In the past two decades, there have been many natural and man made disasters in India. Natural disasters like floods, earthquakes, cyclones, droughts and human made such as terrorist acts, Nuclear or chemical war, fires and industrial accidents. Disasters can significantly lead to a degradation of social and economic progress achieved over decades of initiatives by the people. 80% of countries geographical area is disaster prone and the majority of people live at or below the poverty line.
India has been devastated by three major disasters in last five years- Super Cyclone in Orissa, earthquake in Gujarath and now the latest one the tsunami in the Andaman and Nicober Islands,. Tamilnadu, Andrapradesh and Kerala. Each disaster brought a great deal of miscarry to the affective population.
Definitions of Disaster
A disaster can be defined as any occurrence that cause damage, ecological disruption, loss of human life, deterioration of health and health services, Vs a scale sufficient to warrant as extraordinary response from outside the affected community or area.
(W.H.O.)
An occurrence of a severity and magnitude that normally results in death, injuries and property damage that cannot be managed through the routine procedure and resources of government.
- FEMA (Federal Emergency Management Agency)
A disaster can be defined as an occurrence either nature or man made that causes human suffering and creates human needs that victims cannot alleviate without assistance.
- American Red Cross (ARC)
United Nations defines disaster is the occurrence of a sudden or major misfortune which disrupts the basic fabric and normal functioning of a society or community.
Definitions of Disaster Nursing
Disaster Nursing can be defined as the adaptation of professional nursing skills in recognizing and meeting the nursing physical and emotional needs resulting from a disaster. The overall goal of disaster nursing is to achieve the best possible level of health for the people and the community involved in the disaster.
“Disaster Nursing is nursing practiced in a situation where professional supplies, equipment, physical facilities and utilities are limited or not available”.
‘DISASTER’ alphabetically means:
D - Destructions
I - Incidents
S - Sufferings
A - Administrative, Financial Failures.
S - Sentiments
T - Tragedies
E - Eruption of Communicable diseases.
R - Research programme and its implementation
THE GLOBAL SCENARIO
Impact of natural disaster in the last 30 years.
Ø Death of 3 million people
Ø Economic loss increased due to disaster like flood
Ø In Indian scenario, 34jmijlion people affected per year and 5116 death per year.
Ø In US, economic loss is 400 million dollar and 3 million people died.
Phases of Disaster
1) Preimpact:
a. Occurs prior to the onset of the disaster.
b. Includes the period of threat and warning.
c. May not occur in all disaster.
2) Impact Phase:
a. Period of time when disaster occurs, continuing to immediately following disaster.
b. Inventory and rescues period.
Ø Assessment of extent of losses.
Ø Identification of remaining sources.
Ø Planning for
· Use of resources
· Rescue of victims
· Minimizing further injuries and property damage.
Ø May be brief when disasters strike suddenly and is over in minutes (air plane clash, building collapse) or lengthy as incident continues (earthquake, flood, tsunami etc.)
3) Post impact phase
a. Occurs when majority of rescue operations are completed.
b. Remedy and recovery period.
c. Lengthy phase that may last for years.
Ø Honeymoon phase - feeling of euphoria, appearances of little effect by disaster.
Ø Disillusionment phase - feeling of anger, disappointment and resentment.
Ø Reconstruction phase - acceptance of loss, copping with stereo, rebuilding.
4) Rehabilitation
Ø The final phase in a disaster should lead to restoration of the pre-disaster conditions.
Ø The pattern of healthy needs with change rapidly, moving from casualty treatment to more primary health care.
Disaster Cycle & Management
There are three fundamental aspects of disaster management:
a. disaster response ;
b. disaster preparedness ; and
c. disaster mitigation.
These three aspects of disaster management correspond to different phases in the so - called “disaster cycle” as shown in below.
Disaster Impact
Mitigation
Preparedness
Reconstruction
Rehabilitation
Response
Risk reduction phase before a disaster
Recovery phase after a disaster
Triage (5)
When the quantity and severity of injuries overwhelm the operative capacity of health facilities, a different approach to medical treatment must be adopted. The principle of "first come, first treated", is not followed in mass emergencies. Triage consists of rapidly classifying the injured on the basis of the severity of their injuries and the likelyhood of their survival with prompt medical intervention. It must be adopted to locally available skills. Higher priority is granted to victims whose immediate or long-term prognosis can be dramatically affected by simple intensive care. Moribund patients who require a great deal of attention, with questionable benefit, have the lowest priority. Triage is the only approach that can provide maximum benefit to the greatest number of injured in a major disaster situation.
