key: cord-0040582-eiaghd0e
authors: Temin, Elizabeth S.; Bortolin, Michelangelo; Venier, Alice
title: Rehabilitation and Reconstruction
date: 2015-10-23
journal: Ciottone's Disaster Medicine
DOI: 10.1016/b978-0-323-28665-7.00059-5
sha: a5d355cb337400663bd1e676ea7c1ca0b2bef9ff
doc_id: 40582
cord_uid: eiaghd0e

nan

Elizabeth S. Temin, Michelangelo Bortolin, and Alice Venier

There are four phases of emergency management as noted in the following: 1. Preparedness: Planning a response to a disaster. 2. Response: Activities that occur immediately after a disaster. These actions are designed to provide emergency assistance to victims. This phase usually lasts a few days to a few weeks. 3. Recovery: Returning the community to normal or near normal. This phase may last for many years. 4. Mitigation: Preventing or reducing the effects of a disaster. This phase should be integrated into the other three. 1 This chapter discusses the third and least understood phase of emergency management: recovery. 2 Recovery is a multifactorial process including the physical reconstruction of homes and public buildings, transportation, and basic services infrastructure, as well as psychological mending of the community and economic recovery of lost time and resources. This stage cannot be considered in isolation because mitigation, the fourth phase, must be integrated into recovery for it to be sustainable.

In 1977, Haas and co-workers became the first group to identify and describe the recovery process. 3 They listed recovery as a sequential four-stage model of emergency, restoration, replacement, and development. Current models describe a more fluid recovery process with these stages overlapping and potentially occurring simultaneously. 4 Replacement reconstruction may occur in some locations, while at the same time debris clearance occurs elsewhere. Recovery currently focuses on the idea of sustainable development, a concept created by a United Nations Commission in 1986, which refers to recovery as a way to improve the quality of lives and durability of communities. 4, 5 This concept has been defined in the World Commission on Environment and Development as "meeting the needs of the present without compromising the ability of future generations to meet their own needs." 6 In the short run, it may cost more; better materials may be used, houses and businesses may be relocated, and more stringent building codes and zone laws may be implemented. In the long run, its goal is to protect and strengthen key social and economic infrastructure before disasters strike so as to reduce the likelihood of loss of life and assets and, ultimately, improve community resilience, thus saving money. 5, 7 Out of a vast spectrum of disasters, some may yield predictability based on hazard vulnerability analysis tools, while others will remain unexpected. The process of disaster recovery can adapt currently available recovery tools to fit the specific situation. It is useful to apply a framework to aid comparisons of the similarities and differences in disasters. They can be categorized as natural or human-made, sudden onset or slow onset. Examples of natural disasters that are slow onset are droughts or epidemics such as severe acute respiratory syndrome (SARS); sudden onset examples are floods, hurricanes, and earthquakes. Examples of human-made disasters that are slow onset are wars, such as the war in Iraq, and sudden onset examples are bombings or terrorist activities such as the September 11, 2001 , attacks and the accidental Exxon Valdez oil tanker spill in 1989. The important differences are the duration of impact and severity of direct and indirect effects. Direct effects are defined as the physical destruction and lives lost as a result of the disaster. Indirect effect examples include those such as work time lost, jobs lost, and the change in spending in the community involved.

Recovery framework can also be categorized as vertically or horizontally mediated. Vertical mediation recovery refers to the hierarchy of local communities, the state government, and the federal government. Horizontal mediation refers to the network of groups within a community. Every recovery and management process needs a balance of both vertical and horizontal mediation.

