactions between the government and social organizations that clearly stipulates the participation forms and legal guarantees of relevant units during disaster responses and establishes social public safety knowledge and participation in emergency drills. for example, in october , the ministry of civil affairs issued the "guiding opinions on supporting and guiding social forces to participate in disaster relief work" 《关于支持引导社会力量参与救灾工作的指导意见》. this publication marked the first time that various social forces, including civil emergency relief organizations, were involved in disaster relief work within the government's normative system. on march , , the national people's congress passed the charity law, and the voluntary service regulations were promulgated on august , , which clearly stipulate that: when emergency incidents such as major natural disasters, accident disasters and public health events occur, it is necessary to promptly carry out rescue assistance, [and] the government should establish a coordination mechanism, provide the necessary information, and guide fundraising and rescue activities in a timely and orderly manner. the "opinions of the cpc central committee and the state council on promoting the reform of disaster prevention and mitigation and relief system" 《中共中央国务院关于推进防灾减灾救灾体制机制改革的意见》, issued on december , , concluded that a sound social force participation mechanism is an important part of reforms of the mechanism for disaster prevention, mitigation, and relief and should encourage the full participation of social forces. the work of normal disaster reduction, emergency rescue, transitional resettlement, and restoration and reconstruction, among other efforts, requires multi-participatory social disaster prevention, mitigation, and relief patterns. the national comprehensive disaster prevention and mitigation plan ( - ) also clearly defined social emergency forces, such as volunteer emergency rescue teams. in the current development of communities in mainland china, individual community committees play an important role in mobilizing and integrating various types of community resources as part of their self-governance, which is a process of reducing conflicts, promoting cooperation, and enhancing the power and reputation of their own communities (liu, ) . as a traditional administrative organization, the community committee replaced the unit system and has become an important link for the country and society. during the diversified and rapid development of modern cities, especially as traditional mobilization organizations and administrative control methods are losing their legitimacy, re-mobilizing and absorbing the people to return to the ruling network of the ccp system have become urgent goals of the current reforms of mainland china (chen, ) . the interviewee from the volunteer organization emphasized the role of being a "supporter" of the government: there are specialists in every community, and their working experience may not be as much as our civil society. so we have to help them. when the government organizes large events, we, the civil organizations, will and should participate and provide the necessary assistance. (interviewee k) finally, community committees have also become more closely linked with the political party and the government; this link is rooted in the work of the cpc's party-building efforts. therefore, the interviewees perceived community committees as not having purely civil roles in disaster prevention and relief. on the other hand, non-governmental social organizations and communities are more oriented toward network-based development in disaster prevention and rescue issues. during the focus group discussion, social organizations' party-building work also attracted the authors' attention. interviewees pointed out that such work facilitated a closer relationship, thereby helping the party and the social organizations work together. under the chinese political system, research in recent years has focused on how to ensure that the government and society engage in better interactions and enjoy more effective cooperation. such developments in the decade following the wenchuan earthquake have attracted more discussion from scholars and experts in the field of emergency management. the relationship between the chinese government and its society has consistently maintained the conditions of big government/small society or strong government/weak society. "under such circumstances, it is difficult to carry out emergency social mobilization in an all-round manner, and the all-powerful government will not be able to react flexibly to events due to its rigid branches extended within its organization" (wang, , pp. , ) . therefore, the literature on disaster management has increasingly emphasized the development of community self-organization and social resilience in recent years. in addition to the community's ability to understand its own needs and effectively prevent and respond to disasters through collective actions, it is necessary to enhance community acceptance and community relationships to form closer relationships within the community. in china's political system, the authorization of power from the government to the communities, the cultivation of disaster prevention capabilities, and the level of autonomous decisionmaking are all important issues to examine in the future. from the discussion and analysis presented in this paper, we first find that the role and relationship among government, community, and civil society organizations in disaster management in china have indeed changed in the decade since the wenchuan earthquake. strengthening social resilience, trust, and the sense of community can facilitate efforts to bring all the social entities to work together. during large-scale disasters, the functions that the government fulfills are limited. the large role the chinese government has traditionally played is bound to need adjustment. second, although the chinese government has recognized the important role and function of social organizations in the development of social resilience in emergency management, the development of trust between the government and social organizations has still been a slow process under the current chinese government system. the accumulation of social capital remains weak, which is detrimental to the construction and development of social resilience. in other words, more interaction, communication, understanding, and dialogue between the government and the social groups are necessary in the future. finally, in recent years, relevant laws and regulations to promote the synergy mechanism have also been promulgated; the impact of such efforts on social resilience is a subject worthy of further observation. yet the elements of social resilience involve creativity in addition to resistance and recovery. the main source of this creativity is the selforganization of the community, which the authors believe is currently missing in china's disaster management system. in other words, it would be helpful if the chinese government could give moderately more space for civil society participation, making it more likely to include creative approaches in disaster management. the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. building resilience: 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would like to express our appreciation that part of this study was supported by the research grant from the ministry of science and technology, taiwan. ( - -h- - -my ). key: cord- -ib nqjz authors: coulson, n. edward; mccoy, shawn j.; mcdonough, ian k. title: economic diversification and the resiliency hypothesis: evidence from the impact of natural disasters on regional housing values date: - - journal: reg sci urban econ doi: . /j.regsciurbeco. . sha: doc_id: cord_uid: ib nqjz we estimate the effect regional economic diversification has on the resiliency of the u.s. housing market treating the spatial and temporal variation in natural disasters as exogenous shocks to regional economies. our study demonstrates that diversity dampens both the magnitude and the duration of the effects of a disaster on local real estate values. implications of our findings for the potential benefits of diversification in regional economies are discussed. volatility in local housing markets is the result of many factors. prominent among these are of course speculative demand (goodman and thibodeau, ) , but the condition of the local economy perhaps matters even more. for instance, the extraordinary decline in las vegas home prices may have had its origin in the bursting of the housing bubble, but the momentum of that decline was no doubt exacerbated by the national recession that followed, which particularly took its toll on tourism, upon which the las vegas economy particularly thrives. the lack of diversity in las vegas' economic base created singular difficulty for its economic recovery. this trend continues. in their analysis of cities most likely to be negatively impacted by a coronavirus-induced recession , authors at the brookings institution (munro et al., ) single out las vegas as particularly vulnerable (once again) for its relative lack of diversity in its industrial base. it has been long argued that economic diversity plays a key role in promoting both regional economic growth as well as regional economic stability (parr, ; kort, ; siegel et al., ; siegel et al., ; attaran, ; wagner and deller, ) . commonly, stability is defined in terms of the "absence of variation in economic activity over time" (malizia and ke, p. ) . these concepts are related to the concept of resiliency. formally defined, resilience refers to "the ability or capacity of a system to absorb or cushion against damage or loss" (rose and liao, p. ; holling, ) . for local economies it has been defined as, "the ability of a regional economy to maintain or return to a pre-existing state (typically assumed to be an equilibrium state) in the presence of some type of plausibly exogenous (i.e. externally generated) shock" (hill et al., ; see also martin and sunley, ) . the purpose of this paper is to therefore document the link between diversity of the local economy and the resiliency of housing prices. our focus is on housing prices due to their importance in measuring the health of the local economy (hwang and quigley, ) ; their manifestation of the area's quality of life (albouy, ) ; and perhaps most important, their reflection of the future path of both of those factors. the fundamental empirical challenge to identifying the link between diversity and as we write this in may , the recession is just now unfolding. resilience is that regional housing market downturns are rarely ever exogenous to local labor market conditions. economic diversification is no exception. to circumvent this difficulty, we investigate the link between diversity and resilience by estimating the effect economic diversification has on explaining real estate price dynamics to natural disasters. natural disasters provide a useful context for studying the effect of diversification on resiliency for several reasons. first, the exogenous nature of disasters gives us a unique setting to study housing market responses to shocks net of concerns stemming from potential endogeneity between real estate market performance and regional business cycles. second, with the frequency and severity of natural disasters on the rise, studying the economic impacts of disasters is an economically meaningful pursuit in its own right. through this lens, our paper contributes to broader research efforts in the environmental economics literature on climate change and human adaption by adding a complementary discussion centered on steps local policymakers might take to improve the economic resilience of their locality to climate-induced shocks. we focus our empirical work on housing market responses to hurricanes and typhoons using a panel dataset of purchase-only house price indices at the msa level that are maintained by the federal housing finance agency (fhfa). we link these data to fema's national emergency management system (nemis) which indicates the month, day, year and impacted msa for the universe of federally declared disasters. finally, we compute the usual measure of economic diversification for each msa -a fractionalization index of labor market income across naics supersectors -using industry level data from the quarterly census of employment and wages (qcew). we estimate the impact of a disaster using a difference-in-differences (did) approach. this method allows us to identify the average price effect due to a shock by estimating changes in home prices before and after a disaster hits impacted msas relative to home price dynamics across non-impacted msas. to test the hypothesis that regional economic diversification is a catalyst for resiliency, we estimate the effect that regional economic diversity has on attenuating the impacts of natural disasters on local home prices. estimating the causal effect of diversification on growth presents a set of challenges that originate from the presence of endogeneity stemming from latent j o u r n a l p r e -p r o o f confounders that are both correlated with the outcome of interest and diversity. however, and drawing on a recent study by nizalova and murtazashvili ( ) , we can recover the causal effect of diversity on resilience if we are willing to assume that both regional economic diversity and any potential latent confounders are jointly independent of the occurrence of natural disasters conditional on time-invariant geographic fixed effects. to preface our main findings, our empirical results show that the impact of a disaster depends both on the level of diversity and the time elapsed since a shock. highly concentrated regions experience price declines as large as - . % in the year immediately following a disaster. these initial impacts persist for as long as two years. economic diversity has the effect of dampening the immediate price response due to a shock as well as the persistence of these initial price declines. we estimate that a one standard deviation increase in diversification (relative to the mean level of diversification in the u.s. economy) offsets the immediate (one to two year) price effects of a disaster as much as . % to . %. we then position our empirical findings into broader discussions in the literature centered on the potential "dual effects" of diversifying a regional economy. researchers and policymakers often debate the value of diversification in terms of the direct effect of diversification on growth. in part, the tension in the literature exists given the competing views about the role diversity plays in influencing economic growth. for example, some view diversification as a movement away from potential efficiency gains resulting from specialization and, perhaps, mitigating economic growth (see e.g. izraeli and murphy, ) . others argue that diversification moves the economy towards an environment where knowledge spillovers can occur between industries, thus catalyzing economic growth (see e.g. glaeser et al., ) . further complicating this matter, there is a fundamental empirical challenge to estimating the direct effect of diversification on market outcomes. to identify a causal link, one would have to acknowledge the possibility that unobserved determinants of the market outcome of interest may also be correlated with diversity. motivated by this observation, we build off the earlier work of bartik ( ), card ( ), and ottoviano and perri ( and propose an instrumental variables estimation strategy capable of controlling for this level of endogeneity. we then j o u r n a l p r e -p r o o f show that the benefits of diversification expressed in terms of resiliency do not appear to be offset by any potential costs stemming from a corresponding departure from industrial specialization. as we explain in more depth below, we draw upon several literatures to motivate the theoretical mechanisms we have in mind. the literature has previously established a connection between city-level labor outcomes and the diversity of the labor force, largely focusing on standard insights from portfolio theory that a diverse array of industries will suffer less from shocks that have sector-specific effects. in addition, the literature has discussed the connections between housing and labor markets in a city. as such, resiliency is a natural outcome to examine, in that the recovery from a (negative) shock would be quicker when there is an industrial base that is diverse. it has also been recognized that migration (even only temporary) in response to a shock could influence local labor markets and house price dynamics (boustan et al., ) . as such, and if after a disaster migration tends to occur from concentrated to more diverse areas, migratory dynamics could represent an additional mechanism explaining why diversity drives resiliency. using data on county-to-county migration flows we formally test this hypothesis. like boustan et al. ( ) , we first show that natural disasters lead to statistically significant increases in out-migration and net-migration. additionally, using a difference-in-differences estimation framework we also find that conditional on experiencing a disaster, more diverse economies experience a smaller degree of outmigration and net-migration. viewed through the lens where relative demand for housing falls more in areas with concentrated employment, the migration channel is perhaps one important explanation of our results. we proceed by providing a background on related works in section . we summarize our study area and data in section . we present our empirical methodology in section and our findings in section . in section we discuss potential threats to the identifying assumptions of our model. in section we utilize an instrumental variables approach to estimate the direct effect of diversification on housing values and summarize and conclude in section . see, e.g., barth et al. ( ) , malizia and ke ( ) , izraeli and murphy ( ), siegel et al. ( ) , hammond and thompson ( ), and wagner and deller ( ) . a full description of this literature is provided in section ( ). the analysis brings together several literatures that deal with the various connections between employment diversity, labor market performance, real estate prices, and the economic impact of natural disasters. we take up the connections between various pairs of these concepts in order to provide context for this analysis and the hypotheses that we wish to explore. these include the relationship between ( ) diversity and volatility, the effect diversity may have on ( ) economic performance and ( ) resilience to economic shocks, ( ) the links between home prices, diversity, and economic fundamentals, and ( ) the impact of natural disasters on real estate markets. the argument that industrial diversification may lead to reduced volatility and resilience in metropolitan economies is long-standing. barth et al. ( ) note that, as would be suggested by standard portfolio theory, a diversified portfolio of industry employment yields lower overall volatility in metro employment. the emphasis on the use of portfolio theory as a lens through which to view employment volatility led to the insight that what mattered was not simply diversity as such, but the covariances of sectoral employments. diversity is simply a means to tamp down the effect of these covariances on aggregate employment variability. the portfolio approach was pursued in much of the subsequent literature, including malizia and ke ( ) and izraeli and murphy ( ) with respect to unemployment changes and siegel et al. ( ) and wagner and deller ( ) in the context of an input-output model. hammond and thompson ( ) also note that greater industrial specialization yields greater employment volatility but also emphasized the role of local demographic characteristics. interestingly, carvalho ( ) notes the idea that disaggregating the economy into smaller sectors will serve to dampen the overall effects of a disturbance to any one sector was perpetuated by the earlier work of lucas ( , page ) who writes: "in a complex modern economy, there will be a large number of such shifts in any given period, each small in importance relative to total output. there will be much 'averaging out' of such effects across markets." j o u r n a l p r e -p r o o f inspired by the lessons of the earthquake in japan, carvalho ( ) provides a new and more sophisticated perspective on the role of diversification in the national economy by advancing a multisector general equilibrium model. the key insight of carvalho ( ) is that whether or not diversity catalyzes resiliency may ultimately depend on the complexity of the input-output linkages between sectors in an economy. in effect, carvalho ( ) argues that cyclical fluctuations may arise from small shocks working their way through or across input linkages. in a diversified but horizontal economy, disaggregation leads to decreases in aggregate volatility. in contrast, once carvalho ( ) relaxes the assumption that intermediate producers work in isolation from each other, shocks to one sector may propagate through other sectors. in this paper we abstract away from modeling input-output linkages across sectors within our small regional economies, but instead focus our efforts on modeling the degree to which labor market activity is fractionalized across sectors. there exists a separate debate on the role that diversity plays in promoting productivity and growth. empirical analyses by frenken et al. ( ) notes that a broad variety of industries increases the possibility of jacobs (inter-industry) productivity spillovers (glaeser et al. ) . note, however, that our focus on resilience to shocks has little to do with productivity spillovers and much more to do with the ability of a broader based economy to handle stress. reliance on a small set of industries for economic health can be detrimental when shocks are specific to those sectors. more closely related to our research here is work that deals with the ability of local economies to absorb shocks, and the extent to which diversity aids in the return to the previous steady state. while not concerned with natural disasters, hill et al. ( ) investigate drivers of resilience with quantitative case studies of metropolitan areas and show that diversity may attenuate an economic downturn. similarly, feyrer et al. ( ) ask whether employment diversity helped cities recover from the impacts of the "rust ( ) show that more diverse counties witnessed relatively larger increases in employment following the flood than less diverse counties; a finding which is consistent with the hypothesis that diversity is a driver of economic resiliency. it seems almost a truism that local home prices should depend on local economic conditions, but this truism has substantial empirical support (hwang and quigley, ; gallin, ; zabel, ) . local income and unemployment rates are standard determinants of local home prices. beyond these standard determinants, and recognizing the previous work that relates diversity and economic fundamentals discussed above, coulson et al. ( ) provide the first empirical evidence demonstrating that increases in economic diversification effectively leads to decreases in home price volatility. in a related work, barth et al. ( ) show that home prices in metropolitan statistical areas (msas) starting with a relatively lower degree of diversification tend to rise as these msas become less diversified. our study contributes to various strands of the environmental economics literature centered on real estate market responses to natural disasters (harrison et al., ; bin and polasky, ; hallstrom and smith, importantly, none of these studies is concerned with the recovery period as such, and do not examine the dynamics of real estate prices in the wake of the disaster, much less the economic factors that might speed such recovery. but it is the speed of such recoveries that are inherent in the discussion of "resilience". note that those dynamics are not predetermined by theory. a natural disaster can destroy much of the existing housing stock, shifting the supply curve to the left, but at the same time cause both labor and firms to exit as well, which would cause a simultaneous shift of the demand for housing to the left, leaving the effect on housing price ambiguous. in the event we see that the initial path of home prices after a disaster is in the negative direction, the demand effect outweighs the supply effect. it is then of some interest to ask what factors can return home prices more quickly to the previous steady state, and our above discussion clearly suggests that economic diversity is one of those factors. the literature on diversity and local economies, along with the smaller body of work on diversity and home prices discussed above suggest that a diverse portfolio of industries will mitigate the particular impact that a disaster has on any one sector, leading to quicker recovery overall. the above example of las vegas is evocative of this, but more salient to our use of natural disasters would be a coastal economy reliant on tourism suffering more and for a longer period of time if a disaster has an asymmetric impact on coastally located tourist services (kim and marcouillier, ) . overall, our summary of the literatures above suggests that the value of a diverse portfolio of industries can ameliorate the effects of negative economic shocks. we measure that amelioration through the impact of a disaster on housing prices, and whether the return to the steady state is quickened by greater diversity. we find that it does, and in that sense, conclude that such areas are more resilient. the primary dataset utilized in this paper is the quarterly, purchase-only house price in order to construct a measure of economic diversity, we obtain industry level wage data from the bureau of labor statistics' quarterly census of employment and wages (qcew). of particular interest to us are total wages, which track total compensation paid during the calendar quarter to employees within each naics supersector of each u.s. county. naics supersectors, which are synonymous with two digit naics codes, represent the twenty, top-level industry groupings in the united states. we measure economic diversity by first aggregating total wages within each naics supersector, , across counties residing within the same msa, , at each year-quarter time-step, . we employ the usual measure of economic diversification that is based on the fractionalization index of labor market income across naics supersectors, where ℎ denotes the share of labor market income for industry within msa at time . the index is further standardized to be mean zero with a standard deviation equal to one. thus higher values in the index represent more diverse regions and lower values in the index represent less diverse regions. to make clear how the index is interpreted, a hypothetical value of plus two in the diversity index would represent an area that is two standard deviations above the mean level of diversity, and a hypothetical value of minus two would represent an area that is two standard deviations below the mean level of diversity. we treat the universe of federally declared hurricanes and typhoons as exogenous shocks to local real estate markets. data describing these events are maintained by indicates the impacted county and records the month, day, and year each disaster began. we use the county to msa crosswalk provided by the united states census bureau to map impacted counties into impacted msas. using these data, we can effectively identify the entire history of natural disasters impacting each msa in our study area. we provide a graphical illustration of the msas included in our sample in figure the set of naics supersectors includes: . to visualize differences in the degree of diversification across msas, figure illustrates the average level diversification within each msa over the study period, again, standardized to have a mean of zero and standard deviation equal to one. henceforth, msas in dark green represent the least diversified regions (e.g. those with long-run average diversity levels . to . standard deviations below the mean msa). likewise, msas in bright red represent the most diversified regions; those with long-run average diversity levels . to . standard deviations above the mean msa. lastly, we provide a list of every msa in our sample in appendix table a despite these overall trends in diversity, we learn that there exists an immense amount of heterogeneity in the trajectory of our small regional economies. to further illustrate the variation in the data, we compute the growth rate, , , in economic to study the impact of regional growth shocks on residential housing prices, we estimate a difference-in-differences model exploiting the random nature of regional disasters. more specifically, we employ the fixed effects estimator, ln &'( = ) *+ , • . , + , • . , × ( , + • ( + + + : , # where ln &'( is the log transformed housing price index for msa in time , ( is the fractionalization index for regional economic activity for msa in time , and . , is a treatment-indicator < years prior to or after a disaster-related event. to fix ideas, . is equal to one if at time msa is within to years of a disaster. likewise, . is equal to one if at time t msa is within - to - years of a disaster. additionally, captures msa-specific, time-invariant unobserved heterogeneity. finally, includes an exhaustive set of year-quarter fixed effects and msa specific linear time trends. note, the causal interpretation of + , and , stems from the assumption that whether or not a region is hit by a natural disaster is random conditional on msa and year-quarter fixed effects. we specify equation ( ) with a series of three pre-disaster and three post-disaster event indicators and, similar to gallagher ( ), bin each . , for any time period < < − and for any time period < > by creating single event indicator variables for the end periods of the event study, . and . . the inclusion of . and . simply serve the practical purpose of allowing us to study how home prices evolve in the years shortly after a disaster (e.g. < ∈ [ , ] as well as in the years shortly before a disaster; we normalize all coefficient estimates relative to the year immediately before a j o u r n a l p r e -p r o o f disaster (< = − ). the classical difference-in-differences estimator is typically operationalized by excluding the interaction terms . , × ( from the model. in this case the researcher relies on estimates of + , to identify the average impact of the event of interest. however, the inclusion of . , × ( allows us to estimate how the average effect of a disaster is influenced by economic diversity. letting ( d denote a particular value of ( , the relevant parameter of interest to us is, for the sake of clarity, with ( d set at the mean g hij , parameter estimates of e <, g hij = + , + , • g hij represent the average impact of a disaster in the < k year following a shock. thus, the interpretation of e <, g hij parallels what is typically reported in related works focused more exclusively on estimating the average impact associated with an event. in our empirical work we first present parameter estimates of e <, ( d evaluated across the distribution of ( . we use the superscript "j" to refer to the "j th " percentile of ( . this approach also allows us to evaluate the economic significance of diversification on resiliency by reporting the magnitude of the estimated impact of a shock at different values of diversity, l and l′ (e.g. e <, ( d vs. e <, ( dn ). we formally test the hypothesis that economic diversification is a catalyst for resiliency by examining whether or not the impact of a disaster on home prices is affected by changes in diversity. more precisely, if economic diversity catalyzes price resiliency to disasters then, finally, one of the underlying identifying assumptions of our model is that the average change in home values across impacted msas would have been proportional to the average change in prices in non-impacted msas in the absence of treatment. while we cannot directly test whether or not this assumption holds, we provide supporting evidence of parallel trends by investigating estimates of e <, ( d in the periods leading up to a disaster (e.g. < < − ). for instance, focusing on the th percentile of diversity, model estimates for e − , ( r and e − , ( r are small in magnitude and statistically insignificant. turning attention to columns through , parameter estimates for e"− , ( d # and e"− , ( d # are also statistically insignificant and close to zero in magnitude. independent of the level of diversification, we find no statistical evidence suggesting that home price trends among impacted regions differ from home price trends in non-impacted regions in the years leading up to a shock; an empirical finding that lends credence to the underlying identifying assumption of the model. next, we turn our attention to coefficient estimates of the post-disaster treatment indicators. as indicated in column , at the th percentile of diversity, we estimate that disasters induced a statistically significant reduction in housing prices of . % and . % in the first two years following a shock, respectively. after two years, we do not detect a statistically significant impact of a disaster on housing prices, which suggests that the immediate market impacts of a disaster are economically relevant but nonetheless transitory. next, we focus our attention to parameter estimates of e"+ , ( d #, which capture the immediate, first year impact of a shock. table shows that as we move from the th to the th percentile of diversity, the first-year impact of a disaster decreases in magnitude (in absolute value) from - . % to - . %. estimates further decline as we move j o u r n a l p r e -p r o o f to the th percentile but remain statistically significant. at the average level of diversity in the data (column ), model estimates indicate a . % reduction in home prices. coefficient estimates reported in columns and , which reveal the market impacts of a hurricane at the th and th percentiles of diversity, are not suggestive of a statistically meaningful reduction in prices in the second year following a shock. in contrast, we do estimate a statistically significant price effect two years after a shock when evaluated at the th percentile of diversity. we visualize these findings in figure . specifically, panel (a) of figure plots coefficient estimates on the y-axis against years since a shock on the x-axis for non-diversified msas. panel (b) plots coefficient estimates for the diversified msas. [ figure : about here] note that in the baseline log-linear specification described in equation ( ) table a are qualitatively similar to the estimates reported in table . we also consider the following variant of estimating equation ( ) note, we superscript all model parameters to indicate we are estimating a different model. given estimates of equation ( ), the price effect of a disaster < years after a disaster impacts a region expressed as a function of diversity is, e′ <, ( = +′ , + ′ , • ln ( . # parameter estimates of e′ <, ( which we report in table a are also qualitatively j o u r n a l p r e -p r o o f similar to parameter estimates of e <, ( in table . to summarize our main findings, recall that the parameter e <, ( represents the price impact of a disaster in the < k year after a shock conditioning the level of diversity ( . estimates of e <, ( allow us to evaluate differences in the degree to which housing prices change in response to a disaster at any point in time and at any level of regional diversity. model results reported in table show that highly concentrated regions (e.g. those lying below the th percentile of diversity) experience negative and statistically significant price declines in the first two years following a shock. however, as diversity increases, these immediate price responses attenuate towards zero. collectively, these findings indicate that diversification attenuates both the magnitude and the duration of the impacts of a disaster on regional housing values. the empirical findings presented in the preceding section lend credence to the resiliency hypothesis. to the extent that economic diversification attenuates the immediate impact and the persistence of a shock, our estimates suggest that diversification has an economically meaningful impact on an msas level of resiliency. here, we formally test if diversification has a statistically significant effect on resiliency. we formalize a test of the resiliency hypothesis by first recalling that the estimated price effect of a disaster < years after a disaster hits expressed as a function of diversity is given by, e <, ( = + , + , • ( . # this expression allows us to derive the direct effect that a unit increase in diversity has on attenuating home price responses due to a disaster, oe <, ( o ( = , . # note that ( is bounded above by one. as such, it is useful to consider estimates of table reports estimates of [ , derived from coefficient estimates of equation ( ) as well as p-values associated with hypothesis tests specified in ( ). as shown in table , for post-treatment time periods we reject the null hypothesis that [ , ≤ in favor of the alternative hypothesis that [ , > . for the sake of completeness, we also report estimates of [ , for each pre-treatment period (e.g. periods - , - ). in the absence of a shock, our hypothesis that these estimates should not be statistically different from zero is supported by the statistical evidence in table . [ these findings provide statistical evidence allowing us to reject in the null hypothesis in favor of the resiliency hypothesis. yet, whether or not these tests are valid ultimately depends on the underlying identifying assumptions of our empirical model. we proceed by discussing the potential threats to the identifying assumptions of our modeling exercise. in this section, we elaborate in more detail the underlying identifying assumptions of our main empirical model along with a series of robustness checks. we also investigate whether or not migration is a potential mechanism driving our results. for robustness, we also tested the sensitivity of our model estimates to the exclusion of larger known disasters. to do this, we leveraged the housing assistance dataset published by fema (https://www.fema.gov/medialibrary/assets/documents/ ). for each disaster, the data document the total number of fema applicants (e.g. homeowners) who received an inspection following a major presidential disaster declaration. again, these inspections are required to qualify for assistance options. the data also record the total number of applications who received an inspection but had no damage recorded by the inspector. we use both variables to compute the number of homes that were (a) inspected and (b) determined to be damaged by each disaster. we then flagged outliers by identifying disasters that fell above the th percentile with respect to the number of homes inspected and determined to be damaged by each disaster and obtained estimates of [ , after excluding this set of flagged disasters; our model results are qualitatively unaffected by this data restriction. a key identifying assumption of our empirical model is that conditional on msa and time fixed effects, the shocks we introduce to regional economies appear random. this assumption cannot be explicitly tested. instead, we rely on the conditionally random nature of a natural disaster as one piece of supporting evidence another identifying assumption of our empirical model is that non-impacted msas serve as valid control groups for impacted msas. that is, to interpret our estimates as causal requires one to assume that price trends in impacted msas would have been proportional to price trends in non-impacted msas in the absence of treatment. while this assumption cannot be explicitly tested, our empirical findings in section ( ) provide evidence supporting it. more specifically, model estimates of equation ( ) reported in table demonstrate that in the period of time leading up to a shock, there does not exist economically or statistically meaningful differences in pre-treatment price trends between impacted and non-impacted regions. we highlight that economic diversification ( ( ) appears in our empirical specification both by itself and interacted with a suite of disaster indicators, ( × . , . as such, one might raise the concern that if economic diversity and housing values are both related to some latent confounder, and since coefficient estimates on . , and ( × . , are both used to test the resiliency hypothesis, model estimates of the impact of diversity on resiliency (e.g. coefficient estimates of the interaction terms) are potentially problematic due to the inconsistency of the estimator. like the model set forth in nizalova and murtazashvili ( ), the econometric problem here is akin to a heterogeneous treatment effect analysis where the source of heterogeneity is perhaps endogenous. given their theoretical findings, and key to addressing potential endogeneity here, estimating eq. ( ) via ols will yield estimated coefficients on . , and ( × . , that are consistent so long as both regional economic diversity and any latent confounders are jointly independent-having controlled for msa-specific fixed effectsof the occurrence of natural disasters. said another way, if disasters are conditionally j o u r n a l p r e -p r o o f independent of both : and ( , again controlling for geography that is fixed over time, then the coefficients on the interaction terms ( × . , can still be consistently estimated whether ( is independent of : , or not. thus, even if there are other potential factors correlated with both diversity and home prices, the estimated effect on the interaction terms will not be confounded so long as the aforementioned assumptions hold. henceforth, since we only rely on estimates of the coefficients on ( × . , and . , , the conditionally random nature of disasters allows us to consistently estimate the effect that diversification has on catalyzing resiliency. ( ) without the inclusion of any additional controls. with the goal of including variables measuring both local labor market conditions and firm structures, column replicates column but includes a full set of (linear) control variables measuring labor market income by industry. likewise, column replicates column but also includes a full set of (linear) control variables measuring employment by industry. the set of parameters estimates in column are qualitatively unaffected by the inclusion of these controls. however, we take an additional step in assessing the robustness of our findings by instrumenting for economic diversity and estimating the model via two stage least squares ( sls). employing an instrumental variable approach requires an instrument(s) that is correlated with changes in diversification in a given msa, is otherwise exogenous to local economic conditions in said msa, and is arguably excludable from the structural equation. as such, we construct an instrument by adopting the shift-share methodology used by ottaviano and perri ( ) we use ( ij to instrument for the level of diversification in each msa. here, the identifying assumption is that changes in the national growth rate of sector s are exogenous to the local economic conditions of a specific region . however, diversity enters our main estimating equation by itself, ( , and also through the suite of interaction terms, . , × ( . along these lines, in order to obtain sls estimates of [ , , we first estimate equation ( ) instrumenting ( and . , × ( with the set of instruments ( ij and . , × ( ij . when looking at the results presented in table , three things become apparent. first, the estimated effects in the pre-periods remain statistically indistinguishable from zero. second, the estimated impacts are similar in sign though slightly smaller in magnitude. in particular, the estimated effect one period out is . % (compared to . %), the estimated effect two periods out is . % (compared to . %), and the estimated effect three periods out is . % (compared to . %). third, statistical significance at conventional levels still holds for the estimated effects in the first two post periods and the estimated effect is only marginally insignificant the third post period. the stability of the results when instrumenting for the potential endogenous nature of diversity provides further confidence in our baseline results. in particular, the stability of these results having instrumented for both diversity and the interaction of diversity with the set of natural disaster indicators lends empirical strength to the underlying identifying assumption of disasters appearing random conditional on geography. this conclusion, of course, is only convincing if the exclusion restrictions are valid. the idea that changes in the national growth rate in the share of labor market income for particular sectors is exogenous to the local economic conditions, while at the same time not being a localized determinant of regional home prices, seems reasonable. this argument, however, does preclude the possibility of unobservables that are correlated with both the national growth rate in the share of labor market income from particular sectors and localized home prices conditional on regional economic diversity. lastly, and as noted in the table , the null of underidentification is rejected (p-value = . ) and the estimated first-stage kleibergen-paap f statistic is equal to . . [ boustan et al. ( ) show that migration in response to disasters could influence local labor markets and house price dynamics. along these lines, migration may be a potential mechanism explaining our results if post-disaster net migration is in the direction of more j o u r n a l p r e -p r o o f diverse areas thus leading to more resilient home prices in more diverse areas. this logic motivates us to ask several questions: ) do natural disasters lead to increases in net outmigration (e.g. out-migration net of in-migration)? ) does there exist a tendency for diverse regions to experience more in-migration than out-migration? ) following a disaster, does diversity dampen the degree of net out-migration in a region? we address these questions by obtaining the county-to-county migration flows database that is based on the to american community surveys. the data are constructed based on identifying residents in each u.s. county, and whether or not they lived in the same residence one year ago; for respondents indicating they lived in a different residence the data records the county they currently reside in as well as the county they previously resided in. this information is then used to construct estimates of flow and counter flow migration for all county pairs. our unit of analysis is a county to county pairing, (i,j). for each pairing, we measure out-migration from county i to county j denoted by the variable out-migration ij as well as in-migration to county i from county j denoted by the variable in-migration ij . for the sake of clarity, both of these variables are always greater than or equal to zero. thus, outmigration ij measures the number of people that moved from i to j and in-migration ij measures the number of people that moved to i from j. we then construct the variable net-migration ij = out-migration ij -in-migration ij . henceforth, if net-migration ij > (< ) then the number residents that moved out of county i to j is greater (smaller) than the number of residents that moved into county i from county j. next, we compute the standardized diversity index at the county level and compute the difference in diversity between counties i and j (div i -div j ) for every county to county pairing. finally, we leverage a useful aspect of the timing of disasters in our data. if natural disasters cause increases in net-migration ij , then we would expect the coefficient estimate of + to be positive; that is, + represents the effect of a disaster in county i on the average level of net migration from county i to all other counties. second, note that county i is more diverse than county j when " ( − ( d # > . hence, if there is a tendency for diverse regions to experience more in-migration than outmigration -in effect, leading to a reduction in net-migration -we would expect estimates of + to be negative. lastly, coefficient estimates of + r capture the effect that a relative standard deviation increase in the diversity of region i has on mitigating the average level of net migration from i in response to a disaster. if diversity serves to dampen the net migratory response to a shock, then we would expect coefficient estimates of + r to be negative and statistically significant. we present results of estimating equation ( ) in table . here, robust standard errors are clustered at the level of treatment, which in our case is the county level, but model results are robust to not clustering as well. for completeness, columns and show estimates of equation ( ) using outmigration from i to j as the dependent variable. likewise, columns and show estimates of equation ( ) using net migration from i to j as the dependent variable. first, focusing on the model estimate shown in column which excludes the terms " ( − ( d # and × " ( − ( d #, we learn that disasters lead to a statistically significant increase in outmigration. turning attention to column , we learn that the associated counter flow of residents in response to a disaster does not offset the degree of outmigration; that is, on average, natural disasters lead to a statistically significant (net) increase in the number of residents leaving a region. our main estimating equation is presented in column . coefficient estimates of " ( − ( d # are negative and statistically significant which suggests than on average, residents tend to move to diverse regions. lastly, estimates of the coefficients of × j o u r n a l p r e -p r o o f " ( − ( d # are negative and statistically significant in all models, indicating that heightened levels of economic diversity decrease out-migration and net-migration. [ to aid in interpretation, the coefficient estimate of is - . (p-value < . ) and the coefficient estimate of × " ( − ( d # is - . (p-value < . ). thus, a one standard deviation increase in diversity is estimated to reduce net-migration by (- . / . ) x = . %. clearly, the migration channel, wherein relative demand for residence in areas with concentrated employment falls after disasters, is important for the explanation of our results. our findings show that regional economic diversification tamps down the effects of a disaster on housing values. these findings indicate that there may exist meaningful benefits from enhancing local, urban variety as a means to mitigating housing price responses to externally generated shocks. however, resiliency is only one of the three main objectives policy makers often seek to achieve through diversification; price stability and price appreciation are other relevant considerations. while coulson et al. ( ) demonstrates that economic diversity effectively decreases housing price volatility, less work has been dedicated to understanding the direct effect of economic diversity on housing values. we proceed by addressing this shortcoming of the literature. on the theoretical front, a priori, the relationship between diversity and housing values is ambiguous. some researchers have noted that diversification necessarily implies a departure from specialization. from a pure quantitative perspective, this is true. moreover, and to the extent that efficiency advantages stemming from specialization exist, some have argued that diversification may be an impediment to economic growth thus leading to decreases in home values. izraeli and murphy (p. , ) summarize this sentiment quite succinctly: "the theory of comparative advantage shows very clearly the gain from specialization and trade. in the context of a nation, the geographic concentration of production benefits sub-national units, i.e., regions. this rationale explains why regions specialize in one or few industries in which they enjoy a comparative j o u r n a l p r e -p r o o f advantage over their trade partners." taking a different view, glaeser et al. ( ) emphasize the importance of knowledge spillovers that occur between industries. their idea, which is consistent with the earlier work of jacobs ( ), suggests that the "variety and diversity of geographically proximate industries rather than geographical specialization promote innovation and growth." (p. ) on this account, diversity may ultimately lead to increases in housing values. on the empirical front, there are inherent difficulties in estimating the direct effect of diversity on home prices. as we note earlier, to establish a causal link one would need to confront the possibility that diversification is an endogenous covariate. an ideal but impractical experimental setting is one in which economic diversity in an msa changes randomly and without regard to local economic conditions. given the lack of this ideal setting, alternative approaches must be considered. we advance one such approach here by estimating variants of the following estimating equation, ln &'( = + ! ( ; + + + + : , # using two stage least squares ( sls) instrumenting for ( with ( ij . here, is a complete set of msa fixed effects and an exhaustive set of year-quarter fixed effects. we report ols estimates of equation ( ) in column of table . for completeness, in column we present estimates of equation ( ) allowing diversity to enter the model non-linearly. for the sake of interpretation, in the log-linear specification, column , we present estimates of equation ( ) after standardizing the diversity index mean zero standard deviation one. this allows us to interpret coefficient estimates as the effect of diversity on home prices due to a one standard deviation increase in diversity. columns and report sls estimates of columns and , respectively. additionally, relevant first stage statistics are also reported. [ column suggests a one standard deviation increase in diversification may lead to a . % reduction in price. column indicates that a % increase in diversification may lead to a corresponding . % decrease in housing values; however, both effects are statistically insignificant. further, as shown in columns and , the magnitudes of these estimated price decreases are meaningfully attenuated toward zero after we instrument for diversity suggesting there is no economically discernable relationship between diversification and housing values. diversification is often regarded as a positive policy objective for local real estate markets in terms of improving price resiliency; albeit, this conventional wisdom has persisted in the absence of any formal empirical evidence. our findings demonstrate that economic diversification has the two-pronged effect of attenuating the immediate impact and the relative persistence of a shock in a small regional economy to local housing values. our modeling exercise shows that diversity catalyzes the resiliency of the housing markets to climate shocks. there exists a long-standing debate in the literature on the potential "dual-effects" of diversification on the regional economy in terms of the direct effect of diversification on regional market performance. through the lens of the housing market, we show that the concerns issued in previous studies regarding the potential downsides of diversification stemming from the microeconomic foundations of comparative advantage do not appear to be warranted. after instrumenting for diversity, we find no economically meaningful or statistically relevant relationship between diversity and regional housing values. considering these results, the policy goal of improving resiliency through diversification can likely be achieved net of ancillary concerns of impeding economic progress. albouy, d. ( ). standard errors are reported in parentheses and are clustered at the msa level. e <, ( d represents the estimated impact of a disaster on home prices < years since a disaster struck relative the year before a disaster (< = − conditional on the jth percentile of economic diversity, div j . estimating equation ( ) includes year by quarter fixed effects, msa fixed effects, and msa-specific linear time trends. ( ) ( ). robust standard errors in parentheses and are clustered at the county level. out-migration ij measures the number of people that moved from i to j. net-migration ij = out-migration ij -in-migration ij where in-migration ij measures the number of people that moved to i from j. div i -div j represents the difference in the standardized diversity index between county i and j. disaster i is a binary variable equal to one if county i experienced a disaster in or and zero otherwise. coefficient estimates for disaster i thus represent the estimated effect of a disaster on each outcome, holding the relative level of diversity between regions constant. likewise, coefficient estimates for × " ( − ( d # represent the estimated effect that a relative standard deviation increase in the diversity of region i has on mitigating or exacerbating the average response to a disaster. ( ) j o u r n a l p r e -p r o o f notes: this table reports parameter estimates exp[θ(τ, div j )]- obtained from estimating equation ( ). standard errors are reported in parentheses and are clustered at the msa level. e <, ( d represents the estimated impact of a disaster on home prices < years since a disaster struck relative the year before a disaster (< = − conditional on the jth percentile of economic diversity, div j . estimating equation ( ) includes year by quarter fixed effects, msa fixed effects, and msa-specific linear time trends. notes: this table reports parameter estimates of e′ <, ( obtained from estimating equation ( ). standard errors are reported in parentheses and are clustered at the msa level. e′ <, ( represents the estimated impact of a disaster on home prices < years since a disaster struck relative the year before a disaster (< = − conditional on the jth percentile of economic diversity, div j . estimating equation ( ) includes year by quarter fixed effects, msa fixed effects, and msa-specific linear time trends. • hij where hij refers to the sample standard deviation of diversity in the data and e <, ( the estimated price effect of a disaster < years after a disaster hits expressed as a function of diversity obtained from estimating equation ( ). we report p-values associated with the test & ] : [ , ≤ vs. &`: [ , > in brackets. the estimates reported in column are based on estimating equation ( ) without the inclusion of the set of income by industry controls. in contrast, the estimates reported in columns and estimate equation ( ) including the income by industry controls and employment by industry controls, respectively. ( ) • we use natural disasters as a source of exogenous shocks to examine the effect of economic diversity on the resiliency of us housing markets. • diversity dampens the magnitude and duration of the effects of disasters. • one mechanism is suggested by our subsequent finding that outmigration after disasters is lower in more diverse cities. j o u r n a l p r e -p r o o f did the rust belt become shiny? a study of cities and counties that lost steel and auto jobs in the s related variety, unrelated variety and regional economic growth industrial diversity, growth, and volatility in the seven states of the tenth district learning about an infrequent event: evidence from flood insurance take-up in the united states the long-run relationship between house prices and income: evidence from local housing markets directions for diversification with an application to saskatchewan growth in cities where are the speculative bubbles in us housing markets market responses to hurricanes employment risk in the u.s. metropolitan and nonmetropolitan regions: the influence of industrial specialization on population characteristics environmental determinants of housing prices: the impact of flood zone status key: cord- -s qthxx authors: aven, terje; zio, enrico title: globalization and global risk: how risk analysis needs to be enhanced to be effective in confronting current threats date: - - journal: reliab eng syst saf doi: . /j.ress. . sha: doc_id: cord_uid: s qthxx in the last - years, technological innovation has enabled the advancement of industry at a global scale, giving rise to a truly global society, resting on an interdependent web of transnational technical, economic and social systems. these systems are exposed to scenarios of cascading outbreaks, whose impacts can ripple to very large scales through their strong interdependencies, as recently shown by the pandemic spreading of the coronavirus. considerable work has been conducted in recent years to develop frameworks to support the assessment, communication, management and governance of this type of risk, building on concepts like systemic risks, complexity theory, deep uncertainties, resilience engineering, adaptive management and black swans. yet contemporary risk analysis struggles to provide authoritative societal guidance for adequately handling these types of risks, as clearly illustrated by the coronavirus case. in this paper, we reflect on this situation. we aim to identify critical challenges in current frameworks of risk assessment and management and point to ways to strengthen these, to be better able to confront threats like the coronavirus in the future. a set of principles and theses are established, which have the potential to support a common foundation for the many different scientific perspectives and ‘schools’ currently dealing with risk handling issues. currently the world is suffering as a result of the coronavirus, which among other catastrophic consequences has also led to the implementation of different forms of social isolation as measures of mitigation. this is affecting directly the fundamental element exposed to the health risk, which is also the principal actor in the globalized industrial, economic and social world: people. as a result of people's isolation, many industrial, social and cultural systems have suspended or significantly reduced their production and services, with future effects still to be seen. the coronavirus case demonstrates that the development of disastrous events has dramatically changed during recent years, because of globalization, pushed by technological innovation and strong industrialization. our society now relies on an interdependent web of transnational technical, economic and social systems, which has allowed the massive and wide transportation and distribution of people, materials, products, services, for an unprecedented improvement of welfare in most regions of the world. at the same time, however, the interconnected systems are inevitably exposed to potential scenarios of cascading outbreaks, whose effects can ripple to very large scales through their strong interdependencies. the vulnerabilities are massive and disturbing. the underlying systems have complex features, interactions among the system elements lead to complex dynamics, and surprises occur (turner and pidgeon , meadows , helbing , mcdaniel and driebe . classical risk assessments do not work in these situations, as a potential disaster in such complex systems cannot be foreseen by looking at the chain of events that may occur (leveson ) . the global financial crisis of a few years ago is an example: one bank, lehman brothers, filed for bankruptcy in (mishkin ) , with losses that extended far beyond its own financial value or its thousands of employees who lost their jobs; the effects rippled throughout the global financial system, bringing it to its knees and spreading to other major sectors like the car industry. the main lifeline systems today are all tightly connected in large and intricate networks of dependency and with interdependent links to other sectors and across national borders. with respect to the above , a major issue for risk analysts and managers is how to deal with hazards and threats with a potential for extreme consequences and large uncertainties. we know that in these cases, accurate predictions of what is coming cannot be made and, in fact, the coronavirus case has shown that the world's risk management and governance systems are not working as intended. we have not been effective in protecting people from this virus. as risk scientists, it is necessary to reflect on thisis the reason mainly about unfortunate circumstances or poor risk handling by authorities and agencies? do we, as a risk science community, also bear a responsibility for this failure? have we provided the proper concepts, principles, approaches, methods and models for adequately assessing, communicating, managing and governing the risk? in recent years, various perspectives and approaches have been proposed in the literature, to try to meet the challenges of assessing and handling risk in relation to such extreme situations and complex systems. these perspectives and approaches, which to a large extent can be viewed as scientific schools, include what we will refer to as 'safety science' (highlighting sociotechnical aspects, complexity theory, and resilience analysis), 'risk governance and systemic risk frameworks', 'post-normal science', quality management and 'risk science' (highlighting 'broad' perspectives on risk with an emphasis on uncertainties, knowledge and potential surprises (black swans)). these perspectives and approaches all produce knowledge relevant to the proper assessment, communication and handling of risks subject to large uncertainties. but is the message the same? is the separation between these schoolsas reflected by differences in scientific pillars and preferred journals, conferences, societies, etc. -hampering the development of authoritative guidance to help policy-makers, managers and decisionmakers to properly assess, communicate and handle risk? is there a potential for joining forces, to build a new generation of risk, safety and resilience frameworks for the benefit of society and us all? the present paper discusses all these issues, motivated by the pandemic outbreak that the whole world is experiencing and the consequences that it is suffering because of the coronavirus, covid- . the main aim of the paper is to provide new reflections and knowledge on the proper assessment and handling of risk of the types addressed above, by critically reviewing current perspectives and approaches, and pointing to areas with the potential for enhancements, so that we can be better able to confront global, highly uncertain and large consequence threats like the coronavirus in the future. a key topic discussed is the tension between using scientific methods and models, on the one hand, and applying the precautionary principle, on the other, as we have seen also in the context of the scientific and political debates for the coronavirus. in fact, in relation to the coronavirus case, politicians have to a large extent referred to the precautionary principle (and still are), to justify the implementation of many specific measures. in this respect, we seek to bring new insights about this principle and associated ideas of risk handling, by relating it to the particular case of the global risk of coronavirus and the perspectives of the different scientific schools of risk assessment, management and governance mentioned above. the reminder of this paper is structured in the following way. first, in section , we discuss the general issues involved in preparing for and managing disasters. then, in section , we describe the coronavirus case from a risk assessment and management perspective, addressing relevant specific features and challenges. in section , we summarize and reflect on current perspectives and approaches (schools) for assessing and handling risks of this type, using the classification referred to above. from this basis, in section , we discuss what we can do to improve the way we assess, communicate and handle risks like those of the coronavirus type. finally, section provides some conclusions. in general terms, a disaster is any occurrence that causes damage, destruction, ecological disruption, loss of human life, human suffering, or the deterioration of health and health services on a scale sufficient to warrant an extraordinary response from outside the affected community or area (who, ) . such situations may include natural disasters, such as droughts, earthquakes, floods or storms, and epidemics; or industrial accidents, such as nuclear or chemical ones (lehtveer and hedenus , lidskog and sjödin , and xu et al . the former are addressed within the concept of disaster management (akgün et al ) , but studies of epidemic disaster management are quite rare, compared to those of earthquakes, floods and other disasters, and are mostly focused on predicting the impact of an epidemic if one were to start. the latter (industrial disasters) are typically dealt with by formalized frameworks of technical risk assessment and management, to inform decisions on the design and operation of adequate preventive and mitigative barriers. the physical setting in which disasters may occur has dramatically changed over recent years, because of globalization pushed by technological innovation and strong industrialization. new factors are driving the occurrence and the consequences of disasters, among which population density, urbanization, globalization and climate change are perhaps the most evident. these factors are proving catalysts for the acceleration of pandemic disasters. for example, climate change might play a role in the birth and transmission of specific diseases; the huge trend of urbanization of the world's population, along with the substantial growth in population itself, is a factor that can accelerate epidemic outbreaks into pandemic disasters, through social globalization. all this renders our socio-technical-economic systems vulnerable to a pandemic like the one we are facing today, and more difficult the risk management of disasters and crises in general. disaster management comprises, in general, a set of activities that are performed before, during and after a disaster, with the goal of preventing loss of human life, reducing the impact of the disaster on the economy and re-establishing a normal, or even improved, state of affairs (altay and green iii ) . disaster risk management seeks to identify and adopt adequate measures of prevention, mitigation, preparedness, emergency response and recovery (pettit and beresford ) . various studies have shown that risk management of disasters can save lives and offer relief to those hit by the disaster (pettit and beresford , akgün et al ) . the objectives of disaster preparedness for control and containment of an outbreak of an epidemic or pandemic relate, then, to reducing the rate at which vulnerable individuals become infected, reducing the mortality rate for those already infected and increasing the immunization capacity of the population. the preparation measures for control and containment must build the capabilities to launch quarantine programs over entire geographic regions, where possible. they must provide medical supplies and life commodities. they can be adopted both for prevention of the spread after the initiation of an infectious disease (pre-event measures) or for control and containment of a confirmed outbreak (post-event measures). in the former case, a predetermined amount of medical supplies should be kept in stock and ready to be used at the outbreak of the epidemic. for the specific case of the coronavirus, the european union (eu) has created a stockpile of medical equipment (such as ventilators and protective masks) to help eu countries fight the covid- pandemic. the stockpile includes medical items, such as intensive care medical equipment, for example ventilators, and personal protective equipment, such as reusable masks, and laboratory supplies; its current main aim is to help those eu states that face shortages of the equipment needed to treat infected patients and to protect health care workers (https://ec.europa.eu/commission/presscorner/detail/en/ip_ _ ). in general, the management of the risk of disasters, such as epidemic/pandemic outbreaks, calls for preparedness and a prompt response to control them. certain protocols should be prepared and, then, followed; supplies and human resources (medical and other personnel, particularly in the case of epidemics and pandemics) should be adequately prepared and effectively made available and utilized, for the containment effort to be successful. for example, if a smallpox attack happens, vaccination of the affected population should take place within four days, while, in the case of an anthrax outbreak, the distribution of antibiotics should take place within two days of the event (lee, ) . this calls for an emergency supply chain (sometimes also called a humanitarian supply chain) that is properly designed, managed and operated, to successfully handle the many logistics issues that arise. this entails that financial resource allocation, vital commodities' and medical supplies' stockpiling capacities and locations be optimized, based on an a priori risk assessment, and the logistics operations during emergency for their management transportation and distribution be carried out in conjunction with the available information on the evolution of the disaster, in order to contain its spread and hopefully keep it below critical proportions. governmental agencies and health institutions must be prepared in advance for the control and containment of disasters of epidemic outbreaks. to prepare, they must take risk-informed decisions on contingency plans to be set up so as to ensure the availability of emergency medical stocks and well-trained personnel, their appropriate deployment, and the availability of different types of vehicles for the transportation of essential medical supplies and commodities, etc. an evident common ground and connection exists between the technical risk assessment & management and the disaster management, stemming from the four stages that meet their purpose: prevention/mitigation, protection/preparation, response, and recovery. prevention/mitigation comprises all activities for avoiding the occurrence of the accident/disaster and reducing its probability. protection/preparation relates to all safety measures and activities that are designed and planned to be put into action when the accident/disaster occurs, in order to reduce its impact and minimize losses. response is obtained through the activities of emergency and crisis management implemented during the aftermath of the accident/disaster, to prevent additional damage and loss. finally, recovery is the phase of restoring the back-to-normal situation after the accident/disaster. the four stages of disaster management, thus, match those of resilience management (zio ) or business continuity zio , xing et al ) , typical of engineered systems and industrial companies, respectively. in spite of the importance of taking a risk-informed approach to disaster preparedness, and all the associated logistics operations for disaster control and containment, the scientific community has not yet produced well-established approaches that explicitly incorporate risk assessment as a systemic framework for holistically dealing with the problem of disaster preparedness. this paper is motivated by the pandemic outbreak that the whole world is experiencing because of the coronavirus, covid- . as of april , , . gmt, there are , confirmed cases of coronavirus globally. sadly, there have been , deaths. the current coronavirus pandemic has raised the importance of preparing for disasters, but, unfortunately, once again, only after the factonce the covid- epidemic outbreak in china had escalated to a global pandemic. and although some claim this event to be a black swan (a surprising, unforeseen extreme event), there are aspects that lead to a different perspective on the matter, which make it not surprising at all, in our globalized world, but actually very likely to occur in, say, a ten-year horizon, having in mind the rather high number of similar events in recent years. a set of characteristics defines the risk of global crises that we are exposed to, such as that due to the coronavirus outbreak, and these shape the way we address it. in the specific case of the current pandemic, the probability of and the risk related to the occurrence of the outbreak of such a crisis and of its severity have been judged too low in spite of clear evidence. large uncertainties and weak knowledge have partially caused this, leading to an insufficient level of preparedness in all countries and from all points of view: material, organizational, financial, political and cultural. what has not helped the preparedness is the individual and regionally collective "optimistic bias", which often determines the attitude to risk and the policy measures that follow. from the point of view of individual attitude, the optimistic bias leads people to ignore the risks: it is the superwoman/superman attitude of "it won't happen to me", in most cases supported by the illusion of having control over things. it has led some people to feel that they will avoid the covid- disease and, therefore, they can even ignore protective measures, including confinement (bako and zio ) . this is somewhat fed by certain erroneous, or incomplete at best, communication, e.g. that which fosters the belief that the virus is really only dangerous for old and sick people. communication should, instead, be clear on the fact that nobody can escape infection by the new coronavirus and that the physical reaction to the disease differs from individual to individual, as it is conditioned by a number of factors, mostly unknown. from the point of view of collective communities, it has again to a large extent been an "it won't happen to me" attitude, until it is suddenly revealed that the pandemic is real and there will be a high number of cases and also deaths in this region/country/area. another characteristic refers to the perception that people have of different risks. irrespective of whether there is more or less risk, tangible hazards like those arising from activities like car driving are perceived to be less severe than intangible hazards, like those related to epidemics or nuclear accidents. in the specific case of the coronavirus, the high speed at which it spreads makes it legitimate to feel worried and, so, legitimate questions arise: how does this novel pandemic compare to the "normal" or accepted risk of infectious death? what is the "worst case" scenario? should we panic and shun other people who may be carrying what might kill us? and, although it is rational to advocate that there is no need to become paranoid and fearful, but, on the contrary, there is a need to evaluate the risk and manage it scientifically, this is difficult to do in practice because:  the risk level depends on the characteristics of the virus, including how it spreads to people  a number of factors affect the behavior of the virus and of people, and all are highly uncertain because of lack of knowledge on the physics of the virus and uncertainty in the actions and reactions of people, at all levels  uncertainty affects the effectiveness of measures put in place to control the pandemic. so, the rational and logical approach to dealing with the risk of the occurring pandemic (as with any other risk, for that matter) is not to panic but to limit one's own personal and potential exposure and to minimize both the size and scale of the potentially exposed population. but the risk values produced to guide the decisions on how to do that cannot be exact, as they are based on weak and even potentially erroneous knowledge related to, for example, the spread of the virus and the actuation and respect of the measures implemented. and if risk were judged based on how it is perceived (also biased by "street" news and politics), then intangible hazards would receive the highest attention, as is the case for operating nuclear power plants and today's pandemic. so, professional risk numbers are not enough to deal with situations like the coronavirus crisis. policies crave to be science-based, but science does not have clear answers in cases like this, characterized by large uncertainties due to a weak knowledge base on the phenomenon and the factors involved. and the communication of the risk becomes difficult itself: how to explain what risk is in situations of large uncertainties and little knowledge? how can one say that it is small or large, relating it to uncertainties and knowledge? a risk professional may say that the risk is low (e.g. in the early phases of the outbreak), but the uncertainties are large: how can this be communicated, so that it is properly understood and used for decision making? in a case like this, when the stakes involved and uncertainties are so large, there are no alternatives but to give weight to the precautionary principle. the health experts have been crystal clear about the need for some type of societal lockdown, and politicians, faced with a potential for catastrophic events with thousands and even millions of deaths, have had no other choice than to follow the recommendations of the experts and even to take the precautionary measures some steps further. while trying to limit the spread and control of the pandemic, the healthcare systems have been pushed to the edge of their capacity. the expected economic and social costs are, however, enormous, and this brings strong pressure to lift the measures and reopen everything as soon as possible. in support to this, real-time tests are performed, and extensive research is conducted, to find ways of treating the patients and developing efficient vaccines against the virus, while some form of adaptive, learning-based risk management policy is applied in basically all countries (duffey and zio a and b). we imagine that we are confronted with the coronavirus pandemic, in its early stages of development. authorities must make decisions and take countermeasures to control the pandemic. these decisions and countermeasures imply public investments and can be restrictive for people's activities. the potential impacts of the pandemic are huge and the uncertainties are large concerning the actual evolution of the outbreak and its consequences, as well as the effects of the possible interventions. predictions on the scenarios of the evolution of the spread of the virus are highly desirable, but the influencing factors are many and the models of the phenomena involved need to be based on many assumptions, for most of which there is no absolute justification. this is because the physical, medical, social and economic phenomena involved are not really understood, in spite of the fact that there is field experience and considerable knowledge on such types of viruses, in general, and also on how to best handle their spread and the risks they carry. for situations like this, characterized by large uncertainties, the traditional textbook approaches to risk assessment and management cannot be used. formal risk assessments cannot be applied as is, to accurately predict scenarios of evolution and estimate their consequences, accounting for the effects of alternative countermeasures. thus, the decision-making remains intrinsically dynamic and adaptation to the evolution of the situation is inevitable, as shown by the different decision strategies taken back and forth by the authorities of the countries affected by the covid- pandemic. this motivates a reflection on the approaches to risk assessment and management for different types of risk problems. there are, indeed, many ways of categorizing risk problems. many relate to the severity of the consequences (the stakes involved) and their degrees of uncertainty (e.g. funtowicz and ravetz , renn , aven . from the perspective of these two dimensions, the pandemic situation that we are addressing corresponds to a high risk problem (large consequences with high uncertainty), and the traditional approach to risk assessment and management just does not work. as mentioned in section , different 'schools' exist, to meet this type of situation. in the following, we briefly recall some of these, the main aim being to show that, in fact, they all provide useful perspectives for and approaches to how to meet the challenges of assessing and managing risk in relation to critical situations of the kind that we are experiencing due to the coronavirus pandemic. post-normal science ravetz , ravetz ) acknowledges the need for an alternative and supplementary approach to science and policy making, when the stakes involved and the related uncertainties are largeand, typically, with different values in dispute and decisions urgently needed on which actions to take. this requires extending beyond the traditional perspective that science is not only certain but also value-free, calling for the need of new methods capable of going beyond numbers through different aspects of knowledge and information, dialogue and participation. the post-normal science emphasizes uncertainty and qualitative analysis, and a scheme for how to perform such analysis has been proposedthe nusap system (funtowicz and ravetz , , van der sluijs . nusap uses five categories for the management and communication of uncertainty in science for policy: numeral, unit, spread, assessment and pedigree. through nusap, a qualitative study of the quality and strength of the knowledge base behind the relevant scientific information and risk findings can be made, to inform policy making. . it is undoubted that pandemics, like the one we are experiencing, do pose systemic risk and, from this perspective, must be assessed and managed. system thinking, based on seeing wholes and interconnections, is, then, needed if we are to identify potential surprises and the unforeseenas stressed by many scholars of organizational theory, accident analysis, and the quality discourse (turner and pidgeon , deming , hollnagel et al , leveson )and effectively deal with their consequences. risk governance and systemic risk frameworks rely on three main categories of strategies for handling risk: risk-informed (based on risk assessments), robustness/resilience (based on the cautionary and precautionary principles) and discursive strategies (renn ). the strategy to apply in practice, to confront a systemic risk such as that brought by a pandemic, is normally a combination of these three types of strategies, with robustness/resilience as a main instrument for dealing with uncertainties (including potential surprises and the unforeseen), and dialogue for addressing differences in values. acknowledging complexity and dealing with uncertainties and the potential for surprises, through robustness and resilience-based approaches are key features of the risk governance school. this leads to safety science, and its roots in the 'sociotechnical perspectives on safety', which builds on three pillars (aven and ylönen ): i) a holistic view is needed to manage safety, using knowledge and experiential insights from different fields and disciplines (including technology and social sciences); ii) it is not possible to predict with sufficient accuracy and manage with sufficient control the behaviour of complex systems, their vulnerabilities and their response to accidents and disasters; and iii) robustness and resilience, thus, need to be accommodated, in addition to risk analysis. along these lines of thought, a rich body of literature on resilience has arisen in recent years, as a supplement to the traditional quantitative risk assessment approach, which has shown strong limitations when confronted with the analysis of complex systems and interconnected activities subject to large uncertainties regarding events' occurrences and consequences' evolution. the underlying idea is that, by strengthening the resilience of the system, the safety is improved without the need to calculate all probabilities and risks. we do not need to identify all eventshazards and threatsthat can occur as we have to do in traditional, quantitative risk assessments based on probabilistic methods. theories are developed providing a rationale for moving from 'safety-i', where the focus is on ensuring that 'as few things as possible go wrong', to 'safety-ii', where the aim is to ensure that 'as many things as possible go right' (hollnagel et al ) . in contrast somewhat to this perspective, the high reliability organizations (hros) tradition emphasizes the importance of failures, and that high performance and reliability can be achieved even in complex organizations if properly managed; five principles are highlighted therein: preoccupation with failure, reluctance to simplify, sensitivity to operations, ccommitment to resilience and deference to expertise (weick and sutcliffe ) . potential surprises are also a key focus of the quality discourse (deming , bergman ), with its distinction between 'common-cause variation' and 'special-cause variation'. the former variation relates to 'normal' system variation, whereas the latter is associated with the unusual variation, the surprises (the black swans). understanding the system causes is seen as the key to improving the system. risk science is the final school to be mentioned in this brief overview. it is based on the idea that the concepts, principles, approaches, methods and models for assessing, communicating, managing and governing risk form a distinct science (sra , a ,b, aven . this science provides guidance for all types of situations, including those characterized by the potential for severe consequences and large (deep) uncertainties, like the one we are facing in the covid- pandemic. it provides knowledge about risk fundamentals, for example related to what risk is, how to characterize risk, what methods are suitable for analyzing risk, how to treat uncertainties in risk assessment, how to understand and use the precautionary principle, the difference between professional risk judgments and risk perception, how to best deal with risk related to potential surprises and the unforeseen (black swans), and how to understand the link between risk and resilience. all the other schools can be viewed as providing knowledge to this science. a broad perspective on risk is adopted (sra , aven ), which sees uncertainty as a main component of risk and stresses the importance of knowledge and its strength when assessing and describing risk. the perspective allows for the inclusion of many safety, security, resilience and quality issues and is applicable to all domains (engineering, health, business, etc.). in addition, many different risk management frameworks have been developed to deal with specific issues and domains, for example enterprise risk management (erm) and business continuity management (bcm), in the case of commercial activities. bcm is of special relevance in this context, as it highlights disaster and crisis management, resilience and recovery planning (zeng and zio ) . as a final note on the perspectives taken above on risk, resilience, robustness, safety and security, these follow fundamental work by the society for risk analysis (sra), see sra ( sra ( , a . there are other perspectives than these, as for example that by the us national academy of sciences which defines risk as part of resilience (see e.g. linkov and trump , linkov et al , galaitsi et al. . we also refer to ale et al ( a,b) , jongejan ( ) and aven ( ) for discussions related to the nexus between risk and resilience. it is beyond the scope of the present paper to discuss the justification and rationale of the different perspectives, but one key point should be made clear: the difference is to large extent rooted in different conceptual understandings and terminology. there is a broad recognition of the importance of resilience to meet uncertain and unknown types of threats and disturbances. recent works on resilience and risk analysis and management in relation to covid- (e.g. hynes et al , golan et al , aven and bouder ) demonstrate this by their focus on system response measures and policies to prepare, absorb, recover and adapt. however, the resources are limited and what measures and policies to implement is challengingconsiderations of what will or can happen are needed, as well as overall judgments of what is acceptable levels of risk and vulnerabilities. risk science as referred to above provides one framework for conceptualising and understanding these phenomena; resilience analysis and management others, see the above references. for the purposes of the present paper, such differences in perspectives just underscore the point being made in the coming section: there are many 'schools' providing knowledge on how to handle risk when the uncertainties are large, which to varying degree work together. the overview in the previous section has shown that there are many perspectives and schools providing knowledge on how to understand, assess, communicate and handle risk, in relation to hazards and threats with the potential for extreme consequences, where the uncertainties are large. these perspectives and schools are founded on different scientific fields, developing in, to a large extent, separate activities, such as conferences, research activities, scientific journals and educational programs. yet, we argue here that the similarities and overlaps in the fundamental ideas are stronger than their differences. specifically, we highlight the following theses as common to all these perspectives and schools: a) uncertainty is a key element of all the relevant frameworks. b) an important source of uncertainty is potential surprises and the unforeseen. c) it is essential to distinguish between uncertainty and ways of measuring uncertainty. d) risk assessments provide knowledge about what type of events may occur, how often they may occur and what could be the consequences of these events if they were to occur. e) risk perception reflects aspects like fear and dread, but could also include conscious judgments of uncertainties. f) robustness and resilience are fundamental strategies to deal with the uncertainties. g) sciences about activities, events, processes developing in the world (for example, about the global spread of a virus) are supported by all perspectives and schools through their process of generation of knowledge on how to understand, assess, communicate and handle the risk (vulnerabilities, resilience, etc) and the uncertainties associated with these activities, events, processes. h) precautionary thinking is necessary in cases when the stakes involved are high and there are large (scientific) uncertainties, but the degree of precaution remains a political issue more than a science issue. as a matter of fact, scientific work can be regarded as a precautionary measure to reduce the uncertainties. i) adaptive, learning-based risk handling is suitable and advisable, given the occurrence of the hazard or threat. j) prevention of the occurrence of the potential crises-initiating hazards and threats remains a major priority. k) science informs decision-makers; it does not prescribe what is the best policy, arrangement or measure. l) openness, transparency, dialogue and participation are general features of prudent risk-handling frameworks. acknowledging uncertainty as a key component of risk is critical if we are to properly understand, assess and communicate risk. the traditional approaches to risk assessment and management jump more or less directly to the uncertainty measurement toolprobabilitythe result being that key aspects of uncertainty are not given the attention they require. all the schools discussed in section see this challenge and provide broader frameworks for allowing the analysts to take some steps back from the operational measurement tool and look more deeply into the knowledge supporting the analyses and the uncertainty measures used. risk assessments cannot produce accurate predictions of what is coming; rather, they help us to see what we know and what we do not know. they report the knowledge we have and are used as instruments for gaining new knowledge by, for example, studying how assumptions and model parameters influence key risk metrics. in the current coronavirus case, we have seen a number of models used to estimate the number of deaths, with uncertainty intervals showing the dependencies on key assumptions. however, seldom or never have we seen communicated the actual meaning of these uncertainty intervals and their dependencies on the knowledge basis supporting the evaluation of these intervals. at an early stage of the development of the coronavirus epidemic, many people raised their concerns. however, some experts indicated that lay people's concerns were the result of risk perceptional factors and biases, well-known from the scientific literature on this topic (e.g. kahneman et al , kahneman . the point made was that coronavirus hits all the 'hot buttons': a risk situation which is characterized by features like unknown, new and delayed effects, lack of control and catastrophic potential, commonly summarized by the two dimensions: newness and dread. the implication is that the risk is amplified, and there is a potential for overreaction. but how can we conclude that the response is an overreaction? at the time of concern, we are still faced with considerable uncertainties, and overreaction is a human attitude which reflects that. there is no ground truth to be used as reference for what is or is not an adequate response in such uncertain situations. lay people's risk perception can also include conscious judgments of uncertainties, partly ignored by the professional risk judgments. the insights provided by the different schools referred to above acknowledge that the experts' assessments have limitations and other knowledge sources can also provide valuable input to the overall risk considerations and should be considered. when faced with uncertainties, robustness and resilience-based strategies are important, as we do not know what will happen next. we need to be ready to tackle different types of scenarios, also surprising ones. at the same time, we need to build on the available knowledge and strengthen it to better understand what is happeningwe adapt and learn. the schools discussed in section support this approach to tackling risks, based on adaptation and learning, by providing concepts, principles, approaches, methods and models for how to do this. the perspectives differ partly on terminology and tools but remain similar on the fundamental ideas. inevitably, there is always a balance to be made between measures to create values, on the one hand, and measures to protect, on the other. science does not give us the formula for finding the right balance. it provides relevant knowledge and is, thus, informing the decision-maker, but it does not prescribe what should be done. the authorities in different countries have all labelled their policies "science-based", indicating that their policies are determined by the science findings. this type of notion is misleading, as the policies are at best science-informed. as we know, science produces justified claims about the world, but claims are not facts nor the truth. policies also reflect values, in particular related to how to give weight to uncertainties. in the case of large uncertainties, there is a considerable leap between insights provided by science and the considerations and policies derived by the political institutions. when faced with high stakes and large (scientific) uncertainties, precautionary measures will be and should be given weight in informing the decisions, as in the risk handling related to the coronavirus. the point is simply that we will avoid very high losses, and, given the uncertainties