Although different triage systems have been adopted and. are still in use in some countries, the most common classification uses the internationally accepted four colour code system. Red indicates high priority treatment or transfer, yellow signals medium priority, green indicates ambulatory patients and black for dead or moribund patients.
Triage should be carried out at the site of disaster, in order to determine transportation priority, and admission to the hospital or treatment centre, where the patient's needs and priority of medical care will be reassessed. Ideally, local health workers should be taught the principles of triage as part of disaster training.
Persons with minor or moderate injuries should be treated / at their own homes to avoid social dislocation and the added drain on resources of transporting them to central facilities. The seriously injured should be transported to hospitals with specialized treatment facilities.
Tagging
All patients should be identified with tags stating their name, age, place of origin, triage category, diagnosis, and initial treatment.
Identification of dead
Taking care of the dead is an essential part of the disaster management. A large number of dead can also impede the efficiency of the rescue activities at the site of the disaster. Care of the dead includes : (1) removal of the dead from the disaster scene; (2) shifting to the mortuary; (3) identification; (4) reception of bereaved relatives. Proper respect for the dead is of great importance.
The health hazards associated with cadavers are minimal if death results from trauma and corps are quite unlikely to cause outbreaks of disease such as typhoid fever, cholera or plague. If human bodies contaminate streams, wells, or other water sources as in floods etc., they may transmit gastroenteritis or food poisoning to survivors. The dead bodies represent a delicate social problem.
Relief phase
This phase begins when assistance from outside starts to reach the disaster area. The type and quantity of humanitarian relief supplies are usually determined by two main factors : (1) the type of disaster, since distinct events have different effects on the population, and (2) the type and quantity of supplies available locally.
Immediately following a disaster, the most critical health supplies are those needed for treating casualties, and preventing the spread of communicable diseases. Following the initial emergency phase, needed supplies will include food, blankets, clothing, shelter, sanitary engineering equipment and construction material. A rapid damage assessment must be carried out in order to identify needs and resources. Disaster managers must be prepared to receive large quantities of donations. There are four principal components in managing humanitarian supplies: (a) acquisition of supplies; (b) transportation; (c) storage; and (d) distribution.
Epidemiologic surveillance and disease control
Disasters can increase the transmission of communicable diseases through following mechanisms :
1. Overcrowding and poor sanitation in temporary resettlements. This accounts in part, for the reported increase in acute respiratory infections etc. following the disasters.
2. Population displacement may lead to introduction of communicable diseases to which either the migrant or indigenous populations are susceptible.
3. Disruption and the contamination of water supply, damage to sewerage system and power systems are common in natural disasters.
4. Disruption of routine control programmes as funds and personnel are usually diverted to relief work.
5. Ecological changes may favour breeding of vectors and increase the vector population density.
6. Displacement of domestic and wild animals, who carry with them zoonoses that can be transmitted to humans as well as to other animals. Leptospirosis cases have been reported following large floods (as in Orissa, India, after super cyclone in 1999). Anthrax has been reported occasionally.
7. Provision of emergency food, water and shelter in disaster situation from different or new source may itself be a source of infectious disease.
Outbreak of gastroenteritis, which is the most commonly reported disease in the post-disaster period, is closely related to first three factors mentioned above. Increased incidence of acute respiratory infections is also common in displaced population. Vector-borne diseases will not appear immediately but may take several weeks to reach epidemic levels.
Displacement of domesticated and wild animals increases the risk of transmission of zoonoses. Veterinary services may be needed to evaluate such health risks. Dogs, cats and other domestic animals are taken by their owners to or near temporary shelters. Some of these animals may be reservoirs of infections such as leptospirosis, rickettsiosis etc. wild animals are reservoirs of infections which can be fatal to man such as equine encephalitis, rabies, and infections still unknown in humans.