The first existing literature on reconstruction and rehabilitation dates back to 79 AD when Mount Vesuvius erupted and destroyed surrounding villages. A document by the historian Pliny details search and rescue attempts to save individuals from debris. The Emperor Titus declared a state of emergency and immediately sent his army to assist with the relief effort in Stabia, Ercolano, and Pompei. The survivors were relocated to unaffected areas to rebuild with new cities. Despite all the populations' efforts and funding from Titus, the devastated populations were unable to recover. Only decades later under Emperor Adrian, in 120 AD, was the devastated area restored. 8 The modern concept of recovery, reconstruction, and rehabilitation began in 1755 with the Great Lisbon earthquake. Lisbon was struck by a 9.0 magnitude earthquake which caused between 10,000 and 100,000 deaths. It was one of the deadliest earthquakes in modern history. The Royal Family escaped unharmed from the catastrophe, and the Prime Minister implemented and managed a formal search and rescue initiative with regional rehabilitation efforts. After the first response phase, the King and Prime Minister Marquis de Pombal proposed plans to rebuild the city. Less than a month after the event, five plan options were proposed for the rebuilding of Lisbon and, within a year, the city was cleared of debris and reconstruction began. The event had wideranging effects on the population. Moreover, a disaster recovery program was established that included, among other things, rebuilding the city with more solid construction. 9, 10 A good example of reconstruction and rehabilitation was observed in 1945 after the atomic bomb was dropped on Hiroshima and Nagasaki. The bomb destroyed nearly 70% of each city's infrastructure and had a devastating effect on the population's health. Within the first few months after the bombing, it is estimated that 140,000 people died in Hiroshima, while another 70,000 died in Nagasaki. Among the longterm health effects suffered by survivors, the most deadly was leukemia, and children were the population group affected most severely.

In 1946 a plan was proposed to reconstruct the destroyed cities. However, due to a lack of financial backing, the plan made very little progress. In 1949 the Hiroshima Peace Memorial City Construction Law and the Nagasaki International Culture City Reconstruction Laws were implemented. The initiatives covered by these laws fueled the funding for reconstruction by promoting the development of foreign trade, shipbuilding, and fishing, thereby bolstering the local economy. Little more than a decade later, the cities of Hiroshima and Nagasaki were completely restored and the population had recovered to its former numbers. 11 The 2010 Haiti Earthquake affected nearly 3 million people with a death toll estimated to be about 100,000. Many countries responded to appeals for humanitarian aid, pledging funds and dispatching rescue and medical teams, engineers, and support personnel. Six months after the earthquake as much as 98% of the rubble remained uncleared, making most of the capital impassable. In 2015, more than 5 years after the disaster, the capital is still not completely clear of debris. More than 1.6 million citizens remain displaced and live in refugee camps with no electricity, running water, or sewage disposal. A cholera epidemic, which began in October 2010, killed more than 8000 Haitians. Crime in the camps is widespread with women and children as the predominant victims. Despite the estimated 1.1 billion USD collected for the Haitian relief efforts, 12-14 the rehabilitation and reconstruction have been stagnant. [12] [13] [14] 

In the United States, recovery planning started in 1803 when local resources were overwhelmed during a fire in Portsmouth, New Hampshire. The local government asked Congress for help, creating the first legislative act for federal resources. In 1950 the first permanent and general legislation, the Federal Disaster Act, came into existence. This was revolutionary because it was the first act to create a general response to all disasters. Before this, each disaster resulted in Congress passing a new localized piece of legislation. In 1978, President Jimmy Carter pulled all the distinct response groups together along with the military resources to create FEMA, the Federal Emergency Management Agency, which was formally implemented by executive orders on April 1, 1979.