about the virus and the process of its spread, this leads to extraordinarily cautious policies. all governments now seem to have adopted such policies. some scholars are skeptical about the use of the precautionary principle/approach, indicating that it is not rational and scientific. however, the principle, as interpreted here as a guiding perspective, is in no way non-scientific: because of the uncertainties, there is not sufficient knowledge available to guide us differently on a solid basis. a key precautionary measure becomes, then, research to strengthen the knowledge base. it is acknowledged that different situations call for different approaches for assessing and handling risk -"simple" problems with no or very limited uncertainties require different strategies than those required by problems with high stakes involved and large uncertainties, as considered in this paper. all schools referred to in section acknowledge this, although the different ways of classifying the "problems" vary. uncertainty is, however, a common feature in all classification systems used. these schools also highlight the importance of openness, transparency, dialogue and participation for dealing with situations of the kind discussed in this paper (high stakeslarge uncertainties). there are always some limitations to this in practice, for example on the extent of openness that one can really achieve/obtain, but in many ways these features characterize an ideal in our democratic societies and we should be concerned when they are threatened in any way. finally, we conclude this section with some reflections about the actual risk handling in the coronavirus case. today, the world is faced with an extreme crisis as a result of the coronavirus. thus, we can conclude that the risk handling has failed. the failure can be traced back to i) the origin of the virus, ii) the lack of early control, and iii) the mitigation measures adopted, given its spread. the first type of failure is difficult to analyze at this stage, but thorough investigations and efforts are needed to see whether there are some fundamental problems in our societies, creating this type of threat. openness and international cooperation are required to meet this challenge, but it could be difficult to obtain necessary changes in activities that are grounded in traditional and cultural practices. nonetheless, this issue is a major concern. is it possible to avoid such a virus occurring? nothing would be better than the solution to this question. secondly, it was a failure that the signals and warnings were not taken seriously, which led to a delay in actuating measures for the control of the spread. the health organizations have warned governments and politicians for years that a serious pandemic is likely to occur. national and global risk assessments all point to pandemics as a major risk. yet the signals and warnings were to a large extent ignored. as such, the coronavirus pandemic is not to be seen as a black swan; its occurrence is not a surprising event relative to our knowledge. maybe we could classify the event as a known unknown, indicating that there was knowledge that a serious pandemic could occur quite soon, but when it would occur was unknown to us. surely there is a need to improve the way the world deals with this type of alarms and warnings. international cooperation is needed to develop relevant tools and institutions to look into this. thirdly, governments struggle to justify investments in preparedness measures. there are many threats that we must be protected from and using a lot of public money for something that might happen requires a strong economy and strict prioritizations. however, for pandemic risks, the evidence has been strong and clear, but still the coronavirus spread has been enormous, whereas its mitigation has been weak in many respects. the problems that we are facing have demonstrated the extreme degree of vulnerability that our societies face today because of globalization. necessary equipment is not available locally. all countries now depend on deliveries from specific producers often far away. following the coronavirus case, fundamental pillars for how we have organized the world will be questioned. more decentralized systems will challenge the globalist perspective. one of the reviewers of the original version of this paper questioned the above conclusion that the risk handling in this case has failed. the point made was that some risks were taken and accepted, and the potential consequences were known, see also discussions in ale et al ( a,b) . yes, decision-making about risk acceptance is an important task of risk management and governance, but it also makes sense to challenge this decisionmaking with respect to the outcomes and its rationale. we should question why many risk aspects where accepted and key vulnerabilities not reduced or eliminated. that is exactly what this paper and many others are doing. it is about scrutinizing the current risk handling in order to identify weaknesses and look for ways that it can be improved. the risk management and governance is not based on a destiny perspective, expressing that serious events will occur if we have calculated a probability for these events to occur. an ultimate goal of risk management and governance is to avoid disasters. above, we have pointed to some issues that we consider critical for being able to do this. it is about improving current approaches for risk handling. we also point to the need for the sciences and schools dealing with these challenges to do their job together, supporting the actual risk handling in the world. this is about risk analysts and scientists to make constructive reflections on systems and processes of the world, and on how to improve the handling of these and of their risks, in line with the ideas of science and quality management. in this paper, we have taken the dramatic world crisis of the coronavirus pandemic to reflect on the current frameworks for risk assessment and management and what they can offer in these situations of high stakes and large uncertainties. we have recognized that the contemporary frameworks struggle to provide authoritative unified societal guidance to adequately handle these types of risks. this is clearly shown by the coronavirus case, in which the risk handling has failed in the identification and prevention of the origin of the virus, in the lack of early control and in the efficacy of the decision-making about the mitigation measures to be adopted once the spread had started. we have highlighted that the existing scientific perspectives and schools related to risk share a number of fundamental principles and theses. they all consider uncertainty as a key element and view risk assessment as providing knowledge on what is known and what is not known about the occurrence and consequences of dangerous events, in the different risk situations. recognition is given to the fact that risk perception reflects human feelings, like fear and dread, but could also include conscious judgments of uncertainties different from those of the risk professionals. precautionary thinking, robustness and resilience are necessary approaches to develop adequate policies to address situations of high stakes and large uncertainties. the level of precaution, the decisions on how robust and resilient to be, remain political decisions, which can be informed by science and scientific knowledge: science does not prescribe the best policy of risk handling, but it can provide information for its definition by the decision-makers. it is time to initiate processes to obtain stronger integration of these perspectives and schools. only then, it is likely that we will be able to provide guidance for risk handling that really can have an impact. how to proceed is, however, difficult, given the way academic fields and societies work. the current crisis has been an eye-opener for many of us in different ways; perhaps it can also be that in relation to this challenge. we do hope so. certainly, prevention remains a main priority ("if you think that safety is expensive, try an accident", kletz, ) , and the capabilities for adaptive, learning-based risk handling are required in the event of an occurrence of the hazard or threat. these aspects need to be dealt with in the current setting of our highly vulnerable world, where factors like population density, urbanization, globalization and climate change influence the uncertain occurrence of disasters and their uncertain consequences. for this, more openness, transparency, dialogue and participation at all levels are needed for prudent risk-handling, to be better able to confront global threats like the coronavirus in the future. risk based facility location by using fault tree analysis in disaster management h ( a) precaution, resilience, faith, and covid- h ( b) resilience or faith or/ms research in disaster operations management an emerging new risk analysis science: foundations and implications the science of risk analysis the covid- pandemic: how can risk science help? risk management and governance some foundational issues related to risk governance and different types of risks a risk interpretation of sociotechnical safety perspectives conceptualistic pragmatism: a framework for bayesian analysis? the new 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collectivity: resilient ethics and ethics of resilience. psyarxiv what is post-normal science? precaution and the governance of risk systemic risks: the new kid on the block glossary society for risk analysis risk analysis: fundamental principles core subjects of risk analysis man-made disasters. nd ed risk governance experiences with the nusap system for multidimensional uncertainty assessment in model-based foresight studies managing the unexpected: resilient performance in an age of uncertainty. nd ed risk reduction and emergency preparedness: who six-year strategy for the health sector and community capacity development dynamic business continuity assessment using condition monitoring data natural disasters and social conflict: a systematic literature review an integrated modeling framework for quantitative business continuity assessment the future of risk assessment the authors are grateful to two reviewers for their useful comments and suggestions to the original version of this paper. the work has been carried out by terje aven and enrico zio, based on close collaboration on all aspects of the paper. the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. key: cord- - vf km i authors: holt, g. richard title: making difficult ethical decisions in patient care during natural disasters and other mass casualty events date: - - journal: otolaryngology - head and neck surgery doi: . /j.otohns. . . sha: doc_id: cord_uid: vf km i objective recent experiences in the united states with unprecedented terrorist attacks ( / ) and a devastating natural disaster (hurricane katrina) have demonstrated that the medical care of mass casualties during such disasters poses ethical problems not normally experienced in civilian health care. it is important to ) identify the unique ethical challenges facing physicians who feel an obligation to care for victims of such disasters and ) develop a national consensus on ethical guidelines as a resource for ethical decision making in medical disaster relief. study design a survey of pertinent literature was performed to assess experience and opinions on the condition of medical care in terrorist attacks and natural disasters, the ethical challenges of disaster medical care, and the professional responsibilities and responsiveness in disasters. conclusions it is necessary to develop a national consensus on the ethical guidelines for physicians who care for patients, victims, and casualties of disasters, and to formulate a virtue-based, yet practical, ethical approach to medical care under such extreme conditions. an educational curriculum for medical students, residents, and practicing physicians is required to best prepare all physicians who might be called upon, in the future, to triage patients, allocate resources, and make difficult decisions about treatment priorities and comfort care. it is not appropriate to address these questions at the time of the disaster, but rather in advance, as part of the ethics education of the medical profession. important issues for resolution include inpatient and casualty triage and prioritization, medical liability, altered standards of care, justice and equity, informed consent and patient autonomy, expanding scope of practice in disaster medicine, and the moral and ethical responsibilities of physicians to care for disaster victims. o n tuesday, september , , the american academy of otolaryngology-head and neck surgery foundation was holding its scientific meeting in denver, co. the morning plenary sessions were underway when early reports of tragic events in new york city, pennsylvania, and washington, dc, began to be seen on the television screens in the common areas of the denver convention center. as the events unfolded quickly, the scope of the tragedy soon became apparent. the leadership of the aao-hns/f made the decision to continue with the educational meeting and kept the attendees apprised of what was happening. because the national airspace was closed to air travel, individuals and groups began making alternative travel plans, including purchasing cars, renting vans and trucks, and even chartering buses. for those physicians who lived in the eastern united states, returning to their homes and work was vitally important. because there remained the possibility that terrorist attacks might occur in other parts of the country, everyone wished to travel home. many physicians made the long trek to new york city to volunteer as medical care providers, if needed. there was a general sense of professional responsibility and willingness to help, even at personal risk. fortunately, the terrorist events were limited in scope and location, but they remain the largest death toll from this type of event in the united states to date. the worst natural disaster in us history occurred on august , , when hurricane katrina devastated the gulf cities of biloxi, ms, and new orleans, la, and all areas between these cities. it is estimated that the forces of the hurricane were greater than that of the atomic bomb blasts on hiroshima and nagasaki, japan, in world war ii. the hurricane itself was a bad one, but the resultant loss of integrity of certain sections of the levees in new orleans resulted in a tremendous flooding of much of the mid-city and isolation of many hospitals in the area. dr anna pou, an aao-hns fellow and academic colleague of many, was on duty at memorial medical center in new orleans. although many other physicians in new orleans were either fleeing the city's flooding with their families or unable to reach their medical facilities, dr pou made the brave decision to stay and provide medical care to the patients and staff who, like her, were isolated in the facility. as a head and neck surgeon, dr pou was accustomed to caring for postoperative patients in the surgical intensive care unit, but during her ordeal at memorial, she also took responsibility for caring for very sick and nearly terminally ill patients in an acute care long-term facility located within memorial hospital. as resources began to become scarce and the conditions in the hospital became more extreme, dr pou and other health care providers found it necessary to develop a simple priority system for patient evacuation when outside relief finally materialized. under extremely harsh conditions, dr pou made medical decisions that cannot be second guessed by those who were not there. after her heroic efforts, dr pou found herself facing charges of homicide in the deaths of four elderly and critically ill patients at memorial. fortunately, after nearly years of difficult personal and legal challenges, dr pou was exonerated by an orleans parish grand jury's refusal to indict her. during the ordeal, dr pou was supported by the aao-hns, the american medical association, the american college of surgeons, and the louisiana state medical society. [ ] [ ] [ ] [ ] [ ] these societies acknowledged the difficult decisions that were required under conditions not previously experienced in the us civilian health care system. there are multiple layers of ethical issues that have arisen in the aftermaths of the terrorism events of and the natural disaster of . at the very foundation of the concerns raised is the question of how much personal risk and sacrifice are required or expected of physicians during such mass casualty events. at the higher level, it is the difficult issue of how to make ethical decisions in caring for patients, both existing patients and casualty patients, in the face of limited resources and expanding scope of the disaster. as has been clearly emphasized by the situation with dr anna pou, an otolaryngologist-head and neck surgeon who voluntarily placed herself in a position to render a level of care to patients clearly beyond her training and expertise, most physicians in the united states are ill prepared to face the unique ethical decision making that is required in such situations. it is now apparent, with the constant threat of future terrorist attacks and natural disasters, that consensus national guidelines must be developed that will assist volunteer physicians to make ethical, yet appropriate, decisions in the midst of such uncommon and challenging situations. there are both similarities and differences in the challenges posed by bioterrorism events and natural disasters. if taken in good part, bioterrorism events have the potential to place the physician at greater initial and temporally increasing personal risk for contamination and exposure to toxins or radiation from both the event and the affected patients. with natural disasters, the initial event may pass, and the subsequent risks are lower with the passage of time. past and current disaster response plans have primarily been based on modern military models that have evolved over the years, as both the technology of war and the technology of medicine have advanced. these models depend on a defined area of involvement, with initial treatment of casualties on site and subsequent evacuation by air or ground to a more sophisticated treatment facility in a nearby "safe" area. the terrorist events of / were sufficiently isolated so that this model was generally effective, although the pentagon attack resulted in a rapid medical response on the grounds of the pentagon itself. using the military model and building upon the experiences of / and hurricane katrina, as well as the events of worldwide earthquakes and tsunamis, a new specialty of medicine is emerging-"disaster medicine." a major issue that was found to be a major aspect of the aftermath of katrina and is currently being addressed, is that of the "surge capacity" of us hospitals, in which acute casualties may overwhelm hospitals, requiring a prioritization of care of both the newly ill casualties and the chronically ill inpatients. , there has been significant planning by agencies of the federal government since these two disasters, in good part because the united states was ill prepared to handle these disasters, both from a medical and a response preparedness perspective. the us department of health and human services issued a directive entitled bioterrorism and other public health emergencies-altered standards of care in mass casualty events as a federal guide in response to the / terrorist events and the subsequent anthrax attacks. one of the main issues addressed by the guide was "how current standards of care might need to be altered in response to a mass casualty event in order to save as many lives as possible." additionally, the report proposed that "the basis for allocating health and medical resources in a mass casualty event must be fair and clinically sound." as part of the recommended use of altered standards of health and medical care, a model was proposed for emergency state health powers that recognized the difficulties of providers and institutions when providing care under stress with less than a full complement of resources. it was recommended that the plan would "have to provide for 'hold harmless' agreements or grant immunity from civil or criminal liability under certain circumstances." rolfsen addressed the ethical issues of liability or criminal prosecution in a disaster situation in the journal of the louisiana state medical society. he stated, "during disasters such as katrina, many deaths of both previously healthy and chronically ill patients can be expected. despite society's tendency to attempt to place blame for these tragedies, attributing causation of the deaths to medical providers is a complex process." contributing to the complexity are the harsh and unusual conditions under which medical care must be provided in a disaster, and the overwhelming requirements for medical resources in the face of rapidly dwindling supply. medical care during such disasters should likely fall under a state's good samaritan act to provide freedom from undue legal liability for the providers. a major issue for discussion and guidance is that of the willingness of physicians to participate in the care of patients injured or ill from terrorism attacks or extensive natural disasters. in the earlier example of the rallying of us physicians to be of assistance in the immediate aftermath of the / events, it can be contrasted to the isolation of physicians from new orleans after katrina who were unable to reach their hospitals because of flooding and criminal activities. because most of the ongoing medical care of the katrina victims took place at a distance from the actual flooding, many physicians volunteered to staff the shelters and make-shift medical treatment facilities where hundreds of thousands of individuals received medical care. infectious diseases were rampant in the victims of the hurricane, and some analogy might be drawn from physician volunteerism in severe acute respiratory syndrome (sars) pandemics. ruderman and associates reported on the issue of "the duty to care" by health care professionals. they noted that physicians and nurses who volunteered during the sars pandemic in "continue to struggle with the aftermath of the crisis." they noted that there are no unique guidelines for the moral obligation of physicians to care for sars victims and urged that "organizations give clear indication of what standard of care is expected of their members in the event of a pandemic." they further recommend that there is a pressing need to clarify the rights and responsibilities of health care providers during an infectious disease outbreak, and that "these rights and responsibilities ought to be codified in professional codes of ethics." the american medical association has addressed the issue of physician obligation in disaster preparedness and response in its code of medical ethics. as part of the "opinions on professional rights and responsibilities," the code states: because of their commitment to care for the sick and injured, individual physicians have an obligation to provide urgent medical care during disasters. this ethical obligation holds even in the face of greater than usual risks to their own safety, health, or life. yet there remains the question of whether physicians in the united states (and specifically otolaryngologist-head and neck surgeons) are properly prepared for, and willing to, participate in disaster relief of a significant magnitude, especially when there is grave personal risk. alexander and associates used a national, cross-sectional, random-sample survey in to address this issue. seven hundred forty-four physicians responded to the survey. only % of emergency physicians and % of primary care physicians agreed that they were generally well prepared to play a role in responding to a bioterrorism attack. the majority of the respondents believed that disaster preparedness should also include infectious pandemics. alexander and wynia expanded their examination of physicians' feelings about bioterrorism events and their responsibilities to their willingness to treat patients despite personal risk. eighty percent of respondents reported that they would be willing to treat affected patients in the face of a hypothetical outbreak of an "unknown but potentially deadly illness." belief in a duty to treat was associated with their willingness to treat patients under conditions of personal risk. the authors concluded that "the threat of new disease outbreaks, from bioterrorism or natural causes, has provided an opportunity for physicians to rearticulate and reaffirm longstanding ethical principles regarding the duty to treat." making the decision to care for patients in the face of a nuclear, biological, or chemical terrorist attack; an infectious pandemic; or in an isolated hospital in a natural disaster caring for critically ill patients beyond one's area of expertise requires extraordinary commitment and courage. this level of obligation is similar to that emulated by combat medics and military surgeons who care for wounded soldiers on the battlefield under direct fire themselves. there is no higher achievement of moral commitment and professional dedication than this. however, it must be recognized that not all physicians possess the capabilities to administer effective care under such conditions, or at least may not know whether or not they can until the actual event occurs. the ama code of medical ethics notwithstanding, although it will not be possible to count on every physician to participate in the direct medical care of patients under such conditions, there certainly are other important ways that physicians can be of benefit to the medical disaster relief, such as resource allocation and personnel coordination. larkin and arnold have characterized the extraordinary virtues required of physicians who respond to terrorism events in the face of triage, system overload, and ethical decision making with every patient-"prudence, courage, justice, stewardship, vigilance, resilience, and charity." these are admirable traits that few of us possess in their entirety. they also raise several issues that need to be discussed and guidelines to be provided before the situations might actually be encountered, including the above seven cardinal virtues: the authors further propose that "virtue-based ethics are more adaptable to the multiplicity of rapidly changing disaster circumstances than mere principles, rules, and proto-cols, particularly since the scope, magnitude, and dynamics of a particular terrorist challenge cannot be determined in advance." they applied the seven cardinal virtues to times of terror and how they might be helpful to physicians who find themselves overwhelmed by the tasks at hand in caring for disaster victims. of these virtues, justice, stewardship, and charity imply a sense of obligation for physicians to attend to the sick and wounded, regardless of personal risk. however, "virtue-based ethics" reflects primarily the responsibilities and obligations of physicians to care for victims of such disasters, whereas "utilitarian-based ethics" requires physicians to make medical decisions based on the resources available and a triage system that favors applying those resources to victims who are predicted to have the best chance of survival. as with many ethical dilemmas, virtuebased ethics and utilitarian-based ethics may be in opposition, and the solution may lie in identifying the best applicable aspects of both to the situation at hand. weapons of mass destruction cause a particularly difficult challenge to physicians because of the dosage-related prognosis for exposed victims and the personal risk to physicians of non-decontaminated patients. pesik and associates recommend that triage of the victims be ethically based on the medical model of "best prognosis." under this model, the patients are triaged according to their prognosis or survivability. the authors suggested that "if something cannot be accomplished (i.e., saving all lives with the limited available resources), then there is no ethical obligation to do so." however, whatever model of triage is used in disaster management, the physician's obligation is to care for patients/victims in such a manner as to provide the most benefit to the most patients. the physician assisting in disaster medical relief must move from doing the most he/she can do for each individual patient to doing what can be done for those who have the best chance for survival. this is a difficult transition, and one that may not be easily made without prior planning and acceptance of a new care model. in a commentary on us health policy in the aftermath of hurricane katrina, rosenbaum proposed that the apparent need to improve the public health system in this country to better respond to disasters might also have a positive effect on the just provision of health care for the underserved and low-income population. as exposed by the hurricane effects, the majority of the victims were those who were unable to escape from the flooding, primarily because they lived in the low-income areas adjacent to the levees, as well as not having the transportation capabilities to escape before the hurricane struck. the author admonished that "the notion that the world's most powerful nation would continue to lurch from disaster to disaster, jury-rigging inadequate and temporary solutions, is simply untenable." disasters such as katrina have the ability to expose the frailties of the medical system, and thus, the potential inability to adequately support the efforts of conscientious physicians who put themselves in harm's way to care for the victims. if physicians accept the tenet that it is a professional obligation to care for victims of terrorism attacks and extreme natural disasters, then how can the medical profession best prepare physicians for this role? wynia and gostin reaffirmed that there is sufficient agreement in the profession for physician obligation to treat in these circumstances. yet, it does not serve either the physician or the potential victims/ patients well for a physician to be ill prepared to deal with a wide range of nuclear, biological, chemical, infectious, and other medical problems without adequate ethical guidelines. an integral part of such preparation would be the development of ethical guidelines, both principled and practical, emphasized by case-based scenarios, to be a major part of undergraduate, graduate, and continuing medical education. in a recent study of the self-assessment of public health workers' preparedness for bioterrorism or other public health disasters, the authors identified a wide range of perceived needs for additional training. they suggested using competency-based goals, which would be assessed by drills, exercises, and tests. this approach is not unlike the american graduate medical education system of competencybased learning, with specific goals and objectives. it is possible to apply this system to ethical decision making in disaster medical response, as well. however, before educational models are developed to teach ethical decision making in disaster medicine, it will be necessary for national discussions to occur, with the development of consensus guidelines across medical and surgical specialties that will encourage both virtue-based ethics as well as the cardinal principles of ethical behavior by physicians. such guidelines would need to recognize the practical issues of need/prognosis-based triage, both of incoming casualties as well as patients already hospitalized and requiring large amounts of medical resources. inpatients with do not resuscitate orders and those who are terminally ill would likely be placed in the "expectant" category of patients, with the resources currently applied to their care reallocated to incoming patients with a better chance of survival, save for comfort care and pain palliation. once there is a national consensus within the medical and nursing professions, then the public needs to be educated about the changing requirements for ethical decision making under the dire conditions of disasters. public education will not completely alleviate controversies and concerns about triage, but it would be quite helpful. the educational curriculum for ethical decision making in disaster medicine should become a part of the medical school curriculum, as well as for resident physicians in all specialties. until the students and residents have progressed into practicing physicians, there will be a need to provide continuing medical education courses on this subject for both community and academic physicians, who will bear the responsibility for caring for victims of terrorist attacks and extreme natural disasters. table is a proposed model curriculum for ethical decision making in disaster medicine. it is necessary to develop a national consensus on the ethical guidelines for physicians who care for patients, victims, and casualties of disasters, and to formulate a virtue-based, yet practical, ethical approach to medical care under such extreme conditions. an educational curriculum for medical students, residents, and practicing physicians is required to best prepare all physicians who might be called upon, in the future, to triage patients, allocate resources, and make difficult decisions about treatment priorities and comfort care. it is not appropriate to address these questions at the time of the disaster, but rather in advance, as part of the ethics education of the medical profession. important issues for resolution include inpatient and casualty triage and prioritization, medical liability, altered standards of care, justice and equity, informed consent and patient autonomy, expanding scope of practice in disaster medicine, and the moral and ethical responsibilities of physicians to care for disaster victims. maintaining comfort care and pain palliation for patients the principle of "double effect" as applied to casualty care oe good samaritan laws by state and implications for disaster medicine oe medical liability in disaster medicine oe altered standards of care in mass casualty events oe justice and equality of care in disaster medicine oe informed consent and patient autonomy oe advising hospitals in ethical considerations during the development of hospital-based medical disaster plans oe expanding scope of practice in disaster medicine-when and how capabilities, training, and knowledge of physician vs actual risk to patient oe the moral and professional obligation of physicians to alleviate pain and suffering in disaster relief vs selfinterest and care of one's family-an ethical dilemma oe euthanasia and physician-assisted suicide under conditions of terrorist events and natural disasters-avoiding the pitfalls oe hipaa regulations and patient confidentiality oe case-and scenario-based studies in application of principles of disaster medicine louisiana state medical society statement regarding anna pou american academy of otolaryngology-head and neck surgery statement on the continuing prosecution of dr anna pou american academy of otolaryngology-head and neck surgery american medical association monitors new orleans case, calls for fair investigation american college of surgeons calls for fair investigation in new orleans case a mass casualty care strategy for biological terrorism incidents. department of defense biological chemical command, aberdeen proving ground worldwide disaster medical response: an historical perspective health care facility and community strategies for patient care surge capacity agency for healthcare research and quality. bioterrorism and other public health emergencies-altered standards of care in mass casualty events medical care provided during a disaster should be immune from liability or criminal prosecution on pandemics and the duty to care: whose duty? who cares american medical association code of medical ethics. policy e- . . physician obligation in disaster preparedness and response physicians' preparedness for bioterrorism and other public health priorities ready and willing? physicians' sense of preparedness for bioterrorism ethical considerations in emergency planning, preparedness, and response to acts of terrorism terrorism and the ethics of emergency medical care us health policy in the aftermath of hurricane katrina ethical challenges in preparing for bioterrorism: barriers within the health care system none. key: cord- -yfuuirnw authors: severin, paul n.; jacobson, phillip a. title: types of disasters date: - - journal: nursing management of pediatric disaster doi: . / - - - - _ sha: doc_id: cord_uid: yfuuirnw disasters are increasing around the world. children are greatly impacted by both natural disasters (forces of nature) and man-made (intentional, accidental) disasters. their unique anatomical, physiological, behavioral, developmental, and psychological vulnerabilities must be considered when planning and preparing for disasters. the nurse or health care provider (hcp) must be able to rapidly identify acutely ill children during a disaster. whether it is during a natural or man-made event, the nurse or hcp must intervene effectively to improve survival and outcomes. it is extremely vital to understand the medical management of these children during disasters, especially the use of appropriate medical countermeasures such as medications, antidotes, supplies, and equipment. skeleton as a result of incomplete calcification and active bone growth centers. protected organs, such as the lungs and heart, may be injured due to overlying fractures. cervical spine injuries can also be pronounced, as in patients with head trauma. in fact, spinal cord injury may be present without any radiographic abnormalities of the spine. finally, vital signs will vary based on the pediatric patient's age. this may be a pitfall during rapid evaluation by any nurse or hcp not accustomed to the care of children. younger pediatric patients have higher metabolic rates and, therefore, higher respiratory rates and heart rates. this can be a distinct disadvantage versus older pediatric patients when encountering similar diseases. an example is inhaled toxins (e.g., nerve agents and lung-damaging agents). infants and children will suffer greater toxicity since they inhale at a faster rate due to higher metabolic demands and thus, distribute the toxin more rapidly to various end-organs. understanding respiratory differences is essential to the management of the acutely ill pediatric patient. the most common etiology for cardiorespiratory arrest in children is respiratory pathology, typically of the upper airway. most of the airway resistance in children occurs in the upper airway. nasal obstruction can lead to severe respiratory distress due to infants being obligate nose breathers. their relatively large tongue and small mouth can lead to airway obstruction quickly, especially when the neuromuscular tone is abnormal such as during sedation or encephalopathy. in infants, physiologic (i.e., copious secretions) and pathologic (i.e., edema, vomitus, blood, and foreign body) factors will exaggerate this obstruction. securing the airway in such events can be quite challenging. typically, the glottis is located more anterior and cephalad. appropriate visualization during laryngoscopy can be further hampered by the prominent occiput that causes neck flexion and, therefore, reduces the alignment of visual axes. the omega or horseshoeshaped epiglottis in young infants and children is quite susceptible to inflammation and swelling. as in epiglottitis, the glottis becomes strangulated in a circumferential manner leading to dangerous supraglottic obstruction. children also have a natural tendency to laryngospasm and bronchospasm. finally, due to weaker cartilage in infants, dynamic airway collapse can occur especially in states of increased resistance and high expiratory flow. along with altered pulmonary compensation and compliance, a child may rapidly progress to respiratory failure and possibly arrest. cardiovascular differences are critical in the pediatric patient. typical physiological responses tend to allow compensation with seemingly normal homeostasis. with tachycardia and elevated systemic vascular resistance, younger pediatric patients can maintain normal blood pressure despite decreased cardiac output and poor perfusion (compensated shock). since children have less blood and volume reserve, they progress to this state quickly. in pediatric patients with multiorgan injury or severe gastrointestinal losses, these compensatory mechanisms are pushed to their limits. the unaccustomed hcp may be lulled into complacency since the blood pressure is normal. all the while, the pediatric patient's organs are being poorly perfused. once these compensatory mechanisms are exhausted, the patient rapidly progresses to hypotension and, therefore, hypotensive shock. if not reversed expeditiously, this may lead to irreversible shock, ischemia, multiorgan dysfunction, and death. pediatric patients with altered mental status pose significant problems. the differential diagnosis will be very broad in the comatose patient based on development alone. for example, younger pediatric patients can present with nonconvulsive status epilepticus (ncse) instead of generalized convulsive status epilepticus (gcse). in fact, ncse is more common among younger pediatric patients than gcse, especially in those from to months of age. furthermore, many of them are previously well without preexisting diseases such as epilepsy. other disease states may include poisoning, inborn errors of metabolism, meningitis, and other etiologies of encephalopathy. using the modified pediatric glasgow coma scale (gcs) is the cornerstone when evaluating the young pediatric patient when they are preverbal. pupillary response, external ocular movements, and gross motor response may be challenging to evaluate in a developmentally young or delayed pediatric patient. pediatric traumatic brain injury is extremely devastating. whether considered accidental (motor vehicle crash) or nonaccidental (abusive head trauma), evaluation of the neurological status of the acutely injured pediatric patient can be problematic, especially the gcs. some prefer to use the avpu system (alert, responds to verbal, responds to pain, and unresponsive). due to the disproportionately larger head and weaker neck muscles, there is more risk of acceleration-deceleration injuries (fall from a significant height, vehicular ejection, and abusive head trauma). furthermore, the softer skull, dural structural differences, and vessel supply will place the pediatric patient at risk for brain injury and intracranial hemorrhage. finally, due to pediatric brain composition, the risk of diffuse axonal injury and cerebral edema is much higher. although spinal cord injury is rare in young pediatric patients, morbidity and mortality are significant. in pediatric patients less than years of age, the most commonly seen injuries are in the atlas, axis, and upper cervical vertebrae. in young pediatric patients, spinal injuries tend to be anatomically higher (cervical) versus adolescents (thoracolumbar). furthermore, congenital abnormalities, such as atlantoaxial abnormalities (trisomy ), may exaggerate the process. the clinical presentation of spinal cord injury varies in young pediatric patients due to ongoing development. laxity of ligaments, wedge-shaped vertebrae, and incomplete ossification centers contribute to specific patterns of injuries. finally, spinal cord injury without radiographic abnormality (sciwora) may result. because of the disproportionately larger head, weaker neck muscles, and elasticity of the spine, significant distraction and flexion injury of the spinal cord may occur without apparent ligament or bony disruption (hilmas et al. ; jacobson and severin ; severin ). motor skills develop from birth. gross and fine motor milestones are achieved in a predictable manner and must be assessed during each hcp encounter. cognitive development will follow a similar pattern of maturation. the development of these skills can often predict injuries and their extent. for example, consider a house fire. a young infant, preschooler, and adolescent are sleeping upstairs in house when a fire breaks out in the middle of the night. the smoke detectors begin to alarm. each child is awoken by the ensuing noise and chaos. based on the development, the adolescent will most likely make it out of the house alive. he will comprehend the threat, run down the stairs, and exit the house without delay. smoke inhalation may be minimal. if it is a middle adolescent, an attempt may be made to jump out of the window leading to multiple blunt trauma with or without traumatic brain injury. the preschooler most likely will be too scared and not understand how to escape. tragically, he may hide under a bed or in a closet. when the firefighters arrive and search the house, the preschooler may remain silent because of fear, especially of strangers in the house. he will most likely succumb to thermal injuries along with the effects of carbon monoxide and die. as far as the infant, he cannot walk, climb, crawl, or run. furthermore, he cannot scream for help or know how to escape. as the smoke engulfs the room, he will most likely suffer severe smoke inhalation injury including extensive carbon monoxide toxicity along with thermal injuries and die. this example also points out another important difference in pediatric patients: their dependence on caregivers. when considering neonates, for example, their entire existence depends on the caregiver, including feeding, changing of diapers, nurturing, and environmental safety. these dynamics are essential to the pediatric patient's health and survival, especially during a disaster. another aspect of development is the attainment of language skills. this, too, develops over time in a predictable fashion. one of the biggest challenges in pediatrics is the lack of the patient's ability to verbally convey complaints. as described above, verbal milestones vary among the different age ranges of the pediatric patient. hcps are often faced with a caregiver's subjective assessment of the problem. although it can be revealing and informative, this may not be available in an acute crisis situation. it will take the astute hcp to determine, for example, if an inconsolably crying infant is in pain from a corneal abrasion or something more life-threatening such as meningitis. this can also be a challenging task in a teenager, especially during middle adolescence. an hcp will have to determine, for example, if the seemingly lethargic middle adolescent is intoxicated with illicit drugs or has diabetic ketoacidosis. finally, the hcp will have to address developmental variances among their pediatric patients and any comorbid features. young pediatric patients can regress developmentally during any illness or injury. this is especially seen in patients with chronic medical conditions (cancer) or during prolonged hospitalization with rehabilitation (multisystem trauma). furthermore, those pediatric patients with developmental and intellectual disabilities, for example, will be difficult to evaluate based on the effects of their underlying pathology. these pediatric patients typically have unique variances in their physical exams (jacobson and severin ; severin ) . please refer to chap. for more detailed information on pediatric development. pediatric patients will often reflect the emotional state of their caregiver. they take verbal and physical cues from their caregiver. at times, this may also occur in the presence of a nurse or hcp. the psychological impact of illness will vary greatly with the child's development and experience. children tend to have a greater vulnerability to post-traumatic stress disorder especially with disaster events. furthermore, they are highly prone to becoming psychiatric casualties despite the absence of physical injury to themselves. and as any pediatric hcp can tell you, the younger pediatric patients tend to also have greater levels of anxiety, especially while preparing for invasive procedures such as phlebotomy and intravenous line placement (hilmas et al. ; jacobson and severin ; severin ) . please refer to chap. for more detailed content on mental health. the world health organization and the pan american health organization define a disaster as "an event that occurs in most cases suddenly and unexpectedly, causing severe disturbances to people or objects affected by it, resulting in the loss of life and harm to the health of the population, the destruction or loss of community property, and/or severe damage to the environment. such a situation leads to disruption in the normal pattern of life, resulting in misfortune, helplessness, and suffering, with adverse effects on the socioeconomic structure of a region or a country and/or modifications of the environment to such an extent that there is a need for assistance and immediate outside intervention" (lynch and berman ). types of disasters usually fall into two broad categories: natural and man-made. natural disasters are generally associated with weather and geological events, including extremes of temperature, floods, hurricanes, earthquakes, tsunamis, volcanic eruptions, landslides, and drought. naturally occurring epidemics, such as the h n , ebola, and novel coronavirus outbreaks, are often included in this category. man-made disasters are usually associated with a criminal attack such as an active shooter incident, or a terrorist attack using weapons such as explosive, biological, or chemical agents. however, man-made disasters can also refer to human-based technological incidents, such as a building or bridge collapse, or events related to the manufacture, transportation, storage, and use of hazardous materials, such as the chernobyl radiation leak and the bhopal toxic gas leak. even though disasters can be primarily placed into any of these two categories, they can often impact each other and compound the magnitude of any disaster incident (united states department of homeland security, office of inspector general ). a prime example is the march tohoku earthquake leading to a tsunami (natural) that triggered the fukushima daiichi nuclear disaster (man-made). disasters can also be characterized by the location of such an event. internal disasters are those incidents that occur within the health care facility or system. employees, physical plant, workflow and operations of the clinic, hospital, or system can be disrupted. external disasters are those incidents that occur outside of the health care facility or system. this impacts the community surrounding the facility, proximally or distally, but does not directly threaten the facility or its employees. as with natural and man-made disasters, internal and external disasters can impact each other. for example, an overflow of patients during a high census period may lead to the shutdown of the hospital to any new patients (internal disaster). this will place the hospital on bypass and possibly stress other hospitals in the community beyond their means (external disaster). a terrorist event, such as the release of sarin in a subway system during a busy morning commute, can lead to massive disruption in the community (external disaster). all the victims of the attack will seek medical care at nearby hospitals, possibly overwhelming the health care staff and depleting critical resources (internal disaster). characterization of disasters by geography (local, state, national, and international) can also be used. again, no matter the site of the incident, a disaster in one area could easily create a disaster in another geographical region. for example, a factory and its community could be ravaged by a hurricane (local disaster). if this is the only factory in the world to produce a certain medication, this could lead to critical shortages to hospitals all around the world (international disaster). the term "disaster preparedness" has been used over the years as a way to describe efforts to manage any disaster event. however, preparedness is only one aspect of the process. the use of the term disaster planning is more appropriate. it considers all aspects needed for an effective effort and is dependent on additional phases, not just preparedness. national preparedness efforts, including planning, are now informed by the presidential policy directive (ppd) that was signed by the president in march and describes the nation's approach to preparedness (united states department of education, office of elementary and secondary education, office of safe and healthy students ; united states department of homeland security b). a recommended method for disaster preparedness efforts is the utilization of an "all-hazards" model of emergency management (adini et al. ; waugh ) . the four overlapping phases of the model include mitigation, preparedness, response, and recovery. the mitigation phase involves "activities designed to prevent or reduce losses from a disaster" (waugh ) . examples include land use planning in flood plains, structural integrity measures in earthquake zones, and deployment of security cameras. the preparedness phase includes the "planning of how to respond in an emergency or a disaster, and developing capabilities for more effective response" (waugh ) . examples include training programs for emergency responders, drills and exercises, early warning systems, contingency planning, and development of equipment and supply caches. up to this point, all planning efforts are proactive and not reactive. often times, a hazard analysis is conducted to delineate areas of strengths and identify potential risks. it helps in "the identification of hazards, assessment of the probability of a disaster, and the probable intensity and location; assessment of its potential impact on a community; the property, persons, and geographic areas that may be at risk; and the determination of agency priorities based on the probability level of a disaster and the potential losses" (waugh ) . after a disaster or emergency incident occurs, the response phase, or "immediate reaction to a disaster", (waugh ) begins. examples include mass evacuations, sandbagging buildings and other structures, providing emergency medical services, firefighting, and restoration of public order. in some situations, the response period may be a short (e.g., house fire), intermediate (e.g., bomb detonation), or extended (e.g., pandemic influenza) duration. after a period of time, the recovery phase follows. these are "activities that continue beyond the emergency period to restore lifelines" (waugh ) . examples include the provision of temporary shelter, restoration of utilities such as power, critical stress debriefing for responders, and victims, job assistance and small business loans, and debris clearance. recovery always seems to be the most unpredictable; it may take days to months to years. as demonstrated with recent hurricanes harvey, irma, and maria in , the most affected regions are still in the phase of recovery and may be along a prolonged track as hurricane katrina in . as mentioned, the early phases of planning (mitigation and preparedness) truly hinge upon the environment or community surrounding the health care site (e.g., clinic, hospital, or long-term care facility). identification of potential hazards and risks is a key step in disaster planning. using a hazard vulnerability assessment (hva) or a threat and hazard identification and risk assessment (thira) can provide a basis for mitigation and prevention tasks. an hva/thira emphasizes which types of natural or man-made disasters are likely to occur in a community (e.g., tornado, flood, chemical release, or terrorist event). they further highlight the impact those disasters may have on the community and any capabilities that are in place that may lessen the effects of the disaster (illinois emergency medical services for children ). a basic principle of the hva methodology is to determine the risk of such an event or attack occurring at a given hospital or hospital system. simply, the risk is a product of the probability of an event and the severity of such an event if it occurs (risk = probability × severity). however, there are many complexities in quantifying terrorism risk (waugh ; woo ) . it is important to note that in some circumstances, exposure may need to be included in the equation (risk = probability × severity × exposure), but usually for operational risk management applications (mitchell and decker ) . at any rate, issues to consider for the probability of an event occurring include, but are not limited to, geographic location and topography, proximity to hazards, degree of accessibility, known risks, historical data, and statistics of various manufacturer/vendor products. severity, on the other hand, is dependent on the gap between the magnitude of an event and mitigation for the given event (severity = magnitude -mitigation). magnitude varies upon the impact of the event to humans, property, and/or business. mitigation varies upon the development of internal and external readiness before a disaster strikes. as one can surmise, if the magnitude of the event outstrips the mitigation, the event is considered a threatening hazard. once the hva is completed, the health care site should immediately prioritize planning efforts for the top - hazards and develop plans accordingly. all other identified hazards must also be addressed to ensure a broad and robust disaster plan. it is important to realize that local and regional entities also perform comprehensive hvas. a concerted analysis among a hospital and key community stakeholders is optimal for a coordinated plan. an hva/thira contains both quantitative and qualitative components. specific tools have been developed through private and public organizations (e.g, fema) that can help in the analysis (united states department of homeland security, federal emergency management agency ). using these tools as a guide, the entity can determine what types of hazards have a high, medium, or low probability of occurring within specific geographic boundaries. typically, these tools do not have components specific to children or other at-risk populations. however, the tools can be adapted either directly by adding children to specific hazards or ensuring considerations specific to children are incorporated into the hva/thira calculations. the hva/thira should be reviewed and updated minimally on an annual basis to identify changing or external circumstances. this includes conducting a pediatric-specific disaster risk assessment to identify where children congregate and their risks (e.g., schools, popular field trip designations, summer camps, houses of worship, and juvenile justice facilities) (illinois emergency medical services for children ). of note, hva techniques have been utilized for pediatric-specific disaster plans. having a separate pediatric hva (phva) is crucial to a well-rounded and robust health care disaster plan. first, it demonstrates the extent of the pediatric population in the community. it is estimated that % of the population fits within the age range of pediatric patients. in some situations, it may be more. during the performance of a phva, it was demonstrated that % of the community was less than years of age (jacobson and severin ) . second, a phva increases the situational awareness of those tasked to plan for disasters that involve children and adolescents. often times, children and adolescents are excluded from local and regional disaster plans. the unique vulnerabilities of pediatric patients will demand appropriate drills, exercises, equipment, medications, and expertise. thirdly, identifying pediatric risks in a community will help prioritize efforts of planning, especially in those hospitals not accustomed to caring for pediatric patients. finally, a phva helps to develop a framework for global pediatric disaster planning. this can extend beyond a local community and actually advance city, state, regional, and national disaster planning efforts. there has been a development of web-based tools to simplify and enhance the phva process (jacobson and severin ) . after an hva/thira has been completed, the results should be used to help direct and plan drills/exercises based on high impact and high probability threats. it is advised to conduct an hva/thira on an annual basis to assess specific threats unique to your organization's physical structure as well as the surrounding geographic environment. it will also provide insight into whether there is an improvement in previous planning efforts. completion of a population assessment that provides a demographic overview of the community with a breakdown of the childhood population is strongly recommended in conjunction with the hva/ thira. collaborating with other community partners, such as local health departments and emergency management agencies, can assist an organization with the conduction of a comprehensive hva/thira (illinois emergency medical services for children ). please see chap. for further information on hospital planning. pediatric supplies, equipment, and medications will be scarce during a disaster. it will become more of an issue if the health care facility is not accustomed to caring for acutely ill pediatric patients. this will be further exacerbated by a massive surge of acutely ill pediatric patients, a widespread or prolonged disaster, and supply line disruptions. to protect the health security of children and families during a public health emergency, the assistant secretary for preparedness and response (aspr) manages and maintains the strategic national stockpile (sns), a cache of medical countermeasures for rapid deployment and use in response to a public health emergency or disaster (fagbuyi et al. ) . various pediatric-specific supplies and countermeasures are included in the sns. maintaining a supply of medications and medical supplies for specific health threats allows the stockpile to respond with the right product when a specific disease or agent is known. if a community experiences a large-scale public health incident in which the disease or agent is unknown, the first line of support from the stockpile is to send a broad-range of pharmaceuticals and medical supplies. place and martin ) . the emergency equipment and supply lists can easily be adapted for any pediatric disaster emergency (place and martin ) or incident requiring pediatric mass critical care (desmond et al. ) . ageappropriate nutrition, hygiene, bedding, and toys/distraction devices should also be available (illinois emergency medical services for children ) (tables . and . ). endotracheal tubes • uncuffed: . and . mm • cuffed or uncuffed: . , . , . , . , and . mm • cuffed: . , . , . , . , and . mm feeding tubes ( f and f) laryngoscope blades curved: and ; straight: , , , and laryngoscope handle magill forceps (pediatric and adult) nasopharyngeal airways (infant, child, and adult) oropharyngeal airways (sizes - ) stylets for endotracheal tubes (pediatric and adult) suction catheters (infant, child, and adult) tracheostomy tubes (sizes . , . , . , . , . , . , and . mm) yankauer suction tip bag-mask device (manual resuscitator), self-inflating (infant size: ml; adult size: ml) clear oxygen masks (standard and nonrebreathing) for an infant, child, and adult masks to fit bag-mask device adaptor (neonatal, infant, child, and adult sizes) nasal cannulas (infant, child, and adult) nasogastric tubes (sump tubes): infant ( f), child ( f), and adult ( f- f) laryngeal mask airway a vascular access arm boards (infant, child, and adult sizes) catheter over-the-needle device ( - gauge) intraosseous needles or device (pediatric and adult sizes) intravenous catheter-administration sets with calibrated chambers and extension tubing and/or infusion devices with ability to regulate rate and volume of infusate umbilical vein catheters ( . f and . f) b central venous catheters ( . f- . f) intravenous solutions to include normal saline, dextrose % in normal saline, and dextrose % in water fracturemanagement devices extremity splints, including femur splints (pediatric and adult sizes) spine-stabilization method/devices appropriate for children of all ages c (continued) laryngeal mask airways could be shared with anesthesia but must be immediately accessible to the ed b feeding tubes (size f) may be used as umbilical venous catheters but are not ideal. a method for securing the umbilical catheter, such as an umbilical tie, should also be available c a spinal stabilization device is one that can stabilize the neck of an infant, child, or adolescent in a neutral position when a pediatric disaster victim presents acutely ill to the hospital, various emergency interventions will be needed to stabilize the patient. evaluation of the pediatric patient should include a primary survey (abcde), secondary survey (focused sample history and focused physical examination), and diagnostic assessments (laboratory, radiological, and other advanced tests). this will guide further therapeutic interventions. particular attention should be given to the identification of respiratory and/or circulatory derangements of the child, including airway obstruction, respiratory failure, shock, and cardiopulmonary failure. interventions will be based on physiologic derangements of the pediatric patient and determined by the scope of practice and protocols, such as standard resuscitation algorithms for neonatal (american academy of pediatrics and american heart association et al. ) and pediatric (american heart association ) victims. the hcp must be knowledgeable of various emergency medications (table . ) used for children, the appropriate dosages and their mechanism of action, any potential side effects, and drug/drug interactions. other medications, such as antibiotics, antidotes, or countermeasures, may be needed as well. pharmacologic therapy should be initiated immediately based on clinical suspicion and not delayed due to pending laboratory tests (e.g., antibiotics for presumed infection/sepsis or antidotes for suspected nerve agents). dosages should be based on the patient's weight or a length-based weight system. (montello et al. ) or hard copy countermeasure manuals may be more practical, especially during a disaster incident when computer service or internet access may be unreliable. in , the centre for research on the epidemiology of disasters (cred) launched the emergency events database (em-dat). em-dat was created with the initial support of the world health organization (who) and the belgian government. the main objective of the database is to serve the purposes of humanitarian action at national and international levels. the initiative aims to rationalize decision-making for disaster preparedness as well as provide an objective base for vulnerability assessment and priority setting. em-dat contains essential core data on the occurrence and effects of over , mass disasters in the world from to the present day. the database is compiled from various sources, including united nation agencies, nongovernmental organizations (ngos), insurance companies, research institutes, and press agencies (cred ). as described in the cred report entitled natural disasters : lower mortality, higher cost, a disaster is entered into the database if at least one of the following criteria is fulfilled: or more people reported killed; or more people reported affected; declaration of a state of emergency; and/or call for international assistance (cred ). in economic losses, poverty and disasters - : cred/unisdr report, the cred defines a disaster as "a situation or event which overwhelms local capacity, necessitating a request at national or international level for external assistance; an unforeseen and often sudden event that causes great damage, destruction and human suffering" (cred ). the cred em-dat classifies disasters according to the type of hazard that triggers them. the two main disaster groups are natural and technological disasters. there are six natural disaster subgroups. geophysical disasters originate from the solid earth and include earthquake (ground movement and tsunami), dry mass movement (rock fall and landslides), and volcanic activity (ash fall, lahar, pyroclastic flow, and lava flow). lahar is a hot or cold mixture of earthen material flowing on the slope of a volcano either during or between volcanic eruptions. meteorological disasters are caused by short-lived, micro-to meso-scale extreme weather and atmospheric conditions that last from minutes to days and include extreme temperatures (cold wave, heat wave, and severe winter conditions such as snow/ice or frost/ freeze), fog, and storms. storms can be extra-tropical, tropical, or convective. convective storms include derecho, hail, lightning/thunderstorm, rain, tornado, sand/dust storm, winter storm/blizzard, storm/surge, and wind. derecho is a widespread and usually fast-moving windstorm associated with convection/convective storm and includes downburst and straight-line winds. hydrological disasters are caused by the occurrence, movement, and distribution of surface/subsurface freshwater and saltwater and include floods, landslides (an avalanche of snow, debris, mudflow, and rockfall), and wave action (rogue wave and seiche). flood types can be coastal, riverine, flash, or ice jam. climatological disasters are caused by longlived, meso-to macro-scale atmospheric processes ranging from intraseasonal to multidecadal climate variability and include drought, glacial lake outburst, and wildfire (forest fire, land fire: brush, bush, or pasture). biological disasters are caused by the exposure to living organisms and their toxic substances or vectorborne diseases that they may carry and include epidemics (viral, bacterial, parasitic, fungal, and prion), insect infestation (grasshopper and locust), and animal accidents. extraterrestrial disasters are caused by asteroids, meteoroids, and comets as they pass near-earth, enter earth's atmosphere, and/or strike the earth, and by changes in the interplanetary conditions that affect the earth's magnetosphere, ionosphere, and thermosphere. types include impact (airbursts) and space weather (energetic particles, geomagnetic storm, and shockwave) events (cred ). there are three technological disaster subgroups. industrial accidents include chemical spills, collapse, explosion, fire, gas leak, poisoning, radiation, and oil spills. a chemical spill is an accidental release occurring during the production, transportation, or handling of hazardous chemical substances. transport accidents include disasters in the air (airplanes, helicopters, airships, and balloons), on the road (moving vehicles on roads or tracks), on the rail system (train), and on the water (sailing boats, ferries, cruise ships, and other boats). miscellaneous accidents vary from collapse to explosions to fires. collapse is an accident involving the collapse of a building or structure and can either involve industrial structures or domestic/nonindustrial structures (cred ). technological disasters are considered man-made, but as suggested by their subgroup, they are accidental and not intentional. the united nations office for disaster risk reduction (unisdr) and cred report, economic losses, poverty, and disasters - , reviews global natural disasters during that time period, their economic impact, and the relationship with poverty. between and , climate-related and geophysical disasters killed . million people and left a further . billion injured, homeless, displaced, or in need of emergency assistance. although the majority of fatalities were due to geophysical events, mostly earthquakes and tsunamis, % of all disasters was caused by floods, storms, droughts, heatwaves, and other extreme weather events. the financial impact was staggering. in - , disaster-hit countries reported direct economic losses valued at us$ billion, of which climate-related disasters caused us$ billion or % of the total. this was up from % (us$ billion) of losses (us$ billion) reported between and . overall, reported losses from extreme weather events rose by % between these two -year periods. in absolute monetary terms, over the last -years, the usa recorded the biggest losses (us$ billion), reflecting high asset values as well as frequent events. china, by comparison, suffered a significantly higher number of disasters than the usa ( vs. ) but lower total losses (us$ billion) (cred ) (figs. . , . , . , . , . , . , . , . and . in , climate-related and geophysical incidents in the world were estimated with , deaths and over million people impacted. indonesia recorded approximately half of the deaths with india accounting for half of those impacted by disasters. notable features of were intense seismic activity in indonesia, a series of disasters in japan, floods in india, and an eventful year for both volcanic activity and wildfires. however, an ongoing trend of lower death tolls from previous years continued into (centre for research on the epidemiology of disasters (cred) and united nations office for disaster risk reduction (unisdr) ) (tables . , . , . , . , . , . and . there are no specific deviations when medically managing children after a natural disaster. according to sirbaugh and dirocco ( ) "small-scale mass casualty incidents occur daily in the united states. few present unusual challenges to the local medical systems other than in the number of patients that must be treated at one time. except in earthquakes, explosions, building collapses, and some types of terrorist attacks, the same holds true for large-scale disasters. sudden violent disaster mechanisms can produce major trauma cases, including patients needing field amputations or management of crush syndrome. for the most part, medicine after a disaster is much the same as it was before the disaster, with more minor injuries, more people with exacerbations of their chronic illnesses, and number of patients seeking what is ordinarily considered primary care. this is true for children and adults." it should be noted, however, that children have a predisposition to illness and injury after natural disasters. the hcp must be able to identify any health problems and treat the child effectively and efficiently while utilizing standard resuscitation protocols as indicated. traumatic injuries may be seen after any natural disaster. the injuries can range from minor scrapes and bruises to major blunt trauma or traumatic brain injury. children are at increased risk for injury since adults are distracted by recovery efforts and may not be able to supervise them closely. the environment may not be safe due to environmental hazards, such as collapsed buildings, sinkholes, and high water levels. dangerous equipment used during relief efforts may be present, such as heavy earth moving equipment, chainsaws, and power generators. hazardous chemicals, such as gasoline and other volatile hydrocarbons, may be readily accessible or taint the environment. without suitable shelter, children are also exposed to weather, animals, and insects (sirbaugh and dirocco ) . infectious diseases may also pose a problem to children after a natural disaster. infectious patterns will persist during a disaster based on the season and time of year. there may be outbreaks or epidemics of highly contagious infections (e.g., influenza, respiratory syncytial virus, streptococcus pyogenes) due to mass sheltering of children and families. poor nutrition or decreased availability of food may lower their resistance against infections. various water-borne or food-borne diseases may cause illnesses in children. poor hygiene and mass shelter environments may exacerbate these illnesses. immunized children should be protected against common preventable diseases after a natural disaster but still could be a problem in mass groups that are not completely or appropriately immunized. after the haiti earthquake, there were increased cases of diarrhea, cholera, measles, and tetanus in children months after the earthquake despite some level of vaccination (sirbaugh and dirocco ) . children are at risk for various environmental emergencies. austere environments will impact children greatly. heat exposure coupled with minimal access to drinkable water may lead to severe dehydration. exposure to the cold may lead to frostbite or hypothermia. children are at risk for carbon monoxide toxicity due to generator use or natural gas poisoning due to disrupted gas lines. there is always a risk for thermal injury due to the use of candles and other flame sources. exposure to animals (snakes) and insects (spiders) may increase the risk of envenomation. submersion injury and drowning incidents may escalate. this will be due to lack of supervision of children around storm drains, newly formed bodies of water, or rushing waters of storm diversion systems (sirbaugh and dirocco ) . mental health issues are often seen in children after natural disasters. even though a child may not be injured, they may become "psychiatric casualties" due to the horrific sights they have seen during or after the disaster. children and adolescents with behavioral or psychiatric problems may experience worsening symptoms and signs due to stress, trauma, disruption of routines, or availability of medications. this is often exacerbated if the parent, guardian, caregiver, or hcp is also having difficulty coping with the stress of the disaster. in general, the most common mental health problem in children is a post-traumatic stress disorder. however, separation anxiety, obsessive-compulsive symptoms, and severe stranger anxiety can also be seen in children after a traumatic event (sirbaugh and dirocco ) . see chap. for more detailed information. terrorism impacts children and families all around the world (tables . and . ). after the events of / , much attention has been given to the possibility of another mass casualty act of terrorism, especially with weapons of mass destruction, that include chemical, biological, nuclear, radiological, and explosive devices (cbnre), or other forms of violence such as active shooter incidents and mass shootings (jacobson and severin ) . since then, other incidents, both foreign and domestic, have involved children and complicates the concept of and the response to terrorism. johnston ( ) said it best in his review of terrorist and criminal attacks targeting children: "one of the more accepted defining characteristics of terrorism is that it targets noncombatants including men, women, and children. however, terrorist attacks specifically targeting children over other noncombatants are uncommon. this is for the same reason that most terrorists have historically avoided mass casualty terrorism: the shock value is so great that such attacks erode support for the terrorists' political objectives. the / attacks represent an increasing trend in mass casualty terrorism. at the same time, policymakers are examining this evolving threat, they must increasingly consider the threat of terrorist attacks targeting children." based on historical events, it is clear infants, toddlers, children, and adolescents have been victims of terrorism. this global trend of terrorists targeting children seems to be escalating (johnston ) . therefore, it is imperative to understand terrorism and ways it impacts the children and families served by the health care community. combs ( ) defines terrorism as "an act of violence perpetrated on innocent civilian noncombatants in order to evoke fear in an audience". however, she goes on to argue that to become an operational definition, there must also be the addition of a "political purpose" of the violent act. therefore, "terrorism, then, is an act composed of at least four crucial elements: ) it is an act of violence, ) it has a political motive or goal, ) it is perpetrated against civilian noncombatants, and ) it is staged to be played before an audience whose reaction of fear and terror is the desired result." (combs ) . there are different typologies of terrorism. at least five types of terror violence have been suggested by feliks gross: "mass terror is terror by a state, where the regime coerces the opposition in the population, whether organized or unorganized, sometimes in an institutionalized manner. dynastic assassination is an attack on a head of state or a ruling elite. random terror involves the placing of explosives where people gather (such as post offices, railroads, and cafes) to destroy whoever happens to be there. focused random terror restricts the placing of explosives, for example to where significant agents of oppression are likely to gather. finally, tactical terror is directed solely against the ruling government as a part of a 'broad revolutionary strategic plan'" (combs ). an additional typology offered is "lone wolf terror which involves someone who commits violent acts in support of some group, movement, or ideology, but who does stand alone, outside of any command structure and without material assistance from any group" (combs ) . martin ( ) reviews eight different terrorism typologies in the ever shifting, multifaceted world of modern terrorism. the new terrorism "is characterized by the threat of mass casualty attacks from dissident terrorist organizations, new and creative configurations, transnational religious solidarity, and redefined moral justifications for political violence" (martin ) . state terrorism is "committed by governments against perceived enemies and can be directed externally against adversaries in the international domain or internally against domestic enemies" (martin ) . dissident terrorism is "committed by nonstate movements and groups against governments, ethno-national groups, religious groups, and other perceived enemies" (martin ) . religious terrorism is "motivated by an absolute belief that an otherworldly power has sanctioned and commanded the application of terrorist violence for the greater glory of the faith…[it] is usually conducted in defense of what believers consider to be the one true faith" (martin ) . ideological terrorism is "motivated by political systems of belief (ideologies), which champion the self-perceived inherent rights of a particular group or interest in opposition to another group or interest. the system of belief incorporates theoretical and philosophical justifications for violently asserting the rights of the championed group or interest" (martin ) . international terrorism "spills over onto the world's stage. targets are selected because of their value as symbols of international interests, either within the home country or across state boundaries" (martin ) . criminal dissident terrorism "is solely profit-driven, and can be some combination of profit and politics. for instance, traditional organized criminals accrue profits to fund their criminal activity and for personal interests, while criminalpolitical enterprises acquire profits to sustain their movement" (martin ) . gender-selective terrorism "is directed against an enemy population's men or women because of their gender. systematic violence is directed against men because of the perceived threat posed by males as potential soldiers or sources of opposition. systematic violence is directed against women to destroy an enemy group's cultural identity or terrorize the group into submission" (martin ) . the all-hazards national planning scenarios are an integral component of dhs's capabilities-based approach to implementing homeland security presidential directive : national preparedness (hspd- ). the national planning scenarios are planning tools and are representative of the range of potential terrorist and natural disasters and the related impacts that face the nation. the federal interagency community has developed all-hazards planning scenarios for use in national, federal, state, and local homeland security preparedness activities. the objective was to develop a minimum number of credible scenarios to establish the range of response requirements to facilitate disaster planning (dhs ) (table . ). twelve of the scenarios represent terrorist attacks while three represent natural disasters or naturally occurring epidemics. this ratio reflects the fact that the nation has recurring experience with natural disasters but faces newfound dangers, including the increasing potential for use of weapons of mass destruction by terrorists. the scenarios form the basis for coordinated federal planning, training, exercises, and grant investments needed to prepare for all hazards. dhs employed the scenarios as the basis for a rigorous task analysis of prevention, protection, response, and recovery missions and identification of key tasks that supported the development of essential all-hazards capabilities (united states department of homeland security, federal emergency management agency ) (table . ). each of the scenarios follows the same outline to include a detailed scenario description, planning considerations, and implications. for each of the terrorismrelated scenarios, fema national preparedness directorate (npd) partnered with dhs office of intelligence and analysis (i&a) and other intelligence community and law enforcement experts to develop and validate prevention prequels. the prequels provide an understanding of terrorists' motivation, capability, intent, tactics, techniques and procedures, and technical weapons data. the prequels also provide a credible adversary based on known threats to test the homeland security community's ability to understand and respond to indications and warnings of possible terrorist attacks (united states department of homeland security, federal emergency management agency ). a chemical agent of terrorism is defined as any chemical substance intended for use in military operations to kill, seriously injure, or incapacitate humans (or animals) through its toxicological effects. chemicals excluded from this list are riot-control agents, chemical herbicides, and smoke/flame materials. chemical agents are classified as toxic agents (producing injury or death) or incapacitating agents (producing temporary effects). toxic agents are further described as nerve agents (anticholinesterases), blood agents (cyanogens), blister agents (vesicants), and lung-damaging agents (choking agents). incapacitating agents include stimulants, depressants, psychedelics, and deliriants (banks ; departments of the army, the navy, and the air force, and commandant, marine corps ). nerve agents are organophosphate anticholinesterase compounds. they are used in various insecticide, industrial, and military applications. military-grade agents include tabun (ga), sarin (gb), soman (gd), cyclosarin (gf), venom x (vx), and the novichok series. these are all major military threats. the only known battlefield use of nerve agents was the iraq-iran war. however, other nerve agent incidents, such as the tokyo subway attack (sarin), the chemical attacks in syria (chlorine, sarin, mustard), and the attempted assassination of sergei skripal in salisbury, uk (novichok), support that civilian threats also exist. nerve agents are volatile chemicals and can be released in liquid or vapor form. however, the liquid form can become vapor depending upon its level of volatility (e.g, g-agents are more volatile than vx). the level of toxicity depends on the agent, concentration of the agent, physical form, route and length of exposure, and environmental factors (temperature and wind) (tables . and . ). nerve agents exert their effects by the inhibition of esterase enzymes. acetylcholinesterase inhibition prevents the hydrolysis of acetylcholine. the clinical result is a cholinergic crisis and subsequent overstimulation of muscarinic and nicotinic receptors throughout the body including the central nervous system. clinical muscarinic responses include sludge (salivation, lacrimation, urination, defecation, gastrointestinal distress, and emesis) and dumbels (diarrhea, urinary incontinence, miosis/muscle fasciculation, bronchorrhea/bronchospasm/bradycardia, emesis, lacrimation, and salivation). nicotinic responses vary by site. preganglionic sympathetic nerve stimulation produces mydriasis, tachycardia, hypertension, and pallor. however, stimulation at the neuromuscular junction leads to muscular fasciculation and cramping, weakness, paralysis, and diaphragmatic weakness. central nervous system presentations range from anxiety and restlessness to seizures, coma, and death (banks ; rotenberg and newmark ; rotenberg b ). pediatric manifestations (table . ) may vary from the classic clinical responses due to their unique vulnerabilities (hilmas et al. ): • children may manifest symptoms earliest and possibly more severe presentations. • could be hospitalized for similarly related illnesses and diseases. • smaller mass. • lower baseline cholinesterase activity. • tendency to bronchospasm. • pediatric airway and respiratory differences. • altered pulmonary compensation. • lower reserves of cardiovascular system and fluids. • isolated central nervous system signs (stupor, coma). • less miosis. • vulnerability to seizures and neurotransmitter imbalances (excitability). • immature metabolic systems. differential diagnoses include upper or lower airway obstruction, bronchiolitis, status asthmaticus, cardiogenic shock, acute gastroenteritis, seizures, and poisonings (carbon monoxide, organophosphates, and cyanide). diagnostic tests include acetylcholinesterase levels, red blood cell cholinesterase levels, and an arterial blood gas. treatment (tables . and . ) includes decontamination (reactive skin decontamination lotion ® [potassium , -butanedione monoximate], soap and water, and . % hypochlorite solution), supportive care, and administration of nerve agent antidotes (atropine, pralidoxime chloride, and diazepam). atropine is a competitive antagonist of acetylcholine muscarinic receptors and reverses peripheral muscarinic symptoms. it does not restore function at the neuromuscular junction nicotinic receptors. it does, however, treat early phases of convulsions. pralidoxime chloride separates the nerve agent from acetylcholinesterase and restores enzymatic function. it also binds free nerve agent. the major goal is to prevent "aging" of the enzyme (e.g., gd). diazepam provides treatment of nerve agent-induced seizures and prevents secondary neurologic injury. typically, associated seizures are refractory to other antiepileptic drugs. the antiseizure effect of diazepam is enhanced by atropine (banks ; cieslak and henretig ; messele et al. ) . potential medical countermeasures include trimedoxime (tmb ), hi- (an h-series oxime), obidoxime, "bioscavengers" (butyrylcholinesterase, carboxylesterase, organophosphorus acid anhydride hydrolase, and human serum paraoxonase), novel anticonvulsant drugs, n-methyl-d-aspartate (nmda) receptor antagonists (ketamine, dexanabinol), and common immunosuppressants such as cyclosporine a (jokanovic ; merrill et al. ; national institutes of health ; united states department of health and human services ). all patients should be observed closely for electroencephalographic changes and neuropsychiatric pathologies. polyneuropathy, reported after organophosphate insecticide poisoning, has not been reported in humans exposed to nerve agents and has been produced in animals only at unsurvivable doses. the intermediate syndrome has not been reported in humans after nerve agent exposure, nor has it been produced in animals. muscular necrosis has occurred in animals after high-dose nerve agent exposure but reversed within weeks; it has not been reported in humans (banks ). on march , , sergei skripal, a former russian double agent, and his daughter, yulia skripal, were found unresponsive on a park bench in salisbury, uk. they were brought to a nearby hospital and treated for signs consistent with a cholinergic crisis due to a nerve agent exposure. analysis of the skripals found the presence of a secret nerve agent called novichok. further testing found high concentrations of the agent on the front-door handle of his home. one of the investigating police officers, detective sergeant nick bailey, unknowingly touched the door-handle and also became ill. all three survived due to rapid recognition of the nerve agent exposure by hospital personnel. four months later, two other people, dawn sturgess and charlie rowley, became ill with identical symptoms in the town of amesbury, miles from salisbury. they were later confirmed to have high concentrations of novichok on their hands from a perfume bottle found in a recycling bin. both were immediately treated, but dawn sturgess later died. charlie rowley survived. it was believed the discarded perfume bottle contained novichok and was discarded by the assailants after the attempt on sergei skripal. on september , , the uk government revealed that their investigation uncovered two suspects from closed circuit television (cctv) footage near the skripal's home. the suspects entered the uk on russian passports using the names alexander petrov and ruslan boshirov, stayed in a london hotel for days, visited salisbury briefly, and then returned to moscow. minute traces of novichok were also found in the london hotel where they had stayed. the uk prime minister, teresa may, said that the suspects are thought to be officers from russia's military intelligence service the glavnoye razvedyvatel'noye upravleniye (gru), and that this showed that the poisoning was "not a rogue operation" and was "almost certainly" approved at a senior level of the russian state. the two suspects later appeared on russian tv denying the accusations and saying they were just "tourists" who had traveled all the way from moscow to salisbury just to see the "famous cathedral". however, cctv of the cathedral area found no evidence of the two men visiting the cathedral, although they were captured on cctv near the skripal's home. in a development in september , one of the men was revealed as actually being a russian intelligence officer named colonel anatoliy chepiga and was a decorated veteran of russian campaigns in chechnya and ukraine. and later in october, the second man was named as dr. alexander mishkin, a naval medical doctor allegedly recruited by the gru (chai et al. ; may ) . novichok (Новичоќ: russian for "newcomer") is a highly potent nerve agent developed from the russian classified nerve agent program known as foliant. almost everything known about these agents is due to a russian defector, vil mirzayanov ( ) who was an analytical chemist at the russian state research institute of organic chemistry and technology (gosniiokht). he has described the details of the novichok program in his book "state secrets: an insider's chronicle of the russian chemical weapons program". the first three nerve agents of the novichok series developed in the program were substance- , a- , and a- (table . ). they were synthesized as unitary agents, like vx, tabun, soman, and sarin. unitary means that the chemical structure was produced at its maximum potency. however, the novichok agents were developed as binary agents: maximum potency when two inert substances are combined together prior to deployment to create the active nerve agent (cieslak and henretig ) . very little is known about the chemistry of these weaponized organophosphate agents. however, they appear to be more potent than current nerve agents. for example, the ld of novichok agents is reported . μg/kg similar to -(dimethylamino)ethyl n,n-dimethylphosphoramidofluoridate (vg), a novel fourth generation nerve agent. furthermore, novichok- is × more effective than vx and novichock- is × more effective than soman (cieslak and henretig ; hoenig ) . clinically, they behave like other organophosphates by binding to acetylcholinesterase preventing the breakdown of acetylcholine thereby leading to a cholinergic crisis. there appears to be a similar "aging" process as seen with other nerve agents. in addition, the novichok agents binding to peripheral sensory nerves distinguishes this class of organophosphates. prolonged or high-dose exposure results in debilitating peripheral neuropathy. exposure to these agents is fatal unless aggressively managed (cieslak and henretig ) . decontamination is essential to prevent ongoing exposure to the patient and medical personnel. clothing should be removed and quickly placed in a sealed bag (prevents ongoing exposure to the emission of vapors) followed by thorough washing with soap and water. application of dry bleach powder should be avoided as it may hydrolyze nerve agents into toxic metabolites that can produce ongoing cholinergic effects. supportive care is essential. antidote therapy should be given as usual for nerve agents, including atropine, diazepam, and pralidoxime chloride (united states department of health and human services, office of the assistant secretary for preparedness and response, national library of medicine ; united states department of health and human services, chemical hazards emergency medical management (chemm) ). of note, the toxicity of the novichok agents may not rely on anticholinesterase inhibition. some have suggested that reactive oximes like potassium , -butanedione monoximate are preferred oximes for antidotal therapy (cieslak and henretig ) . cyanide is a naturally occurring chemical. it can be found in plants and seeds. it is also used in many industrial applications and is a common product of combustion of synthetic materials. typical cyanogens include hydrogen cyanide (ac) and cyanogen chloride (ck). low levels of cyanide are detoxified by a natural reaction in the human body using the rhodanese system. there is reversible metabolism with vitamin b a to vitamin b (cyanocobalamin). an irreversible reaction occurs with sulfanes to produce thiocyanates and sulfates. the former is excreted via the urinary tract. when cyanide overwhelms this natural process, cyanide binds to ( ) a vx = venom x (cieslak and henretig ) cytochrome oxidase within the mitochondria and disrupts cellular respiration. cyanide has an affinity for fe+ in the cytochrome a complex and oxidative phosphorylation is interrupted. cells can no longer use oxygen to produce atp and lactic acidosis ensues from resultant anaerobic metabolism. when inhaled, cyanide produces rapid onset of clinical signs. findings include transient tachypnea and kussmaul breathing (from hypoxia of carotid and aortic bodies), hypertension and tachycardia (from hypoxia of aortic body), and neurologic findings such as seizures, muscle rigidity (trismus), opisthotonus, and decerebrate posturing. other findings include cherry red flush, acute respiratory failure/ arrest, bradycardia, dissociative shock, and cardiac arrest. venous blood samples exhibit a bright red color. arterial blood gas may demonstrate a metabolic acidosis with an increased anion gap due to lactic acid (banks ; cieslak and henretig ; rotenberg a) . pediatric manifestations (table . ) may vary from the classic clinical responses due to their unique vulnerabilities (hilmas et al. ): • thinner integument leading to shorter time from exposure to symptom development. • higher vapor density (ck) and concentration accumulation in living zone of children, • higher minute ventilation and metabolism. • abdominal pain, nausea, restlessness, and giddiness are common early findings. • cyanosis mostly noted other than classic cherry red flushing of the skin. • resilient with recovery even when just using supportive measures alone. differential diagnoses include meningitis, encephalitis, gastroenteritis, ischemic stroke, methemoglobinemia, and poisonings (nerve agents, organophosphates, methanol, hydrogen sulfide, and carbon monoxide). diagnostic tests include arterial blood gas, lactic acid, and thiocyanate levels. treatment (tables . and . ) includes decontamination, supportive care, and administration of cyanide antidote kit (nitrites and thiosulfate). the nitrites facilitate the production of