|Year : 2015 | Volume
| Issue : 3 | Page : 123-131
Management of disasters and complex emergencies in Africa: The challenges and constraints
Department of Community Medicine, Ahmadu Bello University, Zaria, Nigeria
|Date of Web Publication||28-May-2015|
Department of Community Medicine, Ahmadu Bello University, Zaria
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Natural and man-made catastrophes have caused significant destruction and loss of lives throughout human history. Disasters accompany a wide variety of events with multiple causes and consequences often leading to a cascade of related events. African continent has not been spared of these events. A new phenomenon in the continent is terrorism that is fuelled by globalization of arms trade and has contributed significantly to escalation of conflicts in sub-Saharan Africa (SSA) resulting in complex emergencies and destruction of socioeconomic structures. The aim of this paper is to review relevant papers on management of disasters and complex emergencies in Africa and the challenges and constraints against the background of a weakened health system. Systematic search of published literature was conducted between 1990 and 2013. Grey literature (technical reports, government documents), published peer review journals, abstracts, relevant books and internet articles were reviewed. The review revealed that the frequency of both natural and man-made disasters in Africa is escalating. Complex emergencies are also on the increase since the Rwandan crisis in 1994. The impact of these events has overstretched and overwhelmed the health care system that is least prepared to handle and cope with the surge capacity and also render normal services. In conclusion, there is an urgent need for national emergency agencies/departments across Africa to develop a robust emergency preparedness and response plan. Every hospital most have a disaster management committee with flexible disaster management plan to respond to these catastrophes. There is a need for curriculum review in tertiary institutions across SSA to introduce and or expand training in disaster management.
| Abstract in French|| |
Catastrophes naturelles et anthropiques ont causé d'importantes destructions et pertes en vies humaines tout au long de l'histoire humaine. Catastrophes accompagnent une grande variété d'événements avec plusieurs des causes et des conséquences qui conduit souvent à une cascade d'événements connexes. Continent africain n'a pas été épargné de ces événements. Un nouveau phénomène sur le continent est le terrorisme qui est alimenté par la mondialisation du commerce des armes et a largement contribué à l'escalade des conflits en Afrique subsaharienne (ASS) aboutissant à des situations d'urgence complexes et de la destruction des structures socio-économiques. L'objectif de cette communication est d'examiner les documents pertinents sur la gestion des catastrophes et des situations d'urgence complexes en Afrique et les défis et les contraintes dans le contexte d'un système de santé affaiblie. La recherche systématique de la littérature publiée a été réalisée entre 1990 et 2013. Littérature grise (rapports techniques, documents officiels), les revues publiées par les pairs, résumés, livres et articles internet ont été examinées. L'examen a révélé que la fréquence des catastrophes naturelles et anthropiques en Afrique s'intensifie. Situations d'urgence complexes sont également en augmentation depuis la crise rwandaise en 1994. L'impact de ces événements a débordé et submergé le système de santé qui est moins préparés à gérer et faire face à la capacité de réaction et aussi rend des services normaux. En conclusion, il est urgent que les ministères et organismes d'urgence nationales dans toute l'Afrique à développer une solide préparation aux situations d'urgence et le plan d'intervention. Tous les hôpitaux ont plus d'un Comité de gestion des catastrophes avec plan de gestion de catastrophe flexible pour répondre à ces catastrophes. Il est nécessaire pour l'examen du programme d'études dans l'enseignement supérieur à travers SSA à introduire et ou d'élargir la formation en gestion des catastrophes.
Mots-clés: Afrique, défis, la gestion des catastrophes, la formation
Keywords: Africa, challenges, disaster management, training
|How to cite this article:|
Aliyu A. Management of disasters and complex emergencies in Africa: The challenges and constraints. Ann Afr Med 2015;14:123-31
| Introduction|| |
Almost half of the world population has lived through a disaster at some point in the past decade. It is enough to make you fear the future…!