The U.S. Congress passed the Stafford Act in 1988, an amended version of the Disaster Relief Act of 1974. This focused FEMA toward hazard mitigation and coordination of disaster recovery programs. The Disaster Mitigation Act of 2000 established specific requirements for hazard mitigation planning, and grants became available to allow local and state governments to use mitigation funds for predisaster planning. 6 In 2001 the actions of September 11 pushed Congress to create the Department of Homeland Security, which was the largest reorganization of federal agencies since the Great Depression. 6 The magnitude of disaster recovery depends on the magnitude of destruction. In a small local disaster, volunteer organizations such as the Red Cross and private insurers may be enough to aid victims. When a disaster overwhelms the recovery forces of a community, that community in the United States can turn to the State government, and ultimately to FEMA, for resources. Within the first 48 hours of a disaster, assessment teams should provide an initial assessment of the damage. This includes identifying immediate needs such as food, shelter, and infrastructural deficits and requirements. Local government will conduct a preliminary damage assessment to determine whether federal aid should be requested. Once the immediate needs are identified, and if federal aid is requested, a second, more in-depth survey should be done by FEMA. This second survey should include reviewing plans of and for the displaced citizens: Do they plan to move, or rebuild in the same spot? Public infrastructure, sewers, and storm drains should be examined. What about the town? What was there before the disaster? What currently exists? Were there any existing plans for expansion of the area that could be used for rebuilding? What are the opportunities looking at the long term? 15 Every U.S. state maintains an Emergency Management Agency (EMA) and an Emergency Operations Plan. Their role is to establish and maintain an emergency program concerned with preparedness, response, mitigation, and recovery; to coordinate and train state and local governments; to recommend whether federal aid is needed in the case of a disaster; and to coordinate state and federal resources and act as an intermediary between local and federal groups. 6 In the past, the majority of these plans have been concerned primarily with the short-term response. 2 Recently states have been trying to adapt to a more long-term response.

When a disaster impacts a community in any part of the United States, the federal government may declare a federal disaster under the Robert T. Stafford Disaster Relief and Emergency Assistance Act, if that state is overwhelmed and state resources are not enough to provide aid. 16 In 2000 there were 45 major disaster declarations from 31 states and the District of Columbia. 17 These disasters ranged from tornados to wildfires to winter storms. Initial resources supplied included food, water, emergency generators, and the mobilization of specialized teams (e.g., search and rescue, medical assistance, damage assessment, and communications). For longer term relief, there are loans and grants to repair or replace housing and personal property, roads, and public buildings. There is also assistance for mitigation opportunities, counseling, and legal services. These services are outlined in the U.S. Federal Response Plan (FRP), which describes the policies and plans of 25 federal departments and the U.S. Red Cross. 16 The FRP can be implemented in conjunction with other specialized groups including plans for telecommunications support, the National Oil and Hazardous Substances Pollution Contingency Plan, the Federal Radiological Emergency Response Plan, and the Terrorism Incident Annex. 16 Some federal agencies have the authority to provide disaster aid even when the magnitude is not sufficient for the president to declare a federal disaster, such as the Department of Agriculture, Department of Commerce, Department of Housing and Urban Development, and the Small Business Association (SBA). The FRP employs a multiagency operations structure based on the Incident Command System (ICS). Disaster Field Offices under the Department of Homeland Security may be created along with a national emergency response team. Recovery efforts are the responsibility of logistics and administration teams within disaster field offices.

The first source of insurance for all homeowners, businesses, and towns is private insurance. If that is not adequate or not available, the next action should be to register with FEMA by the stated deadline, usually within 2 months of the disaster. After individual private insurance carriers, the SBA provides the next largest portion of aid. All those above a minimum income are referred to SBA and should apply for SBA loans. 15 The loans must be repaid, but they carry low interest rates.