The principals of preventing and controlling communicable diseases after a disaster are to - (a) implement as soon as possible all public health measures, to reduce the risk of disease transmission; (b) organize a reliable disease reporting system to identify outbreaks and to promptly initiate control measures; and (c) investigate all reports of disease outbreaks rapidly (5).
Vaccination (5)
Health authorities are often under considerabie public and political pressure to begin mass vaccination programmes, usually against typhoid, cholera and tetanus. The pressure may be increased by the press media and offer of vaccines from abroad.
The WHO does not recommend typhoid and cholera vaccines in routine use in endemic areas. The newer typhoid and cholera vaccines have increased efficacy, but because they are multidose vaccines, compliance is likely to be poor. They have not yet been proven effective, as a large-scale public health measure. Vaccination programme requires large number of workers who could be better employed elsewhere. Supervision of sterilization and injection techniques may be impossible, resulting in more harm than good. And above all, mass vaccination may lead to false sense of security about the risk of the disease and to the neglect of effective control measures. However, these vaccinations are recommended for health workers. Supplying safe drinking water and proper disposal of excreta continue to be the most practical and effective strategy.
Significant increases in tetanus incidence have not occurred after natural disasters. Mass vaccination of population against tetanus is usually unnecessary. The best protection is maintenance of a high level of immunity in the general population by routine vaccination before the disaster occurs, and adequate wound cleaning and treatment. If tetanus immunization was received more than 5 years ago in a patient who has sustained an open wound, a tetanus toxoid booster is an effective preventive measure. In previously unimmunized injured patients, tetanus toxoid should be given only at the discretion of a physician. If routine vaccination programmes are being conducted in camps with large number of children, it is prudent to include vaccination against tetanus.
Natural disasters may negatively affect the maintenance of on going national or regional eradication programmes against polio and measles. Disruption of these programmes should be monitored closely.
If cold-chain facilities are inadequate, they should be requested at the same time as vaccines. The vaccination policy to be adopted should be decided at senior level only.
Nutrition
A natural disaster may affect the nutritional status of the population by affecting one or more components of food chain depending on the type, duration and extent of the disaster, as well as the food and nutritional conditions existing in the area before the catastrophe. Infants, children, pregnant women, nursing mothers and sick persons are more prone to nutritional problems after prolonged drought or after certain types of disasters like hurricanes, floods, land or mudslides, volcanic eruptions and sea surges involving damage to crops, to stocks or to food distribution systems.
The immediate steps for ensuring that the food relief programme will be effective include: (a) assessing the food supplies after the disaster; (b) gauging the nutritional needs of the affected population; (c) calculating daily food rations and need for large population groups; and (d) monitoring the nutritional status of the affected population.
Rehabilitation
The final phase in a disaster should lead to restoration of the pre-disaster conditions. Rehabilitation starts from the very first moment of a disaster. Too often, measures decided in a hurry, tend to obstruct establishment of normal conditions of life. A provision by external agencies of sophisticated medical care for a temporary period has negative effects. On the withdrawal of such care, the population is left with a new level of expectation which simply cannot be fulfilled.
In first weeks after disaster, the pattern of health needs, will change rapidly, moving from casualty treatment to more routine primary health care. Services should be reorganized and restructured. Priorities also will shift from health care towards environmental health measures. Some of them are as follows:
Water supply
A survey of all public water supplies should be made. This includes distribution system and water source. It is essential to determine physical integrity of system components, the remaining capacities, and bacteriological and chemical quality of water supplied.
The main public safety aspect of water quality is microbial contamination. The first priority of ensuring water quality in emergency situations is chlorination. It is the best way of disinfecting' water. It is advisable to increase residual chlorine level to about 0.2-0.5 mg / litre. Low water pressure increases the risk of infiltration of pollutants into water mains. Repaired mains, reservoirs and other units require cleaning and disinfection.
Chemical contamination and toxicity are a second concern in water quality and potential chemical contaminants have to be identified and analyzed.
The existing and new water sources require the following protection measures : (1) restrict access to people and animals, If possible, erect a fence and appoint a guard; (2) ensure adequate excreta disposal at a safe distance from water source; (3) prohibit bathing, washing and animal husbandry, upstream of intake points in rivers and streams; (4) upgrade wells to ensure that they are protected from contamination; and (5) estimate the maximum yield of wells and if necessary, ration the water supply.