methemoglobinemia (fe+ ) which attracts cyanide molecules forming cyanmethemoglobin. amyl nitrite pearls are crushed into gauze and placed over the mouth/nose or in a mask used for bag/mask ventilation. sodium nitrite is given parenterally and dosed according to the patient's estimated hemoglobin so as to prevent severe methemoglobinemia. since the formation of cyanmethemoglobin is a reversible reaction, and sodium thiosulfate is given to extract the cyanide. dosing is also dependent upon estimated hemoglobin. along with the naturally occurring rhodanese enzymatic system, the irreversible reaction forms thiocyanate. thiocyanate is water soluble and is excreted harmlessly via the kidneys (banks ; cieslak and henretig ). potential medical countermeasures (national institutes of health ; united states army medical research institute of infectious diseases (usamriid) ) include hydroxocobalamin, cobinamide (a cobalamin precursor), dicobalt edetate, cyanohydrin-forming compounds (alpha-ketoglutarate and pyruvate), s-substituted crystallized rhodanese, sulfur-containing drugs (n-acetylcysteine), and methemoglobin inducers ( -dimethylaminophenol and others). blistering agents, or vesicants, promote the production of blisters. typical examples include sulfur mustard (hd), nitrogen mustard (hn), and lewisite (l). these agents, especially sulfur mustard, are considered capable chemical weapons since illness may not occur until hours or days later. vesicants are alkylating agents that affect rapidly reproducing and poorly differentiated cells in the body. however, they can also produce cellular oxidative stress, deplete glutathione stores, and promote immature cognitive function unable to flee emergency immature coping mechanisms inability to discern threat, follow directions, and protect self high risk for developing ptsd bbb blood-brain barrier, bsa body surface area, cns central nervous system, ptsd post-traumatic stress disorder (hilmas et al. ) intense inflammatory responses. clinical findings are initially cutaneous (erythema, pruritus, yellow blisters, ulcers, and sloughing), respiratory (hoarseness, cough, voice changes, pneumonia, respiratory failure, acute lung injury, and acute respiratory distress syndrome), and ophthalmologic (pain, irritation, blepharospasm, photophobia, conjunctivitis, corneal ulceration, and globe perforation) in nature. after exposure through these primary portals of entry, other sites are affected, including the gastrointestinal tract (nausea, vomiting, and mucosal injury), the hematopoietic system (bone marrow suppression), the cardiovascular system (l), reproductive system (hd, hn) , and the central nervous system (lethargy, headache, malaise, and depression) (banks ; yu et al. ) . pediatric manifestations (table . ) may vary from the classic clinical responses due to their unique vulnerabilities (hilmas et al. ): • thinner integument leading to shorter time from exposure to symptom development. • higher vapor density and concentration accumulation in the living zone. • higher minute ventilation and metabolism. • greater pulmonary injury. • ocular findings more frequent (less self-protection and more hand/eye contact). • gastrointestinal manifestations more prominent. • unable to escape and decontaminate. • unable to verbalize complaints (i.e., pain). treatment (tables . and . ) includes decontamination and supportive care. currently, there are no antidotes for mustard toxicity (cieslak and henretig ) . agents under investigation include antioxidants (vitamin e), anti-inflammatory drugs (corticosteroids), mustard scavengers (glutathione, n-acetylcysteine), and nitric oxide synthase inhibitors (l-nitroarginine methyl ester). other therapeutics under investigation include the use of british anti-lewisite (bal), reactive skin protectants, and ocular therapies (national institutes of health ; usamriid ). lung-damaging agents are toxic inhalants and potentially can affect the entire respiratory tract. typical examples include chlorine (cl ), phosgene (carbonyl chloride), oxides of nitrogen, organofluoride polymers, hydrogen fluoride, and zinc oxide. since many of these chemicals are readily available and have multiple industrial applications, they are considered terrorist weapons of opportunity. toxicity is dependent upon agent particle size, solubility, and method of release. large particles produce injury in the nasopharynx (sneezing, pain, and erythema). midsize particles affect the central airways (painful swelling, cough, stridor, wheezing, and rhonchi). small particles cause injury at the level of the alveoli (dyspnea, chest tightness, and rales). highly soluble agents, such as chlorine, dissolve with mucosal moisture and immediately produce strong upper airway reactions. less soluble agents, such as phosgene, travel to the lower airway before dissolving and subsequently causing toxicity. it is important, however, to realize that very few lungdamaging agents affect only the upper or lower airway (e.g., cl ). if the agent is aerosolized, solid or liquid droplets suspend in the air and distribute by size. if it is a gas or vapor release, there is uniform distribution throughout the lungs and toxicity will be based on solubility and reactivity of the agent (banks ; burklow et al. ; cieslak and henretig ) . pediatric manifestations (table . ) may vary from the classic clinical responses due to their unique vulnerabilities (hilmas et al. ): • pediatric airway and respiratory tract issues (obligate nose breathers, relatively small mouth/large tongue, copious secretions, anterior/cephalad vocal cords, omega or horseshoe-shaped epiglottis, tendency of laryngospasm and bronchospasm, and anatomically small, "floppy" airways). • high vapor density and concentration accumulation in the living zone. • unable to verbalize or localize physical complaints. • rapid dehydration and shock secondary to pulmonary edema. • increased minute ventilation and metabolism. differential diagnoses include smoke inhalation injury, cardiogenic shock, heart failure, traumatic injury, asthma, bronchiolitis, and poisoning (cyanide). treatment (tables . and . ) includes decontamination and supportive care. currently, there are no antidotes for lung-damaging agent toxicity (cieslak and henretig ) . potential countermeasures include novel positive-pressure devices, drugs to prevent lung inflammation, and treatments for chemically induced pulmonary edema (beta agonists, dopamine, insulin, allopurinol, and ibuprofen). in addition, drugs are being investigated that act at complex molecular pathways of the lung the centers for disease control and prevention (cdc) has delineated bioterrorism agents and diseases into three categories based on priority. category a agents include organisms with the highest risk because the ease of dissemination or transmission from person-to-person, result in high mortality rates, have the potential for major public health impact, promote public panic and social disruption, and require special action of public health preparedness. these agents/diseases include smallpox (variola major), anthrax (bacillus anthracis), plague (yersinia pestis), viral hemorrhagic fevers (filoviruses [ebola, marburg] and arenaviruses [lassa, macupo]), botulinum toxin (from clostridium botulinum), and tularemia (francisella tularensis). category b agents, the second highest priority, include those that are moderately easy to disseminate, result in moderate morbidity and low mortality rates, and require specific enhancements of diagnostic capacity and enhanced disease surveillance. these agents/diseases include ricin toxin (ricinus communis), brucellosis (brucella species), epsilon toxin of clostridium perfringens, food safety threats (salmonella species, escherichia coli o :h , shigella), glanders (burkholderia mallei), meliodosis (burkholderia pseudomallei), psitticosis (chlamydia psittaci), typhus fever (rickettsia prowazekii), q fever (coxiella burnetii), staphylococcal enterotoxin b, trichothecenes mycotoxin, viral encephalitis (alphaviruses, such as eastern equine encephalitis, venezuelan equine encephalitis, and western equine encephalitis), and water safety threats (vibrio cholera, cryptosporidium parvum). category c agents have the next priority and include emerging pathogens that could be engineered for mass dissemination because of availability, ease of production and dissemination, and have the potential for high morbidity and mortality rates and major health impact. recognition of a biologic attack is essential. there are various epidemiologic clues to consider when determining whether the outbreak is natural or man-made (markenson et al. ; cieslak ; usamriid ) : • the appearance of a large outbreak of cases of a similar disease or syndrome, or especially in a discrete population. • many cases of unexplained diseases or deaths. • more severe disease than is usually expected for a specific pathogen or failure to respond to standard therapy. • unusual routes of exposure for a pathogen, such as the inhalational route for disease that normally occur through other exposures. • a disease case or cases that are unusual for a given geographic area or transmission season. • disease normally transmitted by a vector that is not present in the local area. • multiple simultaneous or serial epidemics of different diseases in the same population. • a single case of disease by an uncommon agent (smallpox, some viral hemorrhagic fevers, inhalational anthrax, pneumonic plague). • a disease that is unusual for an age group. • unusual strains or variants of organisms or antimicrobial resistance patterns different from those known to be circulating. • a similar or identical genetic type among agents isolated from distinct sources at different times and/or locations. • higher attack rates among those exposed in certain areas, such as inside a building if released indoors, or lower rates in those inside a sealed building if released outside. • outbreaks of the same disease occurring in noncontiguous areas. • zoonotic disease outbreaks. • intelligence of a potential attack, claims by a terrorist or aggressor of a release, and discovery of munitions, tampering, or other potential vehicle of spread (spray device, contaminated letter). one should know the cellular, physiological, and clinical manifestations of each biologic agent. furthermore, knowledge of distinct presentation patterns of children will be helpful to diagnosis. in any event, the ten steps in the management of biologic attack victims, pediatric, or otherwise, should be applied (cieslak and henretig ; cieslak ; usamriid smallpox is caused by the orthopoxvirus variola and was declared globally eradicated in . the disease is highly communicable from person-to-person and remains a threat due to its potential for weaponization. the only stockpiles are at the cdc and at the russian state centre for research on virology and biotechnology. however, clandestine stockpiles in other parts of the world are unknown. since the cessation of smallpox vaccination, the general population has little or no immunity. the three clinical forms of smallpox include ordinary, flat, and hemorrhagic. another form, modified type, occurred in those previously vaccinated who were no longer protected. the asymptomatic incubation period is from to days (average days) after exposure. a prodrome follows that lasts for - days and is marked by fever, malaise, and myalgia. lesions start on the buccal and pharyngeal mucosa. the rash then spreads in a centrifugal fashion, and the lesions are synchronous. initially, there are macules followed by papules, pustules, and scabs in - weeks. other clinical features include extensive fluid loss and hypovolemic shock, nausea, vomiting, diarrhea, bacterial superinfections, viral bronchitis and pneumonitis, corneal ulceration with or without keratitis, and encephalitis. death, if it occurs, is typically during the second week of clinical disease. variola minor caused a mortality of % in unvaccinated individuals. however, the variola major type caused death in % and % in those vaccinated and unvaccinated, respectively. flat (mostly children) and hemorrhagic (pregnant women and immunocompromised) types caused severe mortality in those populations infected. the differential diagnoses for smallpox include chickenpox (varicella), herpes, erythema multiforme with bullae, or allergic contact dermatitis. varicella typically has a longer incubation period ( - days) and minimal or no prodrome. furthermore, the rash distributes in a centripetal fashion and the progression is asynchronous (images . and . ). diagnosis of smallpox is mostly clinical (centers for disease control and prevention a). if considered, contact public health immediately. laboratory confirmation (cdc or who) can be done by dna sequencing, polymerase chain reaction (pcr), restriction fragment-length polymorphism (rflp), real-time pcr, and microarrays. these are more sensitive and specific than the conventional virological and immunological approaches (goff et al. ) . generally, treatment is largely supportive (table . ). fluid losses and hypovolemic shock must be addressed. also, due to electrolyte and protein loss, replacement therapy will be required. bacterial superinfections must be aggressively treated with appropriate antibiotics. biologic countermeasures and antivirals against smallpox are under investigation, including cidofovir, brincidovir (cmx- ), and tecovirimat (st- ). these agents have shown efficacy in orthopoxvirus animal models and have been used to treat disseminated vaccinia infection under emergency use. cidofovir has activity against poxviruses in animal studies (in vitro and in vivo) and some humans (eczema vaccinatum and molluscum contagiosum). brincidovir is an oral formulation of cidofovir with less nephrotoxicity and has recently been announced as an addition to the strategic national stockpile (sns) for patients with smallpox. tecovirimat is a potent and specific inhibitor of orthopoxvirus replication. a recent study found that treatment with tecovirimat resulted in % survival of cynomolgus macaques challenged with intravenous variola virus. the disease was milder in tecovirimat-treated survivors and viral shedding was reduced compared to placebo-treated survivors. prophylaxis comes in the form of the smallpox vaccine (vaccinia virus), acam ® , which replaced wyeth dryvax™ in . safety profile of the two vaccines appears to be similar. side effects of vaccination range from low-grade fever and axillary lymphadenopathy to inadvertent inoculation of the virus to other body sites to generalized vaccinia and cardiac events (myopericarditis). rare, but typically fatal complications include progressive vaccinia, eczema vaccinatum, postvaccination encephalomyelitis, and fetal vaccinia. modified vaccinia ankara (mva) smallpox vaccine (bavarian nordic's imvamune ® ) is a live, highly attenuated, viral vaccine that is under development as a future nonreplicating smallpox vaccine (greenberg et al. ; kennedy and greenberg ). passive immunoprophylaxis exists in the form of vaccinia immune globulin (vig) and is used for primarily treating complications from smallpox vaccine. limited information suggests that vig may be of use in postexposure prophylaxis of smallpox if given the first week after exposure and with vaccination. monoclonal antibodies may represent another form of immunoprophylaxis. postexposure administration of human monoclonal antibodies has protected rabbits from a lethal dose of an orthopoxvirus. as mentioned, smallpox is highly communicable person-to-person (table . ). contact precautions with full personal protective equipment (ppe) are required. airborne isolation with the use of an n- mask is needed for baseline protection. an n- mask or powered airpurifying respirator (papr) is recommended for protection during high risk procedures (beigel and sandrock ; goff et al. ; rotz et al. ; pittman et al. ; usamriid ). anthrax is caused by the aerobic, spore-forming, nonmotile, encapsulated gram-positive rod bacillus anthracis. it is a naturally occurring disease in herbivores. humans contract the illness by handling contaminated portions of infected animals, especially hides and wool. infection is introduced by scratches or abrasions on the skin. there is concern for potential aerosol dispersal leading to intentional infection through inhalation: it is fairly easy to obtain, capable of large quantity production, stable in aerosol form, and highly lethal. anthrax spores enter the body via skin, ingestion, or inhalation. the spores germinate inside macrophages and become vegetative bacteria. the vegetative form is released, replicates in the lymphatic system, and produces intense bacteremia. the production of virulence factors leads to overwhelming sepsis. the main virulence factors are encoded on two plasmids. one produces an antiphagocytic polypeptide capsule. the other contains genes for the synthesis of three proteins it secretes: protective antigen, edema factor, and lethal factor. the combination of protective antigen with lethal factor or edema factor forms binary cytotoxins, lethal toxin, and edema toxin. the anthrax capsule, lethal toxin, and edema toxin act in concert to drive the disease. three clinical syndromes occur with anthrax: cutaneous, gastrointestinal, and inhalational. cutaneous anthrax is the most common naturally occurring form. after an individual is exposed to infected material or the agent itself, there is a - day (average days) incubation period. a painless or pruritic papule forms at the site of exposure. the papule enlarges and forms a central vesicle, which is followed by erosion into a coal-black but painless eschar. edema surrounds the area and regional lymphadenopathy may occur. gastrointestinal anthrax is rare. typically, it develops after ingestion of viable vegetative organisms found in undercooked meats of infected animals. the two forms of gastrointestinal anthrax, oropharyngeal and intestinal, have incubation periods of - days. the oropharyngeal form is marked by fever and severe pharyngitis followed by ulcers and pseudomembrane formation. other findings include dysphagia, regional lymphadenopathy, unilateral neck swelling, airway compromise, and sepsis. the intestinal form begins with fever, nausea, vomiting, and abdominal pain. bowel edema develops which leads to mesenteric lymphadenitis with necrosis, shock, and death. endemic inhalational anthrax (woolsorters' disease) is also extremely rare and is due to inhaling spores. therefore, any case of inhalational anthrax should be assumed to be due to intentional exposure until proven otherwise. the incubation period is - days but can be up to days. there is a prodrome of - days consisting of fever, malaise, and cough. within h, the disease rapidly progresses to respiratory failure, hemorrhagic mediastinitis (wide mediastinum), septic shock, multiorgan failure, and death. patients with inhalational anthrax may also have hemorrhagic meningitis. mortality is greater than % in - h despite aggressive treatment of inhalational anthrax. the differential diagnoses of ulceroglandular lesions include antiphospholipid antibody syndrome, brown recluse spider bite, coumadin/heparin necrosis, cutaneous leishmaniasis, cutaneous tuberculosis, ecthyma gangrenosum, glanders, leprosy, mucormycosis, orf, plague, rat bite fever, rickettsial pox, staphylococcal/ streptococcal ecthyma, tropical ulcer, tularemia, and typhus. the differential diagnoses of ulceroglandular syndromes include cat scratch fever, chancroid, glanders, herpes, lymphogranuloma venereum, melioidosis, plague, staphylococcal and streptococcal adenitis, tuberculosis, and tularemia. the differential diagnoses for inhalational anthrax include influenza and influenza-like illnesses from other causes. the differential diagnoses of mediastinal widening include normal variant, aneurysm, histoplasmosis, sarcoidosis, tuberculosis, and lymphoma. the diagnosis of anthrax is by culture and gram stain of the blood, sputum, pleural fluid, cerebrospinal fluid, or skin. specimens must be handled carefully, especially by lab personnel and those performing autopsies. elisa and pcr are available at some reference laboratories. the chest radiograph of inhalational anthrax shows the classic widening of the mediastinum. additional findings include hemorrhagic pleural effusions, air bronchograms, and/or consolidation (purcell et al. ). supportive treatment is indicated, including mechanical ventilation, pleural effusion drainage, fluid and electrolyte support, and vasopressor administration. for inhalational anthrax, antibiotic treatment is unlikely to be effective unless started before respiratory symptoms develop. treatment (table . ) includes ciprofloxacin (or levofloxacin or doxycycline), clindamycin, and penicillin g. raxibacumab, a monoclonal antibody, was approved by the fda in for the treatment of inhalational anthrax in combination with recommended antibiotic regimens and prophylaxis for inhalational anthrax when other therapies are unavailable or inappropriate. it works by inhibiting anthrax antigen binding to cells and, therefore, prevents toxins from entering cells (kummerfeldt ) . the adult dose is mg/kg given iv over h and min. the dose for children is weight based; ≤ kg: mg/kg; > - kg: mg/kg; > kg: mg/kg. premedication with diphenhydramine iv or po is recommended h before the infusion. it can also be used as postexposure prophylaxis in high risk spore exposure cases (cieslak and henretig ; migone et al. ; the medical letter ). obiltoxaximab (anthim) is a recently approved monoclonal antibody treatment for inhalational anthrax in combination with recommended antibiotic regimens and prophylaxis for inhalational anthrax when other therapies are unavailable or inappropriate. adults and children > kg should receive a single obiltoxaximab dose of mg/kg. the recommended dose is mg/kg for children > - kg and mg/kg for those weighing ≤ kg. premedication with diphenhydramine is recommended to reduce risk of hypersensitivity reactions (the medical letter ). in patients with inhalational anthrax, intravenous anthrax immune globulin (anthrasil) should be considered in addition to appropriate antibiotic therapy (mytle et al. ; the medical letter ; usamriid ). postexposure prophylaxis includes ciprofloxacin (or levofloxacin or doxycycline) for days plus administration of vaccine; since spores can persist in human in addition to appropriate antibiotic regimen, monoclonal antibody therapy (see text for dosing) and intravenous anthrax immune globulin should be administered for inhalational anthrax c levofloxacin or ofloxacin may be an acceptable alternative to ciprofloxacin d rifampin or clarithromycin may be acceptable alternatives to clindamycin as a drug that targets bacterial protein synthesis. if ciprofloxacin or another quinolone is employed, doxycycline may be used as a second agent because it also targets protein synthesis e ampicillin, imipenem, meropenem, or chloramphenicol may be acceptable alternatives to penicillin as drugs with good cns penetration f assuming the organism is sensitive, children may be switched to oral amoxicillin ( - mg/kg/d divided q h) to complete a -day course. the first days of therapy of postexposure prophylaxis, however, should include ciprofloxacin or levofloxacin and/or doxycycline regardless of age. vaccination should also be provided; if not, antibiotic course will need to be longer g according to most experts, ciprofloxacin is the preferred agent for oral prophylaxis h ten days of therapy may be adequate for endemic cutaneous disease. a full -day course is recommended in the setting of terrorism, however, because of the possibility of concomitant inhalational exposure tissues for a long time, antibiotics must be given for a longer period if vaccine is not also given. the anthrax vaccine adsorbed (ava biothrax™) is derived from sterile culture fluid supernatant taken from an attenuated strain of bacillus anthracis and does not contain any live or dead organisms. the vaccine is given . ml intramuscularly at and weeks then at , , and months followed by yearly boosters (pittman et al. ; usamriid ) . consult with cdc for current pediatric recommendations. anthrax is not contagious in the vegetative form during clinical illness (table . ). contact with infected animals increases likelihood of spread. therefore, contact should be limited and the use of appropriate ppe in endemic areas is indicated (beigel and sandrock ; purcell et al. ; usamriid ) . plague is caused by yersinia pestis, a nonmotile, nonsporulating gram-negative bacterium. it is a zoonotic disease of rodents. it is typically found worldwide and is endemic in western and southwestern states. humans develop the disease after contact with infected rodents, or being bitten by their fleas. after a rodent population dies off, the fleas search for other sources of blood, namely humans. this is when large outbreaks of human plague occur. pneumonic plague is a very rare disease and when it is present in a patient, it may be highly suspicious for intentional dispersal of this deadly agent. three clinical syndromes occur with plague: bubonic plague ( %), septicemic plague ( %), and primary pneumonic plague ( - %). bubonic plague occurs after an infected flea bites a human. after an incubation period of - days, there is onset of high fever, severe malaise, headache, myalgias, and nausea with vomiting. almost % have abdominal pain. around the same time, a characteristic bubo forms which is tender, erythematous, and edematous without fluctuation. buboes typically form in the femoral or inguinal lymph nodes, but other areas can be involved as well (axillary, intraabdominal). the spleen and liver can be tender and palpable. the disease disseminates without therapy. severe complications can ensue, including pneumonia, meningitis, sepsis, and multiorgan failure. pneumonia is particularly concerning since these patients are extremely contagious. mortality of untreated bubonic plague is %, but % with efficient and effective treatment. septicemic plague is characterized by acute fever followed by sepsis without bubo formation. the clinical syndrome is very similar to other forms of gram-negative sepsis: chills, malaise, tachycardia, tachypnea, hypotension, nausea, vomiting, and diarrhea. in addition to sepsis, disseminated intravascular coagulation can ensue leading to thrombosis, necrosis, gangrene, and the formation of black appendages. multiorgan failure can quickly follow. untreated septicemic plague is almost % fatal versus - % in those treated. pneumonic plague is very rare and should be considered due to an intentional aerosol release until proven otherwise. the incubation period is relatively short at - days. sudden fever, cough, and respiratory failure quickly follow. this form produces a fulminant pneumonia with watery sputum that usually progresses to bloody. within a short period of time, septic shock and disseminated intravascular coagulation develop. ards and death may occur. mortality rate of pneumonic plague is very high but may respond to early treatment. plague meningitis is a rare complication of plague. it can occur in % of patients with septicemia and pneumonic forms and is more common in children. usually occurring a few weeks into the illness, it affects those receiving subtherapeutic doses of antibiotics or bacteriostatic antibiotics that do not cross the blood-brain barrier (tetracyclines). fever, meningismus, and other meningeal signs occur. plague meningitis is virtually indistinguishable from meningococcemia. the differential diagnoses of bubonic plague include tularemia, cat scratch fever, lymphogranuloma venereum, chancroid, scrub typhus, and other staphylococcal and streptococcal infections. the differential diagnoses of septicemic plague should include meningococcemia, other forms of gram-negative sepsis, and rickettsial diseases. the differential diagnosis of pneumonic plague is very broad. however, sudden appearance of previously healthy individuals with rapidly progressive gram-negative pneumonia with hemoptysis should strongly suggest pneumonic plague due to intentional release. diagnosis can be made clinically as previously described. demonstration of yersinia pestis in blood or sputum is paramount. methylene blue or wright's stain of exudates may reveal the classic safety-pin appearance of yersinia pestis. culture on sheep blood or macconkey agar demonstrates beaten-copper colonies ( h) followed by fried-egg colonies ( h). detection of yersinia pestis f -antigen by specific immunoassay is available, but the result is available retrospectively. chest radiograph of patients will demonstrate patchy infiltrates (centers for disease control and prevention a; worsham et al. ) . treatment includes mechanical ventilation strategies for ards, hemodynamic support (fluid and vasopressor administration), and antimicrobial agents (table . ). gentamicin or streptomycin is the preferred antimicrobial treatment. alternatives include doxycycline or ciprofloxacin or levofloxacin or chloramphenicol. in cases of meningitis, chloramphenicol is recommended due to its ability to effectively cross the blood-brain barrier. streptomycin is in limited supply and is available for compassionate use. it should be avoided in pregnant women. postexposure prophylaxis includes doxycycline or ciprofloxacin. no licensed plague vaccine is currently in production. a previous licensed vaccine was used in the past. it only offered protection against bubonic plague but not aerosolized yersinia pestis. the plague bacterium secretes several virulence factors (fraction (f ) and v (virulence) proteins) that as subunit proteins are immunogenic and possess protective properties. recently, an f -v antigen (fusion protein) vaccine developed by usamriid provided % protection in monkeys against high-dose aerosol challenge. there is no passive immunoprophylaxis (i.e., immune globulin) available for pre-or postexposure of plague (usamriid ). use of standard precautions for patients with bubonic and septicemic plague is indicated. suspected pneumonic plague will require strict isolation with respiratory droplet precautions for at least h after initiation of effective antimicrobial therapy, or until sputum cultures are negative in confirmed cases. an n- respirator should be used for baseline protection (table . ). it is also recommended to use an n- respirator or papr for high risk procedures (beigel and sandrock ; ; centers for disease control and prevention ; centers for disease control and prevention b; pittman et al. ; usamriid ) . in a mass casualty setting, parenteral therapy might not be possible. in such cases, oral therapy (with analogous agents) may need to be used b ofloxacin (and possibly other quinolones) may be acceptable alternatives to ciprofloxacin or levofloxacin; however, they are not approved for use in children c concentration should be maintained between and μg/ml. some experts have recommended that chloramphenicol be used to treat patients with plague meningitis, because chloramphenicol penetrates the blood-brain barrier. use in children younger than may be associated with adverse reactions but might be warranted for serious infections d ribavirin is recommended for arenavirus or bunyavirus infections and may be indicated for a viral hemorrhagic fever of an unknown etiology although not fda approved for these indications. for intravenous therapy use a loading dose: kg iv once (max dose, g), then mg/kg iv q h for days (max dose, g), and then mg/kg iv q h for days (max dose, mg). in a mass casualty setting, it may be necessary to use oral therapy. for oral therapy, use a loading dose of mg/kg po once, then mg/kg/day po in divided doses for days viral hemorrhagic fever has a variety of causative agents. however, the syndromes they produce are characterized by fever and bleeding diathesis. the etiologies include rna viruses from four distinct families: arenaviridae, bunyaviridae, filoviridae, and flaviviridae. the filoviridae (includes ebola and marburg) and arenaviridae (includes lassa fever and new world viruses) are category a agents. based on multiple identified characteristics, there is strong concern for the weaponization potential of the viral hemorrhagic fevers. specifically, there has been demonstration of high contagiousness in aerosolized primate models. there are five identified ebola species, but only four are known to cause disease in humans. the natural reservoir host of ebola virus remains unknown. however, on the basis of evidence and the nature of similar viruses, researchers believe that the virus is animal-borne and that bats are the most likely reservoir. four of the five virus strains occur in an animal host native to africa. marburg virus has a single species. geographic distribution of ebola and marburg is africa (fitzgerald et al. ). both diseases are very similar clinically. incubation period is typically - days with a range of - days. symptoms may include fever, chills, headache, myalgia, nausea, and vomiting. there is rapid progression to prostration, stupor, and hypotension. the onset of a maculopapular rash on the arms and trunk is classic. disseminated intravascular coagulation and thrombocytopenia develops with conjunctival injection, petechiae, hemorrhage, and soft tissue bleeding. there is a possible central nervous system and hepatic involvement. bleeding, uncompensated shock, and multiorgan failure are seen. high viral load early in course is associated with poor prognosis. death usually occurs during the second week of illness. mortality rate of marburg is - % and for ebola - %. in a retrospective cohort study of children during the / ebola outbreak in liberia and sierra leone (all less than years with a median age of years with one-third less than years of age), the most common features upon presentation were fever, weakness, anorexia, and diarrhea. about % were initially afebrile. bleeding was rare upon initial presentation. the overall case fatality rate was %. factors associated with death included children less than years of age, bleeding at any time during hospitalization, and high viral load (smit et al. ) . in another retrospective cohort study of children at two ebola centers in sierra leone in (all less than years of age), presenting symptoms included weakness, fever, anorexia, diarrhea, and cough. about % were afebrile on presentation. the case fatality rate was higher in children less than years ( %) versus - years of age ( %) and times more likely to die if child had a higher viral load. signs associated with death included fever, emesis, and diarrhea. interestingly, hiccups, bleeding, and confusion were only observed in children who died (shah et al. ) . lassa virus and new world viruses (junin, machupo, sabia, and guanarito) are transmitted from person-to-person. the vector in nature is the rodent. the incubation period is from to days. the geographical distribution is west africa and south america, respectively. the south american hemorrhagic fevers are quite similar but differ from lassa fever. the onset of the south american viruses is insidious and results in high fever and constitutional symptoms. petechiae or vesicular enanthem with conjunctival injection is common. these fevers are associated with neurologic disease (hyporeflexia, gait abnormalities, and cerebellar dysfunction). seizures portend a poor prognosis. mortality ranges from % to over %. on the contrary, lassa viruses are mild. less than % of infections result in severe disease. signs include chest pain, sore throat, and proteinuria. hemorrhagic disease is uncommon. other features include neurologic disease such as encephalitis, meningitis, cerebellar disease, and cranial nerve viii deafness (common feature). mortality can be as high as %. differential diagnoses include malaria, meningococcemia, hemolytic uremic syndrome, thrombotic thrombocytopenic purpura, and typhoid fever. diagnosis is through detection of the viral antigen testing by elisa or viral isolation by culture at the cdc. no specific therapy is present and generally involves supportive care, especially mechanical ventilation strategies for ards, hemodynamic support, and renal replacement therapy. for the arenaviridae and bunyaviridae groups, ribavirin may be indicated ( (pittman et al. ) . there is no current vaccine for ebola that is licensed by the fda. an experimental vaccine called rvsv-zebov was found to be highly protective against ebola virus in a trial conducted by the world health organization (who) and other international partners in guinea in . fda licensure for the vaccine is expected in . until then, , doses have been committed for an emergency use stockpile under the appropriate regulatory mechanism in the event and an outbreak occurs before fda approval is received (centers for disease control and prevention b; henao-restrepo et al. ) . another ebola vaccine candidate, the recombinant adenovirus type- ebola vaccine, was evaluated in a phase trial in sierra leone in . an immune response was stimulated by this vaccine within days of vaccination and strict contact precautions (hand hygiene, double gloves, gowns, shoe and leg coverings, and face shield or goggles) and droplet precautions (private room or cohorting, surgical mask within ft) are mandatory for viral hemorrhagic fevers. airborne precautions (negative-pressure isolation room with - air exchanges per h) should also be instituted to the maximum extent possible and especially for procedures that induce aerosols (e.g., bronchoscopy). at a minimum, a fit-tested, hepa filter-equipped respirator (e.g., an n- mask) should be used, but a battery-powered papr or a positive pressure-supplied air respirator should be considered for personnel sharing an enclosed space with, or coming within ft of, the patient. multiple patients should be cohorted in a separate ward or building with a dedicated airhandling system when feasible (table . ). environmental decontamination is accomplished with hypochlorite or phenolic disinfectants (beigel and sandrock ; radoshitzky et al. ; usamriid ; won and carbone ) . francisella tularensis, a small aerobic, nonmotile gram-negative coccobacillus, causes tularemia (rabbit fever). clinical disease is caused by two isolates, biovars jellison type a and b. this organism can be stabilized for weaponization and delivered in a wet or dry form. the incubation period is usually - days (range - days). initial symptoms are nonspecific and mimic the flu-like symptoms or other upper respiratory tract infections. there is acute onset of fever with chills, myalgias, cough, fatigue, and sore throat. the two clinical forms of tularemia are typhoidal and ulceroglandular diseases. typhoidal tularemia ( - %) occurs after inhalational exposure and sometimes intradermal or gastrointestinal exposures. there is abrupt onset of fever, headache, malaise, myalgias, and prostration. it presents without lymphadenopathy. nausea, vomiting, and abdominal pain are sometimes present. untreated, there is a % mortality rate in naturally acquired cases (vs. - % in those treated). it is higher if pneumonia is present. this form would be most likely seen during an aerosol release of the agent. ulceroglandular tularemia ( - %) occurs through skin or mucus membrane inoculation. there is abrupt onset of fever, chills, headache, cough, and myalgias along with a painful papule at the site of exposure. the papule becomes a painful ulcer with tender regional lymph nodes. skin ulcers have heaped up edges. in - %, there is focal lymphadenopathy without an apparent ulcer. lymph nodes may become fluctuant and drain when receiving antibiotics. without treatment, they may persist for months or even years. in some cases ( - %), the primary entry port is the eye leading to oculoglandular tularemia. patients have unilateral, painful, and purulent conjunctivitis with local lymphadenopathy. chemosis, periorbital edema, and small nodular granulomatous lesions or ulceration may be found. oropharyngeal tularemia with pharyngitis may occur in % of patients. findings include exudative pharyngitis/tonsillitis, ulceration, and painful cervical lymphadenopathy. the differential diagnosis is antibiotic unresponsive pharyngitis, infectious mononucleosis, and viral pharyngitis. pulmonary involvement ( - %) is seen in naturally occurring disease. it ranges from mild to fulminant. various processes include pneumonia, bronchiolitis, cavitary lesions, bronchopleural fistulas, and chronic granulomatous diseases. left untreated, % will die. differential diagnoses include those for typhoidal (typhoid fever, rickettsia, and malaria) or pneumonic (plague, mycoplasma, influenza, q-fever, and staphylococcal enterotoxin b) tularemia. diagnosis should be considered when there is a cluster of nonspecific, febrile, systemically ill patients who rapidly progress to fulminant pneumonitis. tularemia can be diagnosed by recovering the organism from sputum (pcr or dfa) or serology at a state health laboratory. chest radiograph is nonspecific with possible hilar adenopathy. treatment is streptomycin or gentamicin (table . ). alternatives include doxycycline, ciprofloxacin, or chloramphenicol. a live-attenuated vaccine (ndbr ) exists and typically used for laboratory personnel working with francisella tularensis. there is no passive immunoprophylaxis. ciprofloxacin or doxycycline can be given as pre-and postexposure prophylaxis (beigel and sandrock ; hepburn et al. ; pittman et al. ; usamriid ) . botulinum neurotoxins (bont) are produced from the spore-forming, gram-positive, obligate anaerobe clostridium botulinum. it is the most potent toxin known to man. a lethal dose is ng per kilogram. it is , times more toxic than sarin (gb). there are seven serotypes of botulinum toxin (a through g). a new serotype (h) has been tentatively identified in a case of infant botulism but has not been fully investigated. most common are serotypes a, b, and e. the toxin acts on the presynaptic nerve terminal of the neuromuscular junction and cholinergic autonomic synapses. this disrupts neurotransmission and leads to clinical findings. there are three forms of botulism: foodborne, wound, and intestinal (infant or adult intestinal). botulinum toxin can also be released as an act of bioterrorism via ingestion or aerosol forms. incubation can be from h after exposure to several days later. clinical findings of botulism include cranial nerve palsies such as ptosis, diplopia, and dysphagia. this is followed by symmetric descending flaccid paralysis. however, the victim remains afebrile, alert, and oriented. death is typically due to respiratory failure. prolonged respiratory support is often required ( - months). differential diagnoses include guillain-barre syndrome, myasthenia gravis, tick paralysis, stroke, other intoxications (nerve gas, organophosphates), inflammatory myopathy, congenital and hereditary myopathies, and hypothyroidism. diagnosis is mostly clinical. laboratory confirmation can be obtained by bioassay of patient's serum. other assays include immunoassays for bacterial antigen, pcr for bacterial dna, and reverse transcriptase-pcr for mrna to detect active synthesis of toxin. cerebrospinal fluid demonstrates normal protein (unlike guillain-barre syndrome). emg reveals augmentation of muscle action potential with repetitive nerve stimulation at - hz. treatment (table . ) is mainly supportive including intubation and ventilator support. tracheostomy may be required due to prolonged respiratory weakness and failure. antibiotics do not play a role in treatment. botulism antitoxin heptavalent [a, b, c, d, e, f, g]-equine (bat) was approved by the fda in . bat was developed at usamriid as one of two equine-derived heptavalent bont antitoxins. bat is approved to treat individuals with symptoms of botulism following a known or suspected exposure. it has the potential to cause hypersensitivity reactions in those sensitive to equine proteins. the safety of bat in pregnant and lactating women is unknown. evidence regarding safety and efficacy in the pediatric population is limited. in , the fda approved botulinum immune globulin intravenous (babybig), a human botulism immune globulin derived from pooled plasma of adults immunized with pentavalent botulinum toxoid. it is indicated for the treatment of infants with botulism from toxin serotypes a and b. immediately after clinical diagnosis of botulism, adults (including pregnant women) and children should receive a single intravenous infusion of antitoxin (bat or, for infants with botulism from serotypes a or b, babybig) to prevent further disease progression. the administration of antitoxin should not be delayed for laboratory testing to confirm the diagnosis. the pentavalent toxoid vaccine (previously for protection against a, b, c, d, and e; but not f or g) is no longer available as of . no replacement vaccine is currently available. standard isolation precautions (table . ) should be followed (beigel and sandrock ; dembek et al. ; pittman et al. ; timmons and carbone ; usamriid ). ricin is a potent cytotoxin derived from the castor bean plant ricinus communis. it is related in structure and function to shiga toxins and shiga-like toxin of shigella dysenteriae and escherichia coli, respectively. it consists of two glycoprotein subunits, a and b, connected by a disulfide bond. the b-chain allows the toxin to bind to cell receptors and gain entrance into the cell. once ricin enters the cell, the disulfide chemical linkage is broken. the free a chain then acts as an enzyme and inactivates ribosomes thereby disrupting normal cell function. cells are incapable of survival and soon die. ricin has a high terrorist potential due to it characteristics: readily available, ease of extraction, and notoriety (maman and yehezkelli ) . three modes of exposure exist: oral, inhalation, and injection. four to eight hours after inhalation exposure, the victim develops fever, chest tightness, cough, dyspnea, nausea, and arthralgias. airway necrosis and pulmonary capillary leak ensues within - h. this is followed quickly by severe respiratory distress, ards, and death due to hypoxemia within - h. injection may cause minimal pulmonary vascular leak. pain at the site and local lymphadenopathy may occur. however, it may be followed by nausea, vomiting, and gastrointestinal hemorrhage. ingestion leads to necrosis of the gastrointestinal mucosa, hemorrhage, and organ necrosis (spleen, liver, and kidney). diagnosis is suspected when multiple cases of acute lung injury occur in a geographic cluster. serum and respiratory secretions can be checked for antigen using elisa. pulmonary intoxication is managed by mechanical ventilation. gastrointestinal toxicity is managed by gastric lavage and use of cathartics. activated charcoal has little value due to the size of ricin molecules. supportive care is indicated for injection exposure. in general, treatment is largely supportive, especially for pulmonary edema that can result from the capillary leak. there is no vaccine available or prophylactic antitoxin for human use. however, there are two ricin vaccines in the development that focus on the ricin toxin a (rta) chain subunit. a mutant recombinant rta chain vaccine, rivax, has been shown to be safe and immunogenic in humans. the other vaccine is another recombinant rta chain vaccine, rvec . it has shown effectiveness in animal models by producing protective immunity against aerosol challenge with ricin in animal models. standard precautions are advised for health care workers (pittman et al. ; roxas-duncan et al. ; traub ; usamriid ). recent events which include the nuclear reactor meltdown at fukushima and international tension between nuclear powers, spark concern over potential devastation from nuclear catastrophes. there are numerous examples of radiation disasters in history. sixty-six thousand people were killed in hiroshima and thirty-nine thousand people were killed in nagasaki from nuclear bombs detonated over these cities in (avalon project-documents in law, history and diplomacy n.d.). many other people suffered from long-term consequences of radiation poisoning. in , , square kilometers of land in russia, ukraine, and belarus were contaminated with radiation from a meltdown at a nuclear power plant in chernobyl, ukraine. one hundred and thirty-five thousand people were permanently evacuated from their homes (likhtarev et al. ) . long-term health consequences included many children who developed thyroid cancer several years later. many of these children died. a tsunami pummeled the east coast of japan in march of . the power outage that ensued at the fukushima power plant led to a failure of the cooling system of the fuel rods, leading to a meltdown of four of the reactors at the plant. a massive quantity of radiation was released into the atmosphere, forcing people to evacuate their homes indefinitely. creative thinking and heroic actions by the tokyo fire department prevented entire populations of cities from being poisoned with radiation. terrorism experts are concerned that terrorist organizations will produce and detonate a radiological dispersion device (rdd), sometimes referred to as a dirty bomb. this is a conventional explosive, loaded with radioactive material which would be dispersed upon detonation. this would likely involve only one radioisotope. fewer people would be exposed and a smaller area would be contaminated than what would transpire with the detonation of a nuclear weapon. spreading fear and panic would be the primary purpose of such a device (mettler jr and voelz ) . radiation is the emission and propagation of energy through space or through a medium in the form of waves. radiation can be ionizing or nonionizing depending on the amount of energy released. most radiation that people encounter is low energy and, therefore, nonionizing with no biological effects. ionizing radiation emits enough energy to strip electrons from an atom, which provokes cellular changes and thereby, results in biological effects. radiation emitted from nuclear decay is always ionizing (radiation emergency assistance center/training site (react/s-cdc) ). atomic nuclei are held together by a very powerful binding energy despite positively charged protons repelling each other. this energy is released from unstable nuclei in the form of electromagnetic waves or particles. when ionizing radiation reaches biological tissue, chemical bonds are disrupted, free radicals are produced, and dna is broken. electromagnetic waves are of two types, x-rays and gamma rays. x-rays are relatively low energy and less penetrating. gamma rays have a shorter wavelength and contain relatively higher energy, making them more penetrating of biological tissue. ionizing radiation in the form of particles consists of alpha particles, beta particles, and neutrons. alpha particles are the largest of the forms of particulate radiation. they are composed of two neutrons and two protons. they do not easily penetrate solid surfaces, including clothes and skin. however, they can cause severe damage to an organism if internalized. in , in the united kingdom, alexander litvienko, an ex kgb agent was poisoned with a radioactive element called polonium (mcphee and leikin ). a small amount of polonium was sprinkled into his food. polonium releases alpha particles when it decays. it was relatively safe for the assassin to carry this element with him because of the relatively poor ability of alpha particles to penetrate clothing and skin. once it is ingested, however, alpha particles have profound biological effects. mr. litvienko became very ill, and ultimately died. beta particles are high energy electrons discharged from the nucleus and are highly penetrating. neutrons emitted from a nucleus are also highly penetrating. in general, neutrons are only released by the detonation of a nuclear weapon. ionizing radiation of any form cannot be detected by our senses. it is not smelled, felt by touch, tasted, or seen. it is possible to be exposed to a lethal dose of radiation without realizing it. in goiania, brazil, in , children found a canister of radioactive cesium ( cs) that had been looted from a medical center and left in the street. the children liked the appearance of the substance but were not able to sense any abnormalities or danger with it. they began to rub it on their bodies because they liked the way it made them glow in the dark. the children all became ill. ultimately, people were exposed to this radioisotope. it took days before physicians recognized that the people had radiation poisoning. four people died of acute radiation syndrome. four factors determine the severity of exposure to ionizing radiation: time, distance, dose, and shielding. time is the time of exposure to the radiation source. distance is the distance from the radiation source. based on the inverse square law, exposure is reduced exponentially with increasing distance from the radiation source. dose is measured by the amount of energy released by the source and is numerically described by how many disintegrations per second occur, in curies (ci) or becquerels (bq). shielding is the efficacy of the barrier to the radioactive source. lead is well-known to be a very effective shield to x-rays. in a radiation exposure, injury to skin from trauma or burns may cause a greater degree of contamination because of loss of the shielding of the skin. there are four important principles for the nurse or hcp to understand with regard to exposure to ionizing radiation: external exposure, external contamination, internal contamination, and incorporation. external contamination occurs when radioactive material is carried on a person after exposure. this person can then contaminate others. removing contaminated clothing eliminates % of the toxin. others are then less vulnerable to exposure. internal contamination is when a radioactive substance enters the body through inhalation, ingestion, or translocation through open skin. incorporation is internalization of the toxin into body organs. incorporation is dependent on the chemical and not the radiological properties of the radioactive toxin. radioactive iodine, i, is taken up by the thyroid gland because iodine enters the gland as part of normal physiology (advanced hazmat life support (ahls) ). ionizing radiation can damage chromosomes directly and indirectly, causing ravaging biological effects. indirect damage comes from the production of h + and oh − . free radical formation upsets biochemical processes and causes inflammation. these effects can take anywhere from seconds to hours to be expressed. clinical changes can take from hours to years to be realized (zajtchuk et al. ). immediately after a major radiation exposure, the clinical matters of most concern are those related to trauma from blast and thermal injuries. these injuries may be life-threatening and must be addressed first. after thermal and traumatic injuries are addressed, attention should be paid to the severity of radiation exposure. severe exposure can cause acute radiation syndrome. "the acute radiation syndrome is a broad term used to describe a range of signs and symptoms that reflect severe damage to specific organ systems and that can lead to death within hours or up to several months after exposure" (national council on radiation protection (ncrp) and measurements ; national council on radiation protection (ncrp) and measurements ). the mechanism of cell death from toxic radiation exposure is related to the inhibition of mitosis. organs with the most rapidly dividing cells are the most susceptible. the gastrointestinal and the hematopoietic are the organ systems most notably affected. the organs of pediatric patient have a higher mitotic index, in general, to those of adults and are more vulnerable to injury from radiation poisoning. the time of onset and the severity of acute radiation syndrome are controlled by the total radiation dose, the dose rate, percent of total body exposed, and associated thermal and traumatic injuries. there is a % death rate (ld ) within days for people exposed to a dose of radiation of . - . gy. the ld is lower for the pediatric population. the acute radiation syndrome is composed of four phases: prodromal, latent, manifest illness, and death or recovery. inflammatory mediator release during the prodromal phase causes damage to cell membranes. this phase occurs during the first h after exposure to radiation. nausea and vomiting and fever can occur during this time. if these symptoms occur during the first h after exposure, there is a poor prognosis. the onset of the latent phase is usually in the first days post exposure but can ensue anytime during the first days thereafter. all cell lines of the hematopoietic system are affected. lymphocytes and platelets, the most rapidly dividing cells of the bone marrow, are most severely affected. the illness phase manifests after days since radiation exposure. infection, impaired wound healing, anemia, and bleeding occur during this time of illness. the hematopoietic, gastrointestinal, central nervous, and integumentary are the organ systems affected. there is a marked reduction of cells from all cell lines of the bone marrow. there is a direct correlation with the drop in absolute lymphocyte count with the dose of radiation received. the absolute lymphocyte count is commonly used to estimate the dose of radiation received. the gastrointestinal (gi) epithelial lining, one of the most rapidly dividing cell lines of the body is the second most vulnerable to radiation poisoning. the radiation dose required to affect the gi system is gy. vomiting, diarrhea, and a capillary leak syndrome for gi tract are common manifestations. hypovolemia and electrolyte instability ensue. translocation of bacteria into the bloodstream, combined with the diminished immunity caused by the decimation of the hematopoietic system, place victims at high risk for septic shock. another organ system affected by the acute radiation syndrome is the central nervous system. this requires a large dose of at least gy. manifestations include cerebral edema, disorientation, hyperthermia, seizures, and coma. acute radiation syndrome that involves the central nervous system is always fatal. the integumentary system is frequently affected by the acute radiation syndrome, especially if the skin is in direct contact with a radioisotope. epilation, erythema, dry desquamation, wet desquamation, and necrosis occur respectively with increasing severity associated with increasing doses of radiation. radiation burns can be distinguished from thermal or chemical burns by their delayed onset. it can take days to weeks for radiation burns to affect victims. thermal and chemical burns cause signs and symptoms more acutely. hospitals that anticipate victims of radiation should prepare areas of triage with decontamination supplies and techniques ready to be deployed. an emergency department (ed) should be divided into "clean" and "dirty" areas. the dirty area is created for the purpose of decontamination to prevent the spread of radioisotopes. all health care personnel should wear ppe including surgical scrubs and gowns, face shields, shoe covers, caps, and two pairs of gloves. the inner pair of gloves is taped to the sleeves of the gown. each health care worker should be monitored for the exposure of the radiation and its dose with a dosimeter worn underneath the gown. the radiation safety officer of the hospital should take a leadership role in health care worker protection and decontamination procedures. consultation from the radiation emergency, assistance center (react/ts) is imperative. react/ts is a subsidiary of the u.s. department of energy. its contact information is as follows: phone number during business hours is - - . the phone number is - - after business hours. the react/ts website is http://orise.orau. gov/reac/ts/. as victims arrive, triage protocols of mass casualty scenarios should be implemented. it should be noted that radiation exposure is not "immediately" lifethreatening. initial clinical management should focus on the abcde (airway, breathing, circulation, disability, and exposure) of basic trauma protocol. the "d" in the above acronym can also be a symbol for decontamination. after airway, breathing, and circulation are addressed, initial phase of decontamination entails careful removal of potentially contaminated clothing. caution should be exercised to remove the clothing gently, while rolling garments outward to prevent the release of dust of radioactive material that could contaminate people in the treatment area. further decontamination procedures take place after initial stabilization. skin decontamination procedures are identical to those of toxic chemical exposure with the following exceptions: • ppe are slightly different as described above. • gentle skin rubbing is done to prevent provocation of an inflammatory response and further absorption of the radioactive toxin. • only soap and water are used. rubbing alcohol and bleach should be avoided. it is advisable to shampoo the hair first, because it is usually the site of the highest level of contamination of the body, and runoff onto the body can then be cleansed during skin decontamination (radiation event medical management (remm) of the u.s. dept. of health and human services n.d.). it should be noted that health care workers are not at risk for contamination if they wear proper ppe during the resuscitation and decontamination process. the lack of knowledge of this point may lead to reluctance to treat patients and increase morbidity and mortality for victims. "no hcp has ever received a significant dose of radiation from handling, treating, and managing patients with radiation injuries and/or contamination."(react/s-cdc ). when initial resuscitation and decontamination have been completed, attention should be paid to ongoing support of ventilation, oxygenation, the management of fluid and electrolytes, and treatment of traumatic and burn injuries. infection control procedures are important due to the impending immunocompromised state of the victims. it is important to ascertain the details of the catastrophic event. data on the nature and size of the exposure and the types of radioactive agents involved are vital for ongoing management and decontamination. after the details of the nature of the exposure are uncovered, diagnostic tests should be done, including serial cbc and cytogenetic analysis of lymphocytes, otherwise known as cytogenic dosimetry (react/s-cdc ). measurements of change in lymphocyte counts and cytogenetic dosimetry are sensitive markers for the dose of radiation received by a victim. measurements of internal decontamination are done by the sampling and analysis of nasal and throat swabs, stool, and h urine. wound samples and irrigation fluid should also be sampled. after initial stabilization, external decontamination, and diagnostic testing, internal decontamination is performed. external decontamination involves removal of clothes and cleaning the skin and hair. internal decontamination removes radioisotopes that are internalized via inhalation, ingestion, and entry into open wounds. because ionizing radiation is being released inside the body, internal decontamination must be performed promptly after initial resuscitation. since radioisotopes behave identically to their nonradioactive counterparts, antidotes are chosen based on the chemical, and not the radiological properties of the element. basic strategies of internal decontamination include chelation, competitive inhibition, enhanced gastrointestinal elimination, and enhanced renal elimination. specific agents are used for chelation of different radioisotopes. dtpa (diethyenetriaminepentaacetic acid) is administered for the elimination of heavy metals such as americium, californium, curium, and plutonium. dtpa comes in two forms, calcium dtpa (ca-dtpa) and zinc-dtpa (zn-dtpa). ca-dtpa is ten times more effective than zn-dtpa. for adults and adolescents, administration is as follows: • g of ca-dtpa iv initially in the first h, followed by g zn-dtpa iv daily for maintenance. • for children less than years of age administer: • fourteen mg/kg ca-dtpa iv initially, followed by fourteen mg/kg of zn-dtpa iv daily thereafter (national council on radiation protection (ncrp) and measurements ). • the initial dose of dtpa may be administered via inhalation to adolescents and adults if the contamination occurred via inhalation. this method of administration is not approved for pediatric use. chelation with dimercaprol (bal) is used to eliminate polonium. bal is a highly toxic drug and should be administered with caution. the dose is . mg per kg im four times a day for days, then twice a day on the third day and once a day for - days, thereafter (national council on radiation protection (ncrp) and measurements ). alkalinization of the urine is renal protective during administration. a less toxic alternative to bal, dimercaptosuccinic acid (dmsa), otherwise known as chemet ® is also available. the dose of dmsa is ten mg per kg po every h for days. the same dose is given every h for days, thereafter (national council on radiation protection (ncrp) and measurements ). another mechanism for internal decontamination is competitive inhibition. the radioisotope, i, is released during a meltdown of a reactor at a nuclear power plant. potassium iodide (ki) is widely recognized as a competitive inhibitor to its radioactive counterpart, i, from being incorporated into the thyroid gland. ki blocks % of i uptake into the thyroid gland if ki is given within the first hour of exposure. it will block % of incorporation if given within h of exposure. its protective effect lasts for h. with administration of this drug, thyroid function should be monitored closely. dosing guidelines (table . ) are included in the table below (u.s. food and drug administration n.d.). gastrointestinal elimination is another mechanism of internal decontamination (table . ). an ion exchanger, prussian blue, (ferric ferrocyanide), binds elements that circulate through the enterohepatic cycle. since it is not absorbed through the gastrointestinal tract, prussian blue carries the toxins into the stool. it is highly effective in the elimination of cs or thallium and was used during the cs incident in goiania, brazil. the dosing of prussian blue is as follows: • infants: . - . mg per kg po three times a day (not fda approved). • children - years of age: g po three times a day. • children ≥ years of age: g po three times a day. • prussian blue is administered for at least days, and can be adjusted based on the degree of poisoning (national council on radiation protection (ncrp) and measurements ). urinary elimination is another useful method of internal decontamination. tritium can be eliminated with excess fluid administration. uranium is eliminated by alkalinizing the urine to a ph of - . sodium bicarbonate is given at a dose of meq/kg iv every - h and is titrated to effect. if renal injury occurs, dialysis may be required. the basic approach to treating acute radiation syndrome is supportive therapy. gi losses from gastrointestinal difficulties are treated with iv fluids and electrolyte replacement. -ht antagonists can be used to suppress vomiting and benzodiazepines for anxiety. a patient suffering from acute radiation syndrome may be severely immunocompromised and requires a room with positive pressure isolation. colony stimulating agents for granulocytes and erythrocytes can be used for bone anemia and leukopenia. bone marrow transplant may be required for severe cases. a patient with skin contamination with radiation should be decontaminated with soap and water. a geiger counter can be helpful to identify areas of contamination. scrubbing is performed in a concentric matter, beginning at the outer layers of contamination and moving into the center since the area of greatest contamination is in the center. in this way, the area of contamination remains contained. attention should be paid to good nutrition and pain control. burn and plastic surgery service should also be consulted. more details on decontamination can be found in chap. . the psychological impact of a radiation catastrophe on the pediatric victims is likely to be devastating (american academy of pediatrics (aap) ). sleep disturbances, social withdrawal, altered play, chronic fear and anxiety, and developmental regression can occur. a correlation between the parent's psychological response and that of the child would occur as with other types of disaster. mental health professionals should be consulted in the event of this type of situation. please refer to chap. for more information. a lot of concern has been expressed over the possibility of terrorist attacks involving explosive devices in recent years (depalma et al. ) . explosive devices are relatively simple to manufacture and easy to detonate. they can injure and kill many people and spread fear over large populations. victims of bomb blasts sustain more body regions injured, have more body injury severity scores, and require more surgeries than victims of nonexplosive trauma incidents. victims of explosives also have a higher mortality (kluger et al. ) . these observations are also true of pediatric victims (daniel-aharonson et al. ) . many factors influence the number of people injured and the severity of the injuries in an explosion. the magnitude of the explosion and its proximity to people and the number of people in the area affect the severity and number of injuries. other factors include the collapse of building or structure from the blast, promptness of the rescue operation, and the caliber and proximity of medical resources in the vicinity. victims who experience explosions in closed spaces are especially vulnerable to more severe injuries. twenty-nine case reports of injuries from terrorist bombings were reviewed (arnold et al. a) . the investigators compared the injury severity of victims of explosions who sustained injuries from structural collapse, closed space explosions without structural collapse, and open space explosions. the mortality rate for these victims was %, %, and %, respectively. hospitalization rates were %, %, and %, respectively. ed visits were %, %, and %, respectively. victims of closed space explosions without structural collapse experienced greater hospitalizations rates than those involved in a structural collapse, because many of the victims involved in the structural collapse experienced immediate death. an explosion is defined as a rapid chemical conversion of a liquid or solid into a gas with energy release. substances that are chemically predisposed to explosion, called explosives, are characterized as low or high order, depending on the speed and magnitude of energy release. low-order explosives release energy at a relatively slow pace and explosions from these substances tend not to produce large air pressure changes or a "blast." the energy release is caused by combustion, producing heat. the involved material "goes up in flames." gunpowder, liquid fuel, and molotov cocktails are examples of low-order explosives (centers for disease control and prevention ). explosions from high-order materials cause a blast with a pressure wave in addition to causing the release of heat and light. the blast pressure wave causes compression of the surrounding medium which is physically transformed in all directions from the exact point of explosion. when an explosion occurs on land, air is the surrounding medium compressed. in bodies of water, the surrounding medium is water. the degree of medium compression and the distance that the energy wave travels is determined by the magnitude of the explosion. the power of the blast is measured in pounds per square inch (psi). the pressure blast wave has distinctive characteristics. the amplitude of the wave reaches its highest point immediately after the blast. the blast wave then rapidly decays as it travels through space. as the blast wave propagates, and compresses the surrounding medium, it leaves a vacuum because of displaced molecules in the surrounding medium and a negative phase of the wave ensues. in a land explosion, air molecules are displaced by the initial positive pressure, after which a negative pressure occurs in the vacated space. a wave that propagates through a confined space rebounds off of the wall and reverberates. it may interact with victims in the confined space many times, causing more severe injuries (stuhmiller et al. ) (fig. . ). four kinds of injury occur in high energy explosions. primary blast injuries occur directly from the pressure wave of the blast. secondary injuries occur from being struck by flying objects from the blast. these injuries can be blunt or penetrating. tertiary injuries occur when victims are displaced from a location and strike other objects or surfaces. all other injuries related to the blast are called quarternary. they include burns, inhalational injuries, toxic exposures, and traumatic injuries from structural collapse. primary injuries from blast waves affect bodily tissues with a tissue gas interface. when a pressure wave enters the body, tissue of gas filled organs compress slower than the air inside the tissue, causing stress in the tissue, possibly damaging it. this baseline positive phase originally described by friedlander, a blast wave consists of a short, high-amplitude overpressure peak followed by a longer depression phase. injury potential depends on the wave's amplitude as well as the slopes of its increase and decrease in pressure. x-axis refers to time and y-axis refers to pressure. (jacobson and severin ) also known as the "spalling effect." as the negative pressure phase of the blast wave propagates through, it causes more stress on the tissue and further damage. in addition to damaging tissues with an air tissue interface, pressure blasts can cause injury to the brain and can lead to limb detachments. despite the fact that primary blast injuries can be ravaging, they are less common than other types of injury from blasts. the tympanic membranes, lungs, and gastrointestinal tract are the most common organs sustaining injury from pressure waves. the tympanic membrane is the most vulnerable of these three organ systems (depalma et al. ; garth ) . five psi, which is considered a weak blast, will rupture % of tympanic membranes. to put this in perspective, c , a commonly used explosive generates a pressure of four million psi. otoscopy can reveal ruptured tympanic membranes. neuropraxia, deafness, tinnitus, and vertigo are symptoms that can be experienced. severe blast injuries of the ear can result in damage to the organ of corti, resulting in permanent hearing loss. the second most common organ injured from a blast wave is the lung. fifteen psi are required to cause injury to this organ. lung injuries are more likely to occur from a blast within a closed space, or when victims sustain burns (burns commonly cause acute lung injury from release of inflammatory mediators). direct alveolar damage, blood vessel with bleeding, and inflammation are the three different manifestations of lung injury from blasts. alveolar damage can cause pneumothorax and pulmonary interstitial emphysema. when air dissects along the bronchovascular sheath, pneumomediastinum, pneumopericardium, and subcutaneous emphysema can occur. air that enters the pulmonary venous system can result in a systemic arterial air embolism, and possibly, a stroke. inflammation of the lungs from direct pressure damage to the tissue, cause acute lung injury and possibly, disseminated intravascular coagulation. clinical signs of lung injury include tachypnea, chest pain, hypoxia, rales, and dyspnea. if there is vascular disruption, hemoptysis can occur. air leaks from alveolar injury can result in diminished breath sounds, subcutaneous crepitance, increased resonance, and tracheal deviation. hemodynamic compromise will occur with tracheal deviation. alveolar damage, leading to air in the pulmonary venous system, can lead to a systemic arterial air embolism. air in the coronary arteries can lead to coronary ischemia with st and/or t waves changes on ecg. air embolism to cerebral arteries leads to cerebral vascular accidents (strokes) with focal neurological deficits. other manifestations of systemic air embolism include mottling of the skin, demarcated tongue blanching, and/or air in the retinal vessels (the most common sign of arterial air embolus). rapid death after initial survival is most often caused by arterial air embolus. initiation of positive pressure ventilation may trigger this event (ho and ling ) . a lung injury from a blast can also precipitate a vagal reflex resulting in bradycardia and hypotension. it is postulated that this occurs from the stimulation of c fibers in the lungs (guy et al. ). the gastrointestinal system is the third most common organ system affected by primary blast injury. physical stress and/or mesenteric infarct leads to weakening of the bowel wall with possible rupture. hemorrhage can also occur (paran et al. ; sharpnack et al. ) . the most common site of injury is the colon. injury to the bowel can be delayed and occur up to several days after the inciting incident. solid organs are spared because of their homogeneity and lack of air tissue interface. brain injury is becoming increasingly recognized as a result of primary blast. shearing injuries of the brain occur as a result of wave reverberation in the skull. hippocampal injury causing cognitive impairment has been shown in animal studies (cernak ; cernak et al. ; singer et al. ) . observations in humans have revealed electroencephalographic abnormalities and attention deficit disorder (born ) . human autopsies have revealed punctate hemorrhages and disintegration of nissl substance in victims who sustained blast injury without direct head trauma (guy et al. ) . research involving yucatan minipigs revealed that the brain sustains neuronal loss in the hippocampus after being subjected to primary blast injury. brain injury also occurred from the inflammation that ensued post blast (goodrich et al. ) . novel therapeutic approaches may be on the horizon for treatment of traumatic brain injury, including that caused by primary blast. intranasal insulin administered to rats subjected to traumatic brain injury resulted in enhanced neuronal glucose uptake and utilization, and subsequently improved motor function and memory. decreased neuroinflammation and preservation of the hippocampus were also noted (brabazon et al. ) . in a different investigation, a neuroprotective nucleotide, guanosine, was administered to rats subjected to traumatic brain injury. the treatment group of rats had better locomotor and cognitive outcomes than did the placebo group. programmed cell death and inflammation were also attenuated in the treatment group (gerbatin et al. ) . the leading cause of death from blast is from flying objects striking victims (secondary blast injury). eyes are particularly vulnerable. injuries resulting from displacement of the victims who strike objects are known as tertiary injuries. lighter weight children are particularly susceptible to this type of injury. burns, toxic exposures, and crush injuries constitute quaternary injuries. crush injuries commonly occur in explosions with structural collapse. the "crush syndrome" can occur when a trapped limb sustains prolonged compromise to the circulation, leading to rhabdomyolysis. tissue destruction and inflammatory response then occur. lifethreatening electrolyte abnormalities including hyperkalemia, renal failure, hyperuricemia, metabolic acidosis, acute respiratory distress syndrome, disseminated intravascular coagulation, and shock can result from crush syndrome (gonzalez ) . the crush syndrome is commonly seen in natural disasters that result in a lot of structural collapse. structural collapse and fires can cause the release of toxic materials such as carbon monoxide and cyanide. knowledge of the details of a blast can greatly enhance the ability of nurses and hcps to care for victims of a blast in a hospital setting. knowledge of whether a blast occurred in a closed or open space, whether structural collapse occurred, or if a victim was rescued from a collapsed area are details that can alert nurses and hcps as to what kind of injuries that they may anticipate. if toxic substances are released with a blast, nurses and hcps can prepare for decontamination techniques and antidote therapies. it would be advantageous for a hospital to be aware of the number of victims that are arriving for care. a mass casualty incident will stress the resources of the institution. hospital personnel should take stock of the resources that are available. the number of available ventilators and o-blood are examples of finite resources that should be considered. advanced trauma life support (atls) principles should be applied to all blast injury victims. abcd of initial resuscitation is applied. the "d" stands for disability as well as decontamination. decontamination techniques should be deployed if there is uncertainty about toxic exposure as described elsewhere in this chapter. on completion of abcd of initial resuscitation a secondary survey is performed, as described by atls protocol. attention should be paid to potential injuries that occur with blast injuries. ruptured tympanic membranes should alert the nurse or hcp of problems from primary blast injury. impaled objects should remain in place and removed in the operating room by surgical staff so that bleeding may be controlled. a thoracoscopy tube should be placed with an open three point seal over a wound on the side of the chest with an open pneumothorax. a hemothorax is also treated with a thoracoscopy tube. an autotransfusion setup can be applied to recirculate the blood from the pleural cavity of a hemothorax (wightman and gladish ) that would help preserve donor blood for other victims. for severe respiratory distress and/or impending respiratory failure, endotracheal intubation should be performed and positive pressure ventilation should be instituted. because lung tissue could be weakened from primary blast injury, caution should be exercised because of a high risk of pneumothorax, hemorrhage, or arterial air embolus. gentle application of positive pressure ventilation should be applied to avoid these complications. if only one lung is injured unilateral lung ventilation can be considered for larger children and adults. this technique is not suitable for babies and small children. supplemental oxygen with an fio of % should be administered to patients suspected of having an arterial air embolus. hyperbaric oxygen therapy could even be considered to help accelerate the removal of air from the arteries. placement of the patient in the left lateral recumbent position may reduce the likelihood of the air lodging in the coronary arteries. victims of blast injuries should be treated identically to those of other types of trauma after initial resuscitation is completed. if primary blast injury occurred, frequent chest and abdominal x-rays should be performed in consideration of the possibility of lung or gastrointestinal injuries. limbs with open fractures should be immobilized and covered with sterile dressings. systemic, broad spectrum antibiotics should be administered to patients with open limb injuries. eyes that sustained chemical injury should be irrigated with water for an hour. all injured eyes should be covered. most ruptured tympanic membranes will heal spontaneously. victims with tympanic membrane injury should be advised to avoid swimming for some time. topical antibiotics are prescribed if dirt or debris is seen in the ear canal. oral prednisone is prescribed for hearing loss. victims with crush injuries should be treated with large volumes of iv fluids to treat inflammatory shock and possibly rhabdomyolysis. electrolytes should be monitored carefully as these patients are at risk for hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia, and acidosis. smoke inhalation, burns, and toxic exposures should be treated according to guidelines of burn, trauma, and toxicology protocols. mass casualty incidents (i.e. mass shootings, active shooter events, bombings, and other multifatality crimes) often attract extensive media coverage as well as the attention of policy makers. many agencies and organizations record and publish data on these incidents. the measurement and reporting does vary based on the absence of a common definition. however, it is clearly evident that mass casualty incidents (mcis) continue to increase in both number and scope (federal bureau of investigation ; office for victims of crime, office of justice programs, u.s. department of justice ). in the u.s., mass shootings are the most common and most closely tracked. the congressional research service (crs) defines mass shootings as events where more than four people are killed with a firearm "within one event, and in one or more locations in close proximity." congress uses the term mass killings and describes these events as "three or more killings in a single incident." the federal bureau of investigation (fbi) uses the term active shooter, which it defines as "an individual actively engaged in killing or attempting to kill people in a populated area." it is important to realize that nongovernmental ( ranking third of all locations for and , seven of the incidents occurred in educational environments resulting in five killed and wounded. two incidents occurred in elementary schools, resulting in two killed (including a firstgrade student) and eight wounded (one teacher shot, three students shot, and four wounded from shrapnel). one incident occurred in a junior/senior high school, resulting in none killed and four wounded (two from shrapnel, all students). four incidents occurred at high schools (one outside a school during prom), resulting in three killed (all students) and seven wounded (all students). fortunately, no incident occurred at institutions of higher learning during or (advanced law enforcement rapid response training (alerrt) center, texas state university and federal bureau of investigation, u.s. department of justice ). notably, two of the incidents occurred in houses of worship, resulting in killed and wounded. one of these incidents occurred at the first baptist church in sutherland springs, texas, and had the third highest number of casualties ( killed and wounded) in . the dead included women, men, children ( girls and boy), and an unborn child (goldman et al. ) . a summary report has also been developed for all active shooter incidents from to , including incidents per year (fig. . ), casualties per year (fig. . ) , and location ( fig. . ) categories (federal bureau of investigation ; federal bureau of investigation ). overall, there was an increase in number of active shooter incidents and casualties per year. location categories with number of incidents and statistics of their contribution were provided: areas of educational environments account for a large portion of locations for active shooter incidents, ranking only second to commercial areas. of the incidents ( . %) occurring at schools, one took place at a nursery (pre-k) school and one incident occurred during a school board meeting that was being hosted on school property but no students were involved (neither perpetrator or victim). the remainder ( incidents) were perpetrated by or against students, faculty, and/or staff at k- schools (federal bureau of investigation ). finally, active shooter incidents ( %) did occur at institutions of higher learning. as a reminder, no incident occurred at institutions of higher learning during or . table . provides a detailed summary of educational environment incidents from to . since the beginning of , other tragic active shooter attacks have occurred in the u.s. and greatly impacted children and adolescents. two of these such events have occurred in educational environments (united states secret service national threat assessment center ). on february , , a gunman opened fire at marjory stoneman douglas high school. fourteen students and three staff members were killed while fourteen others were injured (follman et al. ) . twelve victims died inside the building, three died just outside the building on school premises, and two died in the hospital. the shooter was a former student of the school. another active shooter event occurred on may , at santa fe high school in santa fe, texas. the shooter killed ten individuals including eight students and two teachers while injuring others. the shooter was an enrolled student at the school (follman et al. ) . based on the statistics of active shooter incidents, casualties, and locations, it is vital to prepare schools and plan for such events. national preparedness efforts, including planning, are now informed by the presidential policy directive (ppd) that was signed by the president in march and describes the nation's approach to preparedness. this directive represents an evolution in our collective understanding of national preparedness based on the lessons learned from terrorist attacks, hurricanes, school incidents, and other experiences. ppd- defines preparedness around five mission areas and can be applied to school active shooter incidents. on march , , at : p.m., jeffery james weise, , armed with a shotgun and two handguns, began shooting at red lake high school in red lake, minnesota. before the incident at the school, the shooter fatally shot his grandfather, who was a police officer, and another individual at their home. he then took his grandfather's police equipment, including guns and body armor, to the school. a total of nine people were killed, including an unarmed security guard, a teacher, and five students; six students were wounded. the shooter committed suicide during an exchange of gunfire with police campbell county comprehensive high school (education) on november , , at : p.m., kenneth s. bartley, , armed with a handgun, began shooting in campbell county comprehensive high school in jacksboro, tennessee. before the shooting, he had been called to the office when administrators received a report that he had a gun. when confronted, he shot and killed an assistant principal and wounded the principal and another assistant principal. the shooter was restrained by students and administrators until police arrived and took him into custody pine middle school (education) on march , , at : a.m., james scott newman, , armed with a handgun, began shooting outside the cafeteria at pine middle school in reno, nevada. no one was killed; two were wounded. the shooter was restrained by a teacher until police arrived and took him into custody essex elementary school and two residences (education) on august , , at : p.m., christopher williams, , armed with a handgun, shot at various locations in essex, vermont. he began by fatally shooting his ex-girlfriend's mother at her home and then drove to essex elementary school, where his ex-girlfriend was a teacher. he did not find her, but as he searched, he killed one teacher and wounded another. he then fled to a friend's home, where he wounded one person. a total of two people were killed; two were wounded. the shooter also shot himself twice but survived and was apprehended when police arrived at the scene orange high school and residence (education) on august , , at : p.m., alvaro castillo, , armed with two pipe bombs, two rifles, a shotgun, and a smoke grenade, began shooting a rifle from his vehicle at his former high school, orange high school in hillsborough, north carolina. he had fatally shot his father in his home that morning. one person was killed; two were wounded. the shooter was apprehended by police weston high school (education) on september , , at : a.m., eric jordan hainstock, , armed with a handgun and a rifle, began shooting in weston high school in cazenovia, wisconsin. one person was killed; no one was wounded. the shooter was restrained by school employees until police arrived and took him into custody west nickel mines school (education) on october , , at : a.m., charles carl roberts, iv, , armed with a rifle, a shotgun, and a handgun, began shooting at the west nickel mines school in bart township, pennsylvania. after the shooter entered the building, he ordered all males and adults out of the room. after a -min standoff, he began firing. the shooter committed suicide as the police began to breach the school through a window. five people were killed; five were wounded on april , , at : a.m., su nam ko, aka one l. goh, , armed with a handgun, began shooting inside oikos university in oakland, california. he then killed a woman to steal her car. seven people were killed; three were wounded. the shooter was arrested by police later that day on august , , at : a.m., robert wayne gladden jr., , armed with a shotgun, shot a classmate in the cafeteria of perry hall high school in baltimore, maryland. the shooter had an altercation with another student before the shooting began. he left the cafeteria and returned with a gun. no one was killed; one person was wounded. the shooter was restrained by a guidance counselor before being taken into custody by the school's resource officer sandy hook elementary school and residence (education) on december , , at : a.m., adam lanza, , armed with two handguns and a rifle, shot through the secured front door to enter sandy hook elementary school in newtown, connecticut. he killed students and six adults, and wounded two adults inside the school. prior to the shooting, the shooter killed his mother at their home. in total, people were killed; two were wounded. the shooter committed suicide after police arrived taft union high school (education) on january , , at : a.m., bryan oliver, , armed with a shotgun, allegedly began shooting in a science class at taft union high school in taft, california. no one was killed; two people were wounded. an administrator persuaded the shooter to put the gun down before police arrived and took him into custody new river community college, satellite campus (education) on april , , at : p.m., neil allen macinnis, , armed with a shotgun, began shooting in the new river community college satellite campus in the new river valley mall in christiansburg, virginia. no one was killed; two were wounded. the shooter was apprehended by police after being detained by an off-duty mall security officer as he attempted to flee santa monica college and residence (education) on june , , at : a.m., john zawahri, , armed with a handgun, fatally shot his father and brother in their home in santa monica, california. he then carjacked a vehicle and forced the driver to take him to the santa monica college campus. he allowed the driver to leave her vehicle unharmed but continued shooting until he was killed in an exchange of gunfire with police. five people were killed; four were wounded sparks middle school (education) on october , , at : a.m., jose reyes, , armed with a handgun, began shooting outside sparks middle school in sparks, nevada. a teacher was killed when he confronted the shooter; two people were wounded. the shooter committed suicide before police arrived arapahoe high school (education) on december , , at : p.m., karl halverson pierson, , armed with a shotgun, machete, and three molotov cocktails, began shooting in the hallways of arapahoe high school in centennial, colorado. as he moved through the school and into the library, he fired one additional round and lit a molotov cocktail, throwing it into a bookcase and causing minor damage. one person was killed; no one was wounded. the shooter committed suicide as a school resource officer approached him berrendo middle school (education) on january , , at : a.m., mason andrew campbell, , armed with a shotgun, began shooting in berrendo middle school in roswell, new mexico. a teacher at the school confronted and ordered him to place his gun on the ground. the shooter complied. no one was killed; were wounded: students and an unarmed security guard. the shooter was taken into custody (continued) on june , , at : p.m., aaron rey ybarra, , armed with a shotgun, allegedly began shooting in otto miller hall at seattle pacific university in seattle, washington. he was confronted and pepper sprayed by a student as he was reloading. one person was killed; were wounded. students restrained the shooter until law enforcement arrived reynolds high school (education) on june , , at : a.m., jared michael padgett, , armed with a handgun and a rifle, began shooting inside the boy's locker room at reynolds high school in portland, oregon. one student was killed; teacher was wounded. the shooter committed suicide in a bathroom stall after law enforcement arrived marysville-pilchuck high school (education) on october , , at : a.m., jaylen ray fryberg, , armed with a handgun, began shooting in the cafeteria of marysville-pilchuck high school in marysville, washington. four students were killed, including the shooter's cousin; students were wounded, including one who injured himself while fleeing the scene. the shooter, when confronted by a teacher, committed suicide before law enforcement arrived florida state university (education) on november , , at : a.m., myron may, , armed with a handgun, began shooting in strozier library at florida state university in tallahassee, florida. he was an alumnus of the university. no one was killed; were wounded. the shooter was killed during an exchange of gunfire with campus law enforcement. umpqua community college (education) on october , , at : a.m., christopher sean harper-mercer, , armed with several handguns and a rifle, began shooting classmates in a classroom on the campus of umpqua community college in roseburg, oregon. nine people were killed; were wounded. the shooter committed suicide after being wounded during an exchange of gunfire with law enforcement. madison junior/ senior high school (education) on february , , at : a.m., james austin hancock, , armed with a handgun, allegedly began shooting in the cafeteria of madison junior/senior high school in middletown, ohio. he shot two students before fleeing the building. no one was killed; four students were wounded (two from shrapnel). the shooter was apprehended near the school by law enforcement officers antigo high school (education) on april , , at : p.m., jakob edward wagner, , armed with a rifle, began shooting outside a prom being held at his former school, antigo high school in antigo, wisconsin. two law enforcement officers, who were on the premises, heard the shots and responded immediately. no one was killed; two students were wounded. the shooter was wounded in an exchange of gunfire with law enforcement officers and later died at the hospital townville elementary school (education) on september , , at : p.m., jesse dewitt osborne, , armed with a handgun, allegedly began shooting at the townville elementary school playground in townville, south carolina. prior to the shooting, the shooter, a former student, killed his father at their home. two people were killed, including one student; three were wounded, one teacher and two students. a volunteer firefighter, who possessed a valid firearms permit, restrained the shooter until law enforcement officers arrived and apprehended him on january , , at : a.m., ely ray serna, , armed with a shotgun, allegedly began shooting inside west liberty salem high school, in west liberty, ohio, where he was a student. after assembling the weapon in a bathroom, the shooter shot a student who entered, then shot at a teacher who heard the commotion. the shooter shot classroom door windows before returning to the bathroom and surrendering to school administrators. no one was killed; two students were wounded. school staff members subdued the shooter until law enforcement arrived and took the shooter into custody freeman high school (education) on september , , at : a.m., caleb sharpe, , armed with a rifle and a pistol, allegedly began shooting at freeman high school in rockford, washington, where he was a student. one student was killed; three students were wounded. a school employee confronted the shooter, ordered