Disasters accompany a wide variety of events with multiple causes and consequences that can be abrupt or insidious. Furthermore, disasters caused by man can include warfare and terrorism as well as technological disaster and other complex emergencies. Natural disasters such as floods, earthquakes, hurricanes and volcanic eruptions etc., have been with us throughout the history of mankind. Technological disasters have likewise been with us since the industrial revolution.  Such disasters often involve explosions, fire, crashes and chemical or radiological releases into the environment.  In recent times, the spectre of weapons of mass destructions (WMDs - biological or otherwise) has focused considerable attention on public health and emergency preparedness and response (EPR) to such situations. Disasters can be defined as a disruption of human ecology which exceeds the community's capacity to adjust, so that outside assistance is needed.  While, complex emergencies are the result of interrelated social, economic and political problems and almost always involve armed confrontation.  Terrorism is regarded by many as an escalating and evolving threat and terrorists nowadays have unparalleled "easy" access to highly destructive technologies.  Globalization of the world arms trade has contributed significantly to the escalation of conflicts in the third world with severe consequences for its people and economies.  Petroleum pipeline explosions in Nigeria are the most deadly and injurious man-made disasters.
There is large-scale population displacement, epidemic disease and food shortages , the social and economic impact of disasters is alarmingly on the increase. The estimated cost of damages due to natural disasters in 2003 was put at US$ 65 billion  and the cost of humanitarian responses to disasters peaked at US$ 17 billion in 2005.  The impact of disasters both natural and man-made has become an important obstacle to sustainable development in Africa. Systematic search of published literature in English was conducted between 1990 and 2013. Grey literature (technical reports, government documents), published peer review journals, abstracts, relevant books and internet articles were reviewed. Manual search of reference lists of selected retrieved articles was checked for further relevant studies.
The management of public health problems of refugees and displaced persons are major challenges and quite often overwhelming. A well-planned medical response team is a sino qua non but is just one of the components of a successful strategy for reducing mortality during disasters and complex emergencies. The big challenge is the long-term recovery and rehabilitation needs in the affected areas using the 3R's (Rescue, Relief and Rehabilitation) of disaster management. Many of the devastated communities already had high levels of poverty and misery. So, the restoration of livelihoods presents a major hurdle for longer-term recovery and sustainable development. Every hospital must have a disaster management committee with flexible disaster management plan. This review provides an insight into disaster management and its challenges in sub-Saharan Africa (SSA).
| Understanding Disasters|| |
Disasters are annoyingly nondiscriminatory in impact whether in a developing region like the horn of Africa or developed country like USA. Major disasters and emergencies have occurred throughout history, and as the world's population grows and resources become limited, communities are increasingly becoming vulnerable to the hazards that cause disasters. Over the past 20 years, natural disasters have affected at least 800 million people, caused well over 3 million deaths and resulted in property damage exceeding US$ 50 billion.  Globally, the incidence of natural disasters appears to be increasing, and the number of vulnerable persons in disaster-prone areas particularly in the developing world is at least 70 million people and growing. , All natural disasters are unique in that each affected region of the world has different geographic, socioeconomic and health backgrounds. There are many types of disasters such as earthquakes, floods, mudslides, landslides, famines, epidemics and structural collapse - buildings, and bridges [Table 1]. Global warming, unprecedented rates of urbanization and environmental degradation have resulted in increased frequency and severity of natural disasters. SSA is prone to climate change because it suffers from natural fragility; its thus exposed to droughts and floods.
|Table 1: Different classes of disasters and complex emergencies and their impacts |
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Terrorism is a new phenomenon, and terrorist attacks have now become a frequent occurrence across SSA. Different factions have been recognized - Boko Haram in Nigeria, Islamist group in Mali and Al-Shabab in East Africa, all of them have been linked to Al-Qaeda. While large numbers of casualties are possible, terrorism by its very definition is primarily designed to produce fears and panic.  Globally, landmines are responsible for more than 15,000 fatalities each year.  Countries affected by landmines in the wake of endemic warfare include Afghanistan, Mozambique, Angola and Rwanda, etc.  Typically, survivors require emergency surgical services and prolonged rehabilitation largely related to lower limb amputations.