In many emergency situations, water has to be trucked to disaster site or camps. All water tankers should be inspected to determine fitness, and should be cleaned and disinfected before transporting water.
Food safety
Poor hygiene is the major cause of food-borne diseases in disaster situations. Where feeding programmes are used (as in shelters or camps) kitchen sanitation is of utmost importance. Personal hygiene should be monitored in individuals involved in food preparation.
Basic sanitation and personal hygiene
Many communicable diseases are spread through faecal contamination of drinking water and food. Hence, every effort should be made to ensure the sanitary disposal of excreta. Emergency latrines should be made available to the displaced, where toilet facilities have been destroyed. Washing, cleaning and bathing facilities should be provided to the displaced persons.
Vector control
Control programme for vector-borne diseases should be intensified in the emergency and rehabilitation period, especially in areas where such diseases are known to be endemic. Of special concern are dengue fever and malaria (mosquitoes), leptospirosis and rat bite fever (rats), typhus (lice, fleas), and plague (fleas). Flood water provides ample breeding opportunities for mosquitoes.
A major disaster with high mortality leaves a substantial displaced population, among who are those requiring medical treatment and orphaned children. When it is not possible to locate the relatives who can provide care, orphans may become the responsibility of health and social agencies. Efforts should be made to reintegrate disaster survivors into the society, as quickly as possible through institutional programmes coordinated by ministries of health and family welfare, social welfare, education, and NGOs.
Post-Traumatic Stress Disorder and Rehabilitation of Disaster Victims
1. Meaning of PTSD:
PTSD is a set of reactions to an extreme stressor such as intense fear, helplessness, or horror that leads individuals to relieve the trauma.
2. Symptoms of PTSD:
Ø Episodes of repeated relieving of the trauma in intensive memories “(flashbacks)” or dreams,
Ø Flashbacks occurring - against the persisting background of a sense of “numbers” and emotional blunting,
Ø Detachment from other people,
Ø Unresponsiveness to surroundings
Ø Anhedonia can inability to experience pleasure
Ø Avoidance of activities and situations reminiscent of the trauma
Ø Fear and avoidance of cues that remind the sufferer of the original trauma
Ø May be dramatic, acute bursts of fear, panic or aggression, triggered by stimuli arousing a sudden recollection and/or re-enactment of the trauma or of the original reaction to it.
3. Incidence and onset of symptoms of PTSD:
Ø 1-14% develops PTSD
Ø From a few weeks to months.
Ø But rarely, exceeds 6 months
Ø Chronic course over many years and endures personality change
4. Diagnostic criteria (ICD-10 F43.1):
Ø Evidence of trauma
Ø Onset within 6 months of a traumatic event
Ø Repetitive, intrusive recollection of reenactment of the even in memories
Ø Day time imagery or dreams
Ø Conspicuous emotional detachment
Ø Numbing of feeling
Ø Avoidance of stimuli that might arouse recollection of the trauma
5. Predisposing factors:
Ø Personality traits - compulsive, asthenic
Ø History of neurotic illness childhood abuse, who then suffer subsequent trauma.
6. Causes of PTSD:
Ø Military combat
Ø Bombing or war
Ø Kidnapping
Ø Robbery
Ø Abuse-Physical, sexual (E.g. rape) or psychological
Ø Terrorist attack
Ø Prisoner of war
Ø Torture
Ø Natural or man-made disasters
Ø Witnessing violence (domestic, criminal)
Ø Severe automobile accidents
Ø Seeing dead body or body parts
Ø Serious injury or death of family member or a close friend
Ø Diagnosis of life threatening disease in self or child
Ø Unexpected death of family member or a close friend
7. Factors contributing to PTSD
Ø Severity
Ø Duration
Ø Proximity to the stressful event
Ø Resilince readily recovering from set backs.
8. High risk group for PTSD
Ø Children
Ø Disabled
Ø Elderly
Ø Women-young, single, widowed, orphaned, disabled, have lost children
Ø Orphans from orphanages
Ø Having history of childhood abuse
9. Terminologies related to PTSD
“Flash backs” - Acting or feeling as if the event were actually
happening/intrusive re-experiencing of the
traumatic event.