him to the ground, and held him there until law enforcement arrived and took him into custody rancho tehama elementary school and multiple locations in tehama county, california (education) on november , , at : a.m., kevin janson neal, , armed with a rifle and two handguns, began shooting at his neighbors, the first in a series of shootings occurring in rancho tehama reserve, tehama county, california. after killing three neighbors, he stole a car and began firing randomly at vehicles and pedestrians as he drove around the community. after deliberately bumping into another car, the shooter fired into the car and wounded the driver and three passengers. the shooter then drove into the gate of a nearby elementary school. he was prevented from entering the school due to a lockdown, so he fired at the windows and doors of the building, wounding five children. upon fleeing the school, the shooter continued to shoot at people as he drove around rancho tehama reserve. law enforcement pursued the shooter; they rammed his vehicle, forced him off the road, and exchanged gunfire. the shooter's wife's body was later discovered at the shooter's home; the shooter apparently had shot and killed her the previous day. in total, five people were killed; were wounded, eight from gunshot injuries (including one student) and six from shrapnel injuries (including four students). the shooter committed suicide after being shot and wounded by law enforcement during the pursuit aztec high school (education) on december , , at approximately : a.m., william edward atchison, , armed with a handgun, began shooting inside aztec high school in aztec, new mexico. the shooter was a former student. two students were killed; no one was wounded. the shooter committed suicide at the scene, before police arrived a in a study of active shooter incidents in the united states between and , the fbi identified locations where the public was most at risk during an incident. these location categories include commercial areas (divided into business open to pedestrian traffic, businesses closed to pedestrian traffic, and malls), education environments (divided into schools [prekindergarten through th grade] and institutions of higher learning), open spaces, government properties (divided into military and other government properties), residences, houses of worship, and health care facilities. in , the fbi added a new location category, other location, to capture incidents that occurred in venues not included in the previously identified locations (federal bureau of investigation ). this table only includes educational environments. an entire list of all incidents from to at all locations can be found at https://www.fbi.gov/file-repository/activeshooter-incidents- .pdf/view (federal bureau of investigation prevention means the capabilities necessary to avoid, deter, or stop an imminent crime or threatened/actual mass casualty incident. prevention is the action schools take to prevent a threatened or actual incident from occurring. protection means the capabilities to secure schools against acts of violence and man-made or natural disasters. protection focuses on ongoing actions that protect students, teachers, staff, visitors, districts, networks, and property from a threat or hazard. mitigation means the capabilities necessary to eliminate or reduce the loss of life and property damage by lessening the impact of an event or emergency at the school. it also means reducing the likelihood that threats and hazards will happen. response means the school's or school district's capabilities necessary to stabilize an emergency once it has already happened or is certain to happen in an unpreventable way, establish a safe and secure environment, save lives and property, and facilitate the transition to recovery. recovery means the capabilities necessary to assist schools affected by an event or emergency in restoring the learning environment. it also means teaming with community partners to restore educational programming, the physical environment, business operations, and social, emotional, and behavioral health. the majority of prevention, protection, and mitigation activities generally occur before an incident, although these three mission areas do have ongoing activities that can occur throughout an active shooter incident. response activities occur during an incident, and recovery activities can begin during an incident and occur after an incident (united states department of education, office of elementary and secondary education, office of safe and healthy students ; united states department of homeland security b; united states department of homeland security ). in the k- school security guide, the u.s. department of homeland security (dhs) focuses on prevention and protection since the activities and measures associated with them occur prior to an incident ( ). effective preventative and protective actions decrease the probability that schools (or other facilities) will encounter incidents of gun violence or should an incident occur, it reduces the impact of that incident. the guide emphasizes that the level of security at a facility will be based on hazards relevant to the facility, people, or groups associated with it. it also warns that as new or different threats become apparent, the perception of the relative security changes and insecurity should drive change to reflect the level of confidence of the people of groups associated with the facility. the dhs utilizes a hometown security approach that emphasizes the process of connect, plan, train, and report (cptr) with the objective to realize effective, collaborative outcomes (united states department of homeland security b). the initial phase is connect and occurs by a school or district reaching out and developing relationships in the community, including local law enforcement. having these relationships before an incident or event can help speed up the response when something happens. each school must begin with identification or development of a security team, group, or organization. this phase also emphasizes outreach, collaboration, and building of a coalition. there should be coalition members from within a school and may include district/school administrators, teachers, aides, facility operations personnel, human resources, administrative, counseling, and student groups. external groups directly related to the school might include boards of education, parent organizations, mental health groups/agencies, and teacher and bus driver unions. external groups indirectly related to the school include all responder organizations such as police and fire departments, sheriff's office, emergency medical services, emergency management, and the local dhs protective security advisor (psa). other tangential groups such as volunteer organizations, utility providers, and facilities in close geographic proximity should also be considered. core and advisory members of the coalition are established. a coalition champion is also identified and is the person who owns the majority of the responsibility for achieving a school's security goals. the champion organizes the coalition as it grows and matures (united states department of homeland security b). the next phase is plan. this will bring the coalition together. the guide for developing high quality school emergency operations plans (united states department of education, office of elementary and secondary education, office of safe and healthy students ) is an excellent resource for the coalition. a school security survey for gun violence can be completed and the coalition or user can quickly and effectively determine a facility's security proficiency (united states department of homeland security. ). specific portions of or topics within a school plan should be assigned to individuals, committees, or working groups most qualified to address them. the planning process must be sustainable. the amount of time spent in the planning phase should be commensurate with the amount of effort expended on the other phases (united states department of homeland security b). the next phase of the process is to train on the plan developed by the coalition. determining who is responsible for what and how it should be done is the basic function of planning. in fact, telling various members of the team what is expected of them and when to do that activity is the function of training. it is vital to utilize the curricula development expertise possessed by the k- community. school administrators should take advantage of this skill set and find creative ways to address difficult topics, such as gun violence. it should be carried out in an effective and nontraumatic way. presenting the training in pieces or steps allows for a more comprehensive learning experience. it is important to validate training through exercises and drills, all of which should include the students. the training event should be followed by the completion and implementation of an after-action improvement plan with adjustment of the cptr as indicated (united states department of homeland security b). the final phase in the process is report. the reporting phase is arguably the most important of all the phases. reporting principles underlie the other three phases and have profound prevention and protection impacts by driving forward information. dhs models the reporting phase using the "if you see something, say something ® " campaign (u.s. dhs, ) and the nationwide suspicious activity reporting (sar) initiative (nationwide suspicious activity reporting initiative (nsi) ). "if you see something, say something ® " focuses on empowering anyone who sees suspicious activity to do something about it by contacting local law enforcement, or if an emergency to call - - (united states department of homeland security a). this is a compelling capability when well organized and managed. a good plan for reporting, especially for a k- school, involves training staff and students on what is considered suspicious. there are many methods in which schools can employ to facilitate this, such as dedicated telephone numbers, websites for anonymous reporting, email or text messaging, and mobile phone applications. conducting simple drills for reporters and receivers keeps skills sharp and reinforces the importance of the effort with the goal to save lives. if the plan includes sharing all suspicious activity calls with the local fusion center then the probability of higher fidelity reporting increases (united states department of homeland security b). when making changes to a school's plans, procedures, and protective measures, it is imperative the needs of individuals with special health care needs be addressed throughout the process. planning, training, and execution should always consider accessible alert systems for those who are deaf or hard of hearing; students, faculty, and staff who have visual impairments or are blind; individuals with limited mobility; alternative notification measures; people with temporary disabilities; visitors; people with limited english proficiency; sign cards with text-and picture-based emergency messages/symbols; and involving people with disabilities in all planning (united states department of homeland security, interagency security committee ). it is important to understand that no "profile" exists for an active shooter (united states department of education, office of elementary and secondary education, office of safe and healthy students ). however, research indicates there may be signs or indicators. o'toole ( ) presents an in depth, systematic procedure for school shooter threat assessment and intervention. the model was designed to be used by educators, mental health professionals, and law enforcement agencies. its fundamental building blocks are the threat assessment standards, which provide a framework for evaluating a spoken, written, and symbolic threat, and the fourpronged assessment approach which provides a logical, methodical process to examine the threatener and assess the risk that the threat will be carried out. schools should learn the signs of a potentially volatile situation that may develop into an active shooter situation and proactively seek ways to prevent an incident with internal resources, or additional external assistance (united states department of education, office of elementary and secondary education, office of safe and healthy students ). potential warning signs of a school shooter may include increasingly erratic, unsafe, or aggressive behaviors; hostile feelings of injustice or perceived wrongdoing; drug and alcohol abuse; marginalization or distancing from friends and colleagues; changes in performance at work or school; sudden and dramatic changes in home life or in personality; pending civil or criminal litigation; and observable grievances with threats and plans of retribution (united states department of homeland security b). at a minimum, schools should establish and enforce policies that prohibit, limit, or determine unacceptable behaviors and consequences of weapons possession/use, drug possession/use, alcohol/tobacco possession/use, bullying/harassment, hazing, cyber-bullying/harassment/stalking, sexual assault/misconduct/harassment, bias crimes, social media abuse, and any criminal acts (united states department of homeland security b). in addition to policies and positive school climates, school districts and administrators should establish dedicated teams to evaluate threats, such as a threat assessment team (tat). the team should include mental health professionals (e.g., forensic psychologist, clinical psychologist, and school psychologist) to contribute to the threat assessment process (united states department of homeland security b). it is the responsibility of the tat to investigate and analyze communications and behaviors to make a determination on whether or not an individual poses a threat to him/herself or others (united states department of education, office of elementary and secondary education, office of safe and healthy students ). as well as tats, some schools have even opted to establish social media monitoring teams which look for keywords that may indicate bullying or other concerning statements. if a school opts to create such a team, it should work very closely with the tat to ensure that applicable privacy, civil rights and civil liberties, other federal, state and local laws, and information sharing protocols are followed. please refer to chap. for further information. after an active shooter incident, field triage (e.g., jumpstart) must commence and the patient must be evaluated by an experienced emergency medicine or trauma surgeon, preferably by a pediatric specialist in those disciplines. if an active shooter incident is coupled with detonation of an explosive device, the child must be screened and decontaminated for radiation exposure ("dirty bomb"). triage tags are extremely helpful when multiple victims present in a short period of time. medical response to an active shooter event will focus on control of external hemorrhage along with circulatory stabilization. operative emergencies will be common and receive the highest priority. severe extremity injuries may be controlled with tourniquet application or other forms of hemorrhage control. re-evaluation is paramount to prevent ischemia to distal regions. however, thoracic or abdominal (truncal) injuries will need immediate surgical exploration and intervention. penetrating trauma will cause more vascular injuries than blunt trauma, and vascular surgical trays may be in short supply at a hospital. major procedure or surgical trays may become short in supply based on the increased operative demand. resuscitative blood transfusion therapy may utilize a massive blood transfusion protocol. since whole blood may be short in supply, some will simply use the : : rule (administer one unit of packed cells: one unit of fresh frozen plasma: one unit of platelets). a unit for children may be substituted as an aliquot based on size of the patient (e.g., administer ml/kg of packed cells: ml/kg of fresh frozen plasma: ml/kg of platelets). calcium must also be replaced when there is a large volume transfusion. due to extensive blood product utilization, there may be a heavy impact on institutional or regional blood supplies. plans should be in place to address these problems, including the implementation of allocation of scarce resources. mental health support and staff debriefs are essential and should be included after an active shooter event (hick et al. ). in conclusion, all forms of disasters, whether man-made or natural, impact infants, children, and adolescents throughout the world. effective and efficient interventions remain the cornerstone of sustaining a child's well-being while reducing untoward complications due to all forms of disasters. having a deep understanding of pediatric physiology and pathophysiology is crucial to all levels of disaster diagnostics and therapeutics. all nurses and hcps have an obligation to understand these principles and deliver excellent, compassionate care to the pediatric disaster victim. advanced law enforcement rapid response training evidence-based support for the all-hazards approach to emergency preparedness ahls advanced hazmat life support provider manual active shooter incidents in the united states in and radiation disasters and children-committee on environmental health apls: the pediatric emergency medicine resource textbook 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-gi zj m authors: gersons, berthold p. r.; smid, geert e.; smit, annika s.; kazlauskas, evaldas; mcfarlane, alexander title: can a ‘second disaster’ during and after the covid- pandemic be mitigated? date: - - journal: european journal of psychotraumatology doi: . / . . sha: doc_id: cord_uid: gi zj m in most disasters that have been studied, the underlying dangerous cause does not persist for very long. however, during the covid- pandemic a progressively emerging life threat remains, exposing everyone to varying levels of risk of contracting the illness, dying, or infecting others. distancing and avoiding company have a great impact on social life. moreover, the covid- pandemic has an enormous economic impact for many losing work and income, which is even affecting basic needs such as access to food and housing. in addition, loss of loved ones may compound the effects of fear and loss of resources. the aim of this paper is to distil, from a range of published literature, lessons from past disasters to assist in mitigating adverse psychosocial reactions to the covid- pandemic. european, american, and asian studies of disasters show that long-term social and psychological consequences of disasters may compromise initial solidarity. psychosocial disruptions, practical and financial problems, and complex community and political issues may then result in a ‘second disaster’. lessons from past disasters suggest that communities and their leaders, as well as mental healthcare providers, need to pay attention to fear regarding the ongoing threat, as well as sadness and grief, and to provide hope to mitigate social disruption. en la mayoría de los desastres que han sido estudiados, la causa subyacente que genera el peligro no persiste por mucho tiempo. sin embargo, durante la pandemia covid- una amenaza a la vida progresivamente emergente es mantenida, exponiendo a todos a variados niveles de riesgo de contraer la enfermedad, morir o infectar a otros. distanciarse y evitar la compañía tiene un gran impacto en la vida social. además, la pandemia covid- tiene un impacto económico enorme para muchos por la pérdida de trabajos e ingreso, lo que está incluso afectando las necesidades básicas como la comida o la vivienda. en adición a esto, la pérdida de seres queridos puede agravar los efectos del miedo y la pérdida de recursos. el objetivo de este artículo es sintetizar a partir de una variedad de literatura publicada, lecciones de desastres pasados para ayudar a mitigar las reacciones psicosociales adversas a la pandemia covid- . trabajos europeos, americanos y asiáticos sobre desastres muestran que las consecuencias a largo plazo tanto sociales como económicas de los desastres pueden poner en peligro la solidaridad inicial. las disrupciones psicosociales, los problemas prácticos y financieros, y los complejos problemas comunitarios y políticos pueden resultar en un 'segundo desastre'. las lecciones de desastres pasados sugieren que las comunidades, sus líderes y también los proveedores de atención en salud mental necesitan prestar atención al miedo en relación a la amenaza en curso, así como a la tristeza y al duelo, y proveer esperanza para mitigar la disrupción social. extensive research on previous disasters has yielded a usable definition of disaster as the result of exposure to a hazard that threatens personal safety, disrupts community and family structures, and results in personal and societal loss, creating demands that exceed existing resources (ursano, fullerton, weisaeth, & raphael, ) . it seems that the current pandemic shares certain characteristics with previous disasters (jacobs et al., ; mcfarlane & van hooff, ; puente, marín, Álvarez, flores, & grassau, ; sundram et al., ; van der velden, bosmans, bogaerts, & van veldhoven, ; watson, brymer, & bonanno, ) . one of the critical challenges is how to use available information and knowledge to inform those who are in charge of the response (fogli & guida, ; krumkamp et al., ) . important sources are the responses to the spanish influenza pandemic (martini, gazzaniga, bragazzi, & barberis, ) and the severe acute respiratory syndrome (sars) epidemic (mak, chu, pan, yiu, & chan, ). specific to the coronavirus disease (covid- ) pandemic is the progressively emerging life threat. this leads, as in other disasters, to a loss of safety; people becoming dependent on each other's behaviour (help and compliance with measures to limit the spread of the virus); the breakdown of infrastructure, with hospitals and healthcare institutions being critically hit and social networks disrupted by lockdowns; and chaos, as illustrated by people hoarding and searching for reliable information, aggravated by the different restrictive measures taken across countries worldwide. finding accurate and reliable sources of information in this pandemic is critical in these circumstances. this has been complicated by the rise of social media as the preferred source of information by some groups in the community, rather than their depending on more carefully edited conventional media outlets (depoux et al., ) . the covid- pandemic and social restrictions have already been shown to impact mental health (fiorillo & gorwood, ; vindegaard & eriksen benros, ) . a sizeable proportion of people recovering from treatment at an intensive care unit (icu) develop posttraumatic stress disorder (ptsd) (davydow, gifford, desai, needham, & bienvenu, ; paparrigopoulos et al., ) . healthcare workers are affected, for whom stressors include confrontation with suffering and death, risk of contracting disease, and moral dilemmas (williamson, murphy, & greenberg, ) . they are at risk of psychological and post-traumatic distress (kisely et al., ) and grief reactions (wallace, wladkowski, gibson, & white, ) . relatives of covid- patients are affected, as they may experience caregiver stress and be confronted with the death of their loved one (hawryluck et al., ) . the initially successful measures taken for containing the virus may be followed by far more socially disruptive consequences related to the psychosocial isolation and the economic consequences (galea & abdalla, ; vigo, thornicroft, & gureje, ; zhang et al., ) . what can we learn from previous disasters? people's response to disasters has previously been described as a phased process (neal, ; raphael, ) . this phased approach enables the identification of the most common reactions to disasters (sundnes, ) . various analyses of these longitudinal models have been conducted and can assist in planning and anticipating the emerging issues in the covid- pandemic response (birnbaum, daily, & o'rourke, ; mcfarlane & williams, ) . in the threat phase, there is an appraisal of the emerging risk, which has been reflected differently between individuals and nations, from the polarity of denial to planning and adaptive action. perhaps, more than in most other disasters, we can see the differential and cascading consequences of the variable willingness to accurately assess an emerging threat. during the initial impact phase, the disaster unfolds, measures to contain its impact are taken, and an emotional outcry is manifested. however, covid- is a continuous disaster and responses to this disaster may vary among different populations as the disaster unfolds (dara, ashton, farmer, & carlton, ) . indeed, communities and countries may differ significantly in the extent to which the spread of the disease is brought to a halt. this, in turn, may lead to great variations in the sense of threat. the covid- pandemic shows a protracted impact phase: expressions of sadness and anger are muted, while powerlessness and alertness remain. the subsequent, in this case less prominent, honeymoon phase is characterized by feelings of relief and connection that are marked by spontaneous acts of solidarity and connectedness, such as clapping for healthcare providers. without a vaccine or established evidence-based treatment, the threat is still ongoing. the disillusion phase reactions may also vary between populations, in part driven by the extent of fractious social media debates and the politicization of the response options, such as whether to wear or not to wear face masks. people have become increasingly tired of chaos and fear, and those affected by the pandemic, such as slowly recovering covid- patients and the families of the deceased, will increasingly feel forgotten. the spotlight progressively will fade out on healthcare workers and caregivers in nursing homes who worked so hard without the necessary equipment. people suffering from diseases such as cancer and cardiovascular disease, and their caregivers, in families who have experienced restricted access to the required health services during lockdown, will have major concerns about their health. others are hit by the economic impact and many will long for the return of normal affective social relations. this phase therefore carries the risk of splintering society between groups that are affected differently, thereby creating a breeding ground for a 'second disaster' to take place (erikson, ; yzermans & gersons, ) . the final phase, the reintegration phase, still seems far away. a further important dynamic of this disaster and its phases is that the source of the threat has not lessened, and a constant reappraisal and adaptation to the risks is required as the impact phase will not come to an end until a vaccine has been developed or the virus has been eliminated from the community. what do previous disasters teach us about containing psychosocial impacts? in response to the / attacks in the usa, five essential elements of interventions were identified to be promoted as part of the disaster response, ranging from provision of community support and public health messaging to clinical assessment and intensive intervention (hobfoll et al., ) . the five elements are summarized in table and applied to the covid- pandemic. first, to promote a sense of safety; for example, by taking measures to limit the spread of the virus and disseminating knowledge about the virus. in the covid- situation, eliminating the disease threat may not be possible, as herd immunity and a vaccine are yet to come. secondly, for authorities and experts to promote calming. during the pandemic this can be achieved by clearly explaining measures, considering the implications involved, and showing genuine compassion. thirdly, to promote a sense of self-and collective efficacy. self-efficacy is the individual's belief that his or her actions generally lead to positive outcomes, and this can be extended to collective efficacy, which is the sense that one belongs to a group that is likely to experience positive outcomes. efficacy beliefs result from accurate information appraisal, considered decision making, behavioural skills, and practised repertoires, as well as access to resources (patterson, weil, & patel, ) . thus, during the covid- pandemic, leadership may enhance collective efficacy by communicating the effects of the measures, showing genuine empathy, sharing the economic burdens, promoting solidarity, and promoting activities that are conceptualized and implemented by the community, such as religious activities and mourning rituals. fourthly, to promote connectedness by preventing disadvantage or exclusion of specific groups, and adjustment of social services to the needs of the most vulnerable groups. fifthly, to instil realistic hope by providing perspective and mitigating feelings of powerlessness and discouragement. sources of hope include effective threat appraisal, self-reliance, demonstrated benefits of scientific appraisal and rational action, religious beliefs, belief in a responsive government, and superstitious beliefs. indeed, the covid- pandemic has seen a rise in religious coping (bentzen, ) . do these elements translate differently to the different affected groups in the process of setting policy and designing intervention strategies? for patients and healthcare workers, the disaster experience involves intense fear of one's own death or the death of someone close, and promoting safety and calming are the first priorities. this requires the active and effective resourcing of the health system, which includes the provision of high-quality personal protective equipment and ensuring the welfare and protection of families of healthcare workers. proper financial support for healthcare workers who become sick and adequate compensation for the families of those who die from the infection are critical. for people experiencing the loss of loved ones or economic needs of the population amid the pandemic actions required by authorities and experts to mitigate the impact of covid- sense of safety immediate actions of public health measures to limit the spread of the infection delivery of reliable information for the general population and various groups about the disease effective resourcing of required medical equipment calming active communication and constant explanation of the actions needed to contain the spread of the infection to the population compassion of authorities towards victims and various groups affected by the pandemic sense of self-and collective efficacy communication of plans on coping with the economic and social effects of the pandemic stimulating in everyone the sense that one belongs to a group promotion of solidarity and community activities, such as mourning or religious rituals connectedness active implementation of digital services in education, public institutions, and other services to ensure social functioning of different groups ensuring the functioning of social services, and adjustment of services to the new models of care for vulnerable groups acknowledgement of loss and sadness in the community hope providing perspective and mitigating feelings of powerlessness and discouragement communication about progress of treatment and vaccine developments symbolic rituals and events to promote resilience facilitation of various community, charity, and business initiatives targeted towards a better future losses, the disaster causes isolation and despair, and promoting connectedness and instilling hope are paramount. promoting a sense of self-and collective efficacy is a key priority for all affected groups. collective failure may create or deepen societal splits along historical and intergenerational fault lines, resulting in a second disaster. this variety in affected groups creates a challenge in dealing with the pandemic's consequences. decision makers may be tempted to focus more on certain affected groups, to the detriment of others, thus creating a hierarchy of suffering. with growing tension, there is a risk that affected groups will come to stand directly opposite each other while losing confidence in the government. a split along intergenerational lines carries particular risks. counterbalancing disillusionment is possible when loss and grief are given a place and when government and businesses explicitly create prospects for those affected economically. efforts are crucial to prevent and treat the mental health impact of the pandemic in all sectors of society, including healthcare workers . care providers in hospitals and residential care organizations for elderly people need peer support, spiritual care, and access to mental healthcare for treatment of burnout, ptsd, moral injury, and other conditions. aftercare for recovered covid- patients needs to include access to specialized treatment of icu-treatment-related ptsd. there is also the risk of post-infection syndromes including chronic pain, depression, and fatigue (moldofsky & patcai, ) . specific attention needs to be paid to the management and treatment of bereaved individuals. grief interventions taking into account the complex circumstances of the loss, such as ritual omissions and other cultural and intergenerational determinants of meaning attribution (smid, ) , may support meaning reconstruction following loss and thereby contribute towards increasing connectedness and inspiring hope. the pandemic affects the traditional means of delivery of psychosocial services, including psychological treatments for mental disorders. this causes challenges in the delivery of the available evidence-based practice models, as novel digital models of care need to be developed and implemented to ensure access to mental health services in various phases of the pandemic (javakhishvili et al., ) . while a number of studies on the effects of the covid- pandemic are emerging, this disaster is still unfolding, with a lot of uncertainty about its course. based on the studies of previous disasters, we identified possible psychological responses to the covid- pandemic. we also foresee that psychosocial disruptions, practical and financial problems, and complex community and political issues associated with the pandemic could result in a second disaster. lessons from past disasters suggest that communities and their leaders, as well as mental healthcare providers, need to address the different needs of various populations in society. in particular, there is a need to pay attention to fear regarding the ongoing threat, as well as sadness and grief; and to provide a sense of safety, connectedness, and hope to mitigate social disruption. we have no commercial interest to disclose. we have not asked for or received any funding for this study. in crisis, we pray: religiosity and the covid- pandemic. london: centre for economic policy research and evaluations of the health aspects of disasters, part iii: framework for the temporal phases of disasters worldwide disaster medical response: an historical perspective posttraumatic stress disorder in general intensive care unit survivors: a systematic review the pandemic of social media panic travels faster than the covid- outbreak the wake of the 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disturbances: a longitudinal study the differential outcomes of coronavirus disease in low-and middle-income countries vs high-income countries covid- pandemic and mental health consequences: systematic review of the current evidence grief during the covid- pandemic: considerations for palliative care providers postdisaster psychological intervention since / covid- and experiences of moral injury in front-line key workers toxic turmoil: psychological and societal consequences of ecological disasters mental health and psychosocial problems of medical health workers during the covid- epidemic in china key: cord- - q jbcl authors: coppola, damon p. title: participants – multilateral organizations and international financial institutions date: - - journal: introduction to international disaster management doi: . /b - - - - . - sha: doc_id: cord_uid: q jbcl multilateral organizations are composed of sovereign governments. they may be regional, organized around a common issue or function, or global. international financial institutions (ifis) are international banks composed of sovereign member states that use public money from the member states to provide technical and financial support for developing countries. the united nations is the organization most involved in the mitigation of, preparedness for, response to, and recovery from disasters around the world. it is considered the best equipped to do so because of its strong relationships with most countries, especially the developing countries where assistance is most needed. when disasters strike, the un is one of the first organizations to mobilize, and it remains in the affected countries during the recovery period for many years after. the consolidated appeal process is one way the un garners international support for relief and reconstruction. in many regions, governments have formed smaller international organizations, many of which address risk, as well. the ifis provide nations with low capital reserves funding in the aftermath of disasters recovery reconstruction. the world bank is regarded as one of the largest sources of development assistance. a multilateral organization is an organization composed of the central governments of sovereign nations. multilateral organizations are also called intergovernmental organizations and international organizations. member states come together under a charter of rules and responsibilities they have drawn up and agreed on. multilateral organizations may be regionally based (e.g., the european union [eu] , the association of south east asian nations [asean]), organized around a common issue or function (e.g., the north atlantic treaty organization [nato] , the organization of the petroleum exporting countries [opec]), or globally based (e.g., the united nations [un] ). like sovereign states, they are recognized as having an established legal status under international law. the un is the most well-known and largest of all of the multilateral organizations because its membership draws from nearly every nation, and because it covers a wide range of issues. the first international organization to address the topic of disaster management was the international relief union (iru), which was founded in italy in and later integrated into the league of single vote, with key issues decided by two-thirds majority. (less significant matters are decided by simple majority.) as mentioned earlier, the general assembly cannot force its decisions on a sovereign state, although they generally receive wide support. the assembly holds regular sessions from september to december, and special/emergency sessions may be called at any time. when not in session, the assembly's work is carried out by its six main committees, other subsidiary bodies, and the secretariat. the un security council's primary responsibility is maintaining international peace and security in accordance with the un charter. this council, which convenes at will, consists of members, five of which are permanent members (china, france, the russian federation, the united kingdom, and the united states). all un member states are obligated to carry out the council's decisions. decisions require nine affirmative votes, including all five votes of the permanent members. when the council source: un, a. considers threats to international peace, it first explores peaceful settlement options. if fighting is under way, the council attempts to secure a cease-fire, and it may send a peacekeeping mission to help the parties maintain the truce and keep opposing forces apart. the council can take measures to enforce its decisions, such as imposing economic sanctions or arms embargoes. on rare occasions, the council has authorized member states to use "all necessary means," including collective military action, to see that its decisions are carried out. these are referred to as "peacemaking operations." the economic and social council is the central mechanism by which international economic and social issues are addressed and by which policy recommendations are created. it also consults with non-governmental organizations (ngos) to create and maintain working partnerships between the un and civil society. the council has members, elected by the general assembly for three-year terms. it meets throughout the year, but its main session is held in july, during which major economic, social, and humanitarian issues are discussed. the council has several subsidiary bodies that regularly meet to address issues such as human rights, social development, the status of women, crime prevention, narcotic drugs, and environmental protection. the trusteeship council originally provided international supervision for trust territories administered by seven member states and ensured that adequate steps were taken to prepare the territories for self-government or independence. by , all trust territories had attained self-government or independence. its work completed, the trusteeship council now consists of the five permanent members of the security council. it has amended its rules of procedure to allow it to meet as and when the occasion may require. the international court of justice, also known as the world court, is the un's main judicial organ. the world court consists of judges elected jointly by the general assembly and the security council. it serves to settle disputes between countries. participation is voluntary, but when a state agrees to participate, it must comply with the court's decision. the court also provides advisory opinions to the general assembly and the security council on request. the secretariat carries out the day-to-day work of the un as directed by the general assembly, the security council, and the other organs. at its head is the secretary general, who provides overall administrative guidance. the secretariat is made up of various departments and offices and maintains a total staff of about , people throughout the world. duty stations include the un headquarters in new york and offices in geneva, vienna, and nairobi, as well as other locations. the secretariat's functions are diverse, ranging from "administering peacekeeping operations to mediating international disputes, from surveying economic and social trends and problems to preparing studies on human rights and sustainable development" . the secretariat staffs also work to publicize the un's work through the world media and to organize conferences on issues of global concern. secretariat staffs are considered international civil servants and answer only to the un for their activities. disaster-response-oriented projects to disaster mitigation, the un adopted the international strategy for disaster reduction to promote disaster reduction and risk mitigation as part of its central mission. this initiative continues to evolve in its pursuit of disaster risk reduction, promoting global resilience to the effects of natural hazards, and reducing human, economic, and social losses by: • increasing public awareness of the hazard risks faced and the options to address them • obtaining commitment from public authorities to mainstream risk reduction into their work • stimulating interdisciplinary and intersectoral partnership and expanding risk-reduction networking at all levels • enhancing scientific research on the causes of natural disasters and the effects of natural hazards and related technological and environmental disasters on societies these strategies are integrated into the work carried out by each un country office and promoted to the national and local governments in each member country where the un works. hazard mitigation and disaster preparedness strategies are communicated to members of all levels of society via public awareness campaigns, and promoted by obtaining commitment from public authorities, facilitating cooperation and communication between various government and non-governmental sectors, and enabling the provision or transfer of technical knowledge. because the un is such a complex organization, it can be difficult to illustrate the myriad ways in which it addresses disaster management other than to describe the role of each organization and agency in this area. the un general assembly does not partake in any operational disaster management activities. however, as the main deliberative organ of the un, it is responsible for launching many influential and effective disaster management programs that are ultimately carried out by the various un offices and by the un member state governments. examples include the endorsement of the undp capacity for disaster reduction initiative (cadri) and the launching of the international decade for natural disaster reduction and its subsequent international strategy for disaster reduction. the general assembly is also responsible for organizing and reorganizing the un system to maximize its disaster management capabilities, as in under the un program for reform ( ) , which created the office for the coordination of humanitarian affairs (ocha) and the un office for disaster risk reduction (unisdr). the un secretariat is the international working staff of un employees located at duty stations throughout the world. the un secretariat employees carry out the diverse day-to-day work of the various un offices. it services the principal un organs and administers the programs and policies laid down by them. at its head is the secretary-general, who is appointed by the general assembly on the recommendation of the security council for five-year renewable terms. the secretariat has approximately , employees. as international civil servants, staff members and the secretary-general answer only to the un and take an oath not to seek or receive instructions from any government or outside authority. under the charter, each member state agrees to respect the appointed valerie amos of guyana to replace mr. john holmes of the united kingdom as under-secretary-general for humanitarian affairs/un emergency relief coordinator. ocha regional offices monitor the onset of natural and technological disasters. staff are trained in disaster assessment and post-disaster evaluation methods before disasters strike. once an impending or actual disaster event is identified, ocha initiates response and generates a situation report to provide the international response community with detailed information, including damage assessment, actions taken, needs assessment, and current assistance provided. if necessary, ocha may then deploy a un disaster assessment and coordination (undac) team to assist relief activity coordination and assess damages and needs. if a disaster appears inevitable or is already unfolding, the erc in consultation with iasc may designate a humanitarian coordinator (hc), who becomes the most senior un humanitarian official on the ground for the emergency. the hc is directly accountable to the erc, increasing the likelihood that the humanitarian assistance provided is quick, effective, and well-coordinated. the hc appointment generally signals that the event merits a long-term humanitarian presence. the criteria used by the erc to determine whether to appoint an hc center on the need for intensive and extensive political ocha organizational chart source: ocha, a. management, mediation, and coordination to enable the delivery of humanitarian response, including negotiated access to affected populations; massive humanitarian assistance requiring action by a range of participants beyond a single national authority; and a high degree of external political support, often from the un security council. an on-site operations coordination center (osocc) may be set up in the field to assist local firstresponse teams to coordinate the often overwhelming number of responding agencies. the osocc has three primary objectives: ( ) to be a link between international responders and the government of the affected country; ( ) to provide a system for coordinating and facilitating the activities of international relief efforts at a disaster site; and ( ) to provide a platform for cooperation, coordination, and information management among international humanitarian agencies. finally, ocha can set up communications capabilities if they have been damaged or do not exist at an adequate level, as required by the un responding agencies. ocha generally concludes its responsibilities when the operation moves from response to recovery. overall, ocha coordination is performed to maximize the response and recovery capabilities that converge on the disaster scene, and to minimize duplications and inefficiencies. the structures and policies that have been established to support this function include (adapted from ocha ): • developing common strategies. humanitarian assistance is most effective when common priorities and goals exist among stakeholders and responders agree on tactics and jointly monitor progress. ocha works with its partners to develop a common humanitarian action plan and to establish clear divisions of responsibility. • assessing situations and needs. ocha staff assume responsible for assessing damages and identifying needs, developing a plan of action to meeting those needs, and monitoring progress. responses are adjusted, if necessary, using ongoing analysis of political, social, economic, and military environments and by assessing humanitarian needs to help the responding agencies better understand the situation. • convening coordination forums. in its role as coordinator, ocha holds a wide range of meetings to bring together the various disaster management players for planning and information exchange. these meetings help the participants to more accurately analyze the overall status of humanitarian relief efforts as well as network and share lessons learned and best practices. • mobilizing resources. through the cap, ocha leads the drive to get governments to commit funding and resources necessary to address the identified needs. allocation of funds has been found to be more efficient within this centralized system. • addressing common problems. every crisis is unique, and both new and old problems arise. as coordinator, ocha analyzes and addresses problems common to humanitarian actors, such as negotiating with warring parties to gain access to civilians in need, or working with un security officials to support preparedness and response measures in changing security situations. • administering coordination mechanisms and tools. ocha, and the un in general, have several tools with which they can better address the humanitarian needs of disaster victims. these include the iasc; rapid-response tools, such as the un disaster assessment and coordination teams and the international search and rescue advisory group; and smaller forums such as the geographic information support team. ocha also assists with civil-military cooperation, ensuring a more efficient use of military and civil defense assets in humanitarian operations. the field coordination support unit in geneva manages ocha's human, technical, and logistical resources. these resources are primarily provided by the danish and norwegian refugee councils, the danish emergency management agency, the swedish rescue services agency, and the emergency logistics management team of the united kingdom overseas development administration. the under-secretary-general for humanitarian affairs/emergency relief coordinator advises the un secretary-general on disaster-related issues, chairs the executive committee on humanitarian affairs (echa), and leads the iasc. the coordinator is assisted by a deputy, who holds the position of deputy emergency relief coordinator (derc) and is responsible for key coordination, policy, and management issues. the inter-agency standing committee (iasc) was established in under un resolution / . it serves as a platform within which the broad range of un and non-un humanitarian partners (including un humanitarian agencies, the international organization for migration, three consortia of major international ngos, and the red cross movement) may come together to address the humanitarian needs resulting from a disaster. the iasc's primary role is to formulate humanitarian policy that ensures a coordinated and effective response to all kinds of disaster and emergency situations. the primary objectives of the iasc are to: • develop and agree on system-wide humanitarian policies • allocate responsibilities among agencies in humanitarian programs • develop and agree on a common ethical framework for all humanitarian activities • advocate common humanitarian principles to parties outside the iasc • identify areas where gaps in mandates or lack of operational capacity exist • resolve disputes or disagreement about and between humanitarian agencies on system-wide humanitarian issues (ocha ) iasc members (both full members and standing invitees) include: • the ocha donor relations section (drs), separated from the cap in , is the focal point for all relations with donors, particularly for funding-related issues. drs advises the senior management team on policy issues related to interaction with donors and resource mobilization. in addition, it plays a key role in facilitating the interaction of all ocha entities with donors, both at headquarters and in the field level. the coordination and response division (crd) was created in by joining the former new yorkbased humanitarian emergency branch and the geneva-based response coordination branch. crd is responsible for providing disaster-related direction, guidance, and support to the erc, the un resident/humanitarian coordinators, and ocha's field offices (including the deployment of extra personnel as necessary, or providing emergency cash grants). based in geneva, the ocha emergency services board (esb) was created to expedite the provision of international humanitarian assistance. esb develops, mobilizes, and coordinates the deployment of ocha's international rapid response "toolkit"-the expertise, systems, and services that aim to improve humanitarian assistance in support of disaster-afflicted countries. esb's humanitarian response activities include the coordination of disaster response and assessment (undac; see in the following section), the setting of international urban search and rescue standards (insarag; see in the following section), and the establishment of osoccs. esb supports ocha field offices through the following: • surge capacity and standby partnerships • military and civil liaison and mobilization of military and civil defense assets • dispatch of relief supplies and specialized assistance in environmental emergencies • dissemination of disaster-related information by means of reliefweb, the central register of disaster management capacities, and the virtual onsite operations coordination center. within the esb are seven separate sections, established to manage particular aspects of disaster response: . civil-military coordination section . emergency preparedness section . environmental emergencies unit . emergency relief coordination centre . field coordination support section . logistics support unit . surge capacity section established by the iasc in , the civil military coordination section (cmcs), previously named military and civil defense unit (mcdu), is the focal point for the efficient mobilization of military and civil defense assets for use in humanitarian emergencies and for liaison with governments, international organizations, regional organizations, and military-civil defense establishments deploying these assets. it also coordinates un agency participation and participates in major military exercises comprising significant humanitarian scenarios. this section is responsible for the overall management of the ocha central register of disaster management capacities, with specific maintenance of the mcda directory of military and civil defense assets and expertise. cmcs acts as a facilitator and secretariat to the development of documents involving the broad international humanitarian community and is custodian of the "oslo" and "mcda" guidelines detailing the use of mcda in support of un humanitarian operations in natural, technological, and environmental disasters and complex emergencies, respectively. the emergency preparedness section (eps) helps to maintain ocha's operational readiness and to reinforce disaster preparedness work. eps works with stakeholders at the national government level in un member countries in order to help build disaster response and recovery capacity in advance of disasters. much of the work performed by this unit is guided by the hyogo framework for action, which recommends the strengthening of disaster preparedness for effective response at all levels. the environmental emergencies unit, or the joint un environmental programme (unep)/ocha environment unit, serves as the integrated un emergency response mechanism that provides international assistance to countries experiencing environmental disasters and emergencies. this joint unit can rapidly mobilize and coordinate emergency assistance and response resources to countries facing environmental emergencies and natural disasters with significant environmental impacts. the unit performs several key functions geared toward facilitating rapid and coordinated disaster response: • monitoring. the unit performs continuous monitoring and ongoing communication with an international network of contacts and permanent monitoring of news services and websites for early notification of environmental occurrences. • notification. when disasters strike, the unit alerts the international community and issues "information and situation" reports to a comprehensive list of worldwide contacts. • brokerage. the unit is able to quickly establish contact between the affected country and donor governments ready and willing to assist and provide needed response resources. • information clearinghouse. the unit serves as an effective focal point to ensure information on chemicals, maps, and satellite images from donor sources and institutions are channeled to relevant authorities in the affected country. • mobilization of assistance. the unit mobilizes assistance from the international donor community when requested by affected countries. • assessment. the unit can dispatch international experts to assess an emergency's impacts and to make impartial and independent recommendations about response, cleanup, remediation, and rehabilitation. • financial assistance. in certain circumstances, the unit can release ocha emergency cash grants of up to $ , to meet immediate emergency response needs. the emergency relief coordination center (ercc) is the physical facility where ocha centralized coordination activities are focused. the facility enables closer collaboration between internal and external humanitarian stakeholders and has the capacity to serve as an ocha situation centre, providing updates on humanitarian relief activities worldwide. the centre consists of a main task force room, a small conference room that can also be used for a second task force, and a technical room to control all facility capabilities. the ercc allows ocha to coordinate two response teams simultaneously. the field coordination support section (fcss) was established within esb in to support national governments and the un resident coordinators in developing, preparing, and maintaining "standby capacity" for rapid deployment to sudden-onset emergencies to conduct rapid needs assessments and coordination. fcss manages several programs and offices to improve international disaster coordination and cooperation, including: • the united nations disaster assessment and coordination (undac) team. the undac team is made up of disaster management specialists selected and funded by the governments of un member states, ocha, undp, and operational humanitarian un agencies (such as wfp, unicef, and who). it provides rapid needs assessments and supports national authorities and the un resident coordinator in organizing international relief. undac teams are on permanent standby status so that they can deploy within hours. • the international search and rescue advisory group (insarag) . insarag is an intergovernmental network within the un that manages urban search and rescue (usar) and related disasterresponse issues. it promotes information exchange, defines international usar standards, and develops methodologies for international cooperation and coordination in earthquake response. • the virtual on-site operations coordination centre (virtual osocc). the internet has made it possible for humanitarian relief agencies to share and exchange disaster information continuously and simultaneously, and between any locations where internet access can be obtained. the virtual osocc is a central repository of information maintained by ocha that facilitates this exchange of information with ngos and responding governments. the information is stored on an interactive web-based database, where users can comment on existing information and discuss issues of concern with other stakeholders. the logistics support unit (lsu) manages stocks of basic relief items that can be dispatched immediately to disaster-or emergency-stricken areas. the stockpile, which is located at the un humanitarian response depot in brindisi, italy, includes nonfood, nonmedical relief items (such as shelter, water purification and distribution systems, and household items) donated by un member governments. the lsu is also involved in other logistical challenges, such as designing contingency plans for the rapid deployment of emergency relief flights and providing interface on logistical matters with other humanitarian agencies (such as wfp, who, unhcr, ifrc, and icrc). the lsu participates in the operation of a un joint logistics center (see exhibit . ) and has co-sponsored an effort to adopt a un-wide system for tracking the un joint logistics center (unjlc) is an interagency facility reporting to the humanitarian coordinator [within a che], and overall to the iasc. its mandate is to coordinate and optimize the logistics capabilities of humanitarian organizations in large-scale emergencies. unjlc operates under the direction of the world food programme (wfp), who is responsible for the administrative and financial management of the centre. the unjlc is funded from voluntary contributions channeled through wfp. the requirement to establish [the unjlc] was born out of the humanitarian response to the eastern zaire crisis, which demanded intensified coordination and pooling of logistics assets among unhcr, wfp, and unicef. the interagency logistics coordination model was applied on subsequent unjlc interventions in somalia, kosovo, east timor, mozambique, india, and afghanistan. in march , unjlc concept was institutionalized as a un humanitarian response mechanism, under the aegis of wfp, by the inter-agency standing committee working group (iasc-wg). the unjlc core unit was subsequently established in rome. in case of major disaster with substantial humanitarian multi-sector involvement during the immediate relief phase, the un agencies involved may consider that the establishment of a joint logistics centre would contribute to the rapid response, better coordination, and improved efficiency of the humanitarian operation at hand. . . . a standby capacity will be developed for facilitating, if required, the timely activation and deployment in the field of a united nations joint logistics centre-unjlc. the unjlc will support the united nations agencies and possibly other humanitarian organisations that operate in the same crisis area. the capacity includes the option to establish satellite joint logistic centres (jlc) dispersed at critical locations in the [affected area] and offering logistics support on a reduced scale. . . . upon [unjlc] activation, agencies will establish a deployment requirements assessment (dra) team to carry out a quick evaluation of the logistics situation and determine the requirements to deploy the unjlc in the crisis area. this dra team will work in close coordination with the humanitarian authorities and, if deployed, with the united nations disaster assessment and coordination (undac) team. it will take all necessary measures for installing the unjlc and draft ad hoc terms of reference (tor) for endorsement by the relevant humanitarian authorities. in case of peacekeeping operations or in a complex environment, the unjlc activation will be coordinated with the department of peacekeeping operations (dpko) or the relevant military entities. • the role of the unjlc will be to optimise and complement the logistics capabilities of cooperating agencies within a well-defined crisis area for the benefit of the ongoing humanitarian operation. • the unjlc will provide logistics support at operational planning, coordination, and monitoring levels. unless specified otherwise, the un agencies and other humanitarian bodies, which are established in the area, will continue (continued) relief supplies and common procedures for air operations. finally, the lsu contributes information related to stockpiles and customs facilitation agreements (which helps speed up the delivery of relief items). the surge capacity section (scs) works to ensure ocha always has the means and resources to rapidly mobilize and deploy staff and materials to address the needs of countries affected by suddenonset emergencies. scs operates using a number of distinct surge capacity resources, which include: • the emergency response roster (err). err, which became active in june , aims to rapidly deploy ocha staff to sudden-onset emergencies to conduct assessments and establish initial coordination mechanisms. the staff included in the err are deployable within hours of a request for their services through a deployment methodology based on the undac model. staff serve on the roster for about six months. • the stand-by partnerships programme (sbpp). sbpp is structured on legal agreements with partner organizations that provide short-term staffing to field operations free of charge when gaps arise. partners maintain their own rosters of trained and experienced humanitarian professionals, many of whom have ocha or other un humanitarian experience. sbpp staff can usually be deployed within four weeks of the formal request, and an average deployment lasts five to six months. • associates surge pool (asp). asp, which was created in late , helps to bridge the gap between the immediate response surge and the arrival of regular staff. asp comprises external disaster management staff who can be deployed for up to six months upon the issuance of a temporary appointment. contracting and deployment preparations take an average of three to four to exercise their normal responsibilities. as a result, the unjlc will not be involved in policy and establishment of humanitarian needs and priorities. • responsibilities will be defined as per the requirements on a case-by-case basis but will, in principle, be limited to logistic activities between the points of entry and distribution in the crisis area. detailed responsibilities . . . would be: • collecting, analysing, and disseminating logistics information relevant to the ongoing humanitarian operation; • scheduling the movement of humanitarian cargo and relief workers within the crisis area, using commonly available transport assets; • managing the import, receipt, dispatch, and tracking of non-assigned food and nonfood relief commodities; • upon specific request, making detailed assessments of roads, bridges, airports, ports, and other logistics infrastructure and recommending actions for repair and reconstruction. • the scope of the unjlc activities may vary with the type of emergency, the scale of involvement of the cooperating partners, and the humanitarian needs. the reso and roso positions were created following a need to have senior surge staff available to deploy to new and escalating emergencies for up to three months to provide leadership and stability to ocha operations. they spend percent of their time in the field and percent at headquarters. when not in the field, resos and rosos work with the surge staff development team to develop and deliver trainings and support lesson learning and other exercises to improve ocha emergency response during non-deployment periods. although ocha's efforts primarily focus on coordinating the response to major disasters, the agency also performs various tasks related to disaster risk reduction. for instance, ocha representatives work with disaster management agencies to develop common policies aimed at improving how the wider stakeholder community of responders prepare for and respond to disasters. it also works to promote preparedness and mitigation efforts in member states to decrease vulnerability. crd and esb work closely with the un development programme, other un programs as necessary, and outside organizations on various projects and activities to increase working relationships with national governments and apply lessons learned from completed disaster responses. ocha's geneva offices are continually monitoring geologic and meteorological conditions, as well as major news services, for early recognition or notification of emerging disasters. working with un resident coordinators, country teams, and regional disaster response advisers, ocha maintains close contact with disaster-prone countries in advance of and during disaster events. ocha's regional disaster response advisers work with national governments to provide technical, strategic, and training assistance. they also provide this assistance to other un agencies and regional organizations to improve international disaster management capacity. • it facilitates the negotiations of member states in many intergovernmental bodies on joint courses of action to address ongoing or emerging global challenges. • it advises national governments on translating un-developed policy frameworks into countrylevel programs and, through technical assistance, helps build national capacities. this final area is where desa addresses disaster management activities within its division for sustainable development. as part of this effort, desa launched a plan of action during the world summit on sustainable development in johannesburg, south africa, that included commitments to disaster and vulnerability reduction. see exhibit . for more information on this plan of action. the un center for regional development (uncrd) is another component of desa that addresses disaster management issues. through its headquarters in nagoya, japan, and its regional offices in nairobi, kenya, and bogotá, colombia, uncrd supports training and research on regional an integrated, multi-hazard, inclusive approach to address vulnerability, risk assessment, and disaster management, including prevention, mitigation, preparedness, response, and recovery, is an essential element of a safer world in the twenty-first century. actions are required at all levels to: . strengthen the role of the international strategy for disaster reduction and encourage the international community to provide the necessary financial resources to its trust fund; . support the establishment of effective regional, subregional, and national strategies and scientific and technical institutional support for disaster management; . strengthen the institutional capacities of countries and promote international joint observation and research, through improved surface-based monitoring and increased use of satellite data, dissemination of technical and scientific knowledge, and the provision of assistance to vulnerable countries; . reduce the risks of flooding and drought in vulnerable countries by, [among other things], promoting wetland and watershed protection and restoration, improved land-use planning, improving and applying more widely techniques and methodologies for assessing the potential adverse effects of climate change on wetlands and, as appropriate, assisting countries that are particularly vulnerable to those effects; . improve techniques and methodologies for assessing the effects of climate change, and encourage the continuing assessment of those adverse effects by the intergovernmental panel on climate change; . encourage the dissemination and use of traditional and indigenous knowledge to mitigate the impact of disasters and promote community-based disaster management planning by local authorities, including through training activities and raising public awareness; . support the ongoing voluntary contribution of, as appropriate, ngos, the scientific community, and other partners in the management of natural disasters according to agreed, relevant guidelines; . develop and strengthen early warning systems and information networks in disaster management, consistent with the international strategy for disaster reduction; . develop and strengthen capacity at all levels to collect and disseminate scientific and technical information, including the improvement of early warning systems for predicting extreme weather events, especially el niño/la niña, through the provision of assistance to institutions devoted to addressing such events, including the international center for the study of the el niño phenomenon; . promote cooperation for the prevention and mitigation of, preparedness for, response to, and recovery from major technological and other disasters with an adverse impact on the environment in order to enhance the capabilities of affected countries to cope with such situations. development issues and facilitates information dissemination and exchange. uncrd maintains a disaster management planning office in hyogo, japan, that researches and develops communitybased, sustainable projects for disaster management planning and capacity-building in developing countries. the hyogo office also runs the global earthquake safety initiative, designed to improve risk recognition and reduction in cities around the world. five regional economic commissions are within the economic and social council. the secretariats of these regional commissions are part of the un secretariat and perform many of the same functions (including the disaster management functions listed earlier). the five commissions promote greater economic cooperation in the world and augment economic and social development. as part of their mission, they initiate and manage projects that focus on disaster management. while their projects primarily deal with disaster preparedness and mitigation, they also work in regions that have been affected by a disaster to ensure that economic and social recovery involves adequate consideration of risk reduction measures. the five regional commissions are: • in response periods of disasters, the united nations development programme (undp) sees that development does not cease during emergencies. if relief efforts are to contribute to lasting solutions, sustainable human development must continue to be vigorously supported, complementing emergency action with new curative initiatives that can help prevent a lapse into crisis. (un, ) the undp was established in during the un decade of development to conduct investigations into private investment in developing countries, to explore the natural resources of those countries, and to train the local population in development activities such as mining and manufacturing. as the concept and practice of development expanded, the undp assumed much greater responsibilities in host countries and in the un as a whole. the undp was not originally considered an agency on the forefront of international disaster management and humanitarian emergencies because, while it addressed national capacities, it did not focus specifically on the emergency response systems (previously considered to be the focal point of disaster management). however, as mitigation and preparedness received their due merit, undp gained increased recognition for its vital risk reduction role. capacity building has always been central to the undp's mission in terms of empowering host countries to be better able to address issues of national importance, eventually without foreign assistance. international disaster management gained greater attention as more disasters affected larger populations and caused greater financial impacts. developing nations, where the undp worked, faced the greatest inability to prepare for and/or respond to these disasters, largely as a result of the development trends described in chapter . undp's projects have shifted toward activities that indirectly fulfill mitigation and preparedness roles. for instance, projects seeking to strengthen government institutions also improve those institutions' capacities to respond with appropriate and effective policy, power, and leadership in the wake of a disaster. undp fully recognizes that disaster management must be viewed as integral to their mission in the developing world as well as to civil conflict and che scenarios. there are implicit similarities between undp ideals and those of agencies whose goals specifically aim to mitigate and manage humanitarian emergencies. undp work links disaster vulnerability to a lack of or a weak infrastructure, poor environmental policy, land misuse, and growing populations in disaster-prone areas. when disasters occur, a country's national development, which the undp serves to promote, can be set back years, if not decades. even small-to medium-size disasters in the least developed countries can "have a cumulative impact on already fragile household economies and can be as significant in total losses as the major and internationally recognized disasters" (undp ) . it is the undp's objective to "achieve a sustainable reduction in disaster risks and the protection of development gains, reduce the loss of life and livelihoods due to disasters, and ensure that disaster recovery serves to consolidate sustainable human development" (un ) . in , as part of the un's changing approach to humanitarian relief, the emergency response division (erd) was created within the undp, augmenting the organization's role in disaster response. additionally, percent of undp budgeted resources were allocated for quick response actions in special development situations by erd teams, thus drastically reducing bureaucratic delays. the erd was designed to create a collaborative framework among the national government, un agencies, donors, and ngos that immediately respond to disasters, provide communication and travel to disaster management staff, and distribute relief supplies and equipment. it also deploys to disaster-affected countries for days to create a detailed response plan on which the undp response is based. in , under the un programme for reform, the mitigation and preparedness responsibilities of the ocha emergency relief coordinator were formally transferred to the undp. in response, the undp created the disaster reduction and recovery programme (drrp) within the erd. soon after, the undp again reorganized, creating the bureau of crisis prevention and recovery (bcpr) with an overarching mission of addressing a range of non-response-related issues: • disaster risk reduction and climate change management • conflict prevention • rule of law, justice, and security in countries affected by crises • women in conflict prevention, peacebuilding, and recovery • immediate crisis response • livelihoods and economic recovery • crisis governance bcpr helps undp country offices prepare to activate and provide faster and more effective disaster response and recovery. it also works to ensure that undp plays an active role in the transition between relief and development. undp's disaster management activities focus primarily on the development-related aspects of risk and vulnerability and on capacity-building technical assistance in all four phases of emergency management. it emphasizes: • incorporating long-term risk reduction and preparedness measures in normal development planning and programs, including support for specific mitigation measures where required; • assisting in the planning and implementation of post-disaster rehabilitation and reconstruction, including defining new development strategies that incorporate risk-reduction measures relevant to the affected area; • reviewing the impact of large settlements of refugees or displaced persons on development, and seeking ways to incorporate the refugees and displaced persons in development strategies; • providing technical assistance to the authorities managing major emergency assistance operations of extended duration (especially in relation to displaced persons and the possibilities for achieving durable solutions in such cases). undp spends between $ and $ million each year on disaster risk reduction projects. the focus of these projects has included the establishment or strengthening of early warning systems, the conduct of risk assessments and drafting of hazard maps, and the establishment of national disaster management agencies. through their projects, undp staff help to strengthen national and regional capacities by ensuring that new development projects consider known hazard risks, that disaster impacts are mitigated and development gains are protected, and that risk reduction is factored into disaster recovery. following conflict, crises, and disasters, countries must transition from response to recovery. many countries are unable to manage the difficult and widespread needs of recovery on their own, as they may have experienced widespread loss of infrastructure and services. displaced persons and refugees may have little to return to, and economies may be damaged or destroyed. bcpr operates during the period when the response or relief phase of the disaster has ended but recovery has not fully commenced (sometimes referred to as the "early recovery period"). sustainable risk reduction is central to the undp recovery mission. the bureau recognizes that local expertise in risk management and reduction may not be available, and that the technical assistance they provide may be the only option these communities have to increase their resilience to future disasters. this program has proved effective in many countries' recovery operations, including cambodia after three decades of civil war, afghanistan after the conflict, and gujarat, india, after the earthquake. the top recipients of undp crisis prevention and recovery funding include: to meet these recovery priorities, five support services have been developed to assist the undp country offices and other undp/un agencies to identify areas where bcpr can provide assistance. these support services include: • early assessment of recovery needs and the design of integrated recovery frameworks. this includes assessing development losses caused by conflict or natural disaster, the need for socioeconomic and institutional recovery, identification of local partners, and the need for capacity building and technical assistance. • planning and assistance in area-based development and local governance programs. area-based development and local governance programs play key roles in recovery from conflict because they tailor emergency, recovery, and development issues across a country area by area, based on differing needs and opportunities. area-based development helps bring together different actors at the operational level, promoting enhanced coordination, coherence, and impact at field level. areabased development is often seen as the core mechanism that most benefits reintegration. • developing comprehensive reintegration programs for idps, returning refugees, and ex-combatants. internal displacement, returning refugees, and demobilized former combatants create a huge need for in-country capacity building on different levels. protection and security become serious issues, and efforts to sustainably reintegrate these populations into their host communities are critical. bcpr provides expertise on reintegration of idps, returnees, and ex-combatants, including capacity building benefiting both the returnees and the formerly displaced, as well as their host communities, through activities such as income generation, vocational training, and other revitalization activities. • supporting economic recovery and revitalization. one main characteristic of disasters and conflict is their devastating impact on the local and national economies. livelihoods are destroyed through insecurity, unpredictability, market collapse, loss of assets, and rampant inflation. for recovery to be successful, these issues need to be well understood from the outset and addressed accordingly. • supporting capacity building, coordination, resource mobilization, and partnerships. protracted conflict and extreme disasters tend to create political stressors that temporarily exceed the capacities of un country offices and other ngo partners. however, many recovery needs must be addressed right away to ensure that recovery sets out on a sustainable course. bcpr offers several services to accommodate the needs of this intense phase through the provision of surge capacity and short-to medium-term staff, assistance in resource mobilization within specific fundraising and coordination frameworks (such as the cap), and partnership building. when required to assist in recovery operations, bcpr may deploy a special transition recovery team (trt) to supplement undp operations in the affected country. the focus for these teams varies according to specific needs. for instance, when neighboring countries have interlinked problems (such as cross-border reintegration of ex-combatants and displaced persons), the trt may support a subregional approach to recovery. it is important to note that the undp has no primary role in the middle of a che peacekeeping response, only a supportive one in helping to harmonize development with relief. during recovery and reconstruction, together with others, they take the lead. in addition to the previously mentioned roles and responsibilities, the undp leads several interagency working groups. one such group (which consists of representatives from the wfp, who, the food and agriculture organization [fao] , the un populations fund, and unicef) develops principles and guidelines to incorporate disaster risk into the common country assessment and the un development assistance framework. the international strategy for disaster reduction working group on risk, vulnerability, and disaster impact assessment sets guidelines for social impact assessments. undp also coordinates a disaster management training programme in central america, runs the conference "the use of microfinance and micro-credit for the poor in recovery and disaster reduction," and has created a program to elaborate financial instruments to enable the poor to manage disaster risks. the undp has several reasons for its success in fulfilling its roles in the mitigation, preparedness, and recovery for natural and man-made disasters. first, as a permanent in-country office with close ties to most government agencies, activities related to coordination and planning, monitoring, and training are simply an extension of ongoing relationships. the undp works in the country before, during, and long after the crisis. it is able to harness vast first-hand knowledge about the situations leading up to a crisis and the capacity of the government and civil institutions to handle a crisis, and can analyze what weaknesses must be addressed by the responding aid agencies. in addition, its neutrality dispels fears of political bias. second, the undp functions as a coordinating body of the un agencies concerned with development, so when crisis situations appear, there is an established, stable platform from which it may lead. from this leadership vantage, it can (theoretically) assist in stabilizing incoming relief programs of other responding un bodies, such as the wfp, unicef, the department of humanitarian affairs, and the unhcr. once the emergency phase of the disaster has ended and ocha prepares to leave, undp is in a prime position to facilitate the transition from response efforts to long-term recovery. and third, the undp has experience dealing with donors from foreign governments and development banks, and can therefore handle the outpouring of aid that usually results during the relief and recovery period of a disaster. this contributes greatly to reducing levels of corruption and increasing the cost-effectiveness of generated funds. in several recent events, the undp has established formalized funds to handle large donor contributions, which have been used for long-term post-disaster reconstruction efforts. (see exhibits . and . ). when a major disaster operation requires extended efforts, the undp may accept and administer special extra-budgetary contributions to provide the national government with both technical and material assistance, in coordination with ocha and other agencies involved in the un disaster management team (dmt). an example of such assistance includes the establishment and administration of a un dmt emergency information and coordination (eic) support unit. special grants of up to $ . million also may be provided, allocated from the special programme resources funds for technical assistance to post-disaster recovery efforts following natural disasters. see exhibit . for information about the undp capacity for disaster reduction initiative (cadri). like most major un agencies, unicef (formerly known as the united nations international children's emergency fund) was established in the aftermath of world war ii. its original mandate was to aid children suffering in postwar europe, but this mission has been expanded to address the needs of women and children throughout the world. unicef is mandated by the general assembly to advocate for children's rights, to ensure that each child receives at least the minimum requirements for survival, and to increase children's opportunities for a successful future. under the convention on the rights of on may , , the government of sri lanka declared military victory over the rebel liberation tigers of tamil eelam, formally ending a decades-long armed conflict. in the wake of the war, undp demonstrated that developing and building on strong partnerships is key to ensuring a fast and well-targeted response. an estimated , idps gathered in camps during the first half of . many of them lacked basic documentation, making it difficult to access basic services and prove claims to land and assets. undp assisted the registrar general to establish a temporary office inside one of the largest camps with capacity to process birth and marriage certificates per day, complemented by additional staffing capacity in colombo to handle the increased number of document requests. between july and december the camp office processed close to , requests, prioritizing those from children who needed identification to sit for national school exams. undp also supported mine action coordination and management. survey and clearance activities advanced rapidly, and by the end of a total of square kilometers of land had been released for resettlement. this allowed the pace of returns and resettlements to increase exponentially in the fourth quarter of , with over , idps returning or resettling. in the eastern province, fao, ilo, wfp, unhcr, and undp continued to champion the "delivering as one" approach to support community-based recovery and contribute to the stability of returnees in selected divisions of the east. as the funding conduit, undp was in charge of the overall coordination of project implementation while also directly implementing small-scale infrastructure construction such as roads, wells, and community centers (which provided a space for cooperatives and trading groups to come together). the selection of target communities was informed through village profile maps and data generated by unhcr, while wfp provided six months' worth of food supply rations, until the foundations for agricultural self-reliance and food security for resettled families were laid. undp also launched a new initiative in to foster partnerships between sri lanka's manufacturers and resettled communities. undp, with its presence in the field, played a catalytic role, identifying the resettled communities, facilitating meetings with the large consumer companies, securing fair and long-term contracts, and supporting training as well as supply of equipment to improve production. through this project, farming and fishing families in the north and the east have secured income for the next two to three years. on may , , cyclone aila hit southern bangladesh, resulting in widespread tidal flooding and the destruction of large parts of the region's protective embankment network. economic losses were estimated at $ million and more than , families were affected in satkhira, the district that had also suffered the most from cyclone sidr in . many of the affected were still recovering from the impact of the earlier disaster. the government of bangladesh provided emergency relief and planned for the reconstruction of the damaged embankment network, but many of the most vulnerable families have been unable to return to their homes, which remain submerged. with funding from the undp bureau of crisis prevention and recovery (bcpr), an early recovery program focused on livelihoods was developed, covering all villages in the worst-affected part of satkhira. the program included a cash-forwork component that built on self-recovery efforts of affected families. this resulted in the creation of an estimated , work days devoted to road repair and ground elevation. the program also included support for the restoration of essential community infrastructure; support to local small enterprises through working capital grants for carpentry tools, sewing machines, and tea stall equipment; and assistance for home-based income-generating activities, such as vegetable cultivation, crab fattening, handicrafts, poultry rearing, and fish drying. this effort benefited more than , families. the child (crc), a treaty adopted by countries, the unhcr holds broad-reaching legal authority to carry out its mission. as of late , unicef maintains country offices in more than different nations. this is probably its greatest asset in terms of the agency's disaster management capacity. preparedness and mitigation for disasters among its target groups is a priority, with programs able to address both local-level action and national-level capacity building. in keeping with the recommendations laid out by the yokohama strategy and plan of action for a safer world, unicef incorporates disaster reduction into its national development plans. it also considers natural hazard vulnerability and capacity assessments when determining overall development needs to be addressed by un country teams. through public education campaigns, unicef works to increase public hazard awareness and knowledge and participation in disaster management activities. unicef country offices include activities that address these pre-disaster needs in their regular projects. for example, they develop education materials required for both children and adults, and then design websites so educators and program directors can access or download these materials for use in their communities. in situations of disaster or armed conflict, unicef is well poised to serve as an immediate aid provider to its specific target groups. its rapid-response capacity is important because vulnerable groups are often the most marginalized in terms of aid received. unicef works to ensure that children have access to education, health care, safety, and protected child rights. in the response and recovery periods of humanitarian emergencies, these roles expand according to victims' needs. (in countries where uni-cef has not yet established a permanent presence, the form of aid is virtually the same; however, the timing and delivery are affected, and reconstruction is not nearly as comprehensive.) the unicef office of emergency programmes (emops), which has offices in new york and geneva, maintains overall responsibility for coordinating unicef's emergency management activities. cadri was created in as a joint program of the undp bureau for crisis prevention and recovery (undp/bcpr), the united nations office for the coordination of humanitarian affairs (ocha), and the secretariat of the international strategy for disaster reduction (isdr). recognizing that capacity development is a cross-cutting activity for disaster risk reduction as stipulated in the hyogo framework (hf), cadri's creation is designed to support all five priorities of the hf. cadri was formally launched by the three organizations at the global platform for disaster risk reduction meeting, june , geneva. cadri succeeds the un disaster management training programme (dmtp), a global learning initiative, which trained united nations, government, and civil society professionals between and . dmtp is widely known for its pioneering work in developing high-quality resource materials on a wide range of disaster management and training topics. more than trainers' guides and modules were developed and translated. cadri's design builds on the success and lessons learned from the dmtp and reflects the significant evolution in the training and learning field since the start of the dmtp, particularly regarding advances in technology for networking and learning purposes. cadri's design also reflects the critical role that the un system plays at the national level in supporting governments' efforts to advance disaster risk reduction. in the context of the un's increasingly important role, cadri provides capacity enhancement services to the un system at the country level as well as to governments. these include learning and training services and capacity development services to support governments to establish the foundation for advancing risk reduction. emops works closely with the unicef programme division, managing the unicef emergency programme fund (epf; see the following section) and ensuring close interagency coordination with other participating humanitarian organizations. in this role, unicef is also in the position to act as coordinator in specific areas in which it is viewed as the sector leader. for instance, unicef was tasked with leading the international humanitarian response in the areas of water and sanitation, child protection, and education for the asia tsunami and earthquake response. (in aceh province alone, more than agencies addressed water and sanitation issues.) unicef maintains that humanitarian assistance should include programs aimed specifically at child victims. its relief projects generally provide immunizations, water and sanitation, nutrition, education, and health resources. women are recipients of this aid as well, because unicef considers women to be vital in the care of children. (see exhibit . .) to facilitate an immediate response to an emergency situation, unicef is authorized to divert either $ , or $ , from country program resources (depending on whether the country program's annual budget is above or below $ million, respectively) to address immediate needs. if the disaster is so great it affects existing unicef programs operating in the country, the unicef representative can shift these programs' resources once permission is received from the national government and unicef headquarters. unicef also maintains a $ million global epf, which provides funding for initial emergency response activities. by the end of the three weeks of fighting in early in gaza, children had been killed and , injured, and much of gaza's infrastructure, including schools, health facilities, and vital infrastructure for water and sanitation, had been damaged. unicef was on hand to provide humanitarian support. it led the collective efforts of un agencies on the ground to restore