Disasters may be associated with a variety of acute and long-term health consequences. The relative number of injuries and deaths differ, depending on a number of factors - population density and distribution, level of preparedness, state of the environment and time of occurrence. Thus, public health issues associated with floods extends beyond concerns for mortality due to drowning. Flooding may also result in increased numbers of breeding sites for mosquitoes and consequently, an increased risk of exposure to their associated diseases such as malaria or dengue. It has also resulted in outbreaks of cholera in some African countries and has cut-off access to rural health clinics in Zambia and other facilities in Nigeria. , The South African countries of Mozambique, Zambia, Zimbabwe and Malawi have recently experienced floods as a result of heavy rains thereby swelling the Zambezi river, which runs through all the four countries. Nigeria has also witnessed similar flood episodes along the coastal states and the release of water from overflowing dams in some Northern states.
The tsunami (seismic disturbance of the ocean) earthquake of December, 2004 occurred simultaneously across two continents and affected 12 countries. More than 155,000 people were reported killed across Asia and Africa while millions have been injured and rendered homeless.  The disturbance was a low-frequency sound waves that emanate from a point in the earth's interior when sudden, rapid motion has taken place through a submarine earth movement or a volcanic eruption.
When earthquakes occur at night, it is, usually, more deadly. Similarly, earthquakes and building collapse typically cause traumatic injuries and deaths. Immediate public health action required following a flood, usually, include vector control, provision of potable water and the restitution of vital environmental health services. ,,
On the whole, morbidity that results from a disaster situation can be classified into four categories:
(ii) Emotional stress (psychological)
(iii) Epidemic of disease
(iv) Increase in indigenous diseases. 
Management of disasters and complex emergencies
The early 1970s were watershed years for public health in emergencies. The Biafran war in Nigeria, the cyclone in Bangladesh and the sweeping famines in Africa heavily engaged the public health community in trying to meet the need of the affected population. This period also saw the engagement of health care practitioners in the elaboration of international norms in ethics, human rights and humanitarian law in emergency setting. 
Broadly, the challenges facing disaster management in Africa include personnel, weak health system, mismanagement of scarce resources and political instability [Table 2]. Even where there is central coordinating body (for example the National Emergency Management Agency [NEMA] in Nigeria), there is little or no coordination of activities at state and local government or district levels and the affected communities.
|Table 2: Challenges and constraints to disaster management in sub-Saharan Africa|
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There are three fundamental areas of disaster management:
- Disaster response
- Disaster preparedness and
- Disaster mitigation.
Disaster impact and response
The impact of disaster on the community and the affected population can be unpredictable and overwhelming. A well-planned medical response, although important is just one component of a successful strategy for reducing mortality. Advance preparedness of local health care personnel in search and rescue operations and immediate emergency care are crucial for improving victims' survival. But in Africa, most countries lack this capability including hospital disaster preparedness plans. Studies of earthquakes in Turkey and China indicate that 2-6 hours after entrapment, <50% of persons who are buried under collapsed earthen buildings are still alive.  Thus, disaster planning is an enormous undertaking that requires the cooperation of the affected community, local and relevant government officials to devise a comprehensive strategy to meet the myriad needs created by major or structural damages and disruption of services - social, medical and economic. Most often when the impact also results in causalities (mass casualty incident/surge capacity), disaster planning becomes more difficult but then more important because it must incorporate sophisticated medical response. Disaster planning must be based on valid assumptions derived from the study of responses and drills in past disasters. The delivery of medical care in response to a catastrophe differs radically from the routine. In emergency medical care, response time is critical.  Medical resources, personnel, supplies and facilities are carefully allotted to provide the greatest good for the greatest number. Local hospitals and physicians are the initial sources of medical care after any major disaster. However, hospitals have been as vulnerable to the destructive power of disasters as the population they serve.  Uncertainty about the seismic vulnerability of hospitals raises important issues for physicians, emergency medical team, and disaster planners including the questions about the best strategies for evacuating hospital when the need arises. Many of these local hospitals are not equipped enough to handle the surge capacity as recent bomb last incidents in Nigeria has shown. There are a number of recurring problems that plague response to disasters. Often, they arise from lack of accurate information from previous experiences, poor understanding of response plan and the unique character of each disaster. Disaster response is a multidisciplinary activity and all the members involved in planning and response must understand fully the essential components of the response.