“Hyper vigilance” - close attention to and anticipation of approaching
danger.
“Avoidance” - efforts to avoid thoughts, feelings or conversations
associated with trauma
“Numbness” - a condition of being detached, indifferent and
devoid of feeling, particularly for traumatic event.
10. Mechanism of PTSD:
1.1 Neuropharmacological theorie:
Ø Elevated levels of nor epinephrine and epinephrine elevated BP and pulse
Ø Hyper function of sympathetic nervous system Hyper arousal, sleep deprivation, poor concentration and Irritability
Ø Low amounts of serotonin Hyper arousal and mood changes
Ø Administration of antidepressant medications increases levels of Serotonin, selective serotonin reuptake inhibitors (SSRIs) have been shown to reduce symptoms of PTSD.
1.2 Endogenous opioid theory:
1.3 Under extremely stressful conditions, the body releases opioids, which decrease the emotional responses to extreme stress such as fear, helplessness and anxiety.
Traumatised individuals may 'seek' further trauma to release opioids to “self-medicate” their discomfort, fear and PTSD reactions. The result is to inhibit emotional pain, and reduce the fear and panic.
1.4 Neuroendocrine theory:
Under acute conditions of stress, increased amounts of Cortisol are secreted, and in chronic states, PTSD individuals show decreased Cortisol output. After chronic exposure to stress, the endocrine system, working on a feedback signal, senses the initial outpouring of Cortisol and “resets” the system to lower levels.
1.5 Neurodevelopmental and neurobiological theories:
Extreme stress has eliterious effects on brain development particularly reduced hippocampal size and abnormalities in the limbic system. EEG abnormalities in the frontal and temporal lobes seen. These changes results in behaviours commonly seen in PTSD.
1.6 Repetition and Family influences theory:
Those with the history of suffering or witnessing childhood physical or sexual abuse may tend to repeat the abusive behaviour in adulthood. This repetition over generations has been called the '"cycle of violence".
11. Prognosis
Ø Course - chronic in nature
Ø Problem of substance abuse, mood disorders
12. Principles of nursing care in PTSD:
1.1 Consistent empathic approach to help the clients tolerate the intense memories and emotional pain.
1.2 Simple reorienting, reassuring statements to prevent suicidal ideation
1.3 Trusting relationship to covey a sense of respect, acceptance of their distress and belief in the client's reactions.
1.4 Reconnect the individuals with the existing support system,
1.5 Restart activities that provide a sense of mastery
1.6 Promote independence and the client's highest level of functioning.
1.7 Manager counter transference reactions
1.8 Group therapies to decrease isolation, to discuss the effect of trauma and develop alternative coping mechanisms.
1.9 Encourage the client to write/verbalise to manage reactions and feelings
1.10 Help the client identify community resources
1.11 Teach anxiety management strategies like relaxation, breaking techniques and diverting the individuals mind through involvement inactivities.
1.12 Changes in life style such as following a healthy diet, avoiding stimulants/intoxicants, regular exercise and adequate sleep. Use medication as recommended.
Rehabilitation of disaster victims:
In the post-disaster period, along with relief, rehabilitation and the care of physical health and injuries, mental health issues need to be given importance. Apart from material and logistic help, the suffering human beings will require human interventions.
Challenges of rehabilitation:
1. Ensuring that people living in the relief camps have access to
Regular food supplies
Additional sets of clothes
Sanitation drinking water,
Public health intervention - immunization, preventive health care
Heat and rain proof shelters
Child care and education facilities and support
2. Ensuring access to basic entitlements in terms of their compensation, government schemes and credit institutions so that they can rebuild their homes and livelihood back to the some levels as before the disaster.
3. Ensuring livelihood reintegration
4. Ensuring legal right and social justice to the disaster victims including filing of FIRs, investigation and contesting cases in the court.
5. Providing psychosocial counseling and support for dealing with loss, betrayal and anger.
6. Community based care/rehabilitation for widows orphans, elderly, children and physically disabled.
7. Actively rebuilding a culture of communal harmony and trust.
Impact of disaster on victims:
Ø Severe stress & trauma due to disaster
Ø Sudden forced displacement
Ø Difficulties of living in the camps
Ø Uncertainty about the future and continuation of threat
Ø Process of rebuilding personal, family land community life.