education, provide emergency water supplies and sanitation, maintain nutritional standards, and protect children from further harm. from the early days, unicef made sure that first aid and emergency medical kits, essential drugs, and water purification tablets flowed into gaza. emergency education supplies such as classroom tents and school-in-a-box kits maintained some sense of continuity and normalcy for children. unicef and its partners were able to reach more than , school-age children. unicef raised global awareness of the harm being done to children through extensive media coverage and advocacy. attention was also raised by the visits of the special representative of the secretary-general for children and armed conflict, radhika coomaraswamy-who called for the protection of children-and unicef executive director ann m. veneman, as well as goodwill ambassadors mia farrow and mahmoud kabil. unicef also extended psychosocial services, including in-depth counselling and structured recreational activities, across gaza. training reinforced the capacities of psychosocial workers to protect children and help them heal. radio programmes and , leaflets designed for children warned of the risks of mines and unexploded ordnance left behind. unicef water tankers ensured a steady supply of clean drinking water to schools with , students, while desalination units were installed to rid water of dangerous concentrations of chlorides and nitrates. to thwart the risk of acute malnutrition, unicef worked through health clinics for mothers and children to offer supplements of micronutrients and fortified food. the quality and supply of teaching materials were improved through unicef's provision of math and science teaching kits. programmes for vulnerable adolescents concentrated on supporting remedial learning, relieving stress, and providing life skills-based education and opportunities to engage in civic activities. through unicef's systematic advocacy with partner organizations, almost half the attendees were girls. the world food programme (wfp) is the un agency tasked with addressing hunger-related emergencies. it was created in by a resolution adopted by the un general assembly and the un fao. today, the program operates in countries and maintains eight regional offices. in the year alone, the wfp provided . million metric tons of food aid to . million people in countries through its relief programs. over the course of its existence, the wfp has provided more than million metric tons of food to countries worldwide. wfp was an early member of the former inter-agency task force for disaster reduction (see below) and maintains disaster risk reduction as one of its priority areas, focusing on reducing the impact of natural hazards on food security, especially for the vulnerable. the wfp policy on disaster risk reduction and management, approved in , highlights this role as being central to the organization's work. wfp drr programs seek to build resilience and reduce risk through such activities as soil and water conservation, rehabilitating infrastructure, and training community members in disaster risk management and livelihood protection. the meret project in ethiopia is one example. this program targets food-insecure communities in degraded fragile ecosystems prone to drought-related food crises. other programs maintained by wfp include: • r resilience initiative: the rural resilience initiative (r ) is a partnership between wfp and oxfam america, with support from global reinsurance company swiss re, to test a new, comprehensive disaster risk reduction and climate change adaptation approach. the program allows cash-poor farmers and rural households to pay for index insurance with their own labor, so they can both manage and take risks to build resilient livelihoods. • livelihoods early assessment and protection (leap): wfp has been assisting the government of ethiopia to develop an integrated risk management system through the livelihoods early assessment and protection (leap) project. leap provides early warning data on food security that allows a rapid scale-up of the "national productive safety net programme" by activating contingency plans. when a serious drought or flood is detected, resources from a us$ million contingency fund are made immediately available to ensure early and more effective emergency response, thereby protecting livelihoods and saving lives. • the joint wfp/ifad weather risk management facility (wrmf): wrmf supports the development of innovative weather and climate risk management tools, such as weather index insurance (wii). the goal of these programs is to improve quality-of-life issues and to reduce the incidence of food shortages. this program was launched in through funding from the bill and melinda gates foundation. it has been piloted in china and ethiopia. wfp has established a steering committee for disaster mitigation to help its offices integrate these activities into regular development programs. examples of mitigation projects that focus on food security include water harvesting in sudan (to address drought), the creation of grain stores and access roads in tanzania, and the creation of early warning and vulnerability mapping worldwide. because food is a necessity for human survival and is considered a vital component of development, a lack of food is, in and of itself, an emergency situation. the wfp works throughout the world to assist the poor who do not have sufficient food so they can survive "to break the cycle of hunger and poverty." hunger crises are rampant-more than billion people across the globe receive less than the minimum standard requirement of food for healthy survival. hunger may exist on its own, or it may be a secondary effect of other hazards such as drought, famine, and displacement. the wfp constantly monitors the world's food security situation through its international food aid information system (fais). using this system, wfp tracks the flow of food aid around the world (including emergency food aid) and provides the humanitarian community with an accurate inventory and assessment of emergency food-stock quantities and locations. this database also includes relevant information that would be needed in times of emergency, such as anticipated delivery schedules and the condition and capabilities of international ports. in rapid-onset events such as natural disasters, the wfp is a major player in the response to the immediate nutritional needs of the victims. food is transported to the affected location and delivered to storage and distribution centers. (see figure . .) the distribution is carried out according to preestablished needs assessments performed by ocha and the undp. the wfp distributes food through contracted ngos that have the vast experience and technical skills to plan and implement transportation, storage, and distribution. the principal partners in planning and implementation are the host rice donated by japan is loaded by the world food programme onto wfp trucks to feed survivors of the asia tsunami and earthquake events sources: skullard, ; wfp, . governments, who must request the wfp aid, unless the situation is a che without an established government, in which case the un secretary-general makes the request. the wfp works closely with all responding un agencies to coordinate an effective and broad-reaching response, because food requirements are so closely linked to every other vital need of disaster victims. during the reconstruction phase of a disaster, the wfp often must continue food distribution. rehabilitation projects are implemented to foster increased local development, including the provision of food aid to families, who, as a result, will have extra money to use in rebuilding their lives; and food-for-work programs, which break the chains of reliance on aid as well as provide an incentive to rebuild communities. wfp administers the international emergency food reserve (iefr), which was originally designed to store a minimum of , tons of cereals. this program has not enjoyed the full support of donors as agreed in its creation, however, and as such, annual funding levels have fluctuated significantly. if supported, iefr would manage separate resources provided by donors to address long-term operations such as ches, and would dedicate $ million from its general resources for emergency assistance in addition to $ million for long-term emergency assistance. the program's immediate response account is a cash account maintained for rapid purchase and delivery of food in emergency situations. resources would be purchased from local markets (whenever possible), thereby ensuring food arrives sooner than other aid, which must move through regular channels. wfp response begins at the request of the affected country's government. . in the early days of an emergency, while the first food supplies are being delivered, emergency assessment teams are sent in to quantify exactly how much food assistance is needed for how many beneficiaries and for how long. they must also work out how food can best be delivered to the hungry. . equipped with the answers, wfp draws up an emergency operation (emop), including a plan of action and a budget. [the emop] lists who will receive food assistance, what rations are required, the type of transport wfp will use, and which humanitarian corridors lead to the crisis zone. . next, wfp launches an appeal to the international community for funds and food aid. the agency relies entirely on voluntary contributions to finance its operations, with donations made in cash, food, or services. governments are the biggest single source of funding. [more than governments support wfp's worldwide operations.] . as funds and food start to flow, wfp's logistics team works to bridge the gap between the donors and the hungry. [in , the agency delivered . million metric tons of food aid by air, land, and sea.] (wfp ) ships carry the largest wfp cargo, their holds filled to the brim with , tons or more of grain, cans of cooking oil, and canned food; the agency has ships on the high seas every day, frequently rerouting vessels to get food quickly to crisis zones. in extreme environments, wfp also uses the skies to reach the hungry, airlifting or airdropping food directly into disaster zones. before the aid can reach its country of destination, logistics experts often need to upgrade ports and secure warehouses. trucks usually make the final link in wfp's food chain, transporting food aid along the rough roads that lead to the hungry. where roads are impassable or nonexistent, wfp relies on less conventional forms of transport: donkeys in the andes, speedboats in the mozambique floods, camels in sudan, and elephants in nepal. at this stage, local community leaders work closely with wfp to ensure rations reach the people who need it most: pregnant mothers, children, and the elderly. the world health organization (who) was proposed during the original meetings to establish the un system in san francisco in . in , at the united health conference in new york, the who constitution was approved, and it was signed on april , (world health day). who proved its value by responding to a cholera epidemic in egypt months before the epidemic was officially recognized. who serves as the central authority on sanitation and health issues throughout the world. it works with national governments to develop medical and health care capabilities and assist in the suppression of epidemics. who supports research on disease eradication and provides expertise when requested. it provides training and technical support and develops standards for medical care. who was an early member of the former interagency task force for disaster reduction (see below), and continues to assist local and national governments as well as regional government associations with health-related disaster mitigation and preparedness issues. it does this primarily by providing education and technical assistance to government public health officials about early detection, containment, and treatment of disease and the creation of public health contingency plans. who activities address primary hazards, such as epidemics (e.g., avian influenza, malaria, dengue fever, sars, swine flu, and mers/cov), and the secondary health hazards that accompany most major disasters. through their website and collaboration with various academic institutions, who has also worked to advance public health disaster mitigation and preparedness research and information exchange. the who director-general is a member of the iasc and the iasc working group. in those capacities, the who recommends policy options to resolve the more technical and strategic challenges of day-to-day emergency operations in the field. to incorporate public health considerations in un interagency contingency planning and preparedness activities, the who also participates in the iasc task force on preparedness and contingency planning. the who emergency risk management and humanitarian response department was created to enable who to work closely with member states, international partners, and local institutions in order to help communities prepare for, respond to, and recover from emergencies, disasters, and crises. the emergency response framework (erf) was developed in to clarify the who role and their responsibilities in emergency situations (who ). in the event of a disaster, who responds in several ways to address victims' health and safety. most important, it provides ongoing monitoring of diseases traditionally observed within the unsanitary conditions of disaster aftermath. who also provides technical assistance to responding agencies and host governments establishing disaster medical capabilities and serves as a source of expertise. it assesses the needs of public health supplies and expertise and appeals for this assistance from its partners and donor governments. per the erf, who is obligated to respond to emergencies under several conventions and agreements, including the international health regulations and the interagency steering committee. the key functions of hac in times of crises are: • measure health-related problems and promptly assess health needs of populations affected by crises, identifying priority causes of disease and death; • support member states in coordinating action for health; • ensure that critical gaps in health response are rapidly identified and filled; and • revitalize and build capacity of health systems for preparedness and response. when other government agencies, private medical facilities, or ngos cannot meet the public health needs of the affected population, who's country-level emergency response team and international emergency support teams bring together expertise in epidemics, logistics, security coordination, and management, collaborating with un agencies participating in response and recovery. who has several bilateral agreements with other un agencies and ngos (including the red cross and red crescent movement) and coordinates the interagency medical/health task force (imtf), an informal forum that provides guidance on technical and operational health challenges in humanitarian crises. the who global emergency management team (gemt) was created in to lead the planning, management, implementation, monitoring, and evaluation of who's emergency work (including national preparedness, institutional readiness, and emergency response for disasters that exhibit public health consequences.) the gemt is made up of staff from both who headquarters and regional office directors responsible for disaster risk management issues (e.g., preparedness, surveillance, alert, and response). as needed, other relevant staff are invited to join gemt efforts. gemt focuses on all-hazards emergency risk management, notably that of leadership on the health cluster. when technical expertise beyond that held by the team's members is needed, the global emergency network (gen), comprising directors (or delegates) of departments and programs that have various emergency management functions, is consulted. the gemt continuously tracks global health events and the organization-wide use of internal and external resources in all emergencies, and reports on all major emergencies. during an actual emergency or disaster, a subset of the gemt, known as the gemt-response (gemt-r), is mobilized to grade and manage the response to a specific emergency. for larger-scale emergencies, the gemt-r is responsible for making recommendations to executive management on the best use of who resources given the event's scale, scope, duration, and complexity (given other existing requirements in ongoing events). since its inception, six regional offices have been established. these offices focus on the health issues in each region: • regional office for africa • pan american health organization • regional office for south-east asia • regional office for europe • regional office for eastern mediterranean • regional office for the western pacific the food and agriculture organization (fao) was established as a un agency in in quebec city, canada. the organization's mandate is to "raise levels of nutrition, improve agricultural productivity, better the lives of rural populations and contribute to the growth of the world economy" (fao ) . it provides capacity-building assistance to communities that need to increase food production. in , fao pledged to help current and future generations achieve food security by . in spite of their work, more than million people worldwide continue to suffer the effects of food shortages, including more than million children under five years of age who show signs of malnutrition-based growth stunting. fao is headquartered in rome, italy. the organization also maintains five regional, five subregional, and country offices, each of which works with un member countries and other partners to coordinate various activities, including disaster management. it has member nations, two associate member nations, and one member organization (the european union). fao was an early member of the interagency task force on disaster reduction prior to its becoming the global platform for disaster risk reduction. the world food summit mandated fao to assist un member countries in developing national food security, vulnerability information, and specialized mapping systems to cut worldwide malnutrition. a key component of this strategy is strengthening the capacity of communities and local institutions to prepare for natural hazards and respond to food emergencies during disasters and crises. this objective focuses on: • strengthening disaster preparedness and mitigation against the impact of emergencies that affect food security and the productive capacities of rural populations; • forecasting and providing early warning of adverse conditions in the food and agricultural sectors and of impending food emergencies; • strengthening programs for agricultural relief and rehabilitation and facilitating the transition from emergency relief to reconstruction and development in food and agriculture; and • strengthening local capacities and coping mechanisms by guiding the choice of agricultural practices, technologies, and support services to reduce vulnerability and enhance resilience. in , fao released strategic objective i, which guided the organization in conducting "preparedness for, and effective response to, food and agricultural threats and emergencies." this strategy laid out three specific results that were sought, including: . countries' vulnerabilities to crises, threats, and emergencies is reduced through better preparedness and integration of risk prevention and mitigation into policies, programs, and interventions; . countries and partners respond more effectively to crises and emergencies with food-and agriculture-related interventions; and . countries and partners have improved transition and linkages between emergency, rehabilitation, and development. within fao, the emergency coordination group is the organizational mechanism for the overall coordination of emergency and disaster reduction issues. this group strengthens fao's capacity to perform food-based disaster management activities in support of member countries and partners in a more integrated way. ecg is chaired by the director of the office for coordination of normative, operational and decentralized activities and has a secretariat provided by the office of the special advisers to the director-general. key units of this group include: the investment centre division prepares investment programs and projects for funding by major multilateral development banks during the rehabilitation and reconstruction and the recovery phases. fao field offices are in developing countries. regional and subregional offices are also maintained. at any time, fao is involved in some , agricultural projects in the developing world. experts working on these projects in affected countries are frequently called upon to help with emergency needs assessments and field operations. in a disaster, fao representatives in developing countries respond by coordinating with the government and other partners. in countries with ches, fao coordinates actions that address emergency agricultural needs and assists in the development and implementation of strategies for creating conditions conducive to recovery and sustained development. fao's approach is to set up coordination units that: • provide technical assistance to help the impacted government and its citizens to manage agricultural relief; • monitor the ongoing crisis relative to food; • advise ngos and other organizations involved in food and agriculture; • help build the necessary national capacity to transition from response to recovery; and • establish information collection and database management systems. examples of countries where fao emergency coordination units have been set up include bosnia, tajikistan, rwanda, burundi, liberia, sierra leone, somalia, iraq, and angola. fao also maintains a website of disaster reduction information through its world agricultural information center (waicent). this online portal provides access to the global information and early warning system, information on crop prospects, and other relevant documents and data. fao also works to help countries adopt sustainable agricultural and other land-use practices. its land and water division has helped to reverse land loss, thus increasing disaster resilience, by promoting the development of disaster-resistant agro-ecosystems and the sound use of land and water resources. in times of disaster, the emergency operations and rehabilitation division helps communities recover. while other agencies, such as wfp, address immediate food needs by providing the actual food aid to victims, fao provides assistance to restore local food production and reduce dependency on food aid. the fao's first action following disasters, in partnership with wfp, is to send missions to the affected areas to assess crops and food supply status. the emergency operations service of the emergency operations and rehabilitation division leads these missions, sending fao experts to consult with farmers, herders, fisheries, and local authorities to gather disaster and recovery data. using their assessment, fao designs an emergency agricultural relief and rehabilitation program and mobilizes the funds necessary for its implementation. the emergency operations and rehabilitation division distributes material assets such as seeds, fertilizer, fishing equipment, livestock, and farm tools. in a che, fao helps affected communities bolster overall resources and restore and strengthen agricultural assets to make them less vulnerable to future shocks. for example, fao has been working in regions outside government authority in the sudan to conduct community-based training of animal health workers aimed at keeping their livestock-a vital part of local livelihoods-from dying. when a disaster occurs, the emergency operations and rehabilitation division of fao establishes an emergency agriculture coordination unit consisting of a team of technical experts from a wide range of fields (including crop and livestock specialists). this field-level team provides information and advice to other humanitarian organizations and government agencies involved in emergency agricultural assistance in the affected area. fao coordination units also facilitate operational information exchange, reducing duplications of and eliminating gaps in assistance. fao's primary beneficiaries include: • subsistence farmers • pastoralists and livestock producers • artisan "fisherfolk" • refugees and internally displaced people • ex-combatants • households headed by women or children and/or afflicted by hiv/aids the special emergency programmes service (tces), also within the emergency operations and rehabilitation division, is responsible for the effective implementation of specially designed emergency programs. these programs require particular attention because of the political and security context surrounding their interventions and the complexity of the institutional setup. tces was responsible for fao's intervention in the framework of the oil for food program in iraq and fao's emergency and early rehabilitation activities in the west bank and gaza strip. the rehabilitation and humanitarian policies unit (tcer) is the final component of the emergency operations and rehabilitation division. tcer is responsible for making recommendations regarding disaster preparedness, post-emergency, and rehabilitation initiatives. the unit coordinates fao's position on humanitarian policies and ensures that fao addresses the gap between emergency assistance and development. tcer also liaises with other un entities dealing with humanitarian matters. the fao's disaster-and emergency-related projects are funded by contributions from governmental agencies, ngos, other un agencies, and by the fao technical cooperation programme (tcp). each year, approximately percent of fao emergency funds are raised through the cap. fao expenditure on emergency efforts has grown significantly during the past few years, indicative of the greater role the organization has assumed in disaster management. current emergency-related projects include: • improved food security for hiv/aids-affected households in africa's great lakes region • rehabilitation of destroyed greenhouses in the west bank and gaza strip • land-tenure management in angola • emergency agricultural assistance to food-insecure female-headed households in tajikistan • consolidation of peace through the restoration of productive capacities of returnee and host communities in conflict-affected areas in sudan • rehabilitation of irrigation systems in afghanistan • rehabilitation of farm-to-market roads in the democratic republic of the congo the position of united nations commissioner for refugees (unhcr) was created by the general assembly in to provide protection and assistance to refugees. the agency was given a three-year mandate to resettle . million european world war ii refugees. today, unhcr is one of the world's principal humanitarian agencies, operating through the efforts of more than , personnel and addressing the needs of . million people in more than countries. unhcr promotes international refugee agreements and monitors government compliance with international refugee law. unhcr programs begin primarily in response to an actual or impending humanitarian emergency. in complex humanitarian disasters and in natural and other disasters that occur in areas of conflict, there is a great likelihood that refugees and idps will ultimately result. the organization's staffs work in the field to provide protection to refugees and displaced persons and minimize the threat of violence many refugees are subject to, even in countries of asylum. the organization seeks sustainable solutions to refugee and idp issues by helping victims repatriate to their homeland (if conditions warrant), integrate in countries of asylum, or resettle in third countries. unhcr also assists people who have been granted protection on a group basis or on purely humanitarian grounds, but who have not been formally recognized as refugees. unhcr works to avert crises by anticipating and preventing huge population movements from recognized global areas of concern ("trouble spots"). one method is to establish an international monitoring presence to confront problems before conflict breaks out. for example, unhcr mobilized a "preventive deployment" to five former soviet republics in central asia experiencing serious internal tensions following independence. unhcr also promotes regional initiatives and provides general technical assistance to governments and ngos addressing refugee issues. in times of emergency, unhcr offers victims legal protection and material help. the organization ensures that basic needs are met, such as food, water, shelter, sanitation, and medical care. it coordinates the provision and delivery of items to refugee and idp populations, designating specific projects for women, children, and the elderly, who comprise percent of a "normal" refugee population. the blue plastic sheeting unhcr uses to construct tents and roofing has become a common and recognizable sight in international news. unhcr maintains an emergency preparedness and response section (eprs), which has five emergency preparedness and response officers (epro) who remain on call to lead emergency response teams into affected areas. the epros may be supported by a range of other unhcr human resources, including: • emergency administrative officers and emergency administrative assistants, for quickly establishing field offices • the members of the emergency roster, which includes staff with diverse expertise and experience, are posted throughout the world and are available for rapid emergency deployment • staff (by existing arrangement) from the danish refugee council, the norwegian refugee council, and un volunteers, to provide specialized officials on short notice as needed (more than people are available at any given time) • individuals registered on a roster of "external consultant technicians," who are specialized in various fields often required during refugee and idp emergencies (including health, water, sanitation, logistics, and shelter) • select ngos that have been identified as capable of rapid deployment to implement assistance in sectors of need (e.g., health, sanitation, logistics, and social services) unhcr has the capacity to respond to a new emergency impacting up to , people. the agency can also mobilize more than trained personnel within hours. these experts come from its emergency response team (ert) roster. unhcr has also developed mechanisms for the immediate mobilization of financial resources to help meet the response to an emergency without delay. unhcr staff may be supported under an agreement with the swedish rescue services agency, which is prepared to establish a base camp and office in affected areas within hours' notice. other supplies and resources, such as vehicles, communications equipment, computers, personal field kits, and prepackaged office kits are maintained for rapid deployment to support field staff. unhcr maintains stockpiles of relief aid, including prefabricated warehouses, blankets, kitchen sets, water storage and purification equipment, and plastic sheeting. these are stored in regional warehouses or may be obtained on short notice from established vendors that guarantee rapid delivery. unhcr also maintains agreements with stockpiles outside the un system from which they may access items, such as the swedish rescue board and various ngos. unhcr developed a quick impact project (qip) initiative. qips are designed to bridge the gap between emergency assistance provided to refugees and people returning home and longer-term development aid undertaken by other agencies. these small-scale programs are geared toward rebuilding schools and clinics, repairing roads, and constructing bridges and wells. unhcr is funded almost entirely by voluntary contributions from governments, intergovernmental organizations, the private sector, and individuals. it receives a limited subsidy of less than percent of the un budget for administrative costs and accepts "in-kind" contributions, including tents, medicines, trucks, and air transportation. as the number of people protected or of concern by unhcr has reached record highs, its annual budget has likewise jumped several fold in just a few years. in , the unhcr budget was a record $ . billion, yet by that number rose to over $ . billion-a rate that has been maintained ever since. (see figure . .) in , unhcr established a new global emergency stockpile in dubai, united arab emirates. the new stockpile is the largest of several unhcr global stockpiles. it is used to store relief items such as tents, blankets, plastic sheeting, mosquito nets, kitchen sets, and jerry cans, among other items, for up to , people. prefabricated warehouses and other safety and security equipment for staff and office support are also available. in , items from the stockpile were sent to countries, including syria, jordan, lebanon, turkey, and others in africa and asia. the items shipped included , , blankets, , buckets, , jerry cans, , kitchen sets, , sleeping mats, , mosquito nets, , plastic tarpaulins, and , family tents (unhcr ). although unhcr does not often become involved in natural disaster response, rather focusing on areas of conflict, its expertise and assistance were required in the aftermath of the october earthquake that severely impacted south asia. during the response phase of this disaster, unhcr provided flights loaded with supplies from its global and regional stockpiles and contributed , family tents, , blankets, , plastic sheets, and thousands of jerry cans, kitchen sets, stoves, and lanterns. the aid items were drawn from its existing warehouses in pakistan and afghanistan, as well as other locations throughout the world. because of the earthquake, roads used to access , afghan refugees affected by the earthquake were severely damaged, but unhcr was able to quickly assess damages and needs and meet those needs through their existing networks (unhcr ) . in the event of a large-scale disaster, the un may form a disaster management team (dmt) in the affected country. if the disaster clearly falls within the competence and mandate of a specific un agency, that organization will normally take the lead, with the un dmt serving as the forum for discussing how other agencies will work to support that lead agency. the un dmt is convened and chaired by the un resident coordinator and comprises country-level representatives of fao, undp, ocha, unicef, wfp, who, and, where present, unhcr. specific disaster conditions may merit participation by other un agencies. the leader of the undac team, assigned by ocha, automatically becomes a member of the un dmt. a undp official called the disaster focal point officer often serves as the un dmt secretary, but the team is free to choose another person, if necessary. undp is also responsible for providing a venue for the team and any basic administrative support needs. the un dmt's primary purpose is to ensure that in the event of a disaster, the un is able to mobilize and carry out a prompt, effective, and concerted response at the country level. the team is tasked with coordinating all disaster-related activities, technical advice, and material assistance provided by un agencies, as well as taking steps to avoid wasteful duplication or competition for resources by un agencies. the un dmt interfaces with the receiving government's national emergency management team, from which a representative may, where practical, be included in the un dmt. the central emergency response fund (cerf) was created in through un general assembly resolution / to allow for faster operational action by un agencies. the fund, which was originally called the central emergency revolving fund but renamed in under resolution / , is administered on behalf of the un secretary-general by the emergency relief coordinator. during times of disaster, cerf provides agencies involved in the humanitarian response with a constant source of funding to cover their activities. its purpose is to shorten the amount of time between the recognition of needs and the disbursement of funding. agencies that have received pledges from donors but have not yet received actual funds, or agencies that expect to receive funds from other sources in the near future, can borrow equivalent amounts of cash, interest free, through cerf. voluntary contributions from donor nations and private-sector donors have raised billions since the inception of cerf, of which more than $ billion has been allocated in the form of grants to almost countries. the program's goal is to have $ million replenished annually. (see table . for a full list of donors.) at the outset, cerf was designed only for ches, but in the general assembly voted . the lending agency submits a request for an advance to the erc, which includes a descriptive justification on the project or activities to be funded. if a future pledge for funding has been promised by a donor or if the agency has other means for repaying the loan, this information is included in the request. . an ocha officer reviews the request. if it is accepted (statistics show that the majority are accepted), the erc informs the agency and sets out the loan use and repayment terms. . disbursement usually occurs within hours. payment is made through an internal un "voucher." . loans must be repaid within six months. this entire process is conducted at ocha's new york office. figure . illustrates patterns of use by the various un agencies. the consolidated appeals process (cap), which began in , allows humanitarian aid organizations to plan, implement, and monitor their activities. these organizations can work together to produce a common humanitarian action plan (chap; see the following section) and an appeal for a specific disaster or crisis, which they present to the international community and donors. the cap fosters closer cooperation between governments, donors, aid agencies, and many other types of humanitarian organizations. it allows agencies to demand greater protection and better access to vulnerable populations, and to work more effectively with governments and other actors. the cap is initiated in three types of situations: . when there is an acute humanitarian need caused by a conflict or a natural disaster . when the government is either unable or unwilling to address the humanitarian need . when a single agency cannot cover all the needs on november , , typhoon haiyan (yolanda) hit the philippines. the humanitarian situation in the areas devastated by the typhoon was catastrophic. an estimated million people were affected, including million children. close to million people were displaced and in dire need of humanitarian assistance. in response, the united nations emergency relief coordinator, valerie amos, released us$ million to seven united nations agencies and the international organization for migration (iom) on november. • the united nations children's fund (unicef) received $ , , to ensure water, sanitation, and hygiene facilities. unicef also provided child protection, including protective learning environments, and reduced the risk of outbreaks of vaccine-preventable diseases among children aged to months. finally, unicef provided nutrition interventions to children aged to months as well as to pregnant and lactating women. • with an allocation of $ , , the food and agriculture organization (fao) provided emergency food assistance. • the united nations population fund (fpa) received $ , to ensure access to reproductive health services and to prevent gender-based violence. • to support the internally displaced persons (idps), the united nations high commissioner for refugees (unhcr) provided emergency shelter assistance through an allocation of $ , , . • the world food programme (wfp) received $ , , to provide emergency food assistance. wfp also coordinated the humanitarian operations in the areas affected. • the world health organization (who) provided health services through an allocation of $ , , . • the united nations development programme (undp) received $ , , to manage time-critical debris disposal. • through an allocation of $ , , , iom supported evacuation centers and idp sites by procuring and distributing emergency shelter kits and essential non-food items. the cerf allocations were expected to ultimately benefit more than . million people. the cap is led by the hc, who triggers the interagency appeal and collaborates with the iasc country team at the local level and the erc at headquarters. participants in the process include: • iasc. although all team members are encouraged to participate in chap development, some members may make appeals for funding outside of the un and its cap (as is often the case with the red cross). • donors. donors participate in chap development by committing to "good humanitarian donorship principles." • host government(s). the cap is best prepared in consultation with the host government, particularly the ministries the un operational agencies are working with on a day-to-day basis. • affected population(s). whenever possible, it is always advantageous to include the affected populations' perspective into relief and recovery planning. a consolidated appeal (ca) is a fundraising document prepared by several agencies working to outline annual financing requirements for implementing a chap. although governments cannot request funding through the ca, ngos can make a request as long as their proposed project goals are in line with chap priorities. the ca is usually prepared by the hcs in september or october, and then launched globally by the un secretary-general at the donor's conference held each november. the ca lasts as long as is necessary for funding purposes, usually a year or more. the sectors that may be considered by the ca include: • agriculture • coordination and support services the process for filing a ca is as follows: . at the onset of the emergency, a situation report is issued (can cover from day to week ). . in the meantime, a flash appeal may be prepared and launched (covers week to month ). . finally, a ca may be issued. if the situation and needs in the field change, a revision to any part of an appeal can be issued at any time. additionally, projects can be added, removed, or modified within the appeal at any time. approximately percent of cap and flash appeal funding comes from a small group of wealthy nations, including canada, the european community humanitarian office (echo) and the european commission, germany, japan, the netherlands, norway, sweden, the united kingdom, and the united states. in high-profile events, private donors may constitute a large percentage of donations, such as occurred in the case of the tsunami disaster in asia. the chap is a strategic plan developed by agencies working together at the field level that assesses needs in an emergency and coordinates response. it acts as the foundation for a ca, and includes the following information: . common analysis of the context for humanitarian assistance . needs assessment . best, worst, and most likely scenarios . identification of roles and responsibilities (who does what and where) . clear statement of long-term objectives and goals . framework for monitoring strategy and revising as necessary a flash appeal is a special kind of ca, designed for structuring a coordinated humanitarian response for the first three to six months of an emergency. whenever a crisis or natural disaster occurs, the un hc may issue a flash appeal in consultation with all stakeholders involved in the humanitarian response (including the affected government). it is normally issued between the second and fourth weeks of the response and provides a concise overview of urgent lifesaving needs. it may also include early recovery projects if they can be implemented within the appeal's time frame. in , as a part of the inter-agency standing committee (iasc) transformative agenda, the united nations changed the way that the cap was issued. the appeal, which addresses the emergencies, was the largest appeal to date, calling for $ . billion (more than $ . billion greater than the appeal) to support million people in countries. the increase was primarily due to a $ . billion request for the complex humanitarian emergency in syria, as well as another che in the central african republic and typhoon haiyan in the philippines. the changes begin with the document's name, which is now called the "overview of global humanitarian response" rather than the former "overview of consolidated appeals process." the overall goal of the change is to ensure that the cap process is needs-based and funds are adequately monitored. the change is explained in the appeals document as follows: "now, instead of one overweight cap document trying to present all elements of the program cycle, for the key elements appear in a series of documents produced in sequence: humanitarian needs overview; strategic response plan (comprising the country strategy plus cluster plans); and periodic monitoring bulletins reporting on basic delivery and outputs compared to targets. discussions are ongoing about the possible production of end-of-year reports on achievements versus objectives" (un b). (see exhibit . ). since , more than consolidated and flash appeals have been launched, collectively raising more than $ billion for ngos, the international organization for migration (iom), and un agencies. in addition to the un agencies discussed previously, which tend to be the primary agencies involved in all forms of disaster management, a handful of organizations provide more focused assistance as deemed necessary in most disasters that require international participation. as illustrated in figure . , which details un assistance to the various countries affected by the december asian tsunami and earthquake events, a different mix of un assistance is needed in each country, even within the same international disaster scenario. several of these organizations are detailed in the following list. • international labour organization (ilo). the ilo works with the affected population to address issues related to employment, including job creation, skills training, employment services, small business assistance, and other functions. (see exhibit . .) • international organization for migration (iom) . the iom provides rapid humanitarian aid to displaced populations by supplying emergency shelter, transporting relief materials, and assisting in medical evacuations. the organization stabilizes populations through the provision of short-term community and microenterprise development programs. iom also actively supports governments in the reconstruction and rehabilitation of affected communities by being the lead service provider of : haiti cannot afford to become a forgotten crisis. important progress has been made in recent years, but the country is still one of the most exposed to risk from disaster and climate change. multiple disasters combined with high unemployment, increased inequality, and poor access to basic social services have prolonged the vulnerability of an estimated three million haitians to displacement, food insecurity, and fragile living conditions. haiti suffers the world's largest cholera epidemic, which has affected over , people and killed , . although the humanitarian situation in south sudan has stabilized on several fronts, needs remain high-driven primarily by violence and displacement, persistent food insecurity, and chronic poverty. national capacity to deliver basic services is low, with aid agencies the main providers of health care, clean water, livelihoods support, and other services in many parts of the country. while needs are expected to remain high in - , in some areas such as food insecurity, there are opportunities for innovative and more targeted approaches to break recurring cycles of hardship. the strategy for - has three objectives: responding to immediate needs, enhancing communities' resilience against shocks and stresses, and building national capacity to deliver basic services. alongside core programmes to save lives and ease suffering, partners are increasingly integrating actions to reduce the risk of natural disasters, strengthen and diversify livelihoods, and address the long-term needs of vulnerable groups, including refugees and children. the strategy also emphasizes the importance of delivering aid in partnership with line ministries and national ngos to ensure humanitarian relief has a long-term positive impact. the strategy spans three years, to better address deep-rooted challenges and measure the impact of relief actions. requirements: $ . billion funding received against requirements: % people in need: . million people to receive help: . million in yemen, more than half the population needs some form of humanitarian aid. the collapse of basic services in - , endemic food insecurity, destroyed or damaged livelihoods and under-development, along with displacement resulting from conflict, have combined to plunge the country into a humanitarian emergency which may persist into . inflows of refugees and migrants from the horn of africa and returning yemeni migrants count among the vulnerable. ten and a half million people are food-insecure or severely food-insecure, and , , children under five suffer from acute or severe malnutrition. about half the population has no access to adequate water sources or sanitation facilities, and a further . million have insufficient access to health services. an estimated , returnees need assistance to rebuild their lives, while , refugees, mostly from somalia, and tens of thousands of mainly ethiopian migrants are stranded in the country. it is expected that the number of returning yemeni migrants, estimated to be , people, will double in . the weakness of rule-of-law institutions has been identified as a serious protection risk. according to the latest ilo estimates, . million out of the . million workers who have either temporarily or permanently lost their livelihoods were working in the service sector. over one third, or . million, were in agriculture and around per cent in the industry sector. "service sector includes people working in shops, public markets, restaurants, vendors, tricycle and jeepney drivers, mechanics, clerks, teachers, . . . who, like farmers and fisherfolks, have seen their source of income wiped away," said ilo philippine office director lawrence jeff johnson. "at least . million affected workers were already in a vulnerable situation before the typhoon struck, often living at or near the poverty line, doing whatever work they could find to survive and provide for their families. these people have lost the little they had to begin with. they have no home, no income, no savings and no one to turn to for help," said director johnson. "as the reconstruction efforts gather pace, the number one priority is to ensure that these workers have access to decent jobs, which include at least minimum wage, social protection, and safe working conditions," johnson said. the department of labor and employment (dole) and the department of social welfare and development (dswd) are rolling out emergency employment programmes to respond to the enormous reconstruction and livelihoods needs. the ilo is working closely with them as well as with local governments, business' and workers' organizations, and international partners. "these programmes comply with philippine regulation and international labour standards, ensuring that people are not exploited while they help to rebuild their communities and local economies," johnson explains. workers under the emergency employment programmes receive the minimum wage prevailing in the area and are employed for a minimum of days. they also have access to social protection benefits. "this is a very first step to jump start the economy and quickly put the affected communities back in the driver's seat in rebuilding their lives. ensuring minimum wage and social protection will help stimulate economic growth and speed the recovery process." johnson said. source: ilo, . unaids works with victims to protect them from the kinds of violence and activity that spreads hiv. in , the un general assembly held a special session on hiv/aids and declared that through unaids: [the un would] develop and begin to implement national strategies that incorporate hiv/aids awareness, prevention, care, and treatment elements into programs or actions that respond to emergency situations, recognizing that populations destabilized by armed conflict, humanitarian emergencies, and natural disasters, including refugees, internally displaced persons, and in particular, women and children, are at increased risk of exposure to hiv infection; and, where appropriate, factor hiv/ aids components into international assistance programs. (un ) • united nations population fund (unfpa). unfpa works to promote basic human rights throughout the world, and to increase the possibilities of women and young people to lead healthy and productive lives. their work focuses specifically on reproductive health and safe pregnancies and deliveries. during humanitarian crises, there is often a demand for reproductive health services even though distribution and health care systems have broken down. unfpa works closely with its humanitarian relief partners to support early and effective action to meet the reproductive health needs of refugees, idps, and others caught in crisis situations. supply shortages compound health risks in already dangerous situations and are a major obstacle to reproductive health in emergencies. existing supplies may fall far short of demand when large numbers of people move into a safer location. supplies, equipment, and medicine are organized and stored by unfpa for immediate distribution when an earthquake, flood, violent conflict, or other crisis arises. a rapid-response fund enables unfpa to mount a quick response to emergencies, especially in the initial stages. supplies are packaged in different emergency reproductive health kits, including a "clean birthing kit." once an emergency situation stabilizes, the procurement of reproductive health materials becomes a regular part of a more comprehensive healthcare program. • united nations human settlement programme (un-habitat) . un-habitat is mandated by the un general assembly to "promote socially and environmentally sustainable towns and cities with the goal of providing adequate shelter for all" (un ). un-habitat is mandated through the habitat agenda (a global settlement plan adopted in june by the international community) to take the lead in mitigation, response, and post-disaster rehabilitation capabilities in human settlements. the habitat agenda clearly outlines the link between human settlement development and vulnerability to disasters. in addition, it emphasizes the need for coordination and close partnerships with national and local governments, as well as civil society. finally, the habitat agenda recognizes the strong impact disasters have on women, and affirms the need for women's active involvement in disaster management. these steering principles underpin all normative and operational activities of the un-habitat disaster management programme (dmp). dmp operates under the disaster, post-conflict and safety section (dpcss), urban development branch. it was created to marshal the resources of un-habitat and other international agencies to provide local government, civil society, and the private sector with practical strategies for mitigating and recovering from conflicts and natural disasters in the context of human settlements. specific areas of attention include: • protecting and rehabilitating housing, infrastructure, and public facilities • providing technical and policy support to humanitarian agencies before and after crisis in the context of human settlements • building partnerships and providing complementary expertise in resettlement of displaced persons and refugees • restoring local social structures through settlement development • rehabilitating local government structures and empowering civil society • land and settlements planning and management for disaster prevention un-habitat launched the city resilience profiling programme (crpp) to support local government efforts to build capacity to reduce disaster risk. through their guidance, governments are assisted in the development of comprehensive and integrated urban planning and implementation of a resilient management approach. the city resilience profile is a baseline assessment of a city-system's ability to withstand and recover from potential hazards. examples of cities that have participated in the program include balangoda, sri lanka; barcelona, spain; beirut, lebanon; dagupan, philippines; dar es salaam, tanzania; lokoja, nigeria; portmore, jamaica; talcahuano/concepcion, chile; tehran, iran; and wellington, new zealand. un-habitat plays an important role in disaster recovery, given the impact on housing so many disasters have. the organization has lead agency status within the united nations system for coordinating activities related to human settlement. it is mandated in this role through the habitat agenda. the organization's responsibilities in this regard are to support national governments, local authorities, and civil society in ensuring that risk is not retained in the reconstruction housing that follows the event. housing reconstruction often begins soon after the disaster has occurred, and un-habitat seeks to deploy quickly to ensure that resilient building practices are incorporated into the recovery planning process. • united nations environmental program (unep). unep is the un agency focused on the protection of the environment and wise use of natural spaces. unep has several divisions that address global emergency and disaster management needs. • unep's disasters and conflicts sub-program was created to assess and address the environmental impacts of disasters and conflicts, especially as they relate to human health, livelihoods, and security. since , this program has responded to crises in more than countries. their assistance is provided to other un agencies responding as well as directly to the host country government. the disasters and conflicts sub-program has four overarching objectives: • perform post-crisis environmental assessments; • support post-crisis environmental recovery; • foster environmental cooperation for peacebuilding; and • promote disaster risk reduction. as the focal point for environment within the un crisis response system, unep also works to integrate environmental considerations within humanitarian and peacekeeping operations. coordinated by unep's post-conflict and disaster management branch, the disasters and conflicts sub-program is delivered through several key actors and partners, including the joint unep/ocha environment unit, the environment and security (envsec) initiative, and the apell (awareness and preparedness from emergencies on a local level) programme. apell, which is based out of the unep industry and environment office in paris, supports disaster risk reduction and disaster preparedness. it seeks to minimize the occurrence and harmful effects of technological accidents and emergencies resulting from human activity or as the consequence of natural disasters, particularly in developing countries. understandably, unep plays a major role in climate change activities, including climate change adaptation. the organization supports developing countries in their efforts to identify and address risk specifically related to changing temperature and precipitation that are associated with global climate change patterns, including sea level rise. one of the primary functions of this office is to help governments to integrate climate change adaptation policy throughout all sectors of government, such that it becomes a major policy goal rather than a distinct, stove-piped component of government. finally, unep promotes sustainable land-use management and helps countries identify opportunities to reduce carbon emissions, which are often blamed for the bulk of climate variability. • united nations educational, scientific, and cultural organization (unesco). unesco's goal is to contribute to the peace and security of the world through education, science, and culture. unesco has been involved in disaster management for decades. this organization advocates for the need for a shift in emphasis from relief and emergency response to prevention and increased preparedness and education of potentially affected populations. it strongly supports the design and dissemination of mitigation measures, as well as public education and awareness. unesco works to increase the role of academic and research sectors in creating risk and vulnerability reduction measures, and supports existing and new institutions through financial and material support. unesco proclaims that their function regarding disaster management is: to promote a better understanding of the distribution in time and space of natural hazards and of their intensity, to set up reliable early warning systems, to devise rational land-use plans, to secure the adoption of suitable building design, to protect educational buildings and cultural monuments, to strengthen environmental protection for the prevention of natural disasters, to enhance preparedness and public awareness through education and training communication and information, to foster post-disaster investigation, recovery and rehabilitation, to promote studies on the social perception of risks. (unesco ) • in , the un general assembly created un women, which merged four existing un organizations that focused exclusively on gender equality and women's issues. these included the united nations development fund for women (unifem), the international research and training institute for the advancement of women (instraw), the office of the special adviser on gender issues and advancement of women (osagi), and the division for the advancement of women (daw). un women works to ensure that the needs of women are considered in disaster planning and preparedness efforts, as well as in the aftermath of disasters and in the recovery from them, when women face extraordinary vulnerabilities. un women provides financial and technical assistance to innovative programs and strategies to foster women's empowerment and gender equality. (see exhibit . .) • united nations institute for training and research (unitar). unitar was created to provide training and research within the un system with the goal of increasing the effectiveness of all un programs. in recent years, more of these efforts have focused on the four phases of disaster management, addressing many related topics such as climate change, hazardous materials and pollution, land use, and biodiversity. the global platform for disaster reduction was established in as a forum for information exchange. the platform meets every two years and allows participants to discuss innovations and developments in drr as well as to share existing knowledge and build partnerships among the various stakeholders. the goal in creating the program was to improve drr implementation by fostering better communication and coordination among stakeholders, to serve as a way for un members to voice their concerns and needs, and to share their best practices and lessons learned. the global platform replaces the former interagency task force for disaster reduction (iatf/ dr), which was led by the un under-secretary-general for humanitarian affairs and composed of representatives from un agencies, international organizations, ngos, and other civil society for millions of people in rural viet nam, the impacts of climate change are mounting and sometimes deadly. as weather patterns change, many of viet nam's women in particular are paying a high price. "the weather becomes more extreme and erratic. storms, heavy rains, and floods destroy fields and houses, kill animals and people every year," said ranh nguyen, , a farmer and the head of the women's union group in an dung commune, in binh dinh province, central viet nam. there, ranh and her neighbours have joined the viet nam women's union and are working with un women to strengthen the role of women in disaster risk-reduction and disaster-reduction management. some kilometers from the city of binh dinh, an dung commune is always at high risk of flooding, as it only has one road connecting it to other communes,and landslides often occur during the storm season. almost every year, the commune suffers at least one severe flood that damages crops and houses heavily. and women are often the most affected. however, things are starting to change. "thanks to good preparation and detailed mapping that we developed in the meetings before each storm, nobody in the village was killed or injured severely in the last year storm season. crops, fowl, and cattle were saved," explains ranh, now an official member of the committee for flood and storm control in her commune. prior to the project, there were few women on the committees for flood and storm control (cfsc) in the village. through the training of women in disaster management, as well as national lobbying-supported by un women, undp and other stakeholders-the contribution of women has been recognized. a government decree issued in september now provides an official space for the women's union in decision-making boards of the cfsc at all levels. "after being involved in the project, i am more aware of the situation of climate change and its impacts on us. last year, we participated in the training and exchanged experiences with other women. we prepared better for our families and our village before the storm came," ranh said. she said that she talked to the other members of the communal committee for flood and storm control. as a result, before the flooding began, they had plans ready to evacuate people living in lowland areas and near the river. "the mapping we did together in the training was really helpful. we discussed how to encourage people to harvest earlier, before the storm season started." in the end, she said, no lives were lost. last year, a four-year-old boy was saved from drowning because his mother performed cpr on him. she and another women and girls learned this technique from the rescue and first aid training provided by the project. "i could not swim before and used to be frightened by the flooded river. but now i am no longer afraid of water thanks to the swimming classes. i will teach my children how to swim and tell other people to learn how to swim too," ranh said. this project continues to be implemented in four new provinces including thua thien hue, quang binh, ca mau and dong thap, all of which face a high risk of flooding. this project is financed through core funding to un women and from the government of luxemburg. stakeholders. the global platform is organized by the un office for disaster risk reduction (unisdr; see below). the global platform for disaster risk reduction is considered the most significant gathering of disaster risk reduction and disaster management stakeholders worldwide. every ten years, the world conference on disaster reduction is held. the first was held in . the second world conference, held in in kobe, japan, led to the launching of the hyogo framework for action (hfa). the world conference is to be held in sendai, japan, which was significantly impacted by the great east japan earthquake and tsunami in . the focus of the conference is on the follow-up to the hyogo framework for action, termed the post- framework for disaster risk reduction in the lead-up to the conference. the united nations office for disaster risk reduction (unisdr) is the secretariat of the international strategy of disaster reduction and the global hub of the disaster risk reduction community, which includes national governments, ngos, intergovernmental organizations, financial institutions, technical bodies, and others. unisdr serves as the focal point for the implementation of the hyogo framework for action (hfa), the ten-year plan to address global disaster risk that commenced in and is set to expire in . unisdr was created in , at the end of the international decade for natural disaster reduction. the organization functions as a clearinghouse for disaster reduction information; campaigns to raise hazard awareness; and produces articles, journals, and other publications and promotional materials related to disaster reduction. unisdr maintains an organizational vision that is guided by the three strategic goals of the hfa for which it is tasked to oversee. these include: integrating disaster risk reduction into sustainable development policies and planning; . developing and strengthening institutions, mechanisms and capacities to build resilience to hazards; and . incorporating risk reduction approaches into emergency preparedness, response, and recovery programs. the organization describes the four key functions that guide its efforts as follows: • we coordinate international efforts in disaster risk reduction and guide, monitor as well as report regularly on progress of the implementation of the hyogo framework for action. we organize a biennial global platform on disaster risk reduction with leaders and decision makers to advance risk reduction policies and support the establishment of regional, national and thematic platforms. • we campaign and advocate to create global awareness of disaster risk reduction benefits and empower people to reduce their vulnerability to hazards. our current campaigns focus on safer schools and hospitals as well as resilient cities. • we encourage for greater investments in risk reduction actions to protect people's lives and assets including climate change adaptation, more education on drr, and increased participation of men and women in the decision making process. • we inform and connect people by providing practical services and tools such as the risk reduction website preventionweb, publications on good practices, country profiles and the global assessment report on disaster risk reduction, which is an authoritative analysis of global disaster risks and trends. (unisdr ) unisdr is led by the un special representative of the secretary-general for disaster risk reduction. margareta wahlstrom currently holds this post. the position was created in to lead and oversee all drr activities mandated by the un general assembly (ga), the economic and social council (ecosoc), and the hyogo framework for action (hfa), as well as policy directions by the secretary-general. other responsibilities include the ongoing and arduous process of facilitating the development of the post- framework for drr that will follow the hfa, overseeing the management of the trust fund for the international strategy for disaster reduction, and carrying out highlevel advocacy and resource mobilization activities for risk reduction and implementation of the hfa. one of the most significant functions of unisdr is monitoring the progress achieved by nations and global regions per the hyogo framework for action. monitoring is an almost ongoing process, with reports on progress produced every two years (as well as interim reports on off years, in some instances). the hfa monitor is an online reporting system that nations and regional organizations use to assess their capabilities and progress according to the indicators outlined in the hfa. the hfa monitor template, found on the hfa monitor website, defines the areas of assessment. the result of this process is a national or regional hfa progress report. not all countries produce the reports, and for those that do, reports are not necessarily submitted for each reporting period. critics note that it is a self-reporting and ranking system, but in the absence of any other system on the scale of the hfa monitor, the information it provides is highly informative and very useful in estimating capacity. the information is also used to produce papers and reports on various thematic issues, such as gender in disaster management, integration of drr and climate change adaptation, early warning, and others. the world bank and unisdr work closely together on a number of key disaster risk reduction issues, notably those related to development and disaster reconstruction, through a unisdr/world bank global facility for disaster reduction and recovery (wb/gfdrr) partnership. other similar drr-and disaster risk management-focused partnerships have been formed with various regional international organizations, including the association of southeast asian nations (asean), organization of the islamic conference (oic), pan american health organization (paho), applied geoscience and technology division of the secretariat of the pacific community (sopac), economic community of west african states (ecowas), and african union (au). unisdr is headquartered in geneva and has representation at the un headquarters in new york city. the organization also has regional offices in africa (nairobi), the americas (panama and brazil), asia/pacific (bangkok, japan, and korea), the pacific (sub-regional office in suva), the arab states (cairo), europe (brussels and bonn), and central asia (sub-regional office in almaty). (see figure . .) unisdr also works with and advises a number of key thematic platforms on disaster risk reduction issues, including: response (un-spider) the un is the only global international organization of its kind. it is not, however, the only governing organization made up of several national governments. many of the world's regions have pooled their collective resources and services to create large, influential organizations. like the un, these organizations address issues of regional and global importance, many of which focus on or peripherally address disaster management. in times of disaster, both within and outside of their regions of concern, they bring much of the same financial, technical, and equipment resources discussed throughout this book. this section identifies and briefly describes the largest of these organizations. the north atlantic treaty organization (nato) is an alliance of countries from north america and europe formed by a treaty signed on april , . its fundamental goal is safeguarding its members' freedom and security using political and military means. over the years, nato has taken on an increasing role in international disaster management and peacekeeping missions. nato maintains a military force made up of member countries' troops. although they work in concert, troops always remain under the control of their home nation's government. nato has helped to end violent conflicts in bosnia, kosovo, and the former yugoslav republic of macedonia. nato's disaster and crisis management activities, which extend beyond its typical military operations, are geared toward protecting populations. as part of the worldwide civil protection drive described in chapter , nato began developing measures to protect member nation citizens from nuclear attack as early as the s. as elsewhere, nato member countries soon realized that these capabilities could be used effectively during disasters induced by floods, earthquakes, and technological incidents and during humanitarian disasters. nato's first involvement in disaster operations came in , following devastating floods in northern europe. in , it established detailed procedures for the coordination of assistance between nato member countries in case of disasters. these procedures remained in place and provided the basis for nato's civil emergency planning in subsequent years. in , nato established the euro-atlantic disaster response coordination center to coordinate aid provided by member and partner countries to a disaster-stricken area in a member or partner country. it also established a euro-atlantic disaster response unit, which is a non-standing, multinational mix of national civil and military elements volunteered by member or partner countries for deployment to disaster areas. civil emergency planning has become a key facet of nato involvement in crisis management. in recent years, nato has assisted flood-devastated albania, czech republic, hungary, romania, and ukraine, supported the unhcr in kosovo, sent aid to earthquake-stricken turkey, helped to fight fires in the former yugoslav republic of macedonia and in portugal, supported flood response in pakistan, and supported ukraine and moldova after extreme weather conditions destroyed power transmission capabilities. nato has taken an active role in the response to the south asia earthquake, as described in exhibit . . nato also regularly conducts civil emergency planning exercises. the european union (eu) originated in may of , when six european countries (belgium, germany, france, italy, luxembourg, and the netherlands) joined together to address common issues related to the coal and steel industries. since that time, the scope of their work has expanded significantly, as has their membership. the eu is now a major regional international organization representing member states and is in the process of admitting several other eastern and southern european countries in a push toward greater inclusion. the eu considers itself a "family of european countries, committed to working together for peace and prosperity" (bbc ). like the un, it is not a government, nor does it have any authority over its members; it is an organization established for increased regional cooperation. regional international organizations the devastating october earthquake in pakistan is estimated to have killed , people and left up to three million without food or shelter just before the onset of the harsh himalayan winter. on october , , in response to a request from pakistan, nato launched an operation to assist in the urgent relief effort. nato airlifted supplies donated by nato member and partner countries as well as the unhcr via two air bridges from germany and turkey; flights delivered almost , tons of relief supplies. the supplies provided included thousands of tents, stoves, and blankets necessary to protect the survivors from the cold. in addition, nato deployed engineers and medical units from the nato response force to assist in the relief effort. the first teams arrived on october , . in just three months of operations, nato achieved the following: • nato's air bridges flew almost tons of aid to pakistan with flights. these flights carried in nearly , tents, , blankets, nearly , stoves/heaters, more than , mattresses, , sleeping bags, tons of medical supplies, and more. • nato's field hospital treated approximately , patients and conducted major surgeries. mobile medical units treated approximately , patients in the remote mountain villages; they also contributed significantly to the who immunization program that has helped to prevent the outbreak of disease. • in the cities of arja and bagh, nato engineers repaired nearly kilometers of roads and removed over , cubic meters of debris, enabling the flow of aid, commerce, and humanitarian assistance to the inhabitants of the valley. nine school and health structures were completed and tent schools erected. the engineers distributed cubic meters of drinking water and upgraded a permanent spring water distribution and storage system to serve up to , persons per day. • nato engineers also supported the pakistani army in operation winter race, by constructing multipurpose shelters for the population living in the mountains. • nato helicopters transported more than , tons of relief goods to remote mountain villages and evacuated over , disaster victims. • nato set up an aviation fuel farm in abbottabad, which carried out some , refueling missions for civilian and military helicopters. during the mission some , engineers and supporting staff, as well as medical personnel, worked in pakistan. nato was part of a very large effort aimed at providing disaster relief in pakistan. the pakistani army provided the bulk of the response, with the support of nato, the un, and other international organizations and several individual countries. on october , nato received from pakistan a request for assistance in dealing with the aftermath of the october earthquake. the next day, the north atlantic council approved a major air operation to bring supplies from nato and partner countries to pakistan. the airlift began on october and the first tons of supplies arrived in pakistan on october. on october, nato opened a second air bridge from incirlik, turkey, to deliver large quantities of tents, blankets, and stoves donated by the unhcr. on october, in response to a further request from pakistan, nato agreed to deploy engineers and medical personnel from the nato response force to pakistan to further assist in the relief effort. a nato headquarters was deployed to pakistan on october to liaise with pakistani authorities and pave the way for the incoming troops. the first troops, the advance elements of the medical team, began arriving on october, and immediately began treating hundreds of people a day. engineering teams followed and began working in the area around bagh in support of pakistani efforts to repair roads and build shelters and medical facilities. nato engineers also supported the pakistani army in operation winter race, by constructing multipurpose shelters for the population living in the mountains. on november, nato opened a sophisticated -bed field hospital, which provided a wide range of care including complex surgical procedures. on the same day, heavy-lift transport helicopters assigned to nato for the operation began flying and delivering supplies to remote mountain villages and evacuating victims. nato also set up an aviation fuel farm in abbottabad, which carried out refueling for civilian and military helicopters, which were essential to the relief effort. on october, additional foreign secretary of pakistan tariq osman hyder addressed a meeting of the euro-atlantic partnership council at nato headquarters in brussels, asking for further assistance. he said that nato could provide continued airlift, funds, logistic and airspace management, mobile fuel tanks, spare parts for helicopters and tactical aircraft, command and control, and winterized tents and sleeping bags. that same day, nato's euro-atlantic disaster response coordination center (eadrcc) received an urgent request from the unhcr for the transport of additional shelter and relief items stored in turkey to pakistan before the winter sets in. nato's relief mission came to an end, on schedule, on february . nato's short-term relief mission was based on the following five elements: . coordination of donations from nato and partner countries through the eadrcc in brussels; . the air bridge from turkey and germany for the transport of relief goods to pakistan; . five helicopters operating in the earthquake-affected area for the transport of supplies to remote mountain villages and evacuation of victims; . medical support with a field hospital and mobile medical teams in the area of bagh; . engineer support operating in the area around bagh in support of pakistani efforts for the repair of roads and building of shelters, schools, and medical facilities. humanitarian assistance has been a part of the eu mission since , and since that time the organization's work in that area has grown such that today it is the world's most significant humanitarian aid donor. taken together, its members represent a sizeable piece of the global economy, thus enabling them the ability to provide more than percent of all humanitarian aid worldwide. the eu has also structured itself to be an active stakeholder in international disaster management. their work in this regard is not limited to europe and in fact has a global presence. since taking on disaster management responsibilities, the eu has responded through one or more of its various departments to disasters in more than countries. in , the eu restructured its global hazard risk and disaster management capacities. these changes resulted in the merging of two former divisions: one that handled humanitarian assistance and another that centered on civil protection. together these units formed the combined directorate general for humanitarian aid and civil protection (echo). the acronym is a carryover from a former component of the eu's response mechanism called the european community humanitarian office. the move effectively integrated these two functions, which, over time, saw duplicative missions. exhibit . is drawn from an eu factsheet describing how the eu responded to typhoon haiyan in the philippines in using this combined function. through its humanitarian aid and civil protection department (echo), the european commission made available us$ . million to help the survivors of the typhoon with food assistance, shelter, water and sanitation, health and nutrition, short-term livelihood support, reconstruction of schools, emergency logistics, and coordination of relief efforts. within hours after the disaster struck, the european commission's experts had been deployed to identify priority needs. the commission implemented its assistance primarily through the following partner organizations: assistance supported by echo reached approximately . victims in the areas affected by the typhoon. the eu civil protection mechanism was activated to ensure coordination of european relief efforts. participating member states supplied personnel and material to support the operation. the eu civil protection mechanism, coordinated by the commission's emergency response and coordination centre (ercc), also supported the transport of civil protection assets to the region with around us$ . million. in addition to humanitarian funds, the european commission has released $ . million from the eu's development funds to help rebuild people's lives by assisting in recovery and rehabilitation. examples of eu-funded humanitarian projects are described in the following section. • to address food insecurity among the affected population who had little to eat and little to no access to markets, the eu funded the efforts of the world food programme (wfp). wfp provided general distribution of food, including highenergy biscuits during the emergency phase, and then provided supplementary feeding for children and pregnant and lactating women. "food-for-work" and "cash-for-work" initiatives were established. • the eu provided funds to the international committee of the red cross (icrc) and national red cross societies to provide thousands of families with shelter repair kits and to support the livelihoods recovery and wash clusters. the national red cross societies projects supported the delivery of non-food items, including blankets and water storage containers. many families were provided with unconditional cash grants, and communities were given assistance in improving sanitation facilities, restoring primary healthcare services (including medicines), disease prevention, and hygiene awareness. • the eu supported a consortium that includes plan international and oxfam. funding helped to provide relief for the most significantly affected households by enabling livelihoods recovery, distribution of cash-for-work vouchers, and rehabilitation of public service infrastructure, including child-friendly spaces, classrooms, day care centers, and health stations. • to help the approximately million people left homeless by the typhoon, the eu funded the international organization for migration (iom) efforts to improve the well-being and living conditions of those who were displaced, who have returned, or who are planning to go back to their places of origin. special attention was given to persons with disabilities and other special needs. the project provided shelter repair kits to the affected populations and ensured quality management of displacement sites and timely information on communities' return and relocation processes. finally, vulnerable groups targeted by the initiative received health services, psychosocial support, and non-food items such as blankets. based on: ec, . echo enables the eu to respond to most major crises regardless of where they are in the world. at the time of this publication, the eu was involved in the response to ches in syria, south sudan, and the central african republic and was working in several other countries that were no longer entrenched in conflict but nonetheless faced humanitarian needs (e.g., côte d'ivoire). in recent years, the eu annual budget allocation for humanitarian operations has remained at around us$ . billion, or about us$ per person from the combined population of the eu member countries. through this funding, the organization has reached on average about million people each year. echo maintains a staff of more than at its brussels headquarters and more than dispersed throughout field offices in countries worldwide. when a disaster strikes, and presumably upon request, echo staff deploy in order to conduct a needs assessment. if it is determined that assistance is warranted, staff will remain and monitor the situation as it progresses and oversee the implementation of the humanitarian aid projects that echo supports. echo has established relationships with more than other disaster management stakeholders, including un agencies and ngos. echo humanitarian assistance can come in several forms, including food aid; clothing; healthcare supplies; and materials for shelter, water, and sanitation. echo also supports relief work, such as infrastructure repair, removal of mines, psychological support, and education, among many others. echo has a special program, called the "forgotten crisis assessment," that focuses on less salient events. through this program, echo tries to raise the profile of serious incidents it finds are receiving too little attention among the humanitarian community, for the purpose of increasing the funds available to impacted victims. in , echo distributed humanitarian aid worth us$ . billion (which amounts to less than percent of the eu budget, yet is, in gross terms, a significant amount in total funding when compared to most other donors). this funding assisted million people in more than countries outside the european union. echo also oversees the eu civil protection mechanism, which comprised states ( eu member states, plus former yugoslav republic of macedonia, iceland, liechtenstein, and norway). this mechanism enables these nations to coordinate and cooperate in the event of a disaster in one or more eu countries or elsewhere in the world. civil protection agencies from member countries provide inkind assistance, equipment, and teams, or experts that perform damage and needs assessments. echo civil protection relies on the resources of member governments and, if assistance is required in non-eu countries, it typically works in parallel with the humanitarian aid component of echo. for european countries, the coordination and cooperation provided under echo is, in essence, a highly formalized mutual assistance compact that increases the capacity of all nations involved. nations pool their resources and maximize their collective efforts. the key instrument for european civil protection is the civil protection mechanism (cpm), which was established in . the operational heart of cpm is the european commission's monitoring and information centre (mic), which will soon become the european emergency response centre (erc). any country inside or outside eu affected by a disaster and overwhelmed by its magnitude can make an appeal for assistance through the mic/erc. to provide formalized mitigation and preparedness assistance, echo launched its disaster preparedness program, disaster preparedness echo (dipecho), in . dipecho attempts to reduce population vulnerability in disaster-prone regions. between and , dipecho provided more than $ million for hundreds of projects worldwide. dipecho-funded projects are implemented by aid agencies working in the region of concern, and support training, capacity building, awareness raising, and early warning projects, as well the organization of relief services. echo disaster preparedness efforts, however, extend beyond dipecho. many of echo's major humanitarian financing decisions, for example, include disaster preparedness or prevention as an objective. even post-disaster emergency responses can seek to reduce future risk. examples of echo risk-reduction activities include livestock shelters built after extreme cold snaps to protect against further herd depletion (peru), training and equipping of community-based fire brigades in forest fire risk zones (indonesia), cholera preparedness and health information (malawi), and antirust measures to prevent water pollution and protect pipes from the effects of volcanic ash (ecuador). the organization of american states (oas) was established in by nations located in north, central, and south america and the caribbean that wished to strengthen cooperation and advance their common interests in the western hemisphere. through the oas charter these nations committed to a set of common goals. respect for each other's sovereignty has always played a central role in oas affairs. today, all independent nations in the region have ratified the oas charter and serve as members of the organization (though the cuban government was excluded from participation in oas from to , and has yet to rejoin since the lifting of its ban). the oas is heavily involved in disaster risk reduction and preparedness efforts in the region. the vast majority of such projects are facilitated by the oas office for sustainable development and environment (osde), which supports activities in both individual countries and those that involve multiple countries. the more prominent of these activities focus on the following goals: • supporting the management of trans-boundary water resources • improving information for decision making in biological diversity • establishing land-tenure reform and property rights • supporting the exchange of best practices and technical information in environmental law and enforcement, renewable energy, water management, and biodiversity • improving management systems to reduce the impacts of natural disasters • understanding climate-related vulnerabilities affecting small island states the following is a list of projects that illustrates the range of disaster risk reduction and preparedness activities carried out by oas: mitigation capacity building program. the three-year program assisted countries in the caribbean region to develop comprehensive, national hazard vulnerability reduction policies and associated implementation programs, and develop and implement safer-building training and certificate programs. improvement program with assistance from oas to offer hurricane-resistant home improvement options to low-income families. this program trains local builders in safer construction, offers small loans to families wishing to upgrade their homes, and provides the services of a trained building inspector who approves materials to be purchased and checks minimum standards. in addition to the osde, oas supports disaster risk reduction through its inter-american committee for natural disaster reduction (iacndr). iacndr is the organization's main forum for integrating disaster risk reduction into sustainable development practices. the oas general assembly established the iacndr to strengthen its role in natural disaster reduction and emergency preparedness. the southern african development community (sadc) began in , when a loose alliance of nine southern african states formed (then known as the southern african development coordination conference, or sadcc). the organization's aim was to coordinate development projects to decrease economic dependence on south africa. in , it shifted from a "coordination conference" to a development community known as the sadc. sadc member states are angola, botswana, the democratic republic of congo, lesotho, madagascar, malawi, mauritius, mozambique, namibia, seychelles, south africa, swaziland, united republic of tanzania, zambia, and zimbabwe. sadc's primary mission is to help define regional priorities, facilitate integration, assist in mobilizing resources, and maximize regional development. it approaches problems and national priorities through regional cooperation and action. several sadc programs address the region's safety and security, primarily through risk-reduction mechanisms that include disaster preparedness and mitigation. the following are some examples of sadc disaster-related programs: • food, agriculture, and natural resources directorate • regional early warning unit • regional remote sensing unit the coordination center for natural disaster prevention in central america (cepredenac) was established in as a coordination center to strengthen the central american region's ability to reduce their population's vulnerability to natural disasters. in may , cepredenac became an official organization to foster regional cooperation among the governments of costa rica, el salvador, guatemala, honduras, nicaragua, and panama. the organization's headquarters are in guatemala city, guatemala. since its founding, the organization has been instrumental in securing region-wide commitment to disaster risk reduction through the passing of several resolutions and the creation of several plans and strategies signed by participating countries. the organization's agenda parallels and coordinates with other specialized regional entities in areas including hydrological resources, agriculture, nutrition, and food security. the cepredenac regional disaster reduction plan (prrd) was created to foster disaster reduction as an integral part of the sustainability of central american societies. its strategic objectives are: • promoting the incorporation of disaster risk reduction in legislation, policies • enhancing and developing greater resilience of the population to disaster risk • promoting the incorporation of disaster risk analysis in the design and implementation of prevention, mitigation, response, recovery, and reconstruction in the countries of the region a participating state may request disaster response assistance once its capabilities have been overwhelmed. cdema solicits and coordinates the assistance offered by other governments, organizations, and individuals, both within and outside the region. this is cdema's primary function. other functions include: • securing, collating, and channeling disaster information to interested governmental organizations and ngos as needed • mitigating disaster consequences affecting participating states • establishing and maintaining sustainable disaster response capabilities among participating states • mobilizing and coordinating disaster relief from governmental organizations and ngos for affected participating states the cdema participating states are structured into four subregions, each of which is headed by an operation unit known as a sub-regional focal point. the functions of each focal point relevant to the recovery effort are to: • acquire and maintain comprehensive emergency management capacity information • test and maintain communications with the coordinating unit and with national disaster management agencies • ensure subregion continuity of operations membership in cdema requires the participating state to establish or maintain a national disaster organization (ndo) or a national relief organization capable of responding swiftly, effectively, and in a coordinated manner to disasters in participating states (typically the government body tasked with domestic emergency management). ndos are headed by the national disaster coordinator (ndc), who is a government official responsible for the day-to-day management of the organization; ndos are the national focal points for cdera's activities in the participating state. the participating states are, in addition, required to: • establish planning groups