| Critical Areas|| |
Good communication is required to activate, coordinate and conclude disaster response. Enhancement of information systems is a major focus of activity that is driven by the need for hospitals to share information rapidly and efficiently with other public health authorities. Exchange of vital information including available beds, personnel, vehicles and supplies are a crucial component of the response of hospitals (surge capacity) to an emergency.  Information to the victims is also vital during mass casualty events (need to know what to do and where to go, relief tension and anxiety among victims and relatives). The relevant information regarding the disasters is passed on to public through popular media like television. The information to the next-of-kin is passed through display of victims' list on television or display boards at the hospitals as well as contact to dedicated phone numbers.  However, accessibility to the system should be based on a need-to-know basis, which ensures that appropriate agencies and personnel remain in the information loop and receive continued updates. Cellular telephone technology has so far been unreliable in earthquake situations. 
Logistics and supplies
Characterizing the health priorities in a disaster is less complex than overcoming logistic obstacles. Thus, in short-term, the public health needs of the surviving population are familiar: Water, sanitation, food, shelter and appropriate medical care administered to persons remaining in place and the thousands who are living in self-settled displaced communities.  World Health Organization (WHO) recommends a minimum usable floor space of 3.5 m 2 per person in an emergency. Fulfilling the immediate needs on such a massive scale requires resources and represents in large part, a challenge of logistics and coordination. 
Short-term interventions should focus on supplying the recommended 20 L of water per person per day and ensuring adequate, culturally appropriate sanitation facilities to avert outbreaks of cholera, dysentery and hepatitis A. New water sources should ideally be tested which can be done with local water authorities or the use of various kits from other agencies such as Oxfam.  Provision of 250 mg of soap per person per month for personal and domestic hygiene; control of vector-borne diseases (malaria, dengue and Lassa fever) through early treatment and mosquito-control measures and epidemic surveillance to detect the early appearance of communicable diseases are important public health measures to institute. Health education is also a vital component of sanitation programmes. The crowded situations in settlement camps are a "breeding ground" for communicable diseases and risk to health. The refugees need to be educated on hygienic practices concerning washing, water storage, defaecation and disposal. The promotion of good sanitation behavior should be a continuous process; so health education message should be simple and specific mainly focused on themes like health risks and practices that eliminate these risks. A rapid needs assessment must be carried out in order to identify needs and resources. The medical teams must work in tandem to ensure stock of critical items such as dressings, medicines, intravenous fluids and mobilization devices. Fortunately, in many regions affected by disasters, skilled local physicians have survived, so once their clinical practice sites can be restored to functionality and supplies can be delivered, medical services can be re-established.
Equally important is the long-term recovery and rehabilitation needs of the affected areas that may be poorly understood. This is another challenge to aid agencies and international organizations. It is easy to talk about the 3R's of disaster management (Relief, Reconstruction and Rehabilitation) on paper, but the reality is that this is neither simple nor a straightforward task. Relief agencies and organizations must rise above their individualistic perspectives and independent to work with local or national governments, communities and civic structures in reconstruction  and re-establishment of services, healthcare delivery systems and livelihoods. The restoration of livelihoods presents a major obstacle for long-term recovery as many of the affected communities already have high levels of poverty and misery. All activities must be organized and coordinated through the central/national disaster emergency agency (for example, NEMA in Nigeria).