These loans include the following: 1. Home disaster loans to homeowners or renters to repair personal property; 2. Business physical disaster loans to businesses to repair or replace property including real estate, equipment, and inventory (not-forprofit organizations are also eligible); 3. Economic injury disaster loans to small businesses and agricultural cooperatives to replace working capital. 15 FEMA also offers three types of assistance as noted in the following: 1. Individual and family grants: These loans are granted to persons with needs not met by private insurances, SBA, or volunteer 366 SECTION VI Post-Event Topics organizations. These grants are for basic needs only, not to return life to normal. Costs can include medical and counseling assistance, housing repair, funeral expenses, and insurance premiums. 2. Public assistance: This program gives aid to local governments for emergency services and the repair or replacement of public facilities, for example, the removal of debris, repair of infrastructure, or emergency protective measures. It is often the most costly element of recovery, and typically the cost is shared with the state in a 75%/25% split. 6 3. Hazard mitigation grant program: These grants are used by the federal, state, and local governments to incorporate mitigation into the recovery process. 15 Actions may include acquisition of homes, public education, and retrofitting structures to better resist subsequent disasters such as floods and hurricanes. Cost will be shared between federal and state resources. 6 Businesses have special considerations in light of a disaster. The primary objective of recovery planning is to enable an organization to survive a disaster and to continue normal business operations. To survive, the organization must ensure that critical operations can resume or continue normal processing and minimize the duration of a serious disruption to operations and resources (both information processing and other resources); a premade contingency plan is the best method of accomplishing this. 18 Specific measures may include having an alternate site of operations if the current facility is damaged, storing vital documents off-site or virtually in the Cloud, and having an alternative energy source such as a generator which is located well above the high water line and not in a basement. Larger businesses may be better able to withstand a disaster because assets and the workforce may be dispersed across a wider geographic area. 6 A disaster is a life-altering event. Survivors share a considerable experience and come to view the world around them in new and different ways. Seeking help from the government, voluntary agencies, and insurance companies can be a frustrating prolonged process, which may only compound the feelings of helplessness. Anger and despair are common. Mental health staff may assist persons by reassuring them that this "second disaster" is a common phenomenon and that they are not alone in their frustration. 19 Some may not want to seek formal counseling, either because of the perceived stigma associated with seeking help or because they are unwilling to take time away from putting their lives back together or helping others. Very effective mental health assistance can be provided while the worker is helping survivors with concrete tasks. The "over a cup of coffee" method of informal intervention may be the best method to help. A trained effective mental health worker can use skilled but unobtrusive interviewing techniques to help a survivor sort out demands and set priorities while they are jointly sifting through disaster rubble. 19 Although having community involvement is beneficial to the process of recovery, it is also very important for the mental health resilience of the community. Failing to involve the community can lead to resentment and fragmentation. The inhabitants may be unhappy when aid is not appropriate to the community's perceived needs, and this insult may be compounded if they are then labeled unappreciative of the federal help. When people have a hand in their own recovery, they feel empowered and will increase their involvement. This leads to a stronger community network that in turn increases the ability to provide selfhelp and community resilience.

In general, there are two broad problems with disaster recovery: too little horizontal planning or too much dependence on vertical aid. The pitfalls occur when the horizontal and vertical planning are not balanced.

With too much dependence on vertical planning, the community does not contribute anything to the recovery process and the government organizations and nongovernmental organizations dictate the recovery plans. In the past, these groups have come in with the intention of "fixing" the situation. This is referred to as "top-down" theory. 20 In addition to not providing optimal care, this may impede selfsufficiency of these disaster-stricken areas. Assumptions may be made, including the following: (1) the victims are a burden; (2) the host government is weak and cannot manage alone; (3) foreign aid organizations do not require accountability; (4) aid for the victims reflect the defined needs of the victims (when, in fact, the aid reflects the projected need by the donor). 20 An example of this last point was when Hurricane Hugo struck Montserrat in 1989. Ninety-eight percent of all homes were affected, 50% severely and 20% completely destroyed. 20 The Peace Corps brought in large numbers of prefabricated housing to replace all the destroyed homes. Although they were able to help a lot of people numerically, the homes they provided had two-sided pitched roofs instead of the typical Caribbean four-sided roofs that were better able to withstand tropical winds. They also did not have an interior design to allow for cross ventilation. The early recipients of the homes reported this finding to the Peace Corps, but the Peace Corps was unable to change the design. Although well intentioned, the Peace Corps was predominantly meeting the need projected by the donors instead of the actual needs of the victims. 20 Overdependence on vertical planning can also result in a lack of accountability and thus uneven recovery results. In Jamaica, after Hurricane Gilbert, the primary housing aid program was the Building Stamp Programme, which was set up by the Jamaican government, the World Bank, Canada, Germany, Japan, OPEC, and the United States. Homeowners were issued building stamps based on the extent of damages and financial need. These stamps would then be redeemed only at building supply stores who were members of the Jamaican Hardware Merchants Association for building materials, including zinc sheets, nails, and lumber. Squatters and renters were not eligible for stamps and were left without any recourse for finding aid. People who were not at home during the time of the survey were not listed as needing aid. 20 It was also found that the stamps were distributed unequally. As a result, many needy people were left without any support.