and define national policies and priorities to address disasters • provide national relief organizations with adequate support, including named emergency coordinators, liaison officers with key ministries, emergency services, utilities, etc. • define the disaster role and functions of government agencies • establish and equip a suitable emergency operations center (eoc) • develop and maintain an appropriate emergency telecommunications system • perform disaster operations planning and associated drills and exercises • review and rationalize disaster-related statutory authorities • develop an emergency shelter policy program involving local participation • develop and implement a comprehensive disaster public awareness program • develop and implement appropriate training programs for disaster management staff in , twenty-four countries in eastern and southern africa established a drought monitoring centre, with its headquarters in nairobi (the dmcn) and a sub-center in harare (dmch), in response to a series of devastating weather-related disasters. in october , the heads of state and governments of the intergovernmental authority on development (igad) held their th summit in kampala, uganda, where dmcn was adopted as a specialized igad institution. the name of the institution was changed to igad climate prediction and applications centre (icpac) in order to better reflect its expanded mandates, mission, and objectives within the igad system. a protocol was signed in april , integrating the institution fully into igad. icpac is responsible for seven member countries (djibouti, eritrea, ethiopia, kenya, somalia, sudan, and uganda) and three other countries (burundi, rwanda, and tanzania). the centre's vision is "to become a viable regional centre of excellence in climate prediction and applications for climate risk management, environmental management, and sustainable development," while its mission is "provision of timely climate early warning information and support specific sector applications to enable the region to cope with various risks associated with extreme climate variability and change for poverty alleviation, environment management and sustainable development of the member countries" the objectives of the centre are: . to provide timely climate early warning information and support specific sector applications for the mitigation of the impacts of climate variability and change for poverty alleviation, management of environment, and sustainable development; . to improve the technical capacity of producers and users of climatic information, in order to enhance the use of climate monitoring and forecasting products in climate risk management and environment management; . to develop an improved, proactive, timely, broad-based system of information/product dissemination and feedback, at both sub-regional and national scales through national partners; . to expand climate knowledge base and applications within the sub-region in order to facilitate informed decision making on climate risk related issues; and . to maintain quality controlled databases and information systems required for risk/vulnerability assessment, mapping and general support to the national/ regional climate risk reduction strategies. (icpac n.d.) the centre has several functions relative to these objectives, which are: • acquisition of climate and remotely sensed data; • develop and archive national and regional climate databanks including calibration of remote sensing records; • process data and develop basic climatological statistics required for baseline risk scenarios and other applications; • monitor, predict, and provide early warning information of the space-time evolutions of weather and climate extremes over the sub-region; • hazards and climate risk mapping of the extreme climate events thresholds; • networking with wmo, the national meteorological and hydrological institutions as well as regional and international centers for data and information exchange; • capacity building in the generation and applications of climate information and products; • applications of climate tools for specific climate sensitive sector risk reduction, environment management , and sustainable development, including integration of indigenous knowledge; • monitor, assess, detect and attribute climate change and associated impacts, vulnerability, adaptation and mitigation options; • develop relevant tools required to address the regional climate challenges through research and applications in all climate sensitive socio-economic sectors including addressing linkages with other natural and man-made disasters; and • networking and exchange of information regarding disasters in the sub-region. (icpac n.d.) the centre offers a number of informational products, including periodic climate and weather bulletins, updates on climate and el niño, and annual climate summaries. to date, the centre has been instrumental in increasing drr in the sub-region through the provision of capacity enhancement, informational products, networking assistance, and more. the league of arab states (las) is a regional igo based in cairo, egypt and encompassing north africa and southwest asia. las was formed in following the adoption of the alexandria protocol, with a stated goal to "draw closer the relations between member states and co-ordinate collaboration between them, to safeguard their independence and sovereignty, and to consider in a general way the affairs and interests of the arab countries." member states include algeria, bahrain, comoros, djibouti, egypt, iraq, jordan, kuwait, lebanon, libya, mauritania, morocco, oman, state of palestine, qatar, saudi arabia, somalia, sudan, syria, tunisia, united arab emirates, and yemen. in response, and as a follow-up to the first arab summit on socio-economic development, the council of arab ministers responsible for the environment adopted specific actions relating to disaster risk reduction through a decision in may of to develop an arab strategy for disaster risk reduction. this strategy, entitled the arab strategy for disaster risk reduction , adopted in december of , has a two-fold purpose: . to outline a vision, strategic priorities, and core areas of implementation for disaster risk reduction in the arab region, and . to enhance institutional and coordination mechanisms and monitoring arrangements to support the implementation of the strategy at the regional, national, and local level through preparation of a programme of action. the arab strategy for disaster risk reduction is designed to complement existing and ongoing efforts in disaster risk reduction by national institutions and regional technical organizations in the las region. implementing partners of the strategy are to focus on multi-sectorial approaches with the purpose of reducing emerging risks across the arab region by , in line with the global priorities outlined by the hyogo framework for action (hfa) and the millennium development goals. the five priorities of the las strategy directly mirror those of the hfa, including the desire to increase nations' capacity to incorporate drr into disaster recovery. specific commitments detailed under these priorities, which pertain to recovery planning actions in the region, include: • ensuring that disaster risk reduction measures are integrated into post-disaster recovery and rehabilitation processes • establishing disaster preparedness plans, contingency plans, and recovery and reconstruction plans at all administrative levels with the participation of women, the aged, children, idps, and people with special needs • ensuring that national/ local financial reserves and contingency mechanisms are in place and well understood by all stakeholders to ensure effective response and recovery when required • addressing national trans-boundary cooperation on disaster response, preparedness and recovery among arab states in the arab region, funding remains the main challenge faced by national and local authorities, civil society organizations, and humanitarian workers implementing disaster risk reduction measures targeting communities at risk. las encourages its members to dedicate at least percent of national development funding and development assistance toward disaster risk reduction measures. specifically, it was recommended that member states assess the possibility of utilizing existing regional funds and mechanisms (including, among other mechanisms, socio-economic development funds and national disaster relief and response budgets) by allocating a dedicated budget for disaster risk reduction and recovery activities at the subregional, national, or local level. the las regional centre for disaster risk reduction (rcdrr) was established in by a partnership between the kingdom of saudi arabia, the united nations international strategy for disaster reduction (unisdr), and the arab academy for science, technology and maritime transport (aas-tmt), as an intergovernmental organization of the league of arab states targeting the achievement of sustainable development in the arab region. the centre seeks to address risk through knowledge, research, and training of scientific and technical cadres in various disciplines on drr. the main objectives of rcdrr, as per the rcdrr statutes, are: • integration of drr into regional and national sustainable development policies, strategies, and plans • enhancing regional and national capacities in the field of drr research, education, and training • contributing to the development and harmonization of regional drr methodologies and tools, including database and guidelines • promoting partnership building with a multi-stakeholder approach to accelerate the implementation of the hyogo framework of action the south asian association of regional cooperation (saarc) was officially established in . the objectives of the organization are to: • promote the welfare of the people of south asia and to improve their quality of life • accelerate economic growth, social progress, and cultural development in the region and to provide all individuals the opportunity to live in dignity and to realize their full potential • promote and strengthen selective self-reliance among the countries of south asia • contribute to mutual trust, understanding, and appreciation of one another's problems • promote active collaboration and mutual assistance in the economic, social, cultural, technical, and scientific fields • strengthen cooperation with other developing countries • strengthen cooperation among themselves in international forums on matters of common interest • cooperate with international and regional organizations with similar aims and purposes. the saarc member countries include afghanistan, bangladesh, bhutan, india, maldives, nepal, pakistan, and sri lanka. after • establish and strengthen the regional disaster management system to reduce risks and to improve response and recovery management at all levels • identify and elaborate country and regional priorities for action • share best practices and lessons learnt from disaster risk reduction efforts at national levels • establish a regional system to develop and implement regional programs and projects for early warning • establish a regional system of exchanging information on prevention, preparedness, and management of natural disasters • create a regional response mechanism dedicated to disaster preparedness, emergency relief, and rehabilitation to ensure immediate response • create a regional mechanism to facilitate monitoring and evaluation of achievements toward goals and strategies. the saarc disaster management centre (sdmc) was established in october of at the facilities of the national institute of disaster management in new delhi to serve as a center of excellence for knowledge, research, and capacity building in disaster management. the centre has the mandate to serve the saarc member countries by providing policy advice and facilitating capacity building services, including strategic learning, research, training, system development, and exchange of information for effective disaster risk reduction and management in south asia. sdmc conducts studies and research, organizes workshops and training programs, publishes its reports and documents, and provides various policy advisory services to the member countries. the secretariat of the pacific community (spc) was founded in australia in under the canberra agreement to restore order in the region following world war ii. in , the spc applied geoscience and technology division (sopac) was created as a undp regional project, and in it became an independent igo. in , sopac became a new division under spc, dedicated to promoting sustainable development in its member countries, and its work is carried out through its secretariat based in suva, fiji. sopac members include australia, cook islands, fiji islands, guam, federated states of micronesia, kiribati, marshall islands, new zealand, papua new guinea, samoa, solomon islands, tonga, tuvalu and vanuatu, niue, nauru, and palau. associate members (local administrations of nonself-governing territories) include american samoa, french polynesia, new caledonia, and tokelau. the purpose of sopac is to ensure the earth sciences (inclusive of geology, geophysics, oceanography, and hydrology) are utilized fully in the fulfillment of the spc mission. to fulfill this purpose, the division has three technical work programs: • ocean and islands • water and sanitation • disaster reduction these three programs share common technical support services: the sopac disaster reduction programme (drp) provides technical and policy advice and support to strengthen disaster risk management practices in pacific island countries and territories. the program carries out this responsibility in coordination and collaboration with other technical program areas within sopac and also with a range of regional and international development partners and donors. the overarching policy guidance for drp is the hfa-linked pacific disaster risk reduction and disaster management framework for action - (pacific drr and dm framework for action), which supports and advocates for the building of safer and more resilient communities. the other significant regional policy instruments that help to guide the efforts of the drp are the pacific plan and the pacific islands framework for action on climate change - . the sopac disaster risk management policy and planning team (ppt) is responsible for the drm mainstreaming initiative, which sopac spearheads on behalf of the pacific disaster risk management partnership network. in fulfilling this responsibility, the ppt provides the following services to pacific island countries and territories (picts): • leads and coordinates high level advocacy at cabinet/political level to garner support for drm mainstreaming in national, sectorial, local, and community planning and budgetary processes • leads and coordinates the development and implementation of drm national action plans with the support of other members of the pacific drm partnership network • supports the integration of drm and climate change adaptation initiatives at the national level within picts • analyzes budgeted drm investment in annual appropriations of picts • analyzes the economic impact of disaster events • analyzes the cost-benefit of drm measures a major focus of the ppt is to build member country resilience by facilitating the creation of disaster risk management national action plans (naps). the partnership network continued to provide strong support in terms of the realization of drm initiatives linked to nap exercises and also for other risk reduction and disaster management-related activities. in the past several years, this support has shifted to development of joint national action plans (jnaps) that integrate policy on disaster risk reduction and climate change adaptation. several of the countries in the region have established jnaps at the national level. the region is also moving toward a regional-level integrated joint strategy for disaster risk reduction and climate change. at present, regional-level disaster risk reduction and climate change adaptation policies remain separate. sopac led the development of the pacific disaster risk reduction and disaster management framework for action (rfa), signed in , and the secretariat of the pacific community environmental programme (sprep) led the development of the pacific islands framework for action on climate change (pifacc), also signed in . however, these organizations initiated an effort in to establish a more integrated solution to coincide with the year expiration of both frameworks. an ongoing process named "the roadmap" is marked by wide stakeholder involvement via a steering committee and broad technical support provided by a technical working group (which includes spc/sopac, sprep, and unisdr). the roadmap process has to date resulted in a draft-integrated strategy entitled the strategy for disaster and climate resilient development in the pacific (srdp). the draft strategy is designed to promote action that is harmonized with existing member state institutional arrangements for climate change adaptation and disaster risk reduction "[to] ensure that efforts are nested within the context of countries' national development strategies and reflected in their budgets, encourage the participation of multiple stakeholder groups, strengthen countries' capacities for risk governance and support the development of well-coordinated innovative funding mechanisms" (spc ). drp supports the strengthening of disaster management governance, which has included the development of institutional, policy, and decision-making processes such as disaster management legislative and planning frameworks, and national focal points (ndmos) and guidelines or models of good practice for national application. the emergency management preparedness, response, and coordination capabilities within countries will be critically assessed to determine the level of resources and capacity that is available to protect vulnerable communities. a priority will be to ensure that effective emergency response, communication, and coordination processes are established, and that existing resources are utilized in the most effective way. the drp disaster management team provides the following services to picts: • technical advice and support to review and update national drm governance arrangements and legislation, operational plans and procedures • support for the design and conduct of operational and table-top exercises to test emergency response plans and procedures • support for the conduct of disaster risk management training in collaboration with the pacific drm program of the asia foundation/office of us foreign disaster assistance • design and development of professional training courses in collaboration with taf/ofda and the fiji national university in , sopac established the pacific disaster risk management partnership network to provide a collaborative and cooperative mechanism to support disaster risk management capacity building in the region and help pacific island countries and territories adapt and implement the pacific drr and dm framework for action. the partnership is an "open-ended, voluntary" membership of international, regional, and national government and non-government organizations, with comparative advantages and interests in supporting pacific countries toward mainstreaming drm through addressing their disaster risk reduction and disaster management priorities. the members of the partnership network agree that: • disaster risk reduction and disaster management are sustainable development issues within the broader context of economic growth and good governance; • national governments have a critical role in developing disaster risk reduction and disaster management national programs and plans that reflect the needs of all stakeholders in a whole-ofcountry approach; • a regional effort must be responsive to and support and complement national programs and plans to strengthen resilience to disasters; • as regional partners, we commit to coordinating our activities and to work cooperatively and collaboratively under the guidance of the pacific plan and regional framework for action - ; and • we can build safer and more resilient nations and communities to disasters if we work in unison and accept this disaster risk management charter as a basis for future action. international financial institutions (ifis) provide loans for development and financial cooperation throughout the world. they exist to ensure financial and market stability and to increase political balance. these institutions are made up of member states arranged on a global or regional basis that work together to provide financial services to national governments through direct loans or projects. in a disaster's aftermath, nations with low capital reserves often request increased or additional emergency loans to fund the expensive task of reconstruction and rehabilitation. without ifis, most developing nations would not have the means to recover. several of the largest ifis are detailed in the following section, including the world bank; one of its subsidiaries, the international monetary fund (imf); the asian development bank; and the inter-american development bank. the world bank was created in to rebuild europe after world war ii. in , france received the first world bank loan of $ million for post-war reconstruction. financial reconstruction assistance has been provided regularly since that time in response to countless natural disasters and humanitarian emergencies. today, the world bank is one of the largest sources of development assistance. in the fiscal year, it provided more than $ . billion in loans, breaking all previous lending records for the organization. in fiscal year , the amount of loans had fallen to $ . billion, but the bank remains one of the largest development lenders. the world bank is owned collectively by countries and is based in washington, dc. it comprises several institutions referred to as the world bank group (wbg): • international bank for reconstruction and development • international development association the world bank's overall goal is to reduce poverty, specifically to "individually help each developing country onto a path of stable, sustainable, and equitable growth, [focusing on] helping the poorest people and the poorest countries" (wagstaff ) . as disasters and ches take a greater and greater toll on the economic stability of many financially struggling countries, the world bank is taking on a more central role in mitigation and reconstruction. developing nations, which are more likely to have weak disaster mitigation or preparedness capacity and therefore little or no affordable access to disaster insurance, often sustain a total financial loss. in the period of rehabilitation that follows the disaster, loans are essential to the success of programs and vital to any level of sustainability or increased disaster resistance. the world bank lends assistance at several points along this cycle. for regular financial assistance, the world bank ensures that borrowed funds are applied to projects that give mitigation a central role during the planning phase. it utilizes its privilege as financial advisor to guide planners, who otherwise might forego mitigation measures in an effort to stretch the loaned capital as far as possible. ensuring that mitigation is addressed increases systems of prediction and risk analysis in projects funded by the world bank. once a disaster occurs, the world bank may be called on for help. because it is not a relief agency, it will not take on any role in the initial response; however, it works to restore damaged and destroyed infrastructure and restart production capabilities. (see exhibit . .) a world bank team may assist with initial impact assessments that estimate financial losses resulting from the disaster and estimated costs of reconstruction, including raised mitigation standards. the world bank also could restructure the country's existing loan portfolio to allow for expanded recovery projects. in addition, world bank projects that have not yet been approved but are in the application process can be redesigned to account for changes caused by the disaster. finally, an emergency recovery loan (erl) can be granted to specifically address recovery and reconstruction issues. erls restore affected economic and social institutions and reconstruct physical assets such as essential infrastructure. it is important to note that erls are not designed for relief activities. they are most appropriate for disasters that adversely impact an economy, are infrequent (recurrent disasters are accommodated by regular lending programs), and create urgent needs. erls are expected to eventually produce economic benefits to the borrowing government; they are usually implemented within three years and are flexible to accommodate the specific needs of each unique scenario. construction performed with erls must use disaster-resistant standards and include appropriate mitigation measures, thus providing overall preparedness for the country affected. once an erl has been granted, the world bank coordinates with the imf, the undp, ngos, and several other international and local agencies to create a strategy that best utilizes these funds within the overall reconstruction effort. the two lending arms of the world bank are the international bank for reconstruction and development and the international development association. international bank for reconstruction and development (ibrd) . established in , the ibrd reduces poverty in middle-income and creditworthy poorer countries. the ibrd attempts to promote sustainable development activities through its loans. it also provides guarantees and other analytical and advisory services. following disasters, countries with strong enough credit can borrow or refinance their existing loans from the ibrd to pay the often staggering costs of reconstruction. international development association (ida). the ida lends to the world's poorest countries, classified as those with a income of less than $ , per person. sixty-four countries currently are eligible to borrow from the ida. it provides interest-free loans and grants for programs aimed at boosting economic growth and improving living conditions. this need is almost always present in the aftermath of disasters, including those caused by violent conflict. in , the global facility for disaster risk reduction, or gfdrr, was created, with the world bank designated as facility manager on behalf of the countries and eight international organizations that make up its membership. gfdrr has a secretariat, based in the washington dc world bank headquarters, which carries out its day-to-day operations. the purpose of gfdrr is to help developing countries address disaster vulnerability and vulnerability to the effects of climate change. its work is primarily driven by the hyogo framework for action, and its programs focus on mainstreaming exhibit . world bank disaster assistance to bosnia and herzegovina washington, june , - the world bank group's board of executive directors today approved a us$ million credit for the floods emergency recovery project for bosnia and herzegovina (bih), to meet critical needs and restore the functionality of infrastructure essential for public services and economic recovery in affected areas in the aftermath of the worst flooding to hit the country in documented history. the project was prepared in record time in view of the dire situation in the country and will be financed from the international development association's (ida) crisis response window resources. this project will target areas that were hit hardest by the devastating floods. preliminary evidence shows that the largest impact from this disaster was on livelihoods, housing, transport, agriculture, and energy. given the magnitude of the damage caused by flooding and subsequent landslides, the project is designed to support efforts by local and entity governments to quickly re-establish public services to pre-flood levels. the project will also support the government's on-going economic recovery initiatives, in particular in the agriculture sector. in addition to this project, the world bank is working on several other fronts to ensure the provision of a comprehensive package of support for bih as it recovers and rebuilds from the physical and economic devastation. notably, the bank is participating in a systematic recovery needs assessment, led by the bosnia and herzegovina (bih) authorities and supported also by the european union and the united nations. the assessment will provide a basis for developing effective rehabilitation measures for infrastructure and services in the affected areas. the world bank is also considering the restructuring of existing projects in its bih portfolio to meet reconstruction needs. while immediate recovery needs are the top priority of this project, the world bank also stands ready to work with the bih authorities to scale-up flood protection and implement early warning systems. the recently approved drina flood protection project is a good example of the type of work that could be scaled-up, as it addresses the need to prevent future flooding. as emphasized by laura tuck, world bank vice president for europe and central asia, "the floods emergency recovery project will finance critical goods, such as fuel and electricity imports, as well as the reconstruction of local infrastructure. this immediate response, combined with the drina river flood protection project, will support economic recovery in the affected areas, and will help restore bosnia and herzegovina to a growth path following the floods." the world bank portfolio of active projects in bih now includes operations totaling approximately us$ . million. areas of support include agriculture, environment, energy efficiency, health, social safety and employment, local infrastructure, and private sector development. release, . disaster risk reduction and climate change adaptation throughout all government sectors in member countries. gfdrr organizes its efforts according to three "business lines," which include: • track i: global and regional partnerships -track i supports unisdr in helping countries to leverage resources to perform pre-disaster investments and activities related to prevention, disaster risk reduction, and disaster preparedness. the key objectives of track i are to: ) enhance global and regional advocacy, strategic partnerships, and knowledge management for mainstreaming disaster risk reduction; and ) promote the standardization and harmonization of hazard risk management tools, methodologies, and practices. • track ii: mainstreaming disaster risk reduction in development -track ii provides pre-disaster assistance to developing countries to mainstream and expand disaster risk reduction and climate change adaptation activities. work in this track is performed in conjunction with world bank regional teams, un agencies, and national governments, and is aimed at integrating disaster risk reduction into poverty reduction and development efforts. there are also several sub-programs that include risk assessment, risk reduction, risk financing, and climate change adaptation. • track iii: sustainable recovery -track iii is aimed at early post-disaster recovery in low-income countries through its standby recovery financing facility (srff). track iii is less programmatic than track i and track ii because it is deployed for post-disaster situations, but it does work to build national capacity and facilitate knowledge management with the long term in mind. srff support includes two financing windows: ) the technical assistance (ta) fund, which supports damage, loss, and needs assessments and develops national capacity for recovery planning and implementation; and ) the callable fund for accelerated recovery, which provides speedy access to financial resources for disaster recovery and reconstruction. the international monetary fund (imf) was established in to "promote international monetary cooperation, exchange stability and orderly exchange arrangements; to foster economic growth and high levels of employment; and to provide temporary financial assistance to countries to help ease balance of payments adjustment." it carries out these functions through loans, monitoring, and technical assistance. since , the imf has provided emergency assistance to its member countries after they were struck by natural disasters, and, in a great many cases, when affected by complex emergencies. the assistance provided by the imf is designed to meet the country's immediate foreign-exchange financing needs, which often arise because earnings from exports fall while the need for imports increases (among other causes). imf assistance also helps the affected countries avoid serious depletion of their external reserves. in , the imf began to provide this type of emergency assistance to countries facing post-conflict scenarios in order to enable them to reestablish macroeconomic stability and to provide a foundation for recovery, namely in the form of long-term sustainable growth. this type of assistance is particularly important when a country must cover costs associated with an "urgent balance of payments need, but is unable to develop and implement a comprehensive economic program because its capacity has been damaged by a conflict, but where sufficient capacity for planning and policy implementation nevertheless exists" (imf ) . the imf maintains that their support must be part of a comprehensive international effort to address the aftermath of a conflict in order to be effective. its emergency financing is provided to assist the affected country and to gather support from other sources. it is not uncommon for a country to severely exhaust its monetary reserves in response to an emergency situation. in the event of a natural disaster, funding is directed toward local recovery efforts and any needed economic adjustments. the imf lends assistance only if a stable governing body is in place that has the capacity for planning and policy implementation and can ensure the safety of imf resources. after stability has been sufficiently restored, increased financial assistance is offered, which is used to develop the country in its post-emergency status. when a country requests emergency assistance, it must submit a detailed plan for economic reconstruction that will not create trade restrictions or "intensify exchange." if the country is already working under an imf loan, assistance may be in the form of a reorganization of the existing arrangement. it can also request emergency assistance under the rapid financing instrument (rfi). the rapid financing instrument (rfi) is the vehicle that the imf uses to meet disaster-impacted countries' financing needs. the rfi provides funding quickly and with few requirements in instances where it is determined that a disaster or emergency situation has resulted in urgent balance-of-payments needs. emergencies need not be related to a natural or technological hazard-they can also be the result of rapid increases in the price of certain commodities or because of an economic crisis. unlike other imf assistance, there does not need to be a full-fledged financing program in place. prior to the creation of the rfi, the imf used a number of separate programs to address emergency needs, including the emergency natural disaster assistance (enda) program and the emergency post-conflict assistance (epca) program. the creation of the rfi program combines all emergency needs. rfi financial assistance is provided in the form of outright purchases without the need for a full-fledged program or reviews. however, when a country does request assistance under rfi, they must cooperate with the imf to make every effort to solve their balance-of-payment problems, and must explain the economic policies it proposes to follow to do so. the imf makes the rfi program available to all of its members, though oftentimes very poor countries are more likely to seek assistance under a different program called the rapid credit facility (rcf), which provides similar assistance but has economic-based requirements that many wealthier countries cannot meet. funds access under the rfi program is limited to percent of a nation's quota per year and percent of quota on a cumulative basis. under the rcf program, the access limits are percent of a nation's quota per year and percent of quota on a cumulative basis. the level of access in each case depends on the country's balance-of-payments need. financial assistance provided under the rfi is subject to many of the same financing terms that nations would see in other imf programs, and the funds borrowed are ideally paid back within to months (imf ). in certain cases, as decided by the imf and according to specific criteria, recipients of emergency funding may benefit from the imf poverty reduction and growth facility (prgf). the prgf is the imf's low-interest lending facility for low-income countries. prgf-supported programs are underpinned by comprehensive country-owned poverty reduction strategies. under this program, the interest rate on loans is subsidized to . percent per year, with the interest subsidies financed by grant contributions from bilateral donors. this program has been available for post-conflict emergencies since , but in january , following the south asia tsunami events, the imf executive board agreed to provide a similar subsidization of emergency assistance for natural disasters upon request. the government of a country devastated by disaster often requires technical assistance or policy advice because it has no experience or expertise in this situation. this is especially common in post-conflict situations, where a newly elected or appointed government has been established and officials are rebuilding from the ground up. the imf offers technical assistance in these cases to aid these countries in building their capacity to implement macroeconomic policy. this can include tax and government expenditure capacity; the reorganization of fiscal, monetary, and exchange institutions; and guidance in the use of aid resources. the asian development bank (adb) is a multilateral development financial institution whose primary mission is reducing poverty in asia and the pacific. adb was established in by countries from both within and outside the region, and has grown to include members as of . forty-eight are from the region and are from other regions. its clients are the member governments, who are also the adb's shareholders. the adb provides emergency rehabilitation loans to its member countries following disasters. adb determined that its assistance in this critical phase of recovery would allow an affected developing country to maintain its development momentum. bank analysts found that, without such assistance, the affected country may reallocate its scarce budgetary resources away from development issues to cover disaster-related expenses, sidetracking development progress. additionally, they found that the production of goods and services would quickly suffer or fail completely if the country could not perform adequate rehabilitation following a disaster. adb assistance in emergencies began in , but was initially extended only to smaller developing countries (e.g., the maldives, papua new guinea, and the smaller pacific island states). loans were limited to $ , (increased to $ million in ), with funded projects to be completed within months of disbursement. the funding was designed to address only simple repair and rehabilitation activities as needed in the immediate aftermath of a disaster, with more comprehensive repair being covered by regular bank lending programs. lending was designed to be provided within six weeks of being requested. in , emergency lending was extended to all developing member countries regardless of their size. this change included a fundamental shift in what the emergency loans would cover, from simple repairs to more comprehensive, informed rehabilitation activities. most important, adb wanted to ensure that projects funded by its loans reduced overall risk to the affected nation and its population. other major changes in adb emergency lending policy are included in the following list: • introducing a typology of the causes and effects of disasters • more clearly defining the adb's response during various phases of post-disaster situations • identifying the nature, focus, and coverage of rehabilitation projects • introducing detailed, yet simplified, guidelines for processing rehabilitation projects • targeting rehabilitation loans toward restoring infrastructure and production activities, including capacity building and modernization • mandating that risk analysis and disaster prevention measures be included in all adb projects in disaster-prone developing member countries • closely coordinating disaster responses at all levels (local, national, and international) with those of other external funding agencies, ngos, and community groups • specifying that disaster prevention and mitigation activities were to be promoted along with regional cooperation • including non-natural disasters, for example, wars, civil strife, and environmental degradation (adb ) between and , adb provided $ . billion to disaster-affected countries in the form of loans at a rate of approximately one loan per month. the vast majority of the adb emergency loan services during this period were provided in response to natural disaster events, with the remaining dedicated to post-conflict situations. these loans rarely averaged more than percent of the total annual lending by adb and were concentrated primarily in south asia. the project comprises two components: (i) reconstruction and upgrading of damaged roads and bridges in sichuan and shaanxi provinces, and (ii) reconstruction and improvements of damaged schools in shaanxi province. the project will rehabilitate and reconstruct high-priority earthquake-damaged roads in the worst affected counties of sichuan province and subprojects in the four worst affected counties of shaanxi province. the project will rehabilitate and reconstruct highpriority earthquake-damaged education facilities in the three worst affected counties in shaanxi province. these components are designed to be mutually supporting in achieving the overall objective of restoring the affected communities' access to infrastructure to pre-earthquake levels, and ensuring restored infrastructure is in strict compliance with the latest seismic code. based on the government's damage and needs assessment and the request of the prc government, the project identifies specific sectors that require emergency assistance in two of the worst earthquake-affected provinces (i.e., sichuan and shaanxi). the project seeks to (i) build on the immediate relief provided by the government in the earthquake-affected provinces; (ii) contribute to coordinated rehabilitation and reconstruction by different development partners and the government; and (iii) specifically address sustainable recovery priorities by providing indirect livelihood support through public infrastructure rehabilitation and reconstruction, which generates public employment and underpins the restoration of livelihood activities by rehabilitating roads, bridges, and schools. the project design draws on the adb experience in delivering emergency assistance acquired in different developing member countries over the past two decades, and complements relief and other rehabilitation and reconstruction assistance provided by the government, united nations agencies, ngos, bilateral development partners, and the world bank. by meeting the earthquake reconstruction needs of the next three years, the project is consistent with adb's disaster and emergency assistance policy ( ) . the project supports the state overall plan for post-wenchuan earthquake restoration and reconstruction approved by the government on september . the impact of the project is accelerated restoration of education and transport infrastructure in earthquake-affected areas of sichuan and shaanxi provinces. the project will support the government's efforts to (i) restore the livelihoods and economic activities of the affected population; (ii) accelerate poverty alleviation in the earthquake-affected counties, many of which have a high incidence of poverty; and (iii) rehabilitate and reconstruct public and community-based infrastructure that is vulnerable to natural disasters. the outcome of the project is restoration of people's access to transport and education infrastructure to preearthquake levels in counties of sichuan and four counties of shaanxi provinces. the total project cost is estimated at $ . million equivalent. a loan of $ million from adb's ordinary capital resources will be provided under adb's london interbank offered rate (libor)-based lending facility. the loan will have a grace period of years with a maturity period of years, an interest rate determined in accordance with adb's libor-based lending facility, a commitment charge of . % per annum, and such other terms and conditions set forth in the draft loan and project agreements. until june , . adb also provides mitigation-related project loans and regional technical assistance (reta) aimed at reducing member countries' overall disaster vulnerability. between august and december , adb approved $ . billion for more than disaster risk management-related projects (in addition to the $ . billion provided in disaster-related financing). mitigation and preparedness projects are not considered "emergency" in nature and are therefore funded through the bank's regular lending activities. because mitigation and preparedness activities are most often included as components within larger development projects, adb does not maintain records of its total financial risk reduction-based lending. projects may include resilience-increasing activities such as reforestation, watershed management, coastal protection, agricultural diversification, slope stabilization, and land-use planning, although the project's overall goal is more development oriented. reta and single-country technical assistance activities have included hazard management and disaster preparedness software programs and infrastructure protection assistance. adb has december , . as the project is for emergency assistance, implementation will start immediately after approval and be completed within months. sichuan provincial communications department in sichuan province; and hanzhong city government and baoji city government in shaanxi province implementing agencies sichuan highway administration bureau in sichuan province; and county-level highway administration bureaus for roads and bridges, and county-level education bureaus for schools in shaanxi province. the project will bring benefits to the project area by (i) reconstructing and improving road conditions and accessibility in townships and in villages in the sichuan and shaanxi provinces, (ii) reconstructing and improving schools in shaanxi province, and (iii) creating local employment opportunities from project construction and related activities. the project will provide equal benefits to females and males. the economic benefits of the rural roads and bridges include (i) savings in vehicle operating costs as a result of improved traffic and road conditions, (ii) time-savings for rural road users, (iii) savings in road accident costs as a result of fewer accidents, and (iv) economic benefits from generated traffic. the reconstruction and upgrading of rural roads in sichuan and shaanxi provinces will benefit about . million people, three-quarters of whom are rural and one-third of whom are poor. as reliable transport to markets becomes more readily available, cash crop farming in remote or isolated areas will be stimulated and access to off-farm employment opportunities will be broadened. the project will focus on reconstruction of and improvements to model schools to appropriate design standards, including six junior secondary and six primary schools. this will bring immediate benefits to the schools' , students (including more than female students), and long-term benefits to future students drawn from the , residents of the areas serviced by the schools, about % of whom are from rural areas of remote counties. the project will contribute to the government's efforts to rebuild the economy, rehabilitate public infrastructure and utilities, reinstate seismic code compliance, and generate employment. the rehabilitation and reconstruction of damaged schools will enable education services to be restored and will offer long-term benefits for affected persons by supporting opportunities for employment and participation in economic activities. finally, adb assists countries in restarting rehabilitation and overall development in the aftermath of armed conflict. in the past, adb post-conflict intervention focused almost exclusively on infrastructure rehabilitation, an area in which the adb has extensive experience. its focus in this area began to shift in the s to preventing conflicts and helping post-conflict countries move along a solid path of economic and social development. adb is now committed to assisting affected member countries develop mechanisms to effectively manage conflict, including addressing the problems of poor governance and corruption. in , adb established the asia pacific disaster response fund (apdrf) to provide quick funding in the aftermath of a disaster to help governments meet urgent life-saving disaster-response needs. between and , grants were approved under the fund. apdrf assistance is provided as a grant that may be no larger than us$ million per event. the size of the grant is determined by: . the geographical extent of the disaster's damage; . initial estimates of fatalities, injuries, and displaced persons; . the country's disaster response capacity; and . the date and magnitude of the last disaster to have impacted the country (thereby taking into account the cumulative effect of disasters on the country's ability to respond) (adb ). in , adb approved a pilot asian development fund disaster response facility for countries eligible for low-interest loans in the event of a disaster. the pilot program, which runs from to , is being conducted to strengthen adb's ability to respond to disaster-impacted member countries in a manner that is less ad hoc. the drf will require countries that are eligible to borrow from the asian development fund (adf countries) to contribute a small fraction of their allocations for the benefit of accessing the drf in case of a disaster. the drf will be available to these countries in the case of natural disasters, and will support relief, response, recovery, and reconstruction needs. per the pilot program, the size of the drf will be percent of the total performance-based allocation (pba) received. in case of a disaster, an adf country can get up to percent of its annual pba, or us$ million per disaster, whichever is higher, from the drf. a blend country, which is a country eligible for both the adf and adb ordinary capital resources, can receive up to percent of its annual pba from the drf if affected by a disaster. established in december , the inter-american development bank (iadb) is the oldest and largest regional multilateral development institution. it was first created to help accelerate economic and social development in latin america and the caribbean. the iadb has been a pioneer in supporting social programs; developing economic, social, educational, and health institutions; promoting regional integration; and providing direct support to the private sector, including microenterprises. the iadb addresses disaster and risk management through its sustainable development department. through the efforts and actions of this department and its disaster risk management policy, the iadb addresses the root causes of the region's high vulnerability to disasters. building on its mandate to promote sustainable development in latin america and the caribbean, the iadb works with countries to integrate risk reduction into their development practice, planning, and investment, and to increase their capacity to manage risk reduction. it also provides funding that directly or indirectly supports disaster mitigation and preparedness. in their "plan of action: facing the challenge of natural disasters in latin america and the caribbean," the iadb outline their six strategic areas of assistance: . national systems for disaster prevention and response: building national legal and regulatory frameworks and programs that bring together the planning agencies, local governments, and civil society organizations; developing national strategies for risk reduction; and assessing intersectoral priorities, backed by separate budgets. . a culture of prevention: developing and disseminating risk information and empowering citizens and other stakeholders to take risk-reduction measures. . reducing the vulnerability of the poor: supporting poor households and communities in reducing their vulnerability to natural hazards and recovering from disasters through reconstruction assistance. . involving the private sector: creating conditions for the development of insurance markets, encouraging the use of other risk-spreading financial instruments where appropriate, and designing economic and regulatory incentives for risk reduction behavior. . risk information for decision-making: evaluating existing risk assessment methodologies; developing indicators of vulnerability, and stimulating the production and wide dissemination of risk information. . fostering leadership and cooperation in the region: stimulate coordinated actions and to mobilize regional resources for investments in risk mitigation. (iadb ) the iadb created two mechanisms to allow for rapid loan disbursement in times of disaster: the disaster prevention sector facility and the facility for the immediate response to natural and unexpected disasters (formerly the immediate response facility). in the iadb established the natural disaster network, represented by each of its borrowing member countries. network members meet annually to discuss topics related to disaster management, such as "national systems for risk management" ( ) the iadb revised its disaster risk management policy in . the new policy is designed to improve the iadb's ability to assist member countries in reaching their development goals by supporting their disaster risk management efforts. (see appendix . for the full text of the iadb disaster risk management policy guidelines.) . iadb supports disaster risk reduction through the disaster prevention sector facility, which provides up to $ million to assist countries in taking an integrated approach to reducing and managing their risk. the iadb also provides loans to help countries cope with financial or economic crises and natural or other disasters through its emergency lending program. in the case of a financial or economic crisis, the iadb requires that the emergency loan fits within an imf-approved and monitored macroeconomic stabilization program. emergency loan disbursement periods are much shorter than other non-disaster loans, ranging up to months in duration. they may be used to support national, provincial, state, and municipal governments and autonomous public institutions. they have a five-year term and a three-year grace period. in the case of natural or other disasters, the emergency lending program is known as the emergency projects, in order to improve project viability. whenever significant risks due to natural hazards are identified in project preparation, appropriate measures will be taken to secure the viability of the project, including the protection of populations and investments affected by bank-financed activities. the bank has nonreimbursable resources that may be used to cover the transaction costs incurred with the implementation of these guidelines. . . these guidelines will also recommend ways to evaluate the benefits and opportunity costs of loan reformulations and give guidance on how to ensure adequate transparency and effective monitoring, auditing, and reporting on the use of redirected funds. in addition, the guidelines describe precautions to be taken to avoid rebuilding or increasing vulnerability during rehabilitation and reconstruction. . . the guidelines are designed to be flexible in their application to the various situations that borrowing member countries and the bank may experience, in the face of natural hazards and disasters affecting their development prospects and performance. . . the present guidelines apply to all natural hazards, including the hydrometeorological hazards-windstorms, floods, and droughts-that are associated with both the existing climate variability and the expected change in long-term climate conditions. of note for risk assessments, climate change is expected to change some countries' disaster risk (their probable losses) by changing the characteristics of the hydrometeorological hazards. . although uncertainty persists, recent advances in downsizing climate models are allowing disaster managers to better calibrate their risk assessments to understand potential impacts due to climate change at the subnational level. tools for identifying such climate risk at the country and project levels, and measures for mitigating these increased risks to bank investments (climate change adaptation) will be developed under pillar of the bank's sustainable energy and climate change initiative (secci) action plan. purpose and scope . . the purpose of this section is to provide guidance to bank teams on the implementation of directive a- of the disaster risk management policy, particularly for countries classified as having high disaster risk, as well as for those sectors that are associated with a high vulnerability to natural disasters and in which the bank has identified opportunities for financing. in accordance with this policy, the bank will encourage countries to include proactive drm in programming activities in those countries, as indicated in directive a- of the policy: . . a- . programming dialog with borrowing member countries. the bank will seek to include the discussion on proactive disaster risk management in the dialog agenda with borrowing member countries. the bank will give due consideration to vulnerability associated with natural hazards and risk management in relation to the priority areas of intervention discussed and agreed with the borrowers for the development of country and regional strategies, and operational programs. the bank will identify countries according to their level of exposure to natural hazards based on existing indicators and bank experience. for countries that are highly exposed to natural hazards, the bank will identify their potential vulnerability as a major development challenge and propose a country level disaster risk assessment. when the assessments identify that potentially important disruptions in the country's social and economic development could be caused by disasters resulting from natural hazards, the bank will encourage the inclusion of disaster risk management activities in the country strategy and operational program agreed with the borrower. these may include policy reforms, specific institutional strengthening and land-use planning activities, measures of financial protection such as through risk transfer, and investment projects conducive to reducing vulnerability at the national, regional, and municipal levels. where the natural hazards may affect more than one country, the bank will encourage a regional approach within the existing programming framework. the bank will promote the use of the disaster prevention sector facility and the disaster prevention fund, described in section v of this policy, and other means it offers to finance the recommended actions resulting from the assessment process. to meet the requirement of the drm policy to identify countries according to their level of risk exposure, a provisional country classification has been developed. the provisional classification will be subject to change, based on expert knowledge, and eventually on the complete data set of risk information derived from the implementation of the bank's indicators for disaster risk and risk management program in its borrowing member countries. the indicators program has been completed in countries to date. as indicated in directive a- , countries that have been identified as being highly exposed to natural hazards will be encouraged by the bank to include drm as a priority area for bank assistance. in those cases, the bank will propose that a country disaster risk assessment be carried out. the assessment would give an overview of the risks facing a country; identify the sectors and geographical areas that should receive priority attention; and provide initial policy orientation, reviews of relevant institutional capacities, and assistance needs. these assessments may already exist, or may be put together from country and secondary sources. . . the evaluation of the macroeconomic impacts as part of the country disaster risk assessment may allow for the identification of risk reduction needs and the quantification of possible resource gaps between available resources and funding needed for disaster response and recovery. recommendations will be prepared concerning opportunities for the bank to contribute to financial protection against disasters, as appropriate, such as direct funding for risk identification and support for risk transfer in financial markets in order to improve the effectiveness of the country's development efforts in the areas and sectors of bank involvement. . . identification of opportunities for bank financing. in line with the new country development risk framework, a more detailed disaster risk assessment will be recommended when disaster risks faced by certain areas/sectors of bank involvement could significantly jeopardize the achievement of a country's development objectives. these sector-specific or areaspecific assessments would analyze how these risks could affect specific areas/sectors and make recommendations on how best to address the risks identified. for this purpose, loans, technical cooperations, and nonfinancial bank products for proactive drm may be proposed within the country programming activities. . implementation of the country strategy: programming dialogue and portfolio management . . when deemed necessary by the bank and if the borrower agrees, drm activities will be included as in the implementation of the country strategy. the bank will give due consideration to the following: in the programming and portfolio reviews, the bank and the borrower may seek to implement risk reduction investments in the priority sectors and geographical areas through disaster prevention and mitigation measures. these investments may be financed with free-standing loans or as part of larger investment programs, policy based loans (pbl), or private sector operations. technical assistance may be considered for carrying out area-or sector-specific risk evaluations, strengthening risk management through policy reforms, organizational design, land-use planning activities, the preparation of new prevention loan programs, and supporting the implementation of financial protection schemes such as through insurance to cover disaster losses. loan portfolio modifications will likely be necessary due to the occurrence of major disasters during the regular programming cycle. borrowers may request new emergency or reconstruction financing and will have access to either new resources, for instance, through the immediate response facility for emergencies caused by disasters (gn- - and gn- - ), or "existing" resources, through loan reformulations (see directive b- ). . . the results of the drm implementation in-country programming will be evaluated using the monitoring system defined in the country strategy document. the bank may recommend activities of a regional nature whenever it is known that a particular disaster could affect several borrowing member countries simultaneously. examples of this situation are the enso (el niño southern oscillation) phenomenon, and the hurricanes and tropical storms in the caribbean and central america. . . the regional activities that possibly involve bank financing will be agreed beforehand with the affected borrowing member countries and may involve coordination with other international entities. the resulting operations to be included in the regional portfolio of the regional strategy document could be funded through bank instruments, such as technical cooperation of the regional public goods program or disaster prevention fund, or loans prepared in parallel, in close cooperation with the countries interested in a regional program. . . the purpose of this section is to provide guidance to project teams on the implementation of the bank's disaster risk management policy directive a- : risk and project viability. this directive is designed to promote the incorporation of drm in a systematic manner during project preparation and execution. the objective is to reduce risk to levels that are acceptable to the bank and the borrower, as indicated in directive a- of the policy: . . identification and reduction of project risk. bank-financed public and private sector projects will include the necessary measures to reduce disaster risk to acceptable levels as determined by the bank on the basis of generally accepted standards and practices. the bank will not finance projects that, according to its analysis, would increase the threat of loss of human life, significant human injuries, severe economic disruption, or significant property damage related to natural hazards. during the project preparation process project teams will identify if the projects have high exposure to natural hazards or show high potential to exacerbate risk. the findings will be reported to the bank through the social and environmental project screening and classification process. project teams should consider the risk of exposure to natural hazards by taking into account the projected distribution in frequency, duration, and intensity of hazard events in the geographic area affecting the project. project teams will carry out a natural hazard risk assessment for projects that are found to be highly exposed to natural hazards or to have a high potential to exacerbate risk. special care should be taken to assess risk for projects that are located in areas that are highly prone to disasters as well as sectors such as housing, energy, water and sanitation, infrastructure, industrial and agricultural development, and critical health and education installations, as applicable. in the analysis of risk and project viability, consideration should be given to both structural and nonstructural mitigation measures. this includes specific attention to the capacity of the relevant national institutions to enforce proper design and construction standards and of the financial provisions for proper maintenance of physical assets commensurate with the foreseen risk. when significant risks due to natural hazard are identified at any time throughout the project preparation process, appropriate measures should be taken to establish the viability of the project, including the protection of populations and investments affected by bank-financed activities. alternative prevention and mitigation measures that decrease vulnerability must be analyzed and included in project design and implementation as applicable. these measures should include safety and contingency planning to protect human health and economic assets. expert opinion and adherence to international standards should be sought, where reasonably necessary. in the case of physical assets, the bank will require that, at the time of project preparation, the borrower establish protocols to carry out periodic safety evaluations (during construction as well as during the operating life of the project) and appropriate maintenance of the project equipment and works, in accordance with generally accepted industry norms under the circumstances. the bank's social and environmental project screening and classification process will evaluate the steps taken by project teams to identify and reduce natural hazard risk. . . under the bank's new risk management development effectiveness framework, a common approach to the management of project risks is proposed. disaster risk is one of several project risks. these guidelines are an input to the bank's approach on project risk management. they apply to bank-financed investment loans and technical cooperation projects in the public and private sector as well as to operations supported by the multilateral investment fund. . . during the assessment, management, and monitoring of disaster risk at the project level, the disaster risk is reviewed at various stages of project preparation and implementation. on this basis, appropriate actions are taken to protect project benefits and outcomes. . . directive a- requires that the bank's social and environmental project screening and classification process provide for project teams to identify and reduce disaster risk. the recommended drm steps are as follows: project screening and classification outcome: identifies those projects where the drm policy is applicable and classifies as high, moderate or low risk. document: report of the social and environmental safeguards policy filter (spf) and social and environmental safeguards screening form. document: disaster risk profile in the environment and social strategy. disaster risk assessment (dra), including disaster risk management plan outcome: provides a detailed evaluation of the impacts of the significant natural hazards identified during project classification on project components; and outlines appropriate risk management and mitigation measures. document: dra report, prepared by the borrower (this may be a stand-alone report or it may be incorporated into the environmental impact assessment report). disaster risk management summary outcome: provides information on the specific disaster risks associated with the project and the risk management measures proposed by the borrower. document: drm summary, for inclusion in the environmental and social management report (esmr), prepared by project teams. project implementation, monitoring and evaluation outcome: identifies the approaches which the executing agency applies during project implementation; and which project teams apply during project monitoring and evaluation. . . the bank's social and environmental screening and classification system of projects will be used to filter and classify those projects for which disaster risk is likely to be an issue for project viability and effectiveness. . . there are two possible types of disaster risk scenarios: type : the project is likely to be exposed to natural hazards due to its geographic location. type : the project itself has a potential to exacerbate hazard risk to human life, property, the environment or the project itself. . . the purpose of this step is to establish, early in the project preparation process, whether natural hazards are likely to pose a threat to the project area during the execution (construction) period and/or the operational life of the project, due to type and type risk scenarios. project classification . . type risk scenario: the level of disaster risk associated with a given project is dependent on the characteristics of the natural hazards as well as on the vulnerability of the sector and project area. the project is classified on the basis of an estimate of the impacts/losses due to the significant hazards associated with type risk scenario. project teams classify their projects in terms of high, moderate, or low disaster risk on the basis of the (i) projected frequency of occurrence and magnitude or intensity of the hazard and (ii) estimated severity of the impacts associated with the hazard, i.e., the magnitude and extent of the likely social, economic, and environmental consequences of the hazard on the various project components and on the general zone of influence of the project. the classification process also provides project teams with a preliminary indication of the hazards likely to be of greatest significance, as well as their likely impacts on project components. and reported as part of the disaster risk profile presented in the environment and social strategy document. the project team will report its findings to the bank unit responsible for social and environmental screening and classification of projects, as part of the bankwide safeguards and risk management procedure. high-risk projects . . the project will typically be classified as high-risk if one or more of the significant natural hazards may occur several times during the execution (construction) period and/ or the operational life of the project and/or the likely severity of social, economic, and/or environmental impacts in the short to medium term are major or extreme. these impacts are of sufficient magnitude to affect project viability and may affect an area broader than the project site. as such hazards may affect project viability, a more detailed investigation of disaster risk, in the form of a dra, is required. moderate-risk projects . . the project will typically be classified as moderate risk if one or more of the prevalent natural hazards are likely to occur at least once during the execution (construction) period and/or the operational life of the project and/or the likely severity of impact in the short to medium term is average. these impacts are typically confined to the project site and can be mitigated at reasonable costs. projects associated with a moderate disaster risk do not typically require a dra. however, a more limited dra may be required, depending on the complexity of the project and where the anticipated vulnerability of a specific project component may compromise the achievement of project outcomes. low-risk projects . . the project will typically be classified as low risk if natural hazards are not likely to occur during construction and/or the operational life of the project and/or associated with a low severity of impact in the short to medium term. those impacts that occur do not lead to a disruption in the normal functioning of the operation and can be corrected as part of project maintenance. the occurrence of the hazard event does not impact on the achievement of project outcomes. a dra is not required. . . type risk scenario: the impacts associated with type risk scenario are addressed under directive b- of the bank's environment and safeguards compliance policy (op- ). such impacts are thus considered and included in the categorization of environmental impacts. . . the unit responsible for environmental and social risk mitigation reviews the classification of all operations and may recommend a new classification based on the review of the disaster risk profile presented in the environment and social strategy. the unit and line divisions will need to agree on the final classification of the operations, the level of disaster risk assessment required, and a proposed strategy to address and manage the anticipated impacts. for projects that are identified as high-risk, a dra is required and is prepared by the borrower. the objective of the assessment is to evaluate in greater detail the impacts of the significant natural hazards identified during project classification on project components. the results of the risk assessment will guide the selection of appropriate risk management and mitigation measures. evaluates the frequency, intensity, and severity of previous hazard events that have affected the project area, as well as those predicted to affect the site over the project's operational life. identifies the vulnerability and probable losses of project components, i.e., the nature and magnitude of the probable social, economic, and environmental impacts due to each hazard; this includes both direct and indirect impacts. provides a disaster risk management plan, including proposals for the design of disaster prevention and mitigation measures, including safety and contingency plans to protect human health and economic assets, and their estimated costs; an implementation plan; a monitoring program and indicators for progress; and an evaluation plan. the implementation plan includes protocols to undertake periodic safety evaluations from project implementation up to project completion and maintenance of project equipment and works. project teams include a summary of the dra report in the environmental and social management report, which is reviewed by both the bank unit responsible for environmental and social risk mitigation screening and the sector divisions chiefs will sign off on the esmr and safeguard compliance plan, including the drm activities. the drm summary provides information on the specific disaster risks associated with the project and the risk management measures proposed by the borrower. . . the project's proposed management and mitigation measures should comply with international standards of good practice and relevant national laws and regulations, such as national planning policies, laws and regulations, as well as national building codes and standards. . . project teams will analyze the impact of the disaster risk prevention and mitigation elements in their assessment of project viability, verifying that identified hazard impacts on project components are reduced to acceptable levels. . . the executing agency is responsible for ensuring that all drm activities ( including prevention and mitigation measures) associated with the project are implemented in accordance with the provisions of the loan agreement. this includes periodic safety evaluations and appropriate maintenance during project implementation and through project completion. project teams will monitor implementation to verify that the drm actions in the project risk management plan are carried out effectively; they shall use standard monitoring (project performance monitoring report; ppmr) procedures. purpose and scope . . the loan reformulation addressed by these guidelines provides financing for postdisaster response to the impacts of natural hazard events and physical damage (such as structural collapse and explosions) caused by technological accidents or other types of disasters resulting from human activity. loan reformulation includes the diversion of existing loan resources to specific analysis needs to determine performance indicators, based on the possible revisions and reformulations being considered. analysis of loans used as a source of funding . . the impact of redirecting loan resources from existing loans will be estimated taking into account the intended uses and project objectives of the loan or loans to be used as a source relative to the new proposed use of the funds, thereby creating the conditions for more informed decisions. resource transfers could be done between cost categories within a project (in which case more streamlined approval procedures will apply), or between separate loans as stipulated by bank procedures. . . for choosing existing projects as origin of resources, following factors (in order of priority) would be considered: a. public sector projects. only public sector loans would be considered. loans to the private sector should not be included in the package of loans for possible reformulation as a result of disasters. b. development impact in the reformulated operations. the loans that are having a relatively low economic/financial impact in the country should be considered first as a source for redirecting resources from existing loans toward emergency funding. redirecting resources that are within a loan generally have a smaller effect than those involving several operations. the original development objectives may not be achieved due to the new social or economic situation created by the disaster or it could be considered too expensive to reorient the resources within the old operation. recommendations regarding the redirection of resources will be based on project performance indicators used by the bank. c. level of execution. operations with a low level of physical execution or disbursements and commitments could be chosen for redirection, except for those loans with a very high development impact. the selection should not only be based on a low disbursement rate of the existing loans alone, but also on an analysis of the underlying causes of the poor performance and any remaining opportunities for attaining project goals. d. loans in affected sectors. resource transfers within an affected sector will be preferred due to the greater similarity of their respective objectives compared with those of loans in different sectors. e. loans in affected region(s). in general, existing projects in the disaster area will not be used to provide resources to be transferred to other programs in the same area. however, when damage is so severe that the attainment of the original development objectives is in jeopardy, or the continuation of a certain component of the project as a whole is unjustifiable on account of excessive costs, parts or all of the undisbursed balances may be re-channeled toward emergency or rehabilitation and reconstruction projects in the same area. factors to be considered in projects receiving funding . . the following are the recommended actions to be considered by project teams, while preparing the funding analysis: . i. technical analysis. for emergencies, the technical analysis will be aimed at re-establishing basic services and critical infrastructure in a time efficient manner. the attainment of fully functioning facilities and productive capacity through rehabilitation and reconstruction will be measured through a detailed technical analysis with the objective of reaching disaster resistance, and fulfilling technical standards across the board and performance criteria required by the bank. . ii. socioeconomic analysis. for emergency response, the socioeconomic analysis will be limited to the evaluation of the cost-effectiveness of restoring the basic services and critical infrastructure. if information is scarce, the analysis may be done based on comparable data from similar operations elsewhere. any delays in the analysis and processing of the emergency financing may limit the bank to have a meaningful contribution to resolve critical needs that are affecting the population, urgent re-establishment of basic services and critical activities. the analysis for rehabilitation and reconstruction investments will follow standard bank practices. if future project benefits cannot be estimated, cost-effectiveness analysis will be carried out. . iii. evaluation of institutional capacity and coordination. in order to gain sustainability, existing agencies are preferred to the establishment of new, ad hoc entities. a rapid analysis will be carried out of the institutional capacity, procurement management capability, and financial track record of the existing agencies. based on its results, it will be determined if the resources will be disbursed on an ex post or on a concurrent basis. the administrative and technical responsibilities of all the participating institutions in different sectors and means of coordination need to be clearly defined to facilitate successful execution in a limited time frame. planned strategies and activities need to be coordinated with other international agencies participating in the post-disaster financing. . i. procurement procedures. the applicable bank policy and rules will be followed for the procurement of goods and services. as an exception, for emergency situations, specific procurement procedures are available, in view of the special nature of these operations and the urgency involved. . ii. transparency in financing. the financial management and evaluation of procurements, expenses, and the utilization of goods and services to be funded with bank resources for emergency situations will be audited on a concurrent basis, following current bank practices. for rehabilitation and reconstruction investments the review may be on a concurrent or ex post basis depending on risk of lack of transparency estimated by the project teams. loan resources can be used to contract the services of independent public accountants to audit the operation's financial statements as required by the bank. . iii. monitoring and evaluation. bank resources will be subject to review on a concurrent basis for emergency investments. for rehabilitation and reconstruction, an audit will be required on a concurrent or ex post basis, depending on the risk of lack of transparency as estimated by the project team. data collection will be planned for monitoring and evaluation. only direct project impacts will need to be evaluated. . . vulnerability should not be replicated when designing disaster response financing. in the preparation of reformulations for rehabilitation and reconstruction, a proportion of the resources of the operation should be allocated to prevention and mitigation activities. the percentage of the total cost that will be dedicated to prevention and mitigation should be defined and the viability of these investments assessed by the project team. the project team should also justify any potential deviations from international practices in these allocations for disaster prevention and mitigation. purpose and scope . . the purpose of this section is to provide assistance to project teams on the implementation of directive b- : reconstruction. specifically guidance is provided on the precautions that country programming process and project teams should take to promote revitalization of development efforts in the aftermath of disasters, while ensuring that rehabilitation and reconstruction projects do not lead to a rebuilding of or an increase in vulnerability. as indicated in directive b- of the policy: . . avoiding rebuilding vulnerability. operations that finance rehabilitation and reconstruction after a disaster require special precautions to avoid rebuilding or increasing vulnerability. these include the precautions mentioned in a- , as well as correcting deficiencies in risk management policies and institutional capacity as reflected in a- . a significant share of the new investment will be earmarked to reduce vulnerability to future disasters and improve the country's capacity for comprehensive disaster risk management. particular attention must be given to lessons learned from recent hazard events. the bank will not assume that pre-disaster conditions persist in whole or in part in the affected area. disaster risk assessment of the reconstruction project should be carried out taking into account the specifics of the area, the sector, and the infrastructure concerned, as well as the current environmental, social, and economic situation and any changes in the affected area as a result of the disaster. . . reconstruction may follow as a response to the impacts of natural hazard events, and physical damage (such as structural collapse and explosions) resulting from technological accidents or other types of disasters resulting from human activity. . . the guidelines for directive a- : risk and project viability, as described in section of these guidelines, also apply to rehabilitation and reconstruction projects. for projects identified as high risk, the disaster risk assessment, and design and implementation of risk reduction measures, will incorporate the lessons learned from the disaster event, including the performance of the physical works, the relevant sectors, institutions, and other project components. risk reduction measures will include enhancements in national, regional, and sectoral risk management policies and strengthening of institutional capacity. . . in order to avoid the rebuilding of or an increase in vulnerability, a proportion of the resources of the operation will be allocated to prevention, mitigation, and risk transfer. the percentage of the total cost is at the discretion of the project team, but will be guided by international practices. used with permission from iadb, . reconstruction facility or immediate response facility for emergencies caused by natural and unexpected disasters. the emergency reconstruction facility can use up to $ million of the iadb's ordinary capital or up to $ million of the fund for special operations to assist an impacted country the ifis described in this chapter bstdb) • caribbean development bank (cdb) • council of europe development bank (coeb) • development bank of southern africa (dbsa) • european bank for reconstruction and development (ebrd) • islamic development bank (idb) • north american development bank (nadb) proposed loan: peoples republic of china emergency assistance for wenchuan earthquake reconstruction project european commission fao's mandate. fao website facing the challenge of natural disasters in latin america and the caribbean service sector severely affected by typhoon haiyan nato (north atlantic treaty organization), . pakistan earthquake relief operation ocha- fm c/$file/ocha_ar _hi% res.pdf?openelement japan diverts rice to tsunami survivors. world food programme (wfp) roadmap towards a strategy for disaster and climate resilient development in the pacific (srdp) by : executive summary un-habitat. secretary-general's envoy for youth overview of global humanitarian response johannesburg plan of implementation. united nations website disaster profiles: third un conference on least developed countries united nations educational, scientific, and cultural organization) unhcr in dubai: first line responder in emergencies. unhcr supply office, dubai. unicef (united nations children's fund) about the unjlc. unjlc website connect and convince to reduce disaster impacts lives saved in viet nam by involving women in disaster planning. press release economics, health, and development: some ethical dilemmas facing the world bank and the international community fast food: wfp's emergency response food aid information system: quantity reporting emergency response framework world bank group to support flood recovery in bosnia and herzegovina through their efforts to mitigate, prepare for, respond to, and recover from natural disasters, multilateral organizations have a major role in international disaster management. all nations are at risk from disasters and, likewise, all nations face the prospect of one day finding themselves requiring help from one or more of these organizations. multilateral organizations direct the collective experience and tools of their member states to benefit all nations in need of assistance-even the wealthiest ones. the progress witnessed by the international disaster management community in recent years can be traced directly to the work of these multilateral organizations, especially focused initiatives such as the international strategy for disaster reduction. provide effective and efficient support to borrowing members in reducing disaster risks and (ii) to facilitate rapid and appropriate assistance by the bank to its borrowers after a disaster. the guidelines are part of the bank's framework for the management of development risk at the country and project levels. there are four possible strategies to manage risks: (i) acceptance, when risks remain below levels deemed tolerable by the parties involved; (ii) prevention and mitigation; (iii) sharing, when risks can be effectively transferred to a third party, for example through insurance; and (iv) rejection ("avoidance"), when the level of risk exceeds the risk level deemed acceptable but cannot be lowered at a reasonable cost. . . the policy directives outline the actions that are to be used both by the iadb staff and by teams of the borrowers, who are responsible for a. country programming-policy directive a- b. preparation and execution of new projects-directive a- c. loan reformulations for financing disaster response-directive b- d. preparation and execution of reconstruction projects-directive b- . . the guidelines will contribute to the mainstreaming of disaster risk management (drm) into the bank's programming exercises with the borrowers, particularly in high-risk countries.to determine which of the idb's borrowing member countries will require a country risk assessment, a provisional classification of all countries has been prepared. . . the guidelines will be used for the design and implementation of lending programs, technical cooperations, small projects, cofinancing, and preinvestment activities consistent with the identified risk level. they will address ways to manage risk in public and private sector activities within the same project or to another existing project, in order to finance unplanned disaster response. reformulations may thus involve just a single loan or several operations. . . loan reformulation allows for the reallocation of resources from existing loans to other projects under certain circumstances, in the aftermath of disasters, as stipulated in directive b- of the policy: . . the bank may approve the reformulation of existing loans in execution in response to disasters if: (i) a state of emergency or disaster has been officially declared by the government; (ii) the impact of the loan reformulation has been estimated taking into account the intended uses and project objectives of the loan or loans to be reformulated relative to the new proposed use of the funds, thereby creating the conditions for more informed decisions on the part of the approving authorities; (iii) adequate transparency and sufficient mechanisms for monitoring, auditing, and reporting the use of the redirected funds are in place, while taking into account the need of a timely response given the nature of the situation; and (iv) a significant share of the redirected funds will be earmarked to reduce the borrower's vulnerability to future disasters and improve the country's capacity for comprehensive disaster risk management. in order to be considered for loan reformulation funding in response to a disaster, the government must have declared a state of emergency or its equivalent, for a region or the country as a whole, according to the laws and regulations of the country. . . the country office should prepare an originating document after the formal declaration of state of emergency by the government, recommending the decisions that should be taken in relation to the projects/programs potentially affected by the disaster. . . the bank may offer technical support to the government in preparing an official request for financing through loan reformulation, on the basis of the originating report. . . once a financing request is received, a project team is appointed, and the approval process of the reformulation operation(s) will follow the established bank procedures on delegation of authority, according to regular bank procedures. once the bank has received an official request from the borrowing country for financing disaster response, the possibility of using fresh idb resources, such as through the immediate response facility (gn- - and gn- - ), is analyzed. if their use is not considered feasible, the impact of the loan reformulation will be estimated by vpc, with support from vps, taking into account the intended uses and project objectives of the loan(s) to be reformulated either: (i) as a provider of funding or (ii) as a recipient of resources. the analysis for operations receiving funding in response to a natural hazard or physical damage from technological activities or other types of disasters resulting from human activity will reflect the nature of the projects, available information, and use of the reallocated resources for an emergency, rehabilitation, and reconstruction. . . the revision of the portfolio in emergency situations should be done jointly with the borrower. those projects whose development objective is unlikely to be achieved should be considered first as candidates for reformulation. the team responsible for the portfolio key: cord- -q zmnq authors: ha, kyoo-man title: examining professional emergency managers in korea date: - - journal: environ impact assess rev doi: . /j.eiar. . . sha: doc_id: cord_uid: q zmnq although the number of emergency managers has risen in south korea (hereafter referred to as korea) over the years, their role is not yet as defined and noteworthy compared to other professions because of its unidisciplinary approach. this article investigates how korea has to improve emergency managers' disciplinary approach to ultimately contribute to the goal of effective transnational disaster management. this study uses qualitative content analysis of government policies, college curricula, nongovernmental organizations' (ngos') emergency-manager certification, and mass media coverage to compare emergency managers' unidisciplinary and multidisciplinary approaches. the key tenet is that korea must change its emergency managers' unidisciplinary approach into a multidisciplinary approach because the former is less effective when dealing with complicated disaster management systems. to achieve this change, the stakeholders must carry out their assigned responsibilities under risk-oriented management. as for the study's international implications, developing nations may consider the enhancement of related educational curricula, collaborative learning, continuous evaluation, disaster awareness, and disaster prevention for the emergency managers' multidisciplinary approach. the frequency and impact of large-scale disasters in korea are not decreasing, and the characteristics of such disasters are becoming more complicated than ever before. in addition, disasters have become more heterogeneous. the current structure of korean disaster management is unable to fully address the impacts of disasters, due to political, economic, social, and cultural reasons. to resolve this, a more collaborative, integrated, and comprehensive form of emergency management is required. several sub-areas in korea including firefighting, civil engineering, and other businesses officially proclaim that they have produced emergency managers through their own individual programs, focusing on their specific discipline. also, government institutions at the central government level (being similar to the u.s. federal level) have started to recruit emergency managers as public employees. however, governments have maintained that the capability or knowledge of korean emergency managers is still limited when it comes to dealing with diverse disasters, both natural disasters and manmade emergencies (kim, ) . to be professional korean emergency managers, they have to be oriented towards multiple disciplines. such professionals possess specialized training, skill, or education, whereas non-professionals do not. restrictively speaking, professional emergency managers concentrate on their own areas of responsibility, but they clearly need multiple disciplines apart from their own specialization. the premise of this study is that a unidisciplinary approach does not lead to effective disaster planning, whereas a multidisciplinary approach does (doe, ) . by depending upon a single aspect or onesided viewpoint, the unidisciplinary model addresses reactive disaster management, which does not consider planning (culwick and patel, ; hartkopf, ) . on the other hand, a multidisciplinary approach strongly supports disaster planning. note also that similar terms have been used in place of multidisciplinary, such as interdisciplinary, intradisciplinary, crossdisciplinary, and transdisciplinary. among them, interdisciplinary has been used frequently or interchangeably with multidisciplinary. what they all have in common is the need for more than one discipline and the interconnection of one discipline to another. many developed nations have strongly relied upon the multidisciplinary approach for disaster