This can be a "curse or a blessing" as personnel problem, include inevitable onslaught of volunteers that can hinder the response because they are neither knowledgeable nor trained. Their sheer number may create logistic problems as in the case of recent Dana plane crash in Nigeria,  [Figure 1]. However, if they are properly managed, they can accomplish a lot. Using local volunteers with special training and equipment to supplement the work of hospitals in providing initial medical care to disaster victims is not a new idea. Volunteer participation is a long-standing American tradition that can be relied on under disaster conditions.  Afghan volunteers without previous medical experience were able to deliver sophisticated medical care, including amputations and chest-tube insertions, even operating in caves by lantern light.  Rescue personnel, especially medical team, perform best at tasks that are similar to their day-to-day activities and thus leaders should assign them duties that are familiar and easily learned. Equally important, personnel must be able to respect others, recognize their ranks and jobs during rescue operations. Rescue personnel are reluctant to ask for rest, food and water breaks while the victims are in need. The physical and mental demands can be so great that even the strongest and most highly motivated cannot endure.  The operations officers must organize and enforce timely breaks during which personnel may be debriefed and updated, encouraged and also evaluated for stress reactions.
Search and rescue
Probably the most physically and emotionally demanding medical duty associated with disaster response is the search and rescue operations. , Most immediate help comes from uninjured survivors. It is not unusual for the rescue personnel, especially volunteers, physicians and nurses to enter a site and be stunned by the carnage and chaos , as the violent forces of a disaster ravage people and property indiscriminately. The rescue personnel must be properly prepared, or emotional trauma may render them ineffective.
Triage (French: Sorting) means categorization and distribution of casualties that establishes priorities and proper allocation of treatment.  There are several simple triage systems, the simple triage and rapid treatment system using the assessment of respiration, perfusion and mental status is a popular system to use. Most systems colour code or give a numerical value to each patient. ,,,
Triage is an ongoing process that occurs at various stages during a victim's medical care; it is based on the likelihood of survival given the resources available at the time. The approach provides maximum benefit to the greatest number of injured in mass casualty situation. At the disaster site, assess each patient's injuries, classify his/her conditions and designate priorities for treatment and extrication. Basic efforts to stabilize the patient's condition, confined to clearing of the airways and bleeding problems are administered during this first triage. When there are many victims (or trapped victims) rescue team may have to make difficult decisions about who should be treated first and who should be left unattended. Ideally, local health workers should be taught the principles of triage as part of disaster training. There is also need for periodic drills of personnel and volunteers. The final stage of the triage process for the casualties occurs in the hospitals though some hospitals may be destroyed or incapacitated by the disaster. Those remaining most be identified and alerted as early as possible so that they can prepare.
Finally, taking care of the dead is an essential part of 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 - removal from the disaster scene, shifting to mortuary and reception of bereaved relatives. The misconceptions that dead bodies spread epidemics during disaster are a myth.  Although there may be compelling cultural and religious incentives to bury or incinerate the dead quickly, there is no evidence that corpses contribute significantly to epidemics after a disaster. , The only situation in which handling corpses is a risk is during epidemics of infectious diseases such as cholera. Even in these situations, no reason exists to totally deprive families and relatives from honouring their dead if they follow certain precautions. ,
A well-planned and coordinated routing of patients requires available transportation and continuous communication between the disaster scene and the receiving hospitals. Typically, ground transportation is preferable, because rescue vehicles staffed with emergency personnel offer distinct advantages in the continuum of care. A few victims may require helicopters to be transported. The arrangement should ensure that patients are transported in a manner determined by triage. Occasionally, access to the victims may be a problem as recent floods in some parts of Nigeria  and Mozambique has shown.
The crucial role of epidemiologic methods in natural disasters was recognized in the 1970s and 1980s in studies after a series of massive catastrophes. ,
Many factors