Kinds of reactions shown by disaster victims: or Disaster impacts, on victims:
1. Physical impact - Stomach aches, diarrohoea, headaches, and bodyaches, physical impairments (limbs, sight, voice, hearing), injuries, fever, cough, cold, miscarriage etc.
2. Emotional reactions - Anger, betrayal, irritability, revenge-seeking, fear, anxiety, depression, withdrawal, grief, addiction to pan masala, cigarette, beedi, drug abuse (flask backs, numbness, depression)
3. Socio-economic impact - loss of trust between communities, lack of privacy, single parent families, widows, orphan state with loss of both parents, discontinuity in educational plans (E.g. loss of employment, homelessness migration, disorganization of life routines, material loss).
Principles for giving emotional support
1. Everyone who witnesses/experiences disaster is touched by it.
Ø Disaster stress reaction are common
Ø Ways to cope with stressors
Ø Available resources to meet their needs
2. Disaster results in two types of trauma:
i. Individual trauma - Stress & grief reaction
ii. Collective trauma - builds social ties of survivors with each other.
3. Displaced living causes many problems
Ø Practical problems, like finding temporary housing, food, clothing etc-Appropriate relief & support measures are vital.
4. Disaster mental health services must be uniquely tailored to the communities they serve
Ø Interventions based on the demography & characteristics of the population
Ø Consider the ethnic and cultural groups in the community and in the language of the people.
5. Survivors respond to active interest and concern talk with the survivors without any apprehensions of intruding or invading their privacy.
6. Interventions must be appropriate to the phase of disaster
Initial phase - listening, supporting, ventilation, catharasis and grief
resolution help
Later phae - Handling frustration, anger and disillusion ment.
7. Support systems are crucial for the recovery
Ø Keep the family together
Ø Orphaned or widowed or lone survivors require support from other groups.
8. Attitude of the care giver (CLH-Community Level helpers)
Ø Avoid use of mental health labels like “neurotic”, ‘psychotic’, ‘counselling’, ‘psychotherapy’, etc.
Ø Be sensitive, non-judge mental and confidants in all interactions with the survivors.
Psychosocial interventions
Principles
Ø Ventilation
Ø Empathy
Ø Active listening
Ø Social support
Ø Externaliation of interests
Ø Life style choices
Ø Relaxation & recreation
Ø Spirituality
Ø Health care
Work with individuals (willing to talk immediately Unwilling to talk)
Ø For people who are willing to talk immediately
- listen attentively
- Do not interrupt
- Acknowledge that you understand the pain & distress by learning forward
- Look into the eyes
- Console them by patting on the shoulders or touching or holding their hand as they cry. Caution, be sensitive to community norms about touching members of the opposite sex.
- Respect the silence during interaction; do not try to fill it in by talking
- Keep reminding them “I am with you. It is good you are trying to release your distress by crying. It will make you feel better.
- Do not ask them to stop crying
For those unwilling to talk (angry, or remain mute and silent)
- Do not get anxious or feel rejected; remain calm
- Maintain regular contact & greet them
- Maintain interaction
- Acknowledge that you understand they are not to blame
- Tell them you will return the next day or in a couple of days
- Tell them you are not upset or angry because he or she did not talk.
Once the person starts talking, maintain a conversation using the following queries like
Ø How are you & how are your other family members?
Ø What can individuals do to recover?
Work with families:
Ø Share their experience of loss as a family
Ø Contact relatives to mobilize support and facilitate reconvey
Ø Participate in rituals like prayers, keeping the dead persons photographs
Ø Make time for recreation
Ø Resume normal activities of the pre-disaster days with the family
Ø Try & do things together as a writ & support one another
Ø Be together as a family member. Do not send women & children and the aged to far off places for the sake of safety.
Ø Restart activities that are special to your family like having meals together, praying, playing games etc.
Ø Keep touching and comforting your parents, children, spouse and the aged in your family
Ø Keep in constant touch with the family member who is hospitalized.
Work with the community:
Ø Group mourning
Ø Group meetings
Ø Supporting group initiatives
Ø Cultural aspects
Ø Rally
Ø Group participation for rebuilding efforts
Ø Sensitisation process