management. when recruiting emergency managers, the united states prefers to employ those who have a multidisciplinary background (waugh and sadiq, ) . japan has also implemented the multidisciplinary approach to deal with earthquakes and tsunamis, floods accompanying typhoons, and other complex natural disasters (nazarov, ) . the emergency planning college in the united kingdom has traditionally offered multidisciplinary programs, while educating their emergency managers (epc, ) . korean emergency managers have unique characteristics. the job itself lacks professionalism and popularity in korea. for advanced nations, their emergency managers are regularly recruited, paid, and thus contribute significantly to efficient disaster management. modern disaster management in korea started years ago, which is 'new' or less experienced when compared with developed nations such as the united states, the united kingdom, japan, and others. this means that korea has much room for improvement in this field and can learn from examples and practices by developed nations such as the whole community approach in the united states, the establishment of integrated emergency management system in united kingdom, the role of small-scale voluntary organizations in japan, among others. a specific area to consider is adopting a multidisciplinary approach for/by emergency managers to widen their exposure in the field. the purpose of this article is to investigate how korea might improve the disciplinary approach of its emergency managers towards the ultimate goal of effective transnational disaster management through mitigating human loss, economic damages, and psychological impacts. we maintain that korea has to change its emergency managers' unidisciplinary status to multidisciplinary status, and given korea's own experience, the international community must address the need to change related educational curricula, collaborative learning, and sustainable evaluation. there have been two kinds of studies on korean disaster management in the past: those within korea, and those outside of it. the majority of korean researchers or korean language researchers have examined how to organize the national disaster management institution (cho and ahn, ) . considering that the history of modern disaster management in korea started in with the establishment of the national emergency management agency (nema), related researchers paid attention to predicting the next head of nema. with the rise of ministry of public safety and security (mpss) at the end of , they continued to study which professions would require the human resources of mpss. in fact, the nema was transformed into the mpss after experiencing the sinking of ferry sewol in mid- . outside korea, some english language researchers have looked into how disaster management principles would be applied to the case of korea (park, ) . in doing so, they made efforts to examine subjects that korean language researchers had not considered. for example, while disasters have both physical and social impacts, many korean researchers focused only on the physical impacts in the following cases: typhoon maemi in , the sinking of ferry sewol in , the outbreak of middle-east respiratory syndrome (mers) in , among others. conversely, researchers outside korea often delve into the social impact including the psychological impact of disasters, the status of special needs population, and the application of equity to emergency professionals. many researchers have examined the significance of a multidisciplinary aspect on disaster management in the international community (fazey et al., ; leonard et al., ; quick, ; rose, ) . in particular, many educators, nurses, and medical doctors have focused on topics within their areas. at the same time, they have identified, promoted, and implemented multidisciplinary status for professional emergency managers, while elaborating on environmental change, holistic problem solving, dynamic change, and case studies, among many others. although some researchers have attempted to create boundaries between their preferred subject and other specialized subjects in the field of disaster management, many researchers have shared basic knowledge or common disciplines (macinnis and folkes, ; zhang et al., ) . in this context, correlation exists among multidisciplinary subjects and other specialized ones. multidisciplinary approach does not stunt but fuels the advancement of disaster management. further, with a multidisciplinary approach, there is comprehensive planning as part of proactive management. when analyzing that a specific disaster may lead to multiple disasters, disaster management is not oriented for a unidisciplinary but a multidisciplinary model. to illustrate, when a typhoon hits a local area, it usually causes flooding. overflowing water contains a number of chemicals, which need the management of hazardous materials. subsequently, flooding may cause fires due to electric leakage. complex situations such as these scenarios will not be addressed by a linear or single approach. understanding and quick action, looking into alternatives, and applying a multidisciplinary approach have a greater chance of succeeding and in helping to mobilize as many people and organizations as possible to work together to resolve problems. given that disaster management involves a number of interrelated factors and parties, a multidisciplinary perspective is needed to identify and evaluate complicated issues (ali and nitivattananon, ) . unidisciplinary disaster plans typically outline actions for emergency managers from a single discipline or common background. those emergency managers share similar language, training, and emergency function. in addition, they are oriented to handle only one specific aspect of disaster management. in contrast, multidisciplinary disaster plans cover those for emergency managers from diverse fields or different backgrounds. to this point, emergency managers from different disciplines or multidisciplinary disaster plan(s) are expected to handle the multi-faceted aspects of disaster management better than unidisciplinary emergency managers. many challenges come with disaster awareness, decision flexibility, adapting to volatile environments, among others, and for this reason, relying on a single discipline is not likely to adequately explain certain complicated aspects of hazards or risks in disaster management nor will it provide comprehensive solutions (doren et al., ; jensenius, ) . conversely, a multidisciplinary approach may fully address many fragmented issues and concerns towards the goal of effective disaster management, in particular, by comprehensively combining or integrating various knowledge and information. as decision-makers, professional emergency managers in developed nations may get diverse support from their multidisciplinary background (sterlacchini et al., ) . whether as part-time or full-time, shared position or not, as they go about making sound decisions, they also utilize their knowledge on preventive measures during dangerous events. as a result, professional emergency managers play a role in maximizing potential benefits despite limited resources, as long as they fully utilize a multidisciplinary approach. on the other hand, professional emergency managers in korea have not played a specific role in managing diverse disasters. rather, they have taken part in many roles in disaster management such as planners, leaders, administrators, trainers, protectors, communicators, and problem solvers, among others. accordingly, the whole community has expected them to carry out many activities such as hazard identification, efficient emergency response, systematic emergency recovery, ethical conduct, and others (fema, - ). in korea, an increasing number of researchers have studied how efficiently the nation has to operate its disaster management. in doing so, some researchers have indirectly mentioned the category of emergency managers while proposing their theories (incheon city council, ) . however, when reflecting that the concept of professional emergency managers is a relatively new one to korea, almost no rigorous study has been attempted to delve into the issue (yoon, ; yoo et al., ) . to the author's best knowledge, this study is the first to systematically investigate korean professional emergency managers. although this study is not a new attempt outside korea, researchers from other nations can also benefit from or adopt the results of this study at a national level, in particular while studying their national disaster management systems. in other words, this study can serve as an example to other nations in terms of learning from and avoiding similar mistakes. korea can also learn from the experience of advanced nations, potentially applying principles that reflect a multidisciplinary approach. with all the above in mind, the scope of this paper includes not only the characteristics of korean disaster management but also many disaster management principles as observed in the international community. it is not easy to have and maintain emergency managers who are multidisciplined. many practitioners, though knowledgeable, may not be readily available or may not have access to relevant networks on account of (geographical) location or other barriers (e.g., language). some educators, trainers, and researchers also have different means of interpreting certain disaster management data or model (gonzalez et al., ) . for this reason, it is crucial to discuss and establish appropriate techniques and strategies for better communications including exchange of best practices towards solidifying multidisciplinary approach. we used qualitative content analysis as it is able to provide meaningful insights and generalizations that may not be possible in quantitative analysis. this is particularly helpful in evaluating characteristics of professional emergency managers and how they relate to multidisciplines in disaster management (fig. ). in addition, we used comparative perspective, while focusing on qualitative content analysis. similarly, we used qualitative data in this paper. qualitative data are useful in studying disaster management as they may describe qualities, features, or certain characteristics relevant to disaster management including stakeholders' behavior, human relations, effective strategies, and other information (gorodzinsky et al., ) . further, those qualities are helpful in analyzing the disciplinary status of professional emergency managers or in examining the interaction between emergency managers and disaster management. to elaborate, we primarily used several databases for qualitative data collection. in the case of english data, we relied on traditional scholarly journal articles. in the case of korean data, we utilized korean databases to include dbpia, kiss, and government websites. we typed some keywords such as emergency managers, unidisciplinary study, multidisciplinary study, and korean disaster management, among others. in terms of english data analysis, we evaluated data on the u.s. emergency managers that indicate many significant lessons for korea. when thinking that korean data did not directly analyze many things about its emergency managers, we had no choice but to qualitatively interpret them. we maintain that korea has to transform its current emergency managers' unidisciplinary approach into a multidisciplinary approach. in a unidisciplinary setup, the decision-making process is linear whereas in a multidisciplinary approach, inputs come from multiple areas and there is an opportunity to evaluate before concretizing a decision (as reflected by the 'decision box' in the flowchart). to systematically compare two disciplinary approaches, we initiated listing important stakeholders surrounding emergency managers in korea by relying on many qualitative techniques, such as analyzing government documents, discussions with experts, internet searches, and others. the list included the mpss, local governments, disaster management trainers, industries, job applicants, and others. finally, we chose four major stakeholder areas, namely government policies, college curricula, ngos' emergency-manager certification, and mass media coverage. the identified stakeholders and emergency managers are expected to play a number of roles within the field of emergency and disaster management (kim et al., ; yo, ) . for emergency managers, the exercise of their responsibilities will depend on which stakeholder they deal with at a given time in the (disaster) lifecycle. with all the above in mind, we have attempted to draw international implications for many other nations later. when the sinking of ferry sewol happened around jindo island in , unidisciplined maritime policemen attempted to rescue passengers with minimal success. even though they were accustomed to dealing with maritime accidents, the maritime policemen were unable to consider important issues such as disaster victims' psychological needs, the operation of rapid and complex disaster management, interaction with other institutions, and how to use public information officer(s). after rescuing only out of passengers, the public became angry at the poor disaster management actions of the maritime policemen, causing the president to dismantle the institution, which is the nema (hong, ) . the procedures followed by emergency managers during the sewol ferry incident are considered typical of the unidisciplinary approach. only three professionals, namely firefighters, civil engineers, and maritime police make up the mpss, which is a comprehensive disaster management agency in korea (mpss, ) . since the ferry sewol sinking in , the mpss has placed most of the emphasis on maritime accidents as well as house fires and flood accompanied by typhoon. therefore, those who are dealing with each hazard have also turned into the emergency managers for those fields or areas. each professional under the mpss has strongly wanted to dominate the field of disaster management in korea. in particular, the competition between firefighters and civil engineers has been fierce in terms of budget allocation. not much collaboration has been observed among the three professionals. further, other professionals such as humanists, natural scientists, mechanical engineers, lawyers, sociologists, and public administrators have not been allowed to work for disaster management. under politics-oriented management, each of the three emergency managers has come to embrace his or her own principles based on their own disciplines or areas of expertise. . . . college curricula. korean health workers in college hospitals were heavily involved in dealing with the outbreak of the mers in . although health workers knew their responsibilities in terms of medical treatment, they knew relatively little about the phase of medical prevention as part of disaster management lifetime, how to coordinate with other stakeholders to include patients' family members, government officials, and local communities, and other emergency management principles. consequently, because the unidisciplined health workers in college hospitals were not able to consider the other equally important aspects surrounding the situation, the outbreak claimed the lives of patients (ha, a) . many departments in colleges have recently begun offering disaster management programs such as firefighting science, civil engineering, ocean science, medical science, nursing science, public administration, and safety engineering, among others (ha, ) . each department has maintained that their own academic subject, which is a unidisciplinary approach, is the key major in the field of disaster management. they have not seriously attempted to incorporate other disciplines into their own areas. when analyzing departmental curricula, we can see that they have not put significance to the concept of emergency managers (kang et al., ) . without emphasizing the role of emergency managers, they have tried to describe how each has operated its own disaster management. in general, many departments have not realized the status of emergency managers as a professional in the field of disaster management having such certificates is a requirement for some public institutions' recruitment. nevertheless, many emergency manager certificates have been based on the unidisciplinary approach. it means that they have been taught in only one area of study when a more comprehensive and diverse curriculum/training would be better. certificates from kfsa, kdpa, mrsa, and lsa are oriented on their own disciplines including firefighting, flood accompanied by typhoon, maritime rescue, and maritime search and rescue. although the kbcpa has supported multidisciplined emergency managers via classroom sessions, the program towards certification still lacks the aspect of multidisciplinary training. . . . mass media coverage diverse mass media including tv, radio, internet, mobile phones, newspapers, and others have exerted efforts to cover the occurrence of a disaster as breaking news. similarly, they have tried to cover the phase of disaster response or that of recovery much more than that of disaster prevention/mitigation or preparedness (choi et al., ) . in general, many mass media networks have not clearly recognized emergency managers as entities in the field of disaster management. notwithstanding, few mass media such as arirang tv and ytn tv have just begun to talk about emergency managers. there was realization that with the disasters korea has faced so far, the role of korean emergency managers has been neither extraordinary nor maximized. the discussion about the criticality of the profession has not also touched on the needed multidisciplinary approach. korea has a small number of multidisciplined emergency managers in the field of disaster management. they are those professionals who are open-minded and used to interpreting various disaster management concepts in a more critical manner (macaskill and guthrie, ). for example, having a multidisciplinary background helps professional emergency managers to more flexibly interpret diverse issues to include the scientific analysis of complicated evolution, decision making process, the behavior of multiple stakeholders, and others than a unidisciplinary one. without a multidisciplinary background, those emergency managers may not be able to design and implement flexible alternatives quickly during the period of disaster response. there are many reasons why korea has currently had only a few multidisciplinary emergency managers. for example, some stakeholders including governments have politically supported unidisciplinary emergency managers, when reflecting few incumbents' aspiration towards hegemony. in addition, colleges and mass media as well as ngos have not seriously realized the importance of having a multidisciplinary approach on korean emergency managers. in short, either politics or lack of expert knowledge is the fundamental reason for the lack of emergency managers' multidisciplinary approach at present (ha, ) . the nation has just partially enhanced its multidisciplinary approach, as far as the field has failed to embody the full extent of addressing risk-oriented management. without considering risks and having appropriate or sufficient knowledge, resulting also from various experiences on past emergencies or disasters, the nation has not moved to the level of multidisciplined emergency managers (ha and ahn, ). in particular, when assigning resources and priorities, the nation and its emergency managers have not utilized sound principles on disaster management. to elaborate, thanks to the support of international association of emergency managers' (iaem's) certified emergency manager program, korea now has several multidisciplined emergency managers. iaem has played many roles in training emergency managers in the international community. although the number of multidisciplinary emergency managers in korea is not quite big, those certified emergency managers are trying to contribute to the goal of disaster management in the government sector, in colleges, and others. another good case of multidisciplinary emergency managers is that of the association of slope disaster management (asdm). as an ngo in korea, it radically adopted multidisciplinary training and exercise program in despite lack of management funds that almost closed its business. since that time though, asdm has provided many multidisciplinary courses to the trainees by following important lessons from hong kong' slope management. their program included not only the civil engineering perspective but also other multidisciplinary trainings sessions such as on disaster awareness, climate change, and local history. now, the asdm has been able to recruit many trainees. at the same time, those trainees have played a role in managing slopes around their places by successfully practicing multidisciplinary approach. regarding the differences between unidisciplinary and multidisciplinary approaches, quite a few researchers have tried to empirically prove them, in particular, in the research area of emergency medicine and education (beckett et al., ; chen et al., ; ferrario et al., ) . although the focus of each research has been distinct depending on individual viewpoints, many researchers have indicated that the characteristics of multidisciplinary emergency managers are superior to those of unidisciplinary emergency managers (thomson and black, ) . thus, the multidisciplinary model may be evaluated as one of the most innovative solutions for disaster management. certainly, there are different effects between emergency managers' unidisciplinary approach and multidisciplinary approach, see table . the details in the table illustrate that both have benefits. in some aspects, a particular approach is better than the other. in general though, the multidisciplinary approach has more advantages when compared to a unidisciplinary one. in the field of disaster management, multidisciplined emergency managers have traditionally performed better than unidisciplinary emergency managers have. though it is certain that unidisciplinary emergency managers also possess positive characteristics such as their speed of decision making or homogeneity, other aspects still support positive signs for the superiority of multidisciplinary status. in particular, if thinking that the whole community approach is quite necessary in the st century, multidisciplinary approach is more suitable for the operation of disaster management than unidisciplinary approach is. similarly, multidisciplinary disaster plan(s) or related planning are more effective than unidisciplinary disaster plan(s) are. effective means that multidisciplinary emergency managers produce results, and thus, may contribute to the goal of disaster management, compared with unidisciplinary emergency managers (martensson et al., ) . to elaborate, disaster plan(s) include handling diverse kinds of disaster. while dealing with them, multidisciplinary disaster plan(s) or related emergency managers communicate with one another and then implement a series of evaluation processes on uncoordinated problems. their decisions are credible and thus, may flexibly adapt to the complexity of disasters. in short, multidisciplinary emergency managers are able to produce successful outcomes as initially intended during disaster management planning. when korea fully embodies the multidisciplinary approach for emergency managers, it may have the most appropriate or ideal disaster management style. if thinking that the field of disaster management cannot survive without those who are running it, emergency managers are the key to the efficient operations of disaster management (wooten and james, ) . even though dealing with emergency managers is not an easy task, they are considered to be the most valuable resource in the field. while emergency managers have competitive advantages, the korean field of disaster management may develop a new style of its disaster management in particular by breaking down the unidisciplinary approach. not just one or two, but all four stakeholders in korea need to carry out their own assignments for the goal of achieving multidisciplinary approach, following table . in particular, many decision-makers (with vested interests) in each area have not been willing to change the disciplinary approach of their emergency managers in korea (saleh and pendley, ) . hence, the field including the four stakeholders must expand the aspect of multidisciplinary approach into its culture by getting rid of vested interests of those in politics or by being well-informed, and not ignorant. a disaster may happen to anybody, regardless of national boundary (ha, b) . at the same time, the category of professional emergency managers has risen in the international community. emergency managers in each nation have played their own roles in minimizing the impacts of disasters, although the exact extent of their roles is not fixed but continues to vary. with these in mind, many nations may learn important lessons from the disciplinary approach of korean emergency managers to include mistakes or errors made by the korean emergency managers. other nations, which do not have the category of emergency managers in the field or whose emergency managers lack multidiscipline, must realize why the disciplinary approach does matter for the role of emergency managers in their areas. without knowing the significance of multidisciplinary approach, those nations will not develop or improve the position of their emergency managers (ha and ahn, ) . in short, those nations have to consider the multidisciplinary approach as critical to the development of their professional emergency managers. based on disaster awareness, such nations need to diversify their educational curricula for professional emergency managers. when considering that educational curricula provide concepts, principles, instructions, strategies, and tools on disaster management, such curricula as an essential element should be improved by including multiple approaches. while studying multidisciplinary curricula, emergency managers are likely to be equipped with skills to help them quickly create appropriate strategies to address certain aspects of disaster management. it is also necessary for certain nations to utilize collaborative learning among different schools, teams, specialties, communities, and other institutions (alfred et al., ) . when a specific educational unit faces its limits on the expansion of multidisciplinary curricula, it may contact neighboring units and then collaboratively develop its curricula. collaborative learning may bring different disciplines into the activity of emergency managers. those nations may continue to set up collaborative networks on the way to stronger collaborative learning. they can start to establish multidisciplinary environments with the cooperation of diverse individuals and institutions within national boundaries (kozucha and sienkiewicz-malyjurek, ; noran, ) . to this point, various communication channels around them should play an important role in coordinating thorny issues. simultaneously, they may extend collaborative networks internationally by addressing not only different disciplines but also cultural interoperability (ha and park, ) . when recruiting emergency managers, authorities from training centers must consider recruiting from a variety of professionals. they need to include not only firefighters, civil engineers, and maritime police, but also public administrators, environmental engineers, chemical engineers, communicators, psychologists, medical doctors, nurses, and others (becker, ) . vice versa, diverse trainees may outline how different disciplines can work together towards the goal of disaster management. training and exercise in disaster management are also expected to expose challenges experienced by disaster victims, and thus, facilitate or simulate related experience for trainees (martin and hutchon, ) . however, the extent of exposure or experience accruement may not be quite feasible in other nations, due to limited environment such as poor disaster preparedness programs. thus, there is a need to formalize their multidisciplinary training and exercises, and then provide robust training opportunities for professional emergency managers. similarly, it is necessary for other nations in the international community to reflect on diverse knowledge and information during the planning process. by integrating multiple disciplines into emergency operational plans, the competencies of professional emergency managers are expected to be enhanced. in short, multidisciplined emergency managers will be able to efficiently adjust to the demands of multidisciplinary planning process under complicated environments or situations (khorram-manesh, ) . other nations may not easily produce professional emergency managers via a single program or tool. rather, they require a series of programs for the goal of developing professional emergency managers (gfdrr, ) . thus, those nations have to continue to monitor, evaluate, and then improve relevant programs. in addition, because the scope of disaster management is quite wide, those nations must be flexible in introducing changes to related programs or tools via sustainable evaluation. among the many challenges and alternatives, the major finding is that korea has to transform its emergency managers' unidisciplinary approach to multidisciplinary approach in the near future. in so doing, it is necessary for each stakeholder to carry out their own assigned roles and responsibilities under the name of risk-oriented management. likewise, many nations in the international community may learn important lessons from the korean case regarding why a nation should transition to the multidisciplinary style. accredited researchers have studied the exact role of emergency managers in some advanced nations. however, almost no rigorous study has been attempted to examine the role of korean emergency managers or how to change their disciplinary status under their own environment. by suggesting the importance of multidisciplinary approach, this paper may be considered a pioneer study. in a broad sense, this paper may contribute to the goal of transnational emergency management by highlighting the need for multidisciplined emergency managers in the international community. as a future study, researchers may expand their exploration on the disciplinary approaches practiced by professional emergency managers in the international community. korean researchers may further study specifically how their emergency managers will utilize and benefit from a multidisciplinary approach. various researchers in advanced nations may compare their emergency managers' disciplinary approach with other nations and then work towards sharing best practices. researchers in developing nations can also work towards utilizing good disciplinary models for their potential emergency managers. preparing for disasters; education and management strategies explored exercising multidisciplinary approach to assess interrelationship between energy use, carbon emission and land use change in a metropolitan city of pakistan environmental disaster education at the university level: an integrative approach multidisciplinary trauma team care in kandahar, afghanistan: current injury patterns and care practices florida public hurricane loss model: research in multi-disciplinary system 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(in korean) a study on education and training of public servants in the field of disaster and safety management in korea (in koran) a correlation analysis model for multidisciplinary data in research he as an adjunct professor is working for the dept. of public policy and management at pusan national university, korea. he, as certified emergency manager, is serving as the korean representative for the international association of emergency managers. his biography (disaster management researcher) has been selected for marquis who's who in the world key: cord- -l mxmy authors: stangeland, paula a. title: disaster nursing: a retrospective review date: - - journal: critical care nursing clinics of north america doi: . /j.ccell. . . sha: doc_id: cord_uid: l mxmy this article presents a review of the literature related to disaster preparedness and nursing. a definition of disaster as set forth by the american red cross is provided. eight themes, including ( ) defining disaster, ( ) nursing during and after disaster, ( ) nursing education in disaster preparedness, ( ) military nurse preparedness, ( ) postdisaster stress, ( ) ethical issues and intent to respond, ( ) policy, and ( ) hospital emergency policy, were derived from the review and are explored in this article. although a plethora of disaster-related literature exists, the voice of the nurses who worked during these disasters is missing. areas of proposed research illuminated by current research are suggested. cinahl, medline (ovid), pubmed, and psycinfo. in , the robert t. stafford disaster relief act was signed into law, establishing the process by which presidents could declare disasters in states overwhelmed by catastrophic events. therefore, the literature review was limited to the past years. keywords entered into the databases were nursing, disaster, hurricane, posttraumatic stress, and preparedness. the search revealed a vast amount of disaster-related literature, which was categorized into thematic sections: (a) defining disaster, (b) nursing during and after disaster, (c) nursing education in disaster preparedness, (d) military nurse preparedness, (e) postdisaster stress, (f) ethical issues and intent to respond, (g) policy, and (h) hospital emergency policy. the association between disasters and human existence is indisputable, hence many definitions for disaster are found in the literature. a comprehensive definition for disaster is difficult to locate in the literature-most definitions are either too broad or too narrow, and many organizations have created their own definitions for the term. for the purpose of this review, the definition of the term that was deemed most appropriate was that used by the american red cross (arc), which defines disaster as: a threatening or occurring event of such destructive magnitude and force as to dislocate people, separate family members, damage or destroy homes, and injure or kill people. a disaster produces a range and level of immediate suffering and basic human needs that cannot be promptly or adequately addressed by the affected people, and impedes them from initiating and proceeding with their recovery efforts. natural disasters include floods, tornadoes, hurricanes, typhoons, winter storms, tsunamis, hail storms, wildfires, windstorms, epidemics, and earthquakes. human-caused disasters-whether intentional or unintentional-include residential fires, building collapses, transportation accidents, hazardous materials releases, explosions, and domestic acts of terrorism. common to all definitions of disaster is the characteristic that disasters are destructive events that more often than not require assistance from outside the community. researchers report that nurses are one of the largest groups of emergency responders during a disaster and are at risk for psychosocial problems that may need interventions to help them cope with exposure to disasters. , in the immediate aftermath of a disaster, the effects can be overwhelming to nurses working in the area, as there is a great deal of chaos and confusion that nurses must contend with and overcome. , [ ] [ ] [ ] studies indicate disaster emergencies create an atmosphere of pandemonium and uncertainty and that nurses perceive they have been or will be abandoned by leadership. , , , feelings of abandonment by management and a lack of communication play a major role in the decision-making processes of nurses and other hcps when deciding to work during a disaster. [ ] [ ] [ ] nurses state that they feel disaster plans are made by leaders or managers without input from the nurses who will actually be working and taking care of patients during and after the disaster. , giarratano and colleagues conducted an interpretive phenomenological study based on van manen's "lived experience" philosophy. the sample included perinatal nurses who worked during hurricane katrina. the purpose of the study was to stangeland make explicit the perinatal nurses' shared meanings of their lived experience of providing care in new orleans during hurricane katrina. major themes that emerged from the study include (a) duty to care, (b) conflicts in duty, (c) uncertain times, (d) strength to endure, (e) grief, (f) anger, and (g) feeling right again. findings demonstrated that nurses who work during disasters must live through the uncertainty of the situation and be prepared to adapt to the needs that arise in both patient care and self-preservation situations. this study revealed that primary resources needed by nurses while working during a disaster include excellent basic nursing skills, intuitive problem solving, and a sense of staff unity. researchers noted that the nurses exhibited a wide range of problems related to stress. these problems included changed sleep patterns, change in mood, eating problems, substance abuse, and avoidance behaviors. at the same time, it was recognized that the nurse participants practiced in harmony with duty to care values and demonstrated behaviors of strength, courage, and resilience. o'boyle and colleagues completed a qualitative study with a purposive sample of nurses who participated in focus groups ranging from to participants in each group. the sample of nurses was recruited from midwest hospitals that were designated as receiving sites for evacuees. the purpose of the study was to identify beliefs and concerns of nurses who worked in hospitals designated as receiving sites during public health emergencies. abandonment was the major theme that emerged from the focus group interviews. this theme was supported by subthemes including: chaos, unsafe environment, loss of freedom, and limited institutional commitment. nurses felt that policies were not well thought out, and that they were left out of the communication loop. in addition, the nurses stated that they did not receive any preparedness training to handle bioterrorist events. nurses believed that in the event of a bioterrorist attack, there would be a disruption in normal staffing resources. aware that nurse staffing under normal conditions is at times already strained, the nurses feared that they would not be free to leave the workplace. therefore, these researchers reported that the participants in the study believed that a shortage of nursing staff would be indirectly related to nurses who refused to work during a disaster. a limitation of this study is the small number of participants in some of the focus groups, which might have limited the discussions. a qualitative descriptive study completed by broussard and colleagues explored school nurses' feelings and experiences working in the aftermath of hurricanes katrina and rita. the sample consisted of female school nurses from across the state of louisiana who attended an annual school nurse conference held in march . nurse participants had an average age years. researchers reported that the participants were from all areas of louisiana, including areas that were not in the path of either hurricane. participants were asked one question: "please share your experiences and feelings about hurricanes katrina and/or rita". in addition to the qualitative question, demographic data were collected that included: (a) age, (b) years of experience as a school nurse, (c) gender, (d) support systems loss or damage to home and vehicle, (e) damage to school, and (f) change in work assignment as a result of the storm. data analysis was not described; however, findings were categorized into major themes: personal impact and professional impact. personal impact included subthemes: (a) uncertainty, (b) helplessness, and (c) thankfulness. professional impact included themes: practice challenges and practice rewards. the participants portrayed a wide array of emotions and feelings that were similar to previous studies. researchers recommended that all school nurses would benefit from having both formal and informal support systems and mental health services available to them in the aftermath of future hurricanes. identifying the philosophic disaster nursing underpinnings as well as the method for data analysis and rigor would have strengthened the validity of this study. although some nurses identified their experiences of working during and in the aftermath of hurricane katrina and other health emergencies as rewarding, they also identified planning and education as critical needs for providing care in future disasters. , [ ] [ ] [ ] hughes and colleagues report that nurses believe that they need to be involved at the onset of the emergency planning process. during emergencies, nurses stated that they used their most basic skills and teamwork when providing patient care, but recognized that further education is necessary to enhance their knowledge prior to future events. , , according to the international nursing coalition for mass casualty education (incmce), every nurse must have sufficient knowledge and skill to recognize the potential for a mass casualty incident. in addition, the incmce states that every nurse must be able to identify when a mass casualty event may have occurred, know how to protect oneself, know how to provide immediate care for those individuals involved, and be able to recognize their own role and limitations during such a disaster. the incmce also recommends that nurses know where to seek additional educational information and how to access resources. the position of the american nurses association (ana) related to practice during disaster is that all nurses are individually accountable for their actions and should practice according to their code of ethics. , despite that the ana acknowledges that working during disasters places nurses in unusual situations and conditions, the organization's code of ethics defines and directs the responsibilities of all practicing nurses regardless of the situation or setting. however, in the draft of the scope and standards of practice, the ana recognizes that these standards may change during times of disaster. the essentials of baccalaureate education for professional nursing practice was created by the american association of colleges of nursing (aacn). this document provides guidelines for baccalaureate-level nursing schools to prepare students for disaster response. the aacn mandates that the baccalaureate nursing education curriculum contain emergency-preparedness and disaster-response information. specifically, the guidelines state that baccalaureate nursing programs should prepare graduates to use clinical judgment appropriately and provide timely interventions when making decisions and performing nursing care during disasters, mass casualties, and other emergency situations. in addition, nursing students should understand their role and participation in emergency preparedness and disaster response with an awareness of environmental factors and the risks these factors pose to self and patients. it is not known whether the voices of nurses experienced in disaster have informed these essentials of education. educational competencies for associate degree nurses were created by the national league for nurses (nln) with support from the national organization of associate degree nursing. although the document provides core competencies that all associate degree nurses must meet, it does not specifically explicate the responsibilities of associate degree nurses during emergency situations. a particular skill indirectly related to disaster preparedness includes the ability to adapt patient care to changing health care environments. gebbie and qureshi, well-known nurse experts in disaster management, maintain that it is necessary for all nurses to be prepared during disasters. these experts define stangeland the difference between emergency and disaster, and state that disasters disrupt many services and cause unforeseen threats to public health. these researchers further describe disasters as requiring assistance from outside the affected community. gebbie and qureshi, at the request of the centers for disease control and prevention (cdc), developed core emergency preparedness competencies for nurses. although these competencies were developed by nurses; it is not known whether they have been incorporated or implemented in any educational program or facility where nurses work. research has shown that nursing schools may be lacking in the area of preparing students for disaster nursing. , jennings-saunders and colleagues completed a descriptive survey study that investigated nursing students' perceptions regarding disaster nursing. one purpose of the study was to propose recommendations to help advance the discipline of nursing and nurse clinicians. a convenience sample of senior nursing students participated. each participant completed the disaster nursing perception questionnaire and the demographic profile form. data were analyzed for meaning and relationships of words using the data analysis technique of morgan and baxter. this study revealed that nursing students do not comprehend what disaster nursing means and why it is important to know what community resources are available during times of disaster. furthermore, the study revealed that it is not known to what extent nursing faculties teach disaster preparedness in nursing programs, even though it is required. weiner and colleagues administered an on-line survey to united states nursing program deans and nursing program directors to assess the level of disaster preparedness curricula in united states nursing schools. only surveys ( %) were completed and returned. this low response rate was identified as a limitation of the study. baccalaureate and associate degree nursing programs made up more than % of the response rate. the study revealed that faculty was inadequately prepared to teach disaster preparedness and that most programs were overly saturated, leaving little room for disaster-preparedness education. a significant finding revealed that united states nursing school program curricula were limited in the area of disaster preparedness. this review of the literature revealed that nursing school governing bodies have developed competencies to be included in the nursing curriculum; however, nursing programs have been identified as still lacking in the area of disaster nursing curriculum. in addition, studies reveal that nursing faculty members are not prepared to teach disaster nursing. education of faculty in the area of disaster preparedness and response is an area that requires added consideration to adequately prepare students for disaster situations that may arise in the students' future careers. military nursing has played a critical role in the history if nursing. including data related to military nursing further enriches this review by addressing a significant area related to disaster and emergency preparation for nurses. nurses' involvement in war-zone care dates back to the crimean war in the s, when florence nightingale cared for injured soldiers and introduced modern nursing during times of war. researchers today posit that nursing during wartime has increased the profession's understanding of caring and responding during disasters. it is recognized today that military nursing is challenged by working in diverse situations. yet, according to recent studies, literature does not adequately describe military disaster nursing. on december , , the united states declared war on japan after the bombing of pearl harbor. trapped in the midst of this war were army and navy nurses who had no combat training. these nurses were caught in the middle of the battle on bataan, a province of the philippines. a few of the nurses escaped by boat but were captured by the japanese and held captive for years in the philippines. these nurses represent the first group of women in the military to be imprisoned by enemy forces. elizabeth norman had the privilege of interviewing of the female nurses and wrote a book titled we band of angels: the untold story of american nurses trapped on bataan by the japanese. norman began her study in and discovered that only of the nurses were still living. during this study, she also found that most of the nurses had joined the military seeking adventure and romance. the nurses interviewed by norman reported that the philippine islands were paradise until the war broke out and they were captured and held prisoner. norman realized and reported that the nurses always started the conversation with humor but the interview soon found the nurses talking about the painful memories, with a few interviews ending in tears. during the study it was reported that all the nurses had similar accounts of the ordeal of being held captive and that all of the nurses answered the interview questions using "we" instead of "i." these comments led norman to realize that the nurses viewed "unit cohesiveness" as their most important survival tool. baker and colleagues, using a self-report questionnaire, studied the stresses experienced by female nurses in vietnam. a sample of female army nurses was recruited to complete this study. findings revealed that % of the participating nurses reported they were poorly prepared by the military to serve in vietnam. also, registered nurses with less than years of clinical experience before going to vietnam were more likely to experience posttraumatic stress syndrome (ptsd) than nurses with more years of experience. the investigators identified the use of a self-report questionnaire as a study limitation, noting that the nurses had to recall events that occurred between to years prior to the study, adding to possible response bias. baker and colleagues concluded that more research in this area is necessary. ravella completed a descriptive study using a voluntary sample of air force nurses in san antonio, texas, who served in vietnam at various times during the vietnam war. this study used in-depth interviews to gain insight into individual nurse perceptions of their wartime experiences, coping skills, and significant events that they remembered. findings revealed that % of the participants described symptoms of ptsd. participants also reported crucial survival skills including strong social support, maturity, nursing experience, humor, religion, and relaxation. the most significant events remembered were directly related to patient care situations and threats to survival. these events were reported by % of the nurses interviewed. lastly, all of the nurses interviewed reported that their most rewarding professional experience was serving in the vietnam war. using a qualitative design, stanton and colleagues examined and compared experiences of nurses who served during world war ii, the korean war, the vietnam war, and operation desert storm. a sample of nurses who volunteered to participate in the study were interviewed and asked to describe their experiences of serving during wartime. these researchers revealed that military nursing is an experience that is very different from community nursing. the common themes that emerged from the study were: (a) reacting personally to the war experience, (b) living in the military, (c) the meaning of nursing in the military, (d) the social context of war, and (e) images and sensations of war. in a proposed model for military disaster nursing was developed. this model included actions deemed necessary during the phases of disaster: (a) preparedness, (b) response, and (c) recovery. military nurses possess a wide range of skills and are usually leaders in patient care. according to wynd, future disasters will encompass a wide range of disasters causing diverse mass casualties. wynd also emphasized that more research is necessary to determine whether this proposed model for military disaster nursing will be useful during military as well as civilian disasters. although both can be stressful and traumatic, the literature reviewed revealed that nursing in the military is different from community disaster nursing. because the literature reveals that working during disasters and traumatic situations causes increased stress for nurses, it is necessary to include information related to disorders that have been associated with experiencing traumatic situations. working during disasters can have an immense impact on responders. it has been recognized in the literature that ptsd can develop soon after experiencing a traumatic event. during times of disaster, caregivers and first responders react immediately to address physical injuries. however, these same caregivers have a tendency to react slowly or ignore injuries to themselves that are concealed deep within the consciousness. the national institute of mental health (nimh) defines ptsd as: an anxiety disorder that can develop after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened. traumatic events that may trigger ptsd include violent personal assaults, natural or human-caused disasters, accidents, or military combat. according to the nimh, ptsd can start at any time after experiencing a traumatic event. symptoms of ptsd include bad dreams, flashbacks from the traumatic event, feeling like the traumatic incident is happening again, terrifying thoughts that one cannot control, staying away from places and things that are reminders of the event, feeling worried, guilty, or sad, feeling alone, problems sleeping, feeling on edge, angry outbursts, and thoughts of hurting oneself or others. , traumatic stress can change lives forever. researchers report that long-term dissociative and ptsd symptoms may occur after natural disasters. , in addition; survivors of disaster experience traumatic stress and the sights, sounds, and smells of the disaster are embedded in their minds forever. acute stress disorder (asd) is a condition that has a close relationship to ptsd. researchers have documented that women are at higher risk for developing asd and ptsd than men who have experienced traumatic events. , laposa and colleagues completed a secondary data analysis study addressing the correlation between sources of workplace stress and ptsd symptoms. the study sample included emergency department employees located in urban canada. seventythree percent of the participants were identified as nurses. ptsd was assessed using the posttraumatic stress diagnostic scale (pds). stress was measured using the health professionals' stress inventory-revised (hpsi-r). both scales were reported to have a cronbach alpha of . or higher, which is adequate for internal consistency. major findings included that % of the participants met all of the criteria for ptsd. eighty-two percent of the respondents confirmed they did not attend debriefing sessions provided by the hospital and % of the respondents reported they did not receive professional help for stress outside of the workplace. in addition, results revealed that % of the participants reported they had considered changing jobs disaster nursing after stressful incidents. researchers concluded that this study supports the need for employers to provide emotional support for workers who have experienced working during disaster or other traumatizing events that may lead to long-term emotional upset. hughes and colleagues completed a review of the literature to describe nursing's contribution to the psychosocial recovery of survivors of emergencies during all stages of disaster preparedness and recovery over a long-term period. the purpose of the integrative review was to provide guidance to nurses who are involved in emergency planning and response during the acute phase of an emergency. a second objective of the study was to inform nurses of the psychosocial effects that they may experience as health care providers working during disaster situations. these researchers revealed that nurses may experience stress-related psychosocial consequences that continue well past the disaster. relevant factors that must be taken into account are: (a) level of exposure to the disaster, (b) environmental or working conditions and management practices, (c) nurses' perceptions and individual coping and stress reduction practices, and (d) the amount and type of training and previous experience. hughes and colleagues state that nurses are the largest entity of the emergency response team and need to be included from the beginning of emergency planning. nurse responders must also undergo extensive education on the potential psychosocial symptoms that may be experienced as a result of working during a disaster. when entire communities are affected by disaster, it is not possible to maintain previously normal daily activities. conner and colleagues suggest that identifying persons at risk for ptsd may improve outcomes after exposure to disasters and trauma. in addition, it is recognized that many screening and assessment instruments exist that measure ptsd after disaster; however, the validity of these instruments is unclear and more research is needed to verify their appropriateness. brewin and colleagues state that in order for ptsd screening instruments to be useful, they must be brief, consist of the minimum number of items necessary for accurate identification, and be written in a language that is easy to read. furthermore, the symptoms of ptsd and asd that may be experienced by nurses responding specifically to a major hurricane disaster may be different. thus, one must first explore these perspectives by asking those who actually did respond and work in an affected facility. only then will researchers begin to understand why nurses may elect not to respond during future hurricanes. conflicting issues between family and self, safety, and work obligations often make it difficult for nurses and other hcps to decide to work during a disaster. , , ethical opinions vary widely regarding decisions to report to duty during times of disaster and other health emergencies. the duty to report to work in health emergencies remains an intense topic of discussion in the health care arena. as unparalleled demands are placed on nurses and other hcps who are called to work during disasters, some believe that the code of ethics for health care workers should specifically define the responsibilities of the hcp. while the american medical association (ama) and the canadian medical association (cma) have addressed the issue of responsibilities of physicians in their code of ethics, some researchers believe that it remains to be determined whether other health care professions will follow the same course of action in addressing the issue of providing care during health emergencies. the ana revised the code of ethics for nurses to include interpretive statements to accommodate nurses' comprehensive role in the health care environment. because nurses are continually confronted with many challenges including unpredictable and complex medical and emergent conditions that affect both individuals and communities, the revised code of ethics addresses some of the more complex ethical obligations of nurses. the ana code of ethics does not explicitly detail the obligation of nurses to report to duty during emergencies; however, it does address nurses' responsibilities to the public. one such responsibility outlined in the ana code of ethics is that nurses have an obligation to "participate in institutional and legislative efforts to promote health and meet national health objectives." in an effort to examine ethical issues that arise during a pandemic disaster, ehrenstein and colleagues completed a quantitative survey design study. surveys were sent to health care workers (hcws) at a university hospital in regensburg, germany. only surveys were returned and of the returned surveys, of these hcws were nurses. the purpose of the study was to solicit opinions of employees on professional ethics of proper response to pandemic influenza. researchers discovered that ( %) of the hcws surveyed believed that it was professionally acceptable to abandon the workplace to protect themselves and their family during a pandemic. in addition, % of the respondents disagreed that hcws should be permanently dismissed for not reporting to work during a pandemic, and % of the participants believed that hcws without children should care primarily for the influenza patients. the researchers concluded that hcws would benefit from further education regarding efficacy and availability of medications during a pandemic. it was also recognized that professional ethical guidelines are needed to help hcws fulfill their duties in cases of pandemics. although this study revealed interesting information regarding the hcw's willingness to report to work during a pandemic, the survey used to complete the study was a newly developed instrument, and reliability and validity have not been established. qureshi and colleagues completed a quantitative survey design study using a item questionnaire. the sample consisted of hcp in the new york area. the purpose of this study was to assess the ability and willingness of hcps in new york city to report to work during different types of catastrophic events. this study revealed that . % of the participants reported the most frequent reason for employees' unwillingness to report to duty during a disaster was a fear and concern for the safety of their family and themselves. in addition, . % of participants reported that they were most likely to report to duty in cases of mass casualty. however, % of the participants reported that they were not sure of their ability or willingness to report to duty during any catastrophic event. the researchers reported that a majority of the hcp participants in the new york area said they were least likely to report to duty in the case of severe acute respiratory syndrome ( . %), radiation ( . %), chemical terrorism ( . %), and smallpox ( . %). a reported limitation to this study is that it was conducted only in new york and cannot be generalized to other populations. using a survey design, balicer and colleagues explored public health workers' perceptions toward working during an influenza pandemic as well as factors that may influence intent to respond if such an event occurred. the survey was sent to employees of major health departments in maryland, with a return of surveys. clinical staff, nurses, physicians, and dentists accounted for of the respondents. data were analyzed using logistic regression to evaluate the association of demographic variables, and attitudes and beliefs with self-described likelihood of reporting to work during a pandemic disaster. the researchers studied the association between attitudes and beliefs related to pandemic preparedness and the self-reported likelihood of reporting to work. of the participants, only ( . %) stated that they would most likely report to work during a pandemic emergency. forty percent noted that they would be asked by their health department to respond during an influenza pandemic event. balicer and colleagues reported that % of all participants perceived themselves to be at risk when performing their duties during a pandemic event. it was concluded that to reduce the perceived personal threat during a pandemic and increase the likelihood of employees responding during influenza pandemics, hcps would benefit from continuing education regarding pandemics. these individuals must be assured that adequate protective equipment and psychological support would be made available to responders. researchers also concluded that if employees are unwilling to respond during an influenza pandemic emergency, this behavior may cause a considerable deficit in national emergency response plans. limitations to this study include the use of a subjective self-report survey and subject recruitment from clinics in maryland, therefore findings cannot be generalized to other populations. lastly, the power of the study was not reported. grimes and mendias completed a descriptive study that examined nurses' intentions to respond to an infectious disease emergency. this study was guided by icek ajzen's theory of planned behavior. a sample of licensed nurses in texas who completed a state board of nursing mandated -hour bioterrorism continuing education class were recruited to participate in this study. data were collected using researcher-developed questionnaires. the statistical package for the social sciences (spss) version was used to analyze data. according to the researchers, participants completed all questionnaires. the sample included both registered nurses ( %) and licensed vocational nurses ( %), with the majority being female ( %). only % of the nurses who reported that they had a professional duty to respond also had a high intent-to-respond score. this significant finding raises concerns about adequate staffing during times of bioterrorism disasters or infectious disease events. james and colleagues completed a quantitative cross-sectional study with a sample of nurses who worked during hurricane katrina in mississippi. the purpose of this study was to evaluate the impact of hurricane katrina with respect to age on mississippi nurses who worked during hurricane katrina. nurses' ages in this sample ranged from to years. the sample was divided into groups according to age: group was to years old and group was to years old. the researchers reported that there was a significant positive association between nurses aged to years and the development of poststorm depression, anxiety, ptsd, and lower health status when compared with nurses who were to years old. older nurses developed more symptoms of stress-related disorders than the younger nurses. it was concluded that taking into consideration the growing shortage of nurses in the united states, it is important to understand how working during stressful situations affects older nurses, as retention of older nurses is important as a short-term resolution to the nursing shortage. this study used self-report scales to gather data, which can be considered a limitation of the study. self-report questionnaires are an excellent method to gain knowledge about a participant's feelings or beliefs; however, data gathered through self-report relies on the accuracy of the participant's subjective account and may also reveal socially desirable responses. the findings of this study relied solely on self-reported data; hence, the results must be reviewed with caution. individuals as well as whole communities are greatly affected by any type of disaster emergency; whether it is natural or human-made. a study performed by brodie and colleagues reported that there were approximately , hurricane katrina evacuees from new orleans displaced to houston, texas. following hurricane katrina, the cdc and the louisiana department of health and hospitals reported that there were nonfatal injuries such as cuts, broken bones, and animal bites secondary to clean-up efforts after hurricane katrina between september and october , . these incidents make it clear that there is an unquestionable need for nurses to understand the importance of their response in times of disaster emergencies. conflicts of duty to family and work are further complicated by reports of nurses who have lost their jobs for not reporting to duty during times of emergency and impending disaster. , , in addition to conflicts of duty to family and work, there is growing concern among hcps that there is a lack of obligation in the duty of care during emergencies. natural disasters cannot be prevented; however, damage caused by the event may be reduced if advanced action is taken to curtail risk and vulnerability to potentially affected communities. government policies have attempted to address the issue of disaster relief and assistance to communities after large-scale disasters. to better understand disaster-related policy, it is important to review policies that directly impact society as a whole. disasters cause a disruption in government and community functions of affected areas. because of this disruption of functions, congress created and passed the robert t. stafford disaster relief and emergency relief act. this public law authorizes the president of the united states to declare that a state of emergency or a major disaster exists. a stipulation to the president's authority is that the governor of the state(s) affected must request a declaration of disaster to receive assistance. the robert t. stafford disaster relief and emergency assistance act, pl - was signed into law november , and remains in effect today. this law amended the disaster relief act of pl- - and constitutes the statutory authority for most federal disaster response activities, especially as they pertain to the federal emergency management agency (fema) and fema programs. although this law has been amended several times throughout the past few years, the primary purpose remains the same: to provide orderly and systematic assistance to local governments in areas of declared disaster so they can provide aid to citizens. during the bush administration, the directives that were used to disseminate presidential decisions on national security matters were designated as national security presidential directives. the united states department of homeland security requires states to assume an all-hazards approach to the development of competencies to prevent, prepare for, respond to, and recover from a broad array of disasters. these laws are designated as homeland security presidential directives, and stipulate continuity requirements for all executive departments and agencies. the laws provide guidance for state, local, territorial, and tribal governments, as well as private sector organizations, to ensure a comprehensive integrated national program that will enhance the credibility of the united states national security position and enable a rapid and effective response to and recovery from national emergencies. homeland security presidential directive establishes policies to strengthen the preparedness of the united states to prevent and respond to all disasters, and establishes mechanisms for improved delivery of preparedness assistance to federal, state, and local entities. nurses' input into these policies is unknown. although hospitals are but one component of health care during disasters, they are critical entities during disaster response. there is a paucity of research in the literature disaster nursing that directly relates to nursing and hospital policy. hospital policy is guided by standards set forth by the joint commission (tjc). the tjc is an independent, notfor-profit organization that completes reviews, and evaluates and accredits hospitals and other health care organizations, basing its decisions on national quality and safety standards. according to tjc, hospital emergency policies should include disaster incidents both human-made and natural that are specific to the organization. types of disasters that should be included in hospital policies are identified by probability and frequency of incidents for the area, and are based on definitions provided by the arc and the disaster relief act of . using an exploratory, descriptive design, french and colleagues investigated the needs and concerns of the nurses who responded during hurricane floyd. the purpose of the study was to determine whether the written plans of hospitals addressed the needs and concerns of the nurses who worked during this disaster. a sample of nurses who worked in the emergency department of the hospitals participated in focus groups to discuss their experiences. findings revealed that hospital policies were inadequate to deal with valid concerns of nurses. according to french and colleagues, nurses' concerns included personal safety, family safety, and provision of basic needs, wages, adequate leadership, and pet care. furthermore, the study reported that family commitment conflicted with professional obligations, resulting in nurses losing their jobs if they were unable to report to work. bartley and colleagues completed an anonymous pre-and postinterventional study to test the hypothesis that an audiovisual presentation of hospital disaster plans would improve the knowledge, confidence, and skill of hospital employees. the sample included a convenience sample of hospital employees that consisted of nurses, physicians, and administrators who would most likely be in a position of authority during a disaster. findings showed a significant increase in the test passrate results from preintervention ( %) to postintervention ( %). in addition, pretest mean scores were higher for emergency room staff ( . ) versus other staff ( . ) in various areas of the hospital. the researchers also reported that there were no significant results in the general perception of preparedness. bartley and colleagues reported that the participants described the exercise as beneficial to themselves and their departments. it was acknowledged that the convenience sampling technique used to complete this study may have added to bias of the study, and that the small sample size resulted in decreased power of the study. this study suggests that simulation exercises can enhance staff knowledge levels related to disaster planning. however, it is recognized by many that more research is needed in the area of hospital disaster preparedness plans and policies. a plethora of information exists in the literature regarding emergencies and disasters. nevertheless, significant gaps in the science related to nurses working during disasters are revealed. few studies have addressed the perspective of nurses and their intent to respond to future disasters. because nurses are invaluable to disaster response efforts, more research is essential to validate current findings and elucidate the needs of nurses who respond to disasters and other health emergencies. there is a paucity of research in the literature describing nurses' lived experiences of working during hurricanes. natural disasters inevitably inflict human suffering, and nurses are expected to respond and provide services during these catastrophic times. lost within this expectation are the experiences and concerns of the nurses who are stangeland called upon and intend to respond to the disaster, and yet are themselves affected by the disaster. understanding the experiences and needs of nurses who decide to respond to the call of duty and work during disasters remains unclear in the literature. research in the area of disaster response intentions by nurses becomes the initial step in understanding the phenomenon of working during a disaster and creating innovative approaches that address working during disasters. disaster policies have been developed and implemented at the international, national, state, local, and hospital level. nevertheless, disasters continue to adversely impact communities and hospitals at all levels causing injuries, death, and destruction of infrastructure. to reduce the impact of disasters, continued research is needed to inform and strengthen future disaster policies. knowledge gained from future research has great potential to inform nursing education, research, and 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traumatic events dissociative reactions to the san francisco bay area earthquake of predictors of posttraumatic stress symptoms among survivors of the oakland/berkeley, california firestorm sex differences in posttraumatic stress disorder work stress and post-traumatic stress disorder in the emergency department brief screening instrument for post-traumatic stress disorder health care workers' ability and willingness to report to duty during catastrophic disasters on pandemic and the duty to care: whose duty? who cares influenza pandemic and professional duty: family or patients first? a survey of hospital employees nurses' intentions to respond to bioterrorism and other infectious disease emergencies the impact of hurricane katrina on older adult nurses: an assessment of quality of life and psychological distress in the aftermath nursing research: principles and methods nonfatal injuries following hurricane katrina-new orleans louisiana the joint commission emergency management homeland security presidential directive : management of domestic incidents what a disaster? assessing utility of simulated disaster exercise and associated educational process key: cord- -hadtwybp authors: bell, sue anne title: practice informs research and research informs practice: the making of a disaster nurse scientist date: - - journal: j emerg nurs doi: . /j.jen. . . sha: doc_id: cord_uid: hadtwybp nan sue anne bell, phd, fnp-bc, nhdp-bc o ne of the greatest things about being a nurse is the multitude of paths and directions that a nursing career can take. nursing has led me from my first position in a -bed emergency department in south georgia to that of an assistant professor at the university of michigan, studying the health effects of disasters on vulnerable populations. the goal of this editorial is to describe my journey as a disaster nurse scientist, which i hope will inspire others to consider this area of scholarship. growing up in the florida panhandle, i lived through hurricanes and severe storms on a regular basis without too many personal consequences. recently, however, nearly every one of my relatives living there has experienced some kind of disaster-related loss. last year, i traveled with an emergency nurses association delegation to meet with emergency nurses in the town of port st. joe, florida, where i saw evidence of similar damage and loss. hurricane michael had devastated this small town in the fall of . the popular news cycle had already passed on this community's sufferings, but the devastation there still remained; not just damage to buildings and roads but also damage to the health and well-being of its residents. loss of jobs, damage to homes and businesses, changes in access to health care; all of these together critically affect the resilience of a community and the ability of its residents to lead healthy lives. port st. joe is recovering-and will be for years-while disasters across the united states are increasing in frequency and severity, affecting more and more communities, often with protracted recovery periods. , through my experience while studying disasters and health and providing care during the study, one of the most important things i have learned is that words do matter. one of them is 'natural disaster,' a term i avoid using. disasters in themselves are not natural. hazards such as hurricanes, wildfires and tornadoes are naturally occurring, but the impact that they have on societies is largely humanmade. these extreme weather events and fires are occurring more and with greater impact, as the effects of climate change advance. , characterizing disasters as natural implies that we cannot do anything about them, when we absolutely can make changes to become resilient to these events. , consider the difference between seasonal floods in uninhabited areas compared with the effects of flooding on communities, with the lower th ward in new orleans after hurricane katrina as an example. this is an area that has high levels of inequalities and was crippled by its already suspect infrastructure after hurricane katrina, which undoubtedly cost many lives. hurricane katrina devastated new orleans over years ago, but neither have we advanced very far in terms of a scientific understanding of the mechanisms behind disasters that affect health, nor have we taken the steps needed to mitigate their effects. as a new emergency nurse, i knew that i wanted a career where i could contribute in some small way to bring a meaningful change in the world, and that responding to crisis situations, like i experienced in the emergency department, would be part of that. i spent most of my early years in nursing in the emergency department and, later, in public health, both areas of practice that took time to learn and reach the point of practice mastery. then, i focused on issues of health equity in the emergencies that occurred in these settings, whether from a critical illness in the emergency department or loss of housing in the public health setting. these experiences eventually led me to the path of disaster nursing, as a volunteer with a local chapter of the american red cross. there, i supported families affected by small disasters, such as house fires or floods. in this role, i helped navigate immediate health and safety needs, such as obtaining new prescriptions for lost medications or securing short-term housing. one of the most formative parts of my nursing career, though, came when i joined a disaster medical assistance team (dmat) over a decade ago. this is an on-call position with the us department of health and human services national disaster medical system, to respond to disasters, public health emergencies and events of national security significance (such as state funerals) as a clinician. in this role, i have deployed to numerous areas of large-scale disasters and have often been away for weeks at a time with a short (or no) notice. i supported overwhelmed emergency departments after hurricane irma in , spent a month in puerto rico after hurricane maria working in urgent care, provided shelter care after the paradise, california, wildfires, and most recently, responded to separate deployments related to coronavirus (covid- ): one to the cruise ship quarantines and the other to conduct nursing home assessments and provide infection control training in maryland. each deployment brings different challenges and new opportunities to learn-in some i am asked to work to the full extent of my license and training. at other times, i provide very basic nursing care comparable with a novice's skillset. the bottom line for me is that i help meet crucial needs during national emergencies. dmat has also provided me the opportunity to receive the highest level of training available in disaster response; a year ago i spent a week at the university of nebraska's national training, simulation and quarantine center, preparing to respond to highly infectious disease situations, preparation that was then essential for the covid- pandemic, and gaining on-the-ground experience in providing care in disaster settings, experience that is crucial for a nurse scientist, not to mention the lifelong friends and colleagues i have made. a common challenge for academic nurses, such as myself, is walking the line between being a clinician and a scientist. many nursing faculty roles require leaving clinical practice. i am currently involved in efforts calling for new models of nursing education that value the ongoing clinical focus needed to inform research innovations in clinical care. i became a nurse scientist a few years into my nursing career, when i started asking questions about populations that were being affected disproportionately by disasters and about nursing practice in disasters and other emergencies, questions that i could not answer in my clinical setting alone. i knew there were answers to these questions, but i did not have the skills or sufficient knowledge to find these answers on my own at that time. there is much we know anecdotally about the effects of disasters, but much less has been substantiated through research. i also saw the need for leadership in disasters and health, and a space where i could use my clinical experience and educational preparation to advocate for those most likely to experience adverse health effects from disasters. i completed a phd in nursing from the university of michigan, focusing on health promotion and disease prevention, benefiting from formal training in advanced quantitative analysis, qualitative analysis, and health services research. i spent an additional years of postdoctoral training focusing specifically on health policy in the context of disasters. today, my program of research focuses on the longterm health effects of acute community-level disruptions, specifically weather and climate-related disasters, concentrating on aging and the associated vulnerabilities. older age itself does not make an individual vulnerable to disasters; however, social isolation, frailty, chronic and comorbid diseases, and cognitive impairment-all issues common among older adults-do. the shared scientific rationale that i build upon is that adverse health effects on older adults increase after a disaster due to potentially modifiable factors that occur not only at the individual level, but at the community level as well. identifying these factors can allow for progress toward the development of interventions to promote health, well-being and resilience in the face of these events. there is an unmet need for evidence-based interventions to prevent or minimize the impact of health breakdowns and improve health outcomes of older adults related to disasters. in addition to my nursing training, i draw upon multiple disciplines, including sociology, emergency management, geography, and epidemiology; as well as on nursing colleagues to conduct my research. a fundamental goal of my work has been to understand the effects of disasters on health through the analysis of large data sets. this has led to a greater understanding of health care and ed utilization, which impacts staffing for both emergency nursing and clinical practice. i examine the impact the large-scale disruption caused by a disaster has on individual and community functioning among older adults. for example, in an analysis using medicare claims data, we found that hospitalizations for any cause increased significantly among older adults in the -day period following a series of tornadoes in the southeastern united states. this study demonstrated that older adults remain affected by disasters longer than expected outside of the immediate recovery period. i have expanded the results of this study to include recent large-scale disasters, finding similar results. i have also provided evidence of the relationship between health risk behaviors and disasters, demonstrated through an analysis using longitudinal data from a larger study of retired adults. this research shows that this sample of older adults had an increase in weight gain and a more sedentary lifestyle after living through a disaster. and finally, in an analysis of cancer program data, our research team found that individuals with a cancer diagnosis who lived through a disaster were more likely to die sooner than those who did not. through my work, i have sought to understand the mechanisms behind older adults' responses to disasters throughout the disaster life cycle. by studying home-based care, my team identified challenges in provision of care in the postdisaster period for older adults, setting the stage for our ongoing qualitative study of home-based care after a disaster. using the national poll on healthy aging, a nationally representative survey of community-dwelling older adults, my colleagues and i found decreased preparedness actions among older adults, particularly among those who are socially isolated or medically vulnerable. , our systematic review explored the current state of science around health outcomes for older adults after disasters, which demonstrated the need for data-driven solutions on how best to provide care for older adults during and after disasters. these studies are relevant to emergency nursing as they drive decision-making on supporting older adults to remain healthy and resilient to disasters in their community, thereby avoiding ed visits. a crucial aspect of my research and clinical life is being an advocate for nursing and the populations i serve. serving in national leadership positions has been a route for me to contribute to defining and developing policy related to health and disasters. as a member of emergency nurses association's emergency preparedness committee, i had opportunities to co-author topic briefs related to crisis standards of care and active shooter emergencies, and also to contribute to a disaster response toolkit for emergency nurses. [ ] [ ] [ ] in response to the controversy surrounding disaster-related deaths due to hurricane maria in puerto rico, i joined the national academies of science, engineering and medicine committee on best practices to assess morbidity and mortality after large-scale disasters. this committee, sponsored by the federal emergency management agency, is defining the needs of the disaster research community to understand how to account for disaster-related deaths and illnesses, with a report to be released this fall. the covid- pandemic highlighted numerous gaps in the nursing workforce around preparedness. studies included in this special issue of the journal of emergency nursing have found a low-tomoderate level of disaster preparedness of emergency nurses around the globe, suggesting that a quality improvement project to increase nurse disaster preparedness through an education intervention may be an avenue to increase preparedness. leaders in the disaster nursing community and i called for needed changes in policy around pandemic preparedness for nurses in a recent report. finally, i am serving a -year term as health scientist representative on the federal emergency management agency's national advisory council, where i have the unique opportunity to contribute to recommendations to improve the federal response to disasters and other emergencies. in recent weeks, i have spent time as a clinician working with skilled nursing facilities affected by covid- , and i have also labored over my next research grant proposal that will allow me to continue my study of the larger effects of disasters on aging. as a nurse scientist, both are equally important, and both are rewarding. my goal is to build not only a better response to disasters, but also to contribute to building healthy and resilient communities that can withstand the effects of disasters for years to come. billion-dollar weather and climate disasters: overview. national centers for environmental information board on health sciences policy, institute of medicine. healthy, resilient, and sustainable communities after disasters: strategies, opportunities, and planning for recovery. national academy of sciences community resilience building community resilience to disasters: a way forward to enhance national health security maximizing the academic nursing model in the era of covid- and beyond all-cause hospital admissions among older adults after a natural disaster health risk behaviors after disaster exposure among older adults the effect of exposure to disaster on cancer survival home health service provision after hurricane harvey predictors of emergency preparedness among older adults in the united states supporting the health of older adults before, during and after disasters health outcomes after disaster for older adults with chronic disease: a systematic review emergency nurses association. disaster emergency essentials toolkit emergency nurses association. topic brief: crisis standards of care topic brief: active shooter preparedness in the emergency department increasing disaster preparedness in emergency nurses: a quality improvement initiative recommendations for improving national nurse preparedness for pandemic response: early lessons from covid- . security key: cord- -ksmxrp i authors: wang, jianguo title: vision of china's future urban construction reform: in the perspective of comprehensive prevention and control for multi disasters date: - - journal: sustain cities soc doi: . /j.scs. . sha: doc_id: cord_uid: ksmxrp i the covid- pandemic has caused huge deaths, massive damage and losses around the world. looking back in history, the motivation for construction and development of cities was to enhance disaster prevention capacity, while modern cities are built and developed to improve health and wellness for human beings. each disaster would pose some new challenges to the urban planning and architectural design, such as covid- . therefore, the dilemma of future multi disasters (e.g. epidemics) would lead to reflections on the revision or change of urban design regulations. for the post-epidemic era, a comprehensive and integrated prevention system should be established for multi urban disasters, which requires to be optimally formulated based on multiple objectives, i.e., on the equilibrium of disaster occurrence probability and stop loss cost. this will be realized thanks to the rapid development of digital alike advanced technologies. thus, this paper aims to provide a reference for the prevention and control of future city epidemics and disasters in responding to strategies of urban planning and design by considering the reform of urban construction related regulations, further to facilitate creation of healthy and safe urban environments. cities are generally defined as densely populated, well-developed commercial and industrial with large built-up areas of human settlement. throughout human history, human settlement may allow cities to operate with higher operation efficiency and greater economy scales when compared to rural areas. however, urban regions are more prone to outbreaks of epidemic disease, which has led to much reflection and new explorations in urban construction ) (megahed and ghoneim ) (spencer et al. (xu et al. ). the epidemic has not only overwhelmed the health administrative department in the affected areas, but also has caused significant losses to other departments, including the economy, education, tourism, and the construction industry ). according to the congressional research service ( ), % reduction of annual global gross domestic product (gdp) was resulted from covid- , with an additional %- % decline in global trade (mollalo, vahedi and rivera ).as an important production department of the national economy, the epidemic outbreak has posed new challenges to the urban design and architecture (allam and jones ) (haleem et al. ). how to reduce the risk of epidemic spread and restore economic growth by optimizing urban planning and architectural design has become an urgent topic in the post-epidemic era (megahed and ghoneim ). the purpose of this paper are to ( ) call for the inclusion of epidemics and other diseases into urban disaster management strategies; ( ) provide reference for the prevention and control of epidemic cities and even the response strategies to major urban disasters by considering the reform of urban construction; ( ) help and facilitate the process for the creation of healthy and safe urban living environments. enhancing disaster prevention capacity and standards j o u r n a l p r e -p r o o f throughout history, urban planning and architectural design have always been concerned with the destruction caused by natural disasters in cities (okubo ). according to 'the ten books on architecture' written by vitruvius, cities and towns should be built in "healthy locations, high altitude, no draft and fog, and oriented neither cool nor warm" (kim ) . historically, one of the important motivations of urban and architectural advances is the ability to improve disaster prevention capacity and standards (megahed and ghoneim ). each major epidemic brings new challenges to architecture and urban design, and its opportunities to update and improve concepts, methods and code standards (ahsan ) (randremanana et al. ). in , the plague struck milan, italy and caused , deaths (the total population of milan was about , at that time). leonardo da vinci then became interested in sanitation and urban planning and used sketches and written notes to show an ideal urban plan for building along the riverbanks (joseph ) . instead of focusing on cathedrals and palaces, this planning divided milan into ten new towns, each with , houses and a maximum of , inhabitants. this is the planning concept to reduce the risk of epidemic spread through urban cluster zoning. from june to december , the plague caused , deaths in london and in the great fire of london made , people homeless (benevolo ) . two catastrophes led wren to devise a plan for the rebuilding of london (morris ) , replacing "crowded buildings and crooked lanes" (once responsible for the outbreak of the plague and the spread of fire) with "wide streets and rich spaces". the planning concept aimed to reduce the risk of disasters, casualties and economic losses, which made an important impact on urban planning in later years. severe public health problems and their response have not only contributed to the formation and development of the modern public health discipline, but also indirectly led to the birth of modern urban planning. therefore, modern urban planning and design need to pay constant attention to public health and environmental health conditions, in j o u r n a l p r e -p r o o f addition to social, economic and technological development motivations (peng et al. ). in the pre-industrial era, extreme overcrowding, lack of necessary sanitation, and lack of health knowledge were the main causes of poor living conditions in europe's industrial cities (benevolo ). in , cholera epidemic in london was mainly caused by contamination of drinking water with faecal matter (howard et al. ) . in addition, the main transmission methods of typhoid fever, bacterial dysentery (hu et al. modern cities generally adopt the functional zoning of "work, residence, recreation and transportation" as well as the planning and design of 'sunshine, air and greenery' as proposed in the athens charter of (le ). an important catalytic factor is the creation of a healthy living environment. by linking and interacting human beings with j o u r n a l p r e -p r o o f nature and the environment (e.g. physical environment, ecological environment, etc.), a harmonious and unified ideal environmental state can be formed, thus implementing scientific urban planning, optimizing habitat construction, and improving urban health. china now has a clear disciplinary field of "healthy city" (chen ) , the country has natural disasters, such as floods, typhoons and earthquakes, are characterized by high frequency of occurrence, wide geographical distribution and large economic losses, which seriously endanger the health and life safety of human (boustan et al. to sum up, the mechanical mind which was once effective in the era of modernism (e.g. the rational-centric model of urban construction based on formulas, theorems, rules and the like certainty and continuity), it is no longer fully capable of coping with the today's 'black swan' sudden disasters (meteorological, epidemiological, etc.) that are increasingly subject to a high degree of uncertainty, along with 'frog boiling' and 'grey rhino' urban disasters (i.e. cumulative outbreaks). with the increasingly in-depth digital era, a 'digital cloud' can be formed through cim technology, which is able to realize the cross-validation of information from different systems and the use of iterative algorithms to obtain the optimal value interval with the interaction of 'point, line, network and cloud'. then, based on the existing scientific planning and prevention for several single disaster targets, it is possible to construct more complex prevention and control modes for integrated urban disaster preparedness. this could further achieve a compatible unity with instrumental-rational and value-rational multiobjectives under the guidance of probability theory, through which the comprehensive optimal of the global system should be put in priority based on the equilibrium of disaster occurrence probability and stop loss cost. the author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. enabling technologies and sustainable smart cities strategic decisions on urban built environment to pandemics in turkey: lessons from covid- blockchain technology, improvement