There is also a real risk of creating a "dependency syndrome" by not thinking of sustainable development when investing money and effort into the recovery process. 20 This occurs when infrastructural replacement of homes is completed in such a way that replacements are likely to be destroyed by subsequent disasters resulting in the need for continued care for each disaster. Instead of being able to learn from prior occurrences and create a more resilient town and infrastructure, the same mistakes are repeated over and over again. For example, Jamaicans used the stamps to fulfill daily needs such as mattresses and utensils and did not spend time reinforcing their homes against further hurricanes or floods. When the next hurricane hits, these people will have the same destruction to their homes as occurred with Hurricane Gilbert. 20 With too little horizontal planning, the results may be a chaotic lack of cooperation between groups and potential leaders. Internationally, studies have shown that many community plans focus primarily on the emergency period and do not give adequate attention to recovery and reconstruction. If there is a plan, it often exists on paper only and, in the case of an actual disaster, it is not used. Many officials may not be aware that a plan exists. 4 These flaws lead to chaotic implementation of an ad hoc recovery. The community lacks the ability to work together and thus fragments and cannot unify to control its own affairs. As a result, the redevelopment is likely to be inadequate 367 CHAPTER 59 Rehabilitation and Reconstruction to fulfill the needs of the community. If there is aid from government and nongovernmental groups, they are sometimes uncoordinated, either duplicating actions, leaving areas without any aid, or giving aid that is inadequate for the needs of the area. 4 In Saragossa, Texas, a small isolated community devastated by a tornado in 1987, there was no local government in place at all. When a disaster advisory board was created, it was done without any input from the local inhabitants. The outcome was that the Saragossans considered themselves worse off 2 years after the tornado than they had been beforehand, both because of the quality of the rebuilt neighborhoods and because they felt they were looked on as helpless and ungrateful. 2 Studies in the Caribbean have shown that the different power levels in an uncoordinated community may lead to powerful interest groups pressuring public authorities to rebuild first in areas in which they have the greatest interest. Poorer neighbors with weaker ties to public authorities will get delayed care. 2 In the United States, vertical planning predominates because few communities have detailed plans in place and because they may not have the financial reserve to pay for the recovery. When a plan is in place before a disaster, it allows for a strong horizontal network. Then, when a useful vertical element is added, the results can work wonders. By 1975, recurrent floods had repeatedly decimated the town of Soldiers Grove, Wisconsin. Each time the town rebuilt. At one point they added a dam, and they planned for a levee, but were unable because of financial restrictions. They decided they would take the funds allocated for the levee and use it to plan for town relocation. Although federal funds were slow in coming, they did create a plan. In 1978, when the largest flood in the history of the area occurred, they were ready with a fully written strategy. When they were granted funds for reconstruction, they put their plan into effect. Not only did they relocate out of the flood plain to prevent reoccurrence of this destruction, but they also decided to create a town that was 75% solar powered. 5 Because they had had the luxury of time in the planning stage, they had asked each business owner where they wanted to be located and how they wanted their business to be built. As a result, the town became not only exactly what the community wanted, but also its creation instilled a great sense of pride and satisfaction in its citizens, thus creating a happier community as well.

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