suggestions, security challenges on smart grid and its application in healthcare for sustainable development pandemic stricken cities on lockdown. where are our planning and design professionals [now, then and into the future airborne contagion and air hygiene: an ecological study of droplet infections a framework for air quality management zones -useful 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authors: sakurai, mihoko; adu-gyamfi, bismark title: disaster-resilient communication ecosystem in an inclusive society – a case of foreigners in japan date: - - journal: int j disaster risk reduct doi: . /j.ijdrr. . sha: doc_id: cord_uid: ah w o the number of foreign residents and tourists in japan has been dramatically increasing in recent years. despite the fact that japan is prone to natural disasters, with each climate-related event turning into an emergency such as with record rainfalls, floods and mudslides almost every year, non-japanese communication infrastructure and everyday disaster drills for foreigners have received little attention. this study aims to understand how a resilient communication ecosystem forms in various disaster contexts involving foreigners. within a framework of information ecology we try to get an overview of the communication ecosystem in literature and outline its structure and trends in social media use. our empirical case study uses twitter api and r programming software to extract and analyze tweets in english during typhoon (hagibis) in october . it reveals that many information sources transmit warnings and evacuation orders through social media but do not convey a sense of locality and precise instructions on how to act. for future disaster preparedness, we argue that the municipal government, as a responsible agent, should ( ) make available instructional information in foreign languages on social media, ( ) transfer such information through collaboration with transmitters, and ( ) examine the use of local hashtags in social media to strengthen non-japanese speaker’s capacity to adapt. the geographic characteristics of japan makes the country highly vulnerable to disasters such as earthquakes, typhoons, volcanic eruptions, flash floods and landslides [ ] . therefore, disaster risk reduction and resilience measures are enshrined in the every-day activities of the japanese people including school curriculum, building regulations and design, as well as in corporate organization setup [ ] . disaster risk reduction drills often take place in schools, work places, homes, and include the publication of detailed evacuation plans and procedures in all local communities [ ] . however, these efforts of building the capacity of residents facing emergencies could be falling short in terms of coverage and results due to the influx of foreigners who may neither be enrolled in schools or engaged with japanese establishments or are staying only for a short period of time [ ] . the population of foreign residents in japan has been increasing exponentially in recent years according to a report by mizuho research institute [ ] , with their number reaching a record high of . million people by january , . the report reveals an increase by , residents from january to december in . additionally, the japan national tourism organization reports that the number of foreign tourists visiting japan is rapidly increasing. it recorded million in , which was four times as many as visiting in , and six times over the number visiting in . this trend of increased foreign tourists may partly stem from the influence of numerous sporting and other events across the country which include the formula grand prix, the fivb volleyball women's championship and the japan tennis open [ ] . the tokyo olympic and paralympic games, which has been postponed to , as well as the push by government stakeholders to amend bills to relax immigration laws can also be expected to boost the number of foreign residents and tourists in the country [ , ] . even though some foreigners become permanent residents, the qualification for permanent residence status requires a ten-year continuous stay in japan including five years of work, but does not necessarily require the acquisition of japanese language skills [ ] although it may matter at some points. living in japan briefly or as a permanent resident does not necessarily mean the person speaks japanese or is accustomed to disaster risk reduction culture and procedures in japan. although the composition and dynamics of the japanese population is gradually changing in terms of the non-japanese population, existing infrastructure and systems that support non-japanese speakers and foreigners as a whole during disasters seem to last accessed on march , . https://www.jnto.go.jp/jpn/statistics/visitor_trends/ j o u r n a l p r e -p r o o f be inadequate or lacking . the current japanese disaster management system is composed of both vertical and horizontal coordination mechanisms and, depending on the scale of the disaster, activities flow vertically from the national level, through the prefectural to the municipal level before getting down to the communities themselves [ ] . the municipal disaster management council together with other parties are close to disaster victims and responsible for municipal disaster management plans and information [ ] . when necessary, the municipality is also responsible for the issue of evacuation orders to residents during disasters [ ] . again, when it comes to emergency alerts or risk information, there is an existing mechanism where warning messages proceed from the national government (the cabinet, japan meteorological agency (jma)) to local administrations (prefecture, municipalities) and from there to the people. messages may also be transmitted directly top-down through base stations and are received on cell phones. however, reports by news outlets suggest that language barriers, coupled with the inexperience of many foreigners with regard to japanese disaster procedure protocols, create a huge sense of panic and confusion during disasters [ , ] . lack of appropriate risk information and procedural evacuation or alert actions create this confusion amongst the foreigners. therefore, most foreigners access news outlets in their respective countries or rely on social media for disaster risk particulars, alert instructions, or evacuation information [ ] . the use of social media is seen as a significant trend in accessing swift, precise and easy feedback information in critical situations [ ] [ ] [ ] . social media has become the most sourced avenue for information during disasters [ ] . this applies to both japanese and non-japanese users. irrespective of the chaotic nature or confusion that erupts due to limited risk information accessibility and delivery, a certain level of resilience is achieved through instinctive user responses. thus, in extreme events, a spontaneous system of resilience is often formed within the context of all the actors involved in the situation [ ] . this process usually develops because the participating actors share a common interest or find themselves in a situation that requires urgent solutions. the characteristics of this phenomenon create a state of ecosystem which becomes unique to the area affected and to the nature of the event; it generates interactions and communication procedures or methods to reduce vulnerabilities to the disaster [ , ] . the interactions within this ecosystem could be formal or informal, depending on the situation and different communication structures, modes and tools employed. the high frequency of disaster occurrences in japan in conjunction with a booming foreign population up to covid- , and an anticipated, fast rising population again thereafter, provides an ideal case for trying to understand how this ecosystem is established within the context of resilience and communication. resilience in this study is defined as a system's ability to absorb disturbances [ ] . to analyze this ability, we define the system in terms of the information ecology framework. we regard disaster resilience in the information ecology framework to encompass the efforts of collaboration and communication dependencies that exist amongst stakeholders engaged in the situation within a local context. we want to investigate how foreigners in japan obtain disaster related information while facing a language barrier and inexperience with disaster management procedures. this will guide us to understand the characteristics of the communication ecosystem for a foreign population. this paper is divided into the following parts: first, we introduce the information ecology framework as the theoretical premise of a resilient communication ecosystem. a literature review should give us insights into current studies on the topic and their deployment. a key question is how a resilient communication ecosystem is formed in different disaster contexts. to better understand this question, we seek cases amongst the literature which highlight disaster resilience through collaboration, communication and stakeholder participation. cases with such attributes are selected, reviewed and discussed from the view point of information ecology. following the case review, we use the twitter api (application programming interface) application and the r programing language to collect and analyze english language tweets shared on the twitter platform during typhoon hagibis which hit japan in . this gives us an empirical understanding of a resilient communication ecosystem. it is assumed that information shared on twitter in english is meant for consumption by non-japanese. again, media coverage of the typhoon is also monitored to serve as supplementary information to our analysis. based on insights from literature review and findings from tweet analysis, we try to describe a structure which guides our understanding of a communication system applicable to foreigners during a disaster. we conclude the paper with observed limitations and future research directions. information ecology is composed of a framework which is defined as "a system of people, practices, values, and technologies in a particular local environment" [ ]. previous research uses the notion of ecosystem to describe the nature of resilience in a societal context [ ] . information ecology framework, which is an extended notion of the ecosystem, helps us to examine the capabilities of each element within the system. the framework contains five components, including: system, diversity, coevolution, keystone species and locality. table summarizes the elements of information ecology. not shown but also included is the perspective of a technology role which focuses on human activities that are enabled by the given technology implementation. table table table table the presence of keystone species is crucial to the survival of the ecology itself, e.g., skilled people/groups whose presence is necessary to support the effective use of technology. locality locality locality local settings or attributes that give people the meaning of the ecology. given that resilience is defined as a system's ability to absorb disturbances [ ] , information ecology believes that this ability emerges through interrelationships or dependencies between system entities [ ] . these interrelationships exist between a diversity of players equipped with relevant technologies. keystone species play a central role in creating interrelationships, which, in turn, may lead to new forms of coevolution. the notion of locality reminds us of interrelationships and coevolution emerging in a local setting [ ] . the information ecology framework comes down to a set of key elements providing a systematic view of resilience. it enables us to understand who within a network of relationships is a key for realizing resilience, and what relations can be observed within a system and under which local contexts. coevolution is a driving force for forming the resilient ecosystem in times of disaster and is produced by collaboration of systems with j o u r n a l p r e -p r o o f diverse species that provide local context or knowledge [ ] . to this we need to add the role of technology in helping human activities and support the formation of coevolution. we notice a similar framework exists as communication ecology [ ] . it refers to individual or socio-demographic group connections that strengthen neighborhood communication infrastructure. it helps identify communication patterns of local communities or groups of people. in a disaster context, communication ecology includes community organizations, local media and disaster-specific communication sources [ ] . such communication fosters community resilience [ ] , which can be described as the ability of a neighborhood or geographically defined area to collectively optimize their connected interactions for their benefit [ ] . collective ability is required to deal with stressors and resume daily life through cooperation, following unforeseen shocks. hence, community resilience and its collective ability aim to empower individuals in a given community [ ] . resilience is enhanced through economic development, social capital, information and communication, and community competence [ ] . provision of or ensuring access to vital information through proper communication systems is essential to strengthen community capacity towards the unexpected. in this regard, a resilient communication ecosystem that this paper tries to get an understanding of, encompasses the dynamically evolving processes that empower the collective ability of information gathering and provision, as well as interactions and collective communication structures among individuals, communities, and local organizations. a literature review in the following section will help us extract the essential elements of a resilient communication ecosystem based on information ecology. this study follows a systematic mapping approach [ ] as it has the flexibility, robustness and ability to chronologically categorize and classify related materials in research contexts. the process was based on papers which applied the same approach, i.e., [ ] [ ] [ ] . we set the following research question (rq); rq: how is a resilient communication ecosystem formed in time of a disaster? we want to understand how resilience mechanisms are able to evolve spontaneously during disasters through communication, collaboration and the roles of different j o u r n a l p r e -p r o o f stakeholders affected by them. to accomplish this, this study categorized the process into three main activities [ ] . they are ( ) search for relevant publications, ( ) definition of a classification scheme, and ( ) review of relevant journal papers. the search for relevant publications was undertaken in two steps. first, an online database search was conducted with the keywords "collaboration in disaster", "communication in disaster" and "institutional role in disaster" across a number of journal databases such as sciencedirect (elsevier), springerlink, and emerald this procedure resulted in the selection of papers from all the sampled papers. the classification used in this research was to read, clearly identify and arrange the contents of the potential papers to extract the following content; . research titles, . source (type of journal database), . research question of the article . purpose (which keyword is dominant), . type of disaster, . country or region of disaster, . identified stakeholders, . communication tools used, and . communication structure of the case. this stage identified the contents relevant to this study. the communication ecosystem found to be prevalent within the reviewed cases highlights the presence of institutions, individuals and other actors who become involved in disaster events and perform various tasks or activities aimed at reducing either their own risk or that of the stakeholders. in most cases, a system evolved consisting of actors receiving and sharing information when a disaster or crisis took place [ , ] . information ecology promotes sharing and learning; particularly about the use of new technologies, and to reduce given levels of confusion, frustration and ambiguities [ ] . in this review, social media emerges as a new trend in technology and rather becomes the medium for sharing information with the aim to reduce anxiety about a disaster situation that could negatively affect the people involved [ ] . actors include government agencies, non-government agencies, and other actors who evolve to become part of the resilient structure of the framework, matching the nature of each situation. actors can be clearly distinguished based on the roles they play within the system. they include ( ) remote actors, ( ) responsible agents and ( ) transmitters, and ( ) austria [ ] . the world health organization also supports local communities by giving constant guidance and recommendations as a remote actor during ebola outbreak in west africa [ ] . responsible agents have the highest authority and are responsible for issuing needed guidance for people to stay out of risk zones, advising rescue efforts, and providing information on how to reduce risk [ ] . they are the national agencies such as at the level of ministry or governmental organization [ ] , including security agencies and fire brigades [ ] . and information flow between them and other parties [ ] . keystone species identified in the described disasters represent the group or actors whose presence is crucial for all resilience activities. although they are usually described as highly skilled actors, evidence from the reviewed cases also proves that their activities would not be successful without the cooperation and support from other entities [ ] . for instance, staff of the oslo university hospital can be described as "keystone species" in the case of terrorist attacks in norway [ ] . however, actors such as blood donors to the hospital and patients, news agencies who covered all events, individual volunteers who help spread "blood request" alerts by the hospital on social j o u r n a l p r e -p r o o f media, as well as others who sent time situational information on social media to update others can be said to be the auxiliary actors who complemented the "keystone species" effort. they give rise to the notion that resilience efforts are often created by a system of actors or groups who are connected through information sharing and play specific roles in a cohesive and coordinated manner during events or disasters [ ] . furthermore, the key to all these systems are the space or context in which their actions take place [ , ] . in information ecology, it is the "locality" or the setting that initiates all processes. this gives the specification of the context and guides the actions that follow. in some cases, factors such as the geographical location, messaging or information content, characteristics of actors, the medium of information delivery, duration of the event, and the actions taken give the "local identity" of the system [ , , ] . during the ebola crises, this meant the names of the affected countries [ ], while for earthquakes and disasters such as fires it refers to their exact locations. for the purpose of this study, locality refers to a system of individuals, agencies and local communities that refer to a local information and actions to be taken in order to reduce risk within a given area. table summarizes insights from our case review which illustrate the structure of a resilient communication ecosystem. table table table table as stated previously, the japanese governance system is composed of three tiers, national, prefectural, and municipal. among these, municipal government is closest to people at large and therefore is in charge of issuing evacuation orders, opening and operating evacuation centers, and managing relief efforts [ ] . when an evacuation order is issued by a local municipality, residents who live in specific zones are supposed data collection was done using twitter api in r package to scout tweets in the english language. to extract the tweets, the following steps were used: a. registration with twitter api to secure api credentials b. integrating twitter cran (programming language for r package) into r statistical package c. searching by tweets. this was conducted by searching the hashtags "#hagibis" and "#typhoon_ ". to restrict tweets to only english language, the code "en" was added. typhoon hagibis made a landfall on october , . therefore, the tweet search was restricted to search for information of tweets made on that day. the entire code use for the search was (hagibis <-searchtwitter ("#hagibis","#typhoon_ ", n=" ", lang = "en", since = " - - : ", until = " - - : "). five thousand tweets were collected from this search. d. export and further analysis: the results were exported to microsoft excel for further analysis. data analysis was based on the framework of a resilient communication ecosystem. the first aim was to find keystone species supporting the communication ecosystem. therefore, we focused on the number of tweets and twitter id accounts with a high number of retweets. as a result of retweet number analysis, we established the formation of coevolution within the ecosystem. we also aimed to explore the kind of information content exchanged in the ecosystem. hence we conducted thematic analysis [ ] which allowed us to apply key elements of a communication ecosystem. it shows how the communication ecosystem for english language was formed when the typhoon hit japan. in order to extract a sense of locality, we picked up the name of a region or city, and searched for local information such as evacuation orders or emergency alerts within a certain tweet. diversity in this case reflects the number of tweets and different account id information that posted or retweeted with #hagibis or #typhoon_ during the sampled time frame. frame, but could be the n th retweet for that particular tweet. from our findings, the highest number of original tweets from a single account was out of the original tweets. they were sent by @nhkworld_news, a public broadcaster in japan (figure ). this was followed by tweets created through a twitter handle name @earthuncuttv; which is leading online portal, documenting extreme natural events or disasters in the asia pacific region and around the world. around half the tweets within the original tweets were made by individuals. this was determined based on their handle ids. the total aggregated number of retweets we found from our time frame was , . amongst them, % were retweets which originated from @nhkworld_news ( figure ). @earthuncuttv covered % of total retweets while % came from other origins. the results show that within our sample framework, @nhkworld_news is the most dominant tweeter account. the ranking of retweets exceeding one hundred per source is shown in figure . the most retweeted tweet recorded , retweets. the original tweet was posted by @nhkworld_news saying "hagibis is expected to bring violent winds to some areas. a maximum wind speed of kilometers for the kanto area, and kilometers for the tohoku region." the second most retweeted one was posted by an individual account saying "ghost town //shibuya at pm before a typhoon" with a photo taken in shibuya city. the top ten retweeted tweets are shown in table . names in italics stand for region or city name. table table table table the th and th tweets mentioned evacuation orders issued by local municipalities while other tweets shared the event as it happened in different places around japan, or they reported on its effects. we found only three among original tweets that captured the emergency alert issued by jma (figure ). those three were tweeted by individuals and generated only a few retweets. the emergency alert was described in japanese which is translated as "special alert at level for heavy rain has been issued to tokyo area. level alert means the highest level of warning. take action for saving your life. some areas have been newly added under the special alert. check tv, radio, or local municipalities' information," as of october , : pm. the alert requested people to refer to information from local municipalities but all of it was in japanese. our constant monitoring of the event on the internet also reveals that jma was giving constant updates of the real-time weather status and alerts on its website. this information was provided in english. however, most of it did not appear in our sample frame as it did not utilize twitter in english. as the japanese disaster management system also grants direct access of emergency information from jma to the population, an emergency alert was sent to people's cell phones from jma, but this was written in japanese ( figure ) . hence, people who do not speak japanese may not have understood this, and the real time information could only be solicited by a few who originally knew about such a website or the information provided. on the other hand, much evacuation information is issued by municipal government. we found five tweets mentioning evacuation orders. two of those were the j o u r n a l p r e -p r o o f @nhkworld_news (italics refers to location), as follows. as to take [ ] . for example, a dutch man, who had been living in japan for a half year, received an emergency message but he could not find information where to evacuate. another american woman was supported by her friend in translating disaster information. emergency situations generate exceptional communication features which contravene the norm [ ] . therefore, a communication ecosystem forms and breaks up every time a disaster occurs. we observed dynamic characteristics of crisis communication structure with the involvement of various organizations [ ] and tools [ ] . the tools greatly hinge on social media which have become essential for digital crisis communication [ ] . however, more research is required to better capture the nature of social media use in crisis communication [ ] . several studies reported that j o u r n a l p r e -p r o o f local governments especially in thailand and the u.s. are reluctant to utilize social media in disaster situations [ , ] . they prefer to use traditional media such as tv and radio though those mass media tend to allow only one-way communication during a crisis [ ] . as our study shows, information through mass media becomes limited or challenged to meet specific needs due to its broader audience base [ ] compared to the multiple-interaction communication style that characterizes social media [ ] . government, as a responsible agency, needs to understand the characteristics of mass media and social media communication and create an appropriate communication strategy or collaboration scheme when preparing for future catastrophes. in the recent covid- crisis, the need for more targeted health information within a community and the importance of strong partnerships across authorities and trusted organizations are being discussed [ ] . we hold that more consideration should be paid to the provision of targeted information to those who do not share a common context or background of disaster preparedness. on daily-basis practices in japan, almost all local municipal governments prepare a so-called "hazard map" and distribute it to residents. ordinarily, municipalities only issue evacuation orders and do not provide residents with specific information where to evacuate to. from a regular everyday disaster drill, trained residents are expected to know where the evacuation centers are in their area. as people interpret new information based on previously acquired knowledge [ ] , a responsible agent should also consider how to provide information to people who haven't had any disaster training. beside the feature of interactive communication characterizing social media, the pull of multiple information sources and agents creates a sense of assurance and security in coping with or adjusting to events. this was experienced in the haiti earthquake, when social media contributed swiftly to creating a common operating picture of the situation through the collection of information from individuals rather than from a hierarchical communication structure [ ] . in addition, what is important in crisis communication is who distributes a message and how it is mediated in a population [ ] . our study shows that news sources who already seem to have gained social trust played a role as a keystone species in foreign language communication minorities prioritize personal information sources over the media [ ] . these cases suggest that social media promote effective resilience in communication, and that the delivery of information to foreigners in japan from different language backgrounds and cultures further creates traits where personal connection contributes to information accessibility choices. it is also true that social media-based communication raises situation awareness [ ] by receiving warning alerts as well as emotionally-oriented messages such as from friends and relatives [ ] . language barrier is likely to have been an obstacle that actually helped to shape the ecosystem identified in this study. during typhoon hagibis, responsible agents sent warning messages only in japanese language as shown in figure , so this could have been a major factor in harnessing the full potential of social media for disaster communication. results from this study reveal a lack of local knowledge or reference points across twitter communication, which shapes discussion within the ecosystem. for instance, in the case of the chennai flooding in india, tweets covered subjects such as road updates, shelters, family searches and emergency contact information [ ] , none of which were much referred to in our sampled tweets. while in the and philippine flooding, the most tweeted topic was prayer and rescue, followed by traffic updates and weather reports with more than half the tweets written in english [ ] . moreover, around % of those tweets were secondary information, i.e., retweets and information from other sources [ ] . our study recognizes the importance of secondary information. information exchange between agencies and affected residents and tourists assists in reducing risks such as, for example, during hurricane sandy in , where the top five twitter accounts with a high number of followers were storm related organizations posting relevant news and the status of the hurricane [ ] . as a remote actor becomes a source of secondary information, however, such information should guide people in what they should do next, rather than just point to the disaster situation. in this context, we note the importance of instructional messages whose content guides risk reduction behaviors [ ] . an example of such a message is "do not drive a car" which was tweeted by police during a snowstorm in lexington [ ] . it tells what specific life-saving action should be taken [ ] . generally, however, there appears to be little investigation of instructional information in crisis communication [ ] . the findings of this study imply that there could be two types of disaster information: a) risk information that refers to the potential effect of the disaster, i.e., emergency alert or warning, and b) action-oriented information that carries instructions for reducing the risk, i.e., an evacuation order and itinerary to be followed. risk information is published by remote actors while action-oriented information is provided by responsible agents. both types of information must contain local knowledge and allow easy access when people search for that information [ ] . in order to make sure people can reach instructional messages, it is not enough to just point to the information on organizational websites [ ] , as jma did during typhoon hagibis. instead, "localized hashtags" [ , , ] can support people to find life-saving information as quickly as possible. a previously cited study argues that social media can be useful when sending a request for help [ ] . "typhoon damage of nagano" is an example of a localized hashtag, assisting a fire brigade in nagano prefecture utilizing twitter to respond to calls for help from residents during typhoon hagibis . a localized hashtag can also be used as a point of reference where people can find relevant information [ ] . last accessed on july , , http://www.nhk.or.jp/politics/articles/lastweek/ .html. in future disaster communication, local information should be distributed using geographical information with instructions as to what to do next [ ] . responsible agencies should take this into account, while also analyzing which information was shared across social media in previous disaster cases [ ] . furthermore, cultural differences can also be considered, as western culture emphasizes individual action [ ] while asian cultures prioritize collective actions or community commitment. as this may generate behavioral differences among japanese and foreign residents or tourists, further investigation will be beneficial. based on information ecology framework and literature review, the structure of resilient communication ecosystem is proposed and verified through empirical data analysis. the resilient communication ecosystem is structured with heterogeneous actors who could be a driving force for collaboration or coevolution. the empirical case revealed that a media source might transmit warnings and evacuation orders through social media but that such information does not contain points of reference. limited delivery of such information particularly in the english language results in confusion to non-japanese communities who need it most. based on study results and discussions, we suggest that in any disaster a form of ecosystem is spontaneously generated. municipalities, which are often responsible agents should ( ) produce instructional information in foreign languages on social media, ( ) transfer such information through collaboration with transmitters who may have a strong base on social media to assist translating it to reach the wider audience, and ( ) examine, in association with the mass media and weather forecast agencies, the use of local hashtags in social media communication for future disaster preparation. it brings various actors together, creates a sense of locality, and supplements individual efforts in risk reduction. our empirical data is limited to some extent as we only observed twitter for one day, october , . again, we intended to extract tweets in english language just before and after the typhoon hagibis hit japan. hence, we chose hashtag #hagibis and "#tyhoon_ " when we were crawling tweets. we are also aware that our data is based on only a single disaster case and requires further data sets from other disaster events for corroboration. we may consider different characteristics of information and actors in the resilient communication ecosystem in future research. nevertheless, our findings provide interesting insights into disaster communication which may guide the direction of future research. as instructional information sometimes contains ethics and privacy issues [ ] , rules for dealing with specific local or personal information should be taken j o u r n a l p r e -p r o o f into account. behavioral differences are also worth investigating because of increasing human diversity in japanese society. the case of japan reveals the importance and potential of communication as a main mechanism for offering information and response activities to promote resilience and reduce the risk of disasters. social media space serves as a major platform that brings numerous stakeholders together. this platform creates the main avenue for information sharing on events and offers feedback mechanisms for assessment and improvement. for future disaster preparedness, then, we may benefit from a closer understanding of the nature of a resilient communication ecosystem, its structure and the knowledge that it allows us to share. 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social media based crisis communication during hurricane sandy the role of social media for collective behavior development in response to natural disasters understanding the behavior of filipino twitter users during disaster communicating on twitter during a j o u r n a l p r e -p r o o f disaster: an analysis of tweets during typhoon haiyan in the philippines the instructional dynamic of risk and crisis communication: distinguishing instructional messages from dialogue. review of communication conceptualizing crisis communication, in handbook of risk and crisis communication social media and disaster management: case of the north and south kivu regions in the democratic republic of the congo social media and crisis management: cerc, search strategies, and twitter content this work was supported by jsps kakenhi grant number jp k . key: cord- -vyyboega authors: mulvihill, peter r.; ali, s. harris title: disaster incubation, cumulative impacts and the urban/ex-urban/rural dynamic date: - - journal: environ impact assess rev doi: . /j.eiar. . . sha: doc_id: cord_uid: vyyboega this article explores environmental impacts and risks that can accumulate in rural and ex-urban areas and regions and their relation to urban and global development forces. two southern ontario cases are examined: an area level water disaster and cumulative change at the regional level. the role of disaster incubation analysis and advanced environmental assessment tools are discussed in terms of their potential to contribute to more enlightened and effective assessment and planning processes. it is concluded that conventional approaches to ea and planning are characteristically deficient in addressing the full range of impacts and risks, and particularly those originating from pathogens, dispersed and insidious sources. rigorous application of disaster incubation analysis and more advanced forms of ea has considerable potential to influence a different pattern of planning and decision making. in this article we explore the general utility of recent work from disaster research for the enhancement of contemporary methods and approaches to environmental assessment (ea). in particular we discuss the potential disaster research has for assessing slowly evolving and underappraised environmental problems, including environmentally related health impacts and those problems involving the cumulative impacts of the ever changing relations between the urban, exurban and rural regions. to illustrate and discuss this potential of disaster research we give context environmental impact assessment review ( ) - www.elsevier.com/locate/eiar and substance to our analysis by focusing on two case studies, the first involving water contamination/pollution problems in rural ontario and the other focusing on the changing ecological and social landscapes of areas which surround the greater toronto area (gta). these particular cases were selected because frequently ea may neglect or at least minimize the potentially significant impacts of the urban/ex-urban/rural dynamic. this may be perhaps because of the complexities inherently involved in this dynamic, often involving longer time scales and expansive distances, thus making the incorporation and consideration of the factors related to this dynamic difficult. nonetheless, the adoption of certain principles and the general orientation of disaster research, especially if coupled with cumulative impact assessment, may better enable environmental assessors to broaden the conventional lens of ea. in turn, this may facilitate the identification of not only the physical and biological antecedents to many environmental problems, but their social and political economic undercurrents as well, thereby providing a means through which some of the difficulties of incorporating the urban/ex-urban/rural dynamic can be addressed. notably, the analysis of both the physical and social dimensions in a disaster research inspired ea process will enable assessors to more effectively grapple with the vexing issues related to the complex cumulative and latent effects of many understudied and conventionally neglected environmental problems. we begin with an overview of recent approaches in disaster research that are of relevance to ea. generally speaking, disaster research has tended to evolve as an interdisciplinary and applied field, although notable pioneering contributions have been made primarily by geographers and sociologists. traditionally, the field has investigated a large array of issues often related to practical issues such as the role of organizations during emergencies, evacuation behaviours, emergency medical service delivery, the protection of property, the spatial aspects of disasters and so on. recently, there has been increased attention focused on issues related to what turner ( ) has termed "disaster incubation"the period before disaster onset when the causal factors that contribute to, or precipitate, a disaster accumulate and interact in an unnoticed manner. for our discussion in this article, the key feature of the research on disasters is this idea of disaster incubation. the notion of disaster incubation has particular relevance to ea because of the analytical emphasis on the latent character of the causal factors and processes that underlie a given disaster, or more specifically in the case of ea, those latent factors/processes that underlie environmental impacts and problems. over the last several years, there have arisen a number of case studies that illustrate the incubation of various disasters. for example, ali ( ) discusses how the political economy of an industrial city in southern ontario had contributed to a large toxic conflagration at a private recycling firm, while beamish ( beamish ( , relates how one of the largest oil spills in american history occurred on a stretch of land on the guadalupe dunes in california over four decades by chronic leaks that were the result of numerous instances of institutional neglect and corporate malfeasance that accumulated over time. perhaps one of the most notable studies of a the incubation period of a technological disaster was conducted by diane vaughan ( ) who reveals how the space shuttle challenger disaster ( january ) was the outcome of social phenomena involving, for example, among other social factors, the transformation of deviant practices into acceptable behaviours at nasa. specifically, this transformation process is referred to as the "normalization of deviance" wherein danger signals occurring during the pre-disaster period gradually become accepted as normal by those in the organization. as vaughan shows through her institutional ethnography, it was just such a process that ultimately and tragically led to the decision that the space shuttle could be safely launched despite certain technical concerns on launch day. in addition to technological disasters, the analysis of disaster incubation has also been applied to natural disasters, as for example in the case of hurricane katrina in (bakker, rydin, ; seager, ) and the chicago heatwave (klinenberg, ) , in which analysts have noted that particular social groupings, such as poor african-americans and women, were particularly vulnerable to the impacts of the "natural" agents because of land use and political decisions which put the particular groups in harms way. the latter two cases point to the important issue of disaster vulnerability in the urban context, but, as will be discussed, disaster vulnerability is also a particularly relevant consideration for ea in the rural context. at this point in time, research progress in the area of disaster incubation has proceeded on a somewhat incremental and ad hoc basis with particular insights gained through case study analyses. as such, the work on disaster incubation has not yet crystallized into a set of propositions in such a way as to define a formal theory. although it is perhaps true that the study of disaster incubation has not yet achieved paradigmatic status, we contend that there now exists sufficient theoretical and empirical development in this area to define a coherent approach which for the purposes of this article we will refer to as disaster incubation analysis (dia). largely informed through research in organizational sociology, dia has tended to focus on the organizational foundation of disasters. in this vein, turner's pioneering work in the area has been based on the analysis of the inquiry proceedings that followed three high-profile disasters in the united kingdom. notably, his analyses examined how regulatory agencies and firms were implicated in the disaster incubation process. in this connection, turner identified several important underlying organizational factors, including: rigidities in institutional beliefs; the presence of distracting decoy phenomena; the neglect of outside complaints; multiple information-handling difficulties; the exacerbation of the hazards by strangers; the failure to comply with regulations; and the psychological tendency to minimize emergent danger. more recent efforts have built on the work of turner, both by expanding his focus on the organizational foundation of disasters (see for example : clarke, : clarke, , kroll-smith, , ; dynes, ; erikson, ; freudenburg, freudenburg, , freudenburg and gramling, ) as well as through expansion of the analytical scope of dia to now consider the role of biophysical and environmental factors alongside the social factors emphasized by turner (ali, ; klinenberg, ; murphy, ) . it is perhaps this focus on both the biophysical and the socio-organizational factors that holds the most promise for the formal impact assessment and management of natural resource use, such as in the case of ground and surface water impacts we will discuss shortly. in this light, a critical feature of adopting dia for environmental assessment is to address the latency dimension of the problem incubation; in particular, the question as to why the conditions that fostered a particular disaster went unnoticed. as much of the research in dia has been based on post-hoc analyses, the challenge for the environmental assessor is to bring together the relevant insights from these retrospective case studies in order to apply them in a prospective manner to future scenarios in the planning process. this leads to a second point. as foresight is an essential foundation for effective planning, the need to identify the reasons for the failure of foresight is critical and dia facilitates this identification by focusing explicit attention on these very reasons. third, dia is especially well-designed to address those situations in which largely overlooked cumulative impacts are critical. this is the case for example in relation to such processes as: those related to development pressures (such as incrementally increasing urban sprawl), globalized economic activities (such as intensification of livestock operations (i.e. "factory farms)", as well as creeping "natural" disasters such as desertification, global climate change, and the pathogenic contamination of groundwater, all of which may develop gradually over time in an unnoticed manner until the catastrophic impacts can no longer be ignored. let us now consider empirically how such latent biophysical and social processes have environmental impacts and how they can be analyzed using dia by considering the following two cases involving rural ground water and water use within the context of toronto and its ex-urban and rural regions. while public concern about southern ontario's water future is substantial, it is usually focused on more immediate and higher profile issues, at the expense of some of the more insidious and cumulative risks. the broader surroundingsthree of the great lakes are in close proximityhave long ensured public consciousness of water pollution, but also a complacent if misplaced sense of infinite supply and regeneration. surface water issues have commanded most of the attention, while the magnitude of groundwater problems and risks remains largely unknown and neglected. this changed to a significant extent in with the walkerton drinking water contamination disaster. situated within the agricultural heartland of ontario, the town of walkerton is located on the saugeen river about km northwest of toronto and km east of the shores of lake huron. although relatively close to the great lakes, the town is entirely dependent upon groundwater that is drawn from wells. during the third week of may , walkerton (population: ) became the site of the largest outbreak of a waterborne infectious disease in canadian history. after a public outcry, an independent inquiry was commissioned a month later to determine the causes of the outbreak as well as to fulfill the extended mandate of making recommendations about how best to manage the water supplies in the province. the inquiry concluded that the contamination of the municipal water supply occurred after a period of very intense rainfall whereupon cattle manure containing the pathogen e. coli o :h spread on the fields of a nearby farm was washed into a particular well (walkerton inquiry, ) . as this pathogen can only survive in groundwater for very short periods of time, it was suspected that rapid flow of water contaminated with the pathogen was able to reach the municipal water supply because of the presence of fractures in the carbonate substrata structure of the region. aside from identifying the source of contamination, the inquiry commission also identified a list of other factors that contributed to the outbreak, including malfeasance on the part of the local water operator and serious deficiencies in the provincial regulatory framework that governs water management. the case of walkerton immediately raised the question of the magnitude of the groundwater contamination problem within the national and regional context. one of the difficulties faced in identifying the particular pathogen involved in the walkerton case was that e. coli o :h was normally associated with food-borne, and not waterborne, outbreaks. sometimes referred to as "hamburger disease", illness due to e. coli o :h first began to be recognized as a newly emerging public health problem in the s with the onset of several sporadic outbreaks throughout north america (nadakavukaren, ) . from a dia perspective, the association of the disease with food served as distracting decoy phenomenon. as dia casts a wider net in its analysis, it often considers the wider biophysical and social context of a disaster. such an orientation has practical implications for ea, which may benefit from such an expanded perspective by employing a wider scan that would be alert to broader social and ecological trends (for example, see krieg, krieg, , for trends regarding the distribution of hazardous waste in north america). in this spirit, let us consider some of the relevant trends in terms of the walkerton disaster, starting with that related to increased incidence of water contamination in the north american context. by being knowledgeable about such trends, ea processes may be redirected to focus on the more likely scenarios in environmental and land use planning. one relevant trend that ea professionals may want to consider is the increase in new and emerging diseases more generally, as it is likely that the protection of groundwater from such threats will become an issue of growing importance in the future. in recent times, western societies have witnessed the rise of a new class of emerging (and re-emerging) pathogens that are extremely insidious and virulent, including, to name just a few: the severe acute respiratory syndrome (sars) coronavirus, hiv/aids, west nile, huntavirus, ebola, the lyme disease virus, the avian flu virus, the monkey pox virus, and the hoof-and-mouth pathogen (drexler, ; levy and fischetti, ; garrett, , institute of medicine, . the bacteria e. coli o :h involved in the contamination of the walkerton groundwater is another example from this new group of pathogenic threats. the emergence of these new pathogens has several important implications for planning in general and rural planning in particular. first, it needs to be recognized that a wide range of social and environmental factors are involved in the evolution of these pathogens as well as in the onset of the respective disease epidemics themselves. such factors include: ecological, human demographic and behavioural changes; travel and commerce; technology and industry; microbial adaptation and change; and the breakdown of public health measures. for this reason, whether contamination occurs within the groundwater source, through the food distribution system, or through the air and soils, the wider contextual factors that could amplify or mitigate the spread of the pathogen need to be considered as part of the assessment and planning process. in particular, the possible interactions of such factors need to be studied. for example, as is argued below, the need to monitor groundwater for pathogens may not be possible under the tight fiscal circumstances that many resource-based communities face. the rural geographic dimension of the new and emerging pathogenic threats is often neglected in groundwater management. part of the latency of the disaster incubation involved in disease outbreaks is a function of the fact that most of the relevant incubating processes and factors are occurring in remote locationsthey are "under the radar" of most observers. such tendencies are especially worth noting in light of such disaster incubation elements as rigidities in institutional beliefs (as for example with respect to rural versus urban, as well as municipal versus provincial versus federal government agencies) and neglect of outside complaints (as for example, the neglect of the input and concerns of farmers by government agencies). furthermore, most of the new and emerging pathogens are based on animals raised or otherwise inhabiting relatively remote areas. for example, it is thought that the human immunodeficiency virus (hiv) originates from the simian reservoir in the rural jungles of east africa (institute of medicine, ); the sars coronavirus in the palm civet cat reservoir of rural southern china (guan et al., ; martina et al., ) and the avian flu virus in the wild duck and fowl reservoir of the same region (institute of medicine, ) . the crossover of the pathogen from the animal to the human reservoir is influenced by distinctly social processes; thus, for example, it has been noted that the paving of the kinshasa highway through the forests of the rift valley led to increased traffic thereby facilitating the spread of disease from remote posts to urban areas as prostitutes working the stretch of road plied their trade. local doctors estimate that as many as % of those living in this area are infected with hiv (preston, : ) , while strong evidence indicates that the sars coronavirus crossover occurred in live animal markets in urban centers where animals were brought in from rural areas to be sold. the significance of the interrelationship between humans, animals and the environment highlights the importance of the interface of urban-rural areas and particularly the encroachment of humans into formerly untouched environs, as seen by the rise in cases of hantavirus pulmonary syndrome (hps) (buck and aron, : ) and lyme disease. incidence rates increased as exposure to the vectors transmitting the viral agent increased as development into forested areas brought humans into closer contact with deer mice carrying the sin nombre virus in the case of hps and wilderness ticks hosting the bacterium borrelia burgdorferi and carried in songbirds and mice in the case of lyme disease (bourette, ) . a second general trend refers to increased incidence of contamination within rural areas themselves. although drinking water contamination problems tend to be associated with developing nationsthe world health organization notes that the leading cause of illness and deaths in most developing countries is attributable to gastrointestinal infections from the ingestion of water containing pathogens (nadakavukaren, ) the walkerton outbreak dramatically illustrates that the waterborne route of the disease may pose an equal, if not greater, threat to public health in the north american, and particularly, canadian context. the potential for groundwater contamination is particularly noteworthy in light of the finding that approximately % of canada's drinking water is stored as groundwater (howard, ) . at the same time, almost % of those reliant on groundwater as a source of drinking water live in rural areas (howard, ) . the center for disease control and prevention data indicates that between - there were on average outbreaks of waterborne diseases per year in the united states (nadakavukaren, ) while there were published reports of waterborne outbreaks/ incidents associated with drinking water in ontario alone from to (edge et al., ) . in many cases, waterborne disease afflictions run their course in - days and the victim recovers completely without treatment (nadakavukaren, : ) . as a result, it should be noted that the u.s. environmental protection agency (nadakavukaren, ) estimates that for every case of waterborne disease identified, more never appear in the statistics because of haphazard reporting. edge et al. ( ) estimate that only one-tenth of waterborne outbreaks are reported. thus the problem of pathogenic contamination of drinking water may be much more pervasive than what is currently realized. in this way, the neglect of the issue of pathogenic contamination of groundwater may in fact illustrate turner's observation that in disaster incubation, there is a psychological tendency to minimize an emergent threat. again, ea would clearly benefit by being cognizant and vigilant of such tendencies. rural areas tend to face especially challenging water quality problems due to high levels of dissolved organic material and predominantly agricultural drainage basins (peterson, ) . in this connection, the epa has found that the leading source of pollution of contaminated rivers in north america is agricultural runoff (mallory, ; nadakavukaren, ) . in the case of ontario, agricultural runoff in the form of manure (i.e. nutrients), as opposed to herbicides or pesticides, is particularly problematic because of the nature and type of farming practiced in this region. reflecting a more general trend throughout north america, from the second world war onward, agriculture in the province has become more industrialized, with fewer farms that are larger in size and growing many more animals per farm. thus, for example, although today agriculture and food is ontario's second largest industry, employing some , people (omafra, b) , the number of farmers has dropped dramatically over timebetween and the number of dairy farmers in ontario went from approximately , to ; while the number of pork producers dropped from , to (omafra, b) . notably, walkerton itself is situated within one of the rural ontario counties with the highest number of cattle per unit area grown in what are referred to as "factory farms" (nikiforuk, ) . typically, factory farms (also known as feedlots) may contain as many as , cattle feeding in crowded areas the size of a city block (other regions of such intensified farming include specialized regions in alberta, south carolina and iowa). the animal waste generated by these intensive livestock operations is enormous. for example, a , head feedlot will produce , tonnes of waste annuallymore fecal matter than that produced by a city of , humans in the same period (nikiforuk, ) . the animal waste is stored in manure lagoons before being applied to farm fields. contamination problems often arise because these lagoons tend to leak into groundwater and streams, while sometimes the lagoon walls may even collapse, resulting in massive manure spills. further problems can also arise because the manure is frequently applied at rates far above what the crop and soil base can absorbthe resultant excess finding its way into surface and groundwater. the entry of manure into ground and surface water pathways becomes a public health threat if the manure contains pathogens. elevated levels of bacteria in ontario's rural drinking water sources have been detected for at least a decade. for example, a survey of groundwater quality in farm wells across ontario found that % of the wells had bacteria levels above the safety guidelines (michael goss cited by rankine and boyd, ) . second, a health canada study published in found that those counties with the highest cattle density (including walkerton) routinely registered the highest rates of e. coli o :h infection in the province between and (nikiforuk, ) . further still, for several years prior to the outbreak, ontario ministry of environment inspectors were aware that the well contaminated in walkerton was vulnerable to contamination by surface water (referred to as gudigroundwater under the direct influence of surface water) and that the ontario drinking water objectives of required that such sources be monitored continuously for chlorine residuals and turbidity, which they were not in the case of walkerton (walkerton inquiry, ) . if such knowledge existed, the pertinent question that arises is why were preventative planning measures not taken and how could such information be incorporated into effective drinking water management and planning practice? in other words, to use the lexicon of dia, why were danger signals missed? as we shall see, by addressing such questions through a dia-inspired ea process, the knowledge attained from the past experiences of a disaster can be used to more effectively identify and better plan for the impacts of the situation or undertaking currently under consideration. the walkerton case suggests a number of significant implications for water management and planning. first, it suggests that other similar disasters may be incubating, since waterrelated incidents tend to be underreported and since monitoring has been shown to be frequently inadequate. ex-urban areas appear to be at particular risk as the hazards associated with factory farming accumulate and converge. the relatively brief history of farming on such a scale makes it difficult to understand its implications fully and in historical context. second, the case points to the risks of incomplete or partial approaches to monitoring in which some of the risk factors may be watched, but less so in relation to other factors. over time, key risk interrelationships may thus unfold but be missed until disaster strikes. third, the case casts doubt on the reliability or effectiveness of environmental assessment processes to identify the probable cumulative effects of an activity like factory farmingor, more precisely, the recurring reality that many significant development activities are not subject to rigorous or formal assessment at all. fourth, the case confirms the paradox of groundwater resources: they are relied on heavily but taken for granted, literally out of sight and mind most of the time. rural-urban interfaces therefore provide excellent opportunities for such crossovers to occur and need to be incorporated into assessment and planning considerations. the outbreak in walkerton is another case in point; it involves the relationship between the bacteria e. coli o : h , the surface and groundwater environment, livestock and humans. it was clear that the humanmade water distribution system, the geophysical characteristics of the land in the region, and agricultural practices in the area were instrumental in the spread of the disease. in light of the above, it is also apparent that rural and ex-urban areas may be highly vulnerable to waterborne disease outbreaksa situation which could be described in terms of a "rural health penalty" (ali, ) in which such areas are prone to confluence of circumstances that make residents vulnerable to certain health problems. this includes health-threatening conditions due to the rise of factory farming and the use of agricultural pesticides and herbicides that may contaminate drinking water. this increased vulnerability to health threats may also be due to broader social and political circumstances, as an analysis based on an expanded scope of dia reveals. under ontario's climate of cost-cutting that began in earnest in the 's, activities related to the prevention of health threats, such as the protection of drinking water, became particularly difficult for smaller rural communities. not only did such communities have to deal with reductions in the transfer payment funds available to them, but, at the same time, they were forced to absorb the costs of new responsibilities and practices that were formerly conducted by higher levels of government (i.e. the downloading of costs and services from federal and provincial levels to the municipal level). the smaller tax base of rural communities meant that these municipalities did not have an abundance of public money available to them to invest in infrastructure and public projects. consequently, they lacked the sophisticated equipment and facilities as well as the highly trained personnel generally found in larger cities. under such circumstances, it is not surprising that most of the recent outbreaks of e. coli o :h have occurred in municipalities with small water systems. (nadakavukaren, : ) . walkerton was further prone to e. coli o :h contamination because of the costs it had to assume in relation to privatized laboratory testing of water (previously done by the provincial ministry of the environment). the need to pay for private water testing was especially difficult for the town of walkerton. to compete with other small towns in luring new residents, business and industry, inexpensive water is a major selling point, and walkerton offered the cheapest water rates in the area even though its utility company was losing money (perkel, : ) . therefore, any additional financial costs associated with the water monitoring functions (such as privatized water testing) could not be easily assumed by the walkerton public utilities company (puc). furthermore, as part of ontario's neo-liberal initiative to cut public spending, the number of inspections conducted by the ministry of the environment, the number of site visits and other contacts between moe officials and municipal water officials, all decreased dramatically (walkerton inquiry, ) . for example, from to , annual planned inspections for the walkerton region decreased from to , the number of actual annual site inspections decreased from to , while the amount of employee resources expended on municipal water requirements decreased from . % to . % (on a province-wide scale, the number of inspections fell by %)(walkerton inquiry, ). a dynamic and diverse place, southern ontario defies simple description, but a number of aspects are worth noting. in socioeconomic terms, it is an industrial center, dominated by automobile and related industries. it is home to more than a quarter of canada's population, clustered in cities like hamilton, london, windsor, kitchener and, to a rapidly increasing extent, the greater toronto area (gta). the sprawling gta exerts a shadow effect over much of southern ontario, driving development patterns and real estate speculation hundreds of kilometers away. in turn, its economy is shaped by close proximity to some of the most populous regions of the united states. the wide ranging environmental impacts of southern ontario's development have been well documented; loss of high quality farmland in the niagara peninsula, contamination of the great lakes and other waterways, increasing incidence of smog, habitat fragmentation and loss of biodiversity are a few of the many problems. (u.s. epa and environment canada, ) . in recent years, some of southern ontario's most bitterly contested development battles have centered around land uses on urban-rural fringes, pitting forces of sprawl against conservation values. diminishing physical and psychological boundaries remain between the highly urbanized areas and the prized rural landscapes and cottage country. in between, the ex-urban areas are in transition, in some instances clinging to rural character and in others imminently suburban. on a typical journey across this increasingly ex-urban landscape, one would see aggregate pits, horse farms, touristy villages, densely developed subdivisions, factories, brownfields, "estate" properties, woodlots, wetlands, moraines, watercourses and lakes. the geologically and ecologically significant niagara escarpment, some million years old and more than km long, crosses the length of southern ontario, defining and highlighting much of the landscape. (niagara escarpment commission, ) . although development-driven politics have tended to dominate land use planning processes in southern ontario, a mix of environmental laws, policies and practices have ensured a measure of protection. a system of conservation authorities, historically created to address flooding risks, manage many of the river areas. the niagara escarpment commission is responsible for planning and development control along the areas close to the escarpment. a variety of local, national and binational initiatives seek to protect and remediate great lakes waters. growing realization about moraine destruction has led to new greenbelts and other policies limiting development in areas of prime concern. the strategic location of the moraines, just north of toronto's city limits, and their hydrological importance as the "rain barrel" for millions of people helped make one initiativeprotection of the oak ridges morainea galvanizing and consciousness raising ecological issue. while not unequivocal environmental victories, the oak ridges battles have helped foster a broader and more regional view of water resources (oak ridges moraine, ; oak ridges moraine foundation, ) . the ongoing environmental challenges in southern ontario continue to exceed the capability of current management and planning practices. even when the more conventional planning practices such as official community planning processes, land use planning regimes and environmental assessment are augmented by additional protection regimes (such as greenbelts, the niagara escarpment commission, moraine protection measures, conservation areas or trusts) the southern ontario landscape continues to be transformed and urbanized at a rapid and largely uninterrupted pace. the change is particularly evident when considered from a cumulative perspective and the landscape is compared to even the fairly recent past. valuable natural features, resources and systems remain at risk as the transformation unfolds. canada's largest city extends over a vast area, but for most of toronto's history it was known primarily for its setting on lake ontario. many of its current ecological issues continue to concern, directly or indirectly, the lake and its associated waterways. toronto's immediate waters are now synonymous with pollution; its beach waters are hazardous and its surviving rivers and creeks are long-term restoration projects. toronto's drinking water comes from lake ontario via elaborate water treatment systems. water supplies for its suburban and ex-urban areas, however, are more likely to come from groundwater, unless costly and ecologically risky "big pipes" draw the water from the great lakes and transport it to considerable distances. with lake ontario deeply embedded in toronto's identity, it is not surprising that its headwaters tend to be less well known. toronto's waterfront has been the subject of numerous campaigns and planning exercises, most notably a royal commission chaired by former mayor david crombie, which culminated in the early 's (government of canada, ). the crombie commission received national attention and reflected at the time some leading edge thinking about ecologically enlightened planning for water. it advocated a watershed-based approach and went beyond a toronto-centric perspective. as an educational initiative, it made an important contribution in encouraging a more regional-based dialogue on development and restoration, situating the challenges facing toronto's waterfront in a wider perspective. the still largely rural region known as headwaters country lies directly north of the greater toronto area (fig. ) . the contrast in landscape between the two regions is striking, although it is diminishing through sprawl and the expansion of transitional ex-urban areas. the relationship between the two regions raises many questions about urban/rural relationships and sustainability at local, regional and trans-regional scales. headwaters country, comprised of two counties -dufferin and caledonfeatures the origins of four substantial waterwaysthe grand, humber, nottawasaga and credit rivers (fig. ) . it lies just north of the gta, but its ecological significance for canada's most populated region is generally under-appreciated. despite its ecological aptness, the name "headwaters country" is unofficial and used mainly for tourism purposes. in physical fig. . rivers of headwaters country. terms, the region still presents a striking contrast to the highly developed gta, with extensive rural areas, small towns and villages. its inhabitants include many prosperous retirees and urban commuters, but the economy of the region is still based largely on agriculture and related industries. important secondary industries in headwaters country include tourism, recreation and crafts. agriculture remains the largest industry and employer in dufferin county and is equally important in the rest of headwaters country. some of the most contentious environmental issues revolve around the tension between the traditional agricultural economy and newer development trends and impacts. global market forces are pressuring the region's farmers to find new efficiencies, economies of scale, technologies and vertically integrated operations (omafra, a) . the trend to larger, factory farms is strong, conflicting with ideals about traditional farming. factory farms typically demand a large and continuous supply of water to maintain their operationsmuch of it drawn from aquifers. meanwhile, large agribusiness can reduce local autonomy and bring increased vulnerability to globally determined commodity prices. in ontario the percentage of rural non-farm inhabitants continues to grow; one estimate claims that it grew by nearly % in the to period (omafra, a) . rural newcomers often have limited understanding of modern agriculture, and their lifestyles and expectations may clash with those of neighboring farmers. many parts of southern ontario that were rural until recently now feature an uneasy mix of livelihoods, lifestyles and expectations. municipalities are taking planning measures to address impacts of farming that were more acceptable in a rural context but less so in an ex-urban one. these include, for example, nutrient management plans (including adequate manure storage facilities), moratoria or limits on the construction of new livestock barns, and minimum distances between land uses (omafra, ) . meanwhile, farm lot severances are one of the most contentious issues, since they can bring much-needed income to farmers but also tend to fragment landscapes and facilitate sprawl. as agriculture intensifies in scale and is combined with other activities and hazards, groundwater risks can increase. contamination can result from point sources such as landfills, distributed sources such as fertilizers, or line sources such as road salt. hazards may be surface (e.g. direct runoff into watercourses or spills infiltrating into the ground) or sub-surface (e.g. septic tanks, underground storage tanks, improperly sealed abandoned wells or buried waste producing leachate) (howard, ) . sinton et al. ( ) showed that viruses are much more readily transported through sub-surface substrata than are bacteria. in the united states, the epa estimates that agricultural runoff from animal factories and traditional farms are the leading source of water pollution in that country. the practice of "sludging" is increasingly prevalent in headwaters country. it involves the spreading of partly treated human waste on farmers' fields as a form of fertilizer. most of the sludge is trucked in from the gta and applied to fields at little or no direct cost to local farmers. sludging may be a quick fix both from the perspective of urban waste managers and farmers, but it can entail significant ecological and human health risks. the longer-term effects of the pharmaceutical content of the sludge are worrisome and may pose another hazard to groundwater systems, but the full effects may not be apparent for many years. finally, although the region is largely defined by water, the full hydrological picture is not well known, either in terms of quantity or quality. the groundwater resources are typically surveyed only when required and paid for as a direct cost of development processes. with water extraction and export on the increase, and not tightly regulated, groundwater levels may be lower than believed, making assumptions about regeneration speculative at best. compared to the gta, headwaters country is popularly perceived as a quiet, rural hinterland. the reality is quite different and the speed of cumulative change is dramatic, with impacts that may or may not be perceived, assessed or managed. sprawl continues despite greenbelts and moraine protection, leapfrogging over urban/rural boundaries as new subdivisions appear. farmland is lost through severances or conversion, in some cases replaced by large residential estates and in many instances further fragmenting habitats and ecological corridors. moraines are depleted or damaged by development. groundwater resources are depleted or neglected. big pipes traverse regions, distorting regional hydrological systems. rivers and sub-watersheds are stressed. factory farming intensifies contamination risks. overall, cumulative impacts at the regional level are insidious, obscured by the urban/ex-urban/rural dynamic. urban/rural boundaries have significance at administrative, geographic and psychological levels, but in an ecological sense these boundaries exist to a diminishing extent. what is assumed to be an urban shadow, with incremental influence over the hinterland, is in practice a more rapid, synergistic process of regional transformation. in this regard, the rural image that is cultivated in places like headwaters country can backfire, reinforcing visions of an undisturbed and salubrious setting even as irreversible change occurs. with the gta as the main driver of change in headwaters country, and with global economic forces also exerting a strong influence, a number of unsustainable patterns are unfolding upstream and downstream, and the ability of ea and planning processes to intervene and influence is limited. this is due partly to the legal planning arrangements in headwaters country (dufferin county, for example, has official community planning at the municipal level, but no official planning at the regional or county level). it is also due partly to the general under-use of regional level tools such as cumulative effect assessment or strategic environmental assessment. the recent history of southern ontario demonstrates that virtually no region, area or water resource is fully protected from sprawl. history also reveals misplaced confidence in conventional approaches to planning, with the cumulative picture consistently ignored or underestimated. there are strong trends but also key uncertainties driving southern ontario's future; continued strong population growth and sprawl appear to be inevitable for the foreseeable future. the full impacts of sprawl can be unpredictable, cumulative and insidious. vulnerability to pathogens adds further complexity and unpredictability. the ex-urban/rural/urban relationship, along with global forces, thus creates a dynamic that enables a variety of impact scenarios to unfold quietly and cumulatively. greener futures are also possible for headwaters country, but would require a shift to more explicitly ecological forms of planning and development. in support of such a shift, the use of advanced forms of ea would need to be normalized. this might include rigorous approaches to cumulative assessment, use of scenarios and regional visioning exercises, disaster incubation analysis and strategic, regional level ea. more routine approaches to ea, combined with controversial exemptions of undertakings from rigorous ea, tend to merely reinforce the current path of development. the experience of environmental assessment (ea) has provided abundant evidence that impacts frequently originate from sources and pathways that are difficult to detect, assess and manage. even as the art and science of ea continue to be refined, impacts are to a great extent becoming more difficult to detect and studyoriginating, accumulating and playing out in ways that undermine common assumptions. at the regional scale, the urban/ex-urban/rural dynamic exemplifies the complicated challenge of perceiving impacts early enough to influence their timely management. in this dynamic, when rapidly growing urban centers exert inordinate development pressure, sprawl transforms rural places to ex-urban, and less visible but insidious impacts unfold in remaining rural areas. in a context of increasingly globalized economic activity, this unfolding dynamic increases the challenges of cumulative impact assessment and management at the regional scale. the sustainability challenges facing rural and ex-urban places have been well documented in a variety of literature (for example, audirac, ; daniels, ; duany et al., ; nelson, ; storper, ) . in this article we have examined two types of changean area level disaster and the specter of transformative regional changein rural and ex-urban settings in southern ontario. in both cases, water systems, one underground and the other watershed-level, figure prominently. both cases underline the need for more enlightened and sophisticated approaches to assessment and planning. at present, there is relatively little use of longer-term, wider scale and preventive approaches to planning for water in southern ontario, but accumulating experience with water crises of various scales should stimulate increased experimentation. we have argued here that the foundations of improved practice include: ) use of disaster incubation analysis to consider a fuller range of present and historical risk factors; ) increased use of advanced ea tools such as cumulative effects assessment (cea) and strategic environmental assessment (sea), and use of scenario planning to detect weak signals of problematic development trends, cumulative effects and future risk factors. in sum, both the walkerton and headwaters country cases reflect the shift from the standard perspective that impacts arise primarily from primarily local human activities and development processes to more of a pathogen-driven view of impacts in which they originate from dispersed and insidious sources, not only accumulating but also incubating in ways that are difficult to perceive and monitor. they reflect the increasing vulnerability of rural and ex-urban places to an intensifying urban shadow along with global forces. the resulting challenges are complex, transjurisdictional and multi-scalar. the lurking risks and cumulative changes are compounded by incomplete approaches to assessment, underreporting, latency of risk phenomena and decoy issues. in the particular case of southern ontario, persistent urban sprawl ensures continued challenges. ea, in its advanced forms, when applied in a consistent and rigorous fashion and supplemented with innovative approaches such as those informed by disaster incubation analysis, could make a substantial difference and nudge the urban/ex-urban/rural dynamic toward a different pattern of planning, decisions and outcomes. disaster and the political economy of recycling: toxic fire in an industrial city a socio-ecological autopsy of the e. coli o :h outbreak in walkerton rural sustainable development in america katrina: the public transcript of 'disaster' waiting for crisis: regulatory inaction and ineptitude and the guadalupe dunes oil spill ticking bomb? toronto star epidemiological study designs context dependency and risk decision making explaining choices among technological risks the chronic technical disaster: toward a social scientific perspective communities at risk: collective responses to technological hazards when city and country collide: managing growth in the metropolitan fringe secret agents: the menace of emerging infections suburban nation: the 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a social autopsy of the chicago heat wave a socio-historical interpretation of toxic waste sites: the case of greater boston the two faces of toxic waste: trends in the spread of environmental hazards the new killer diseases: how the alarming evolution of germs threatens us all factory farming: an issue affecting human health, the environment, workers, and animals sars virus infection of cats and ferrets nature's temporalities and the manufacture of vulnerability our global environment: a health perspective characterizing exurbia niagara escarpment commission. niagara escarpment plan when water kills: the dangerous consequences of factory farming are being felt all across the country farming and rural affairs). task force on intensive agricultural operations in rural ontario consultation. government of ontario discussion paper on the intensive agricultural operations in rural ontario. government of ontario well of lies: the walkerton water tragedy maintaining drinking water quality, lessons from the prairies and beyond anchor books doubleday when water's not well: contaminated well water is linked to gastrointestinal problems justice and the geography of hurricane katrina noticing gender (or not) in disasters the regional world: territorial development in a global economy the organizational and interorganizational development of disasters implementing indicators : a technical report the challenger launch decision: risky technology, culture and deviance at nasa brief of part one report of the walkerton inquiry he has years of experience with ea as a researcher, educator, practitioner and consultant. his previous articles in eia review appeared in his research interests include environmental disasters, environment and health, environmental sociology and preventive engineering the authors wish to thank the social sciences and humanities research council of canada for its financial support. thanks also to an anonymous reviewer for a number of very helpful comments and suggestions. key: cord- - ejdlxh authors: kalina, marc; tilley, elizabeth title: “this is our next problem”: cleaning up from the covid- response date: - - journal: waste manag doi: . /j.wasman. . . sha: doc_id: cord_uid: ejdlxh the purpose of this discussion is to highlight the essential role that solid waste management must play in a humanitarian response towards disasters, in particular the ongoing covid- pandemic. we highlight a number of potential avenues for scholarly investigation into the waste impacts of our response to covid- , but in particular, briefly unpacks the relationship between disasters, consumption and disposability as one potential research topic. the discussion is intended to start a conversation that is, at the moment, critically relevant, and to contribute to a more inclusive, and less normatively western waste management studies discourse. the spanish island of mallorca has been severly impacted by the covid- /coronavirus pandedmic which, within the first few months of , had spread to nearly every corner of the globe. the human toll has been immense. although the infection rate in the ballaeric islands, the region that contains mallorca, is lower than the national average, spain has become a hotspot for the disease, and as of april th , had passed , total cases, and , deaths (statista, ) . coronavirus updates mallorca is an english language public facebook group created to share virus updates and information amonst the local expatriate community. featuring dozens of new posts daily, most content focuses on changes in lockdown regulations, information from the government about economic relief, as well as posts designed lift spirits during a difficult time. on march rd however, ben morris, a resident of mallorca, made a post that went viral, which, within a week, had been shared over , times. a collage of photos which had appeared to have been taken by morris at a local beach shows dozens of single-use face masks washing ashore: a part of the collective detritus of our efforts to combat the covid- pandemic (see figure ). further investigation revealed, however, that morris had merely cropped and shared the photos, which were not from mallorca at all, but had rather been captured in late february in the soko island's near hong kong (boyle, ; oceansasia, ) . nonethless, the post, its rapid spread, and its confused provenance, are indicative of the power of the image itself, as well as the power of social media to spread information, and misinformation, during a time of crisis. within the media and on social media there has been considerable discussion of the positive environmental benefits of the pandemic and the resulting slowdown in global growth and production i . many of these have proven to be fabrications, such as the images of dolphins frolicking in the canals of venice, but others, like improved air quality in major cities ii and the global decrease in greenhouse gas emissions are both noticeable and verifiable. the other indelible images of this pandemic, have been less eco-friendly, however. with looming uncertainty, and restrictions on movement, the pandemic in many countries has also been characterised by consumption: the stockpiling of supplies, hoarding, and in some instances, panic buying. these more extreme reactions have also been accompanied by more subtle consumption changes: switching to single-use products for hygeine and convenience, using disposable wipes for disinfecting surfaces, carrying small bottles of hand sanitiser, and of course the masks, which may well continue to wash up on shores, either in mallorca or hong kong, long after the pandemic recedes. the covid- pandemic is a disaster on a global scale, and in addition to its human impact, it will produce an immense amount of waste that will need to be managed sustainably. but this reflection is not necessarily groundbreaking. when sharing the pictures of face masks washed ashore on the beach,morris titled his post 'this is our next problem', but this is not new. our responses to disasters, both man-made and natural, have been a significant source of waste and have been producing evocative images for decades, from mountains of discarded water bottles in post-hurricain haiti to piles of cardboard packaging waste outside on the margins of a refugee camp in bangladesh. moreover, disasters, and the management of disaster waste, have been a well invesitaged topic within waste management studies discourses. however, this body of literature is predominantly concerned with the waste directly caused by disasters (i.e. building rubble, plant material, etc.). specific focii of investigation have centered on strategies for managing disaster waste (see (amato et al., ; de magalhães et al., ; domingo & luo, ; dugar et al., ; gabrielli et al., ; karunasena & amaratunga, ; karunasena et al., ) including possible options for reuse or recycling (see (brown & milke, ; regattieri et al., ; tabata et al., ) , the modelling of potential impacts and systems reliability (cheng et al., ; trivedi et al., ) , and the restoration of waste management systems post-disaster (see (petersen, ; ulusan & ergun, ) . however, what is less understood are the waste impacts of the human or societal responses to these disasters, such as disaster relief, socio-economic restrictions, or shifts in consumption patterns. when waste, stemming from the humanitarian or socio-cultural responses to disasters is discussed, the conversations have not occurred within waste management studies literature, but rather in disaster relief and logistics literature, and then, only tangentially iii . moreover, despite substantial scholarly attention within waste management studies towards how to sustainably and hygienically manage infectious and other potentially hazardous medical waste, there has been generally little accounting for disaster scenarios, while the literature on emergency medical disaster relief pays, at best, tokenist lip service to waste management issues iv . although the current covid- pandemic makes this topic feel timely, its urgency is more broadly rooted in climate change. as global temperatures continue to rise, the number of catastrophic climactic events are expected to increase. moreover, there is a strong correlation between population density and the risk of pandemic, and with current population growth trends, the risk of human-made disasters (both climactic and disease), especially within the global south, is expected to increase expontentially (gholipour, ) . as such, the waste impact of these disasters is likely to significantly increase, as well as the waste footprint of our reactions to them. in these circumstances, the current silence within waste management discourses on this topic is unacceptable. the purpose of this discussion is to draw attention to this knowledge gap and to highlight the absolutely essential role that solid waste management must play in a humanitarian response, now, towards covid- , and to other, future disasters. a number of potential avenues for scholarly investigation on the waste impacts on our response to covid- stand out, including: the sound management of infectious waste in disaster scenarios, and in low-resource contexts in particular; the impacts of consumption shifts and movement restrictions on waste pickers and other informal workers; the impacts of movement restrictions on waste management service delivery; and, what we will attempt to umpack briefly here, the relationship between disasters, consumption and disposability. this is far from an exhaustive list, but our purpose is to start a conversation that is, at the moment, critically relevant, and sorely lacking within waste management studies discourses. the covid- pandemic has intensified a widespread practice of single-use products which has been escalating over the past three decades, a trend that has received some scholarly attention in spaces such as discard studies, (see, for instance, hawkins' ( ) excellent commentary on the evolution of disposability). fears of contamination, social distancing regulations, and stay-at-home orders have contributed to a visible resurgence in consumer preference for single-use products for both hygenic reasons, as well as convenience. largely, this has been in response to state-issued instructions and guidelines for disaster preparedness, so we must be cautious how we characterise and contextualise individual choice. nonetheless, as kaufman ( ) has observed, the covid- pandemic has served as an opportunity for the plastics industry to restore a legitimacy to single-use plastic products that had eroded over the past decade. how can we quantify the waste impact of this consumption and disposal, as well its potential impacts on muninicipal waste management systems? moreover, how many of these consumption patterns will become ingrained, and how do we push the reset button to continue to move towards sustainability and zero waste? these shifts may have unforseen consequences which resonate long after the pandemic recedes. for example, lockdown conditions in the global north have corresponded to a dramatic increase in consumers flushing thick, fabric-like wipes down home toilets (kaur, ) . these products cause serious problems for sewer systems that have not been designed for the volume and quantity of this novel material v . coping with the resulting blockages puts a burden on municipal governments already operating under severe strain. moreover, the implications for non-sewered sanitation across much of the global south are even less understood. on march , the guardian newspaper published an article titled "'we can't go back to normal': how will coronavirus change the world?" in the piece the author, peter c. baker ( ) , speculates that the pandemic could be an opportunity to reshape the world-either positively, by tackling structural inequality, or negatively, by exacerbating existing injustices. within waste management academic discourse, however, we should not seek a return to normal, because despite substantive progress in some industrialised nations over the past decades, 'normal' has not worked for much of the world, and the global south, in particular. going back to normal involves returning to the systemic inequalities inherent within the waste management sector globally. rather, this is an opportunity for us all to reflect on how we can contribute to a more inclusive, and less normatively western waste management studies discourse. we recognise that many of the issues raised are not new. however, we do hope this discussion will spur a heightened awareness of this emerging issue within other disciplines, help to foster inter-disciplinary conversation and coordination between relevant sectors, and shine a light on the glaring research gaps that we, as researchers, must address. who offer guidelines for characterisation of medical waste as disaster relief sites. v notwithstanding that often the workers expected to clear these blockages often come from vulnerable groups, and are exposing themselves to extra risk by responding during the pandemic.  the covid- pandemic will produce an immense amount of waste to be managed.  the waste impact of our socio-cultural responses to disasters is poorly understood.  the waste impact of disasters, will increase due to climate change.  we propose several research pathways on waste impacts of our response to covid- . disaster waste management after flood events we can't go back to normal': how will coronavirus change the world? discarded coronavirus face masks and gloves rising threat to ocean life, conservationists warn recycling disaster waste: feasibility, method and effectiveness. resources, conservation and recycling air pollution reduction and mortality benefit during the covid- outbreak in china. medrxiv reliability analysis for disaster waste management systems disaster waste management using systems dynamics: a case study in southern brazil canterbury earthquake construction and demolition waste management: issues and improvement suggestions post-disaster waste management: lessons learnt from nepal earthquake sustainable waste management: policies and case studies disaster waste management in italy: analysis of recent case studies what billion people mean for disease outbreaks capacity building for post disaster construction and demolition waste management. disaster prevention and management post disaster waste management strategies in developing countries: case of sri lanka plastics had been falling out of favor. then came the virus disinfecting wipes are being flushed down toilets and causing major pipe problems restoring waste management following disasters integrated archaeology: a garbage paradigm archaeologies of the contemporary past innovative solutions for reusing packaging waste materials in humanitarian logistics number of confirmed cases of coronavirus (covid- ) in spain as of april , by autonomous community earthquake disaster waste management reviews: prediction, treatment, recycling, and prevention analysis of key factors for waste management in humanitarian response: an interpretive structural modelling approach restoration of services in disrupted infrastructure systems: a network science approach waste: a philosophy of things retrospection-simulation-revision: approach to the analysis of the composition and characteristics of medical waste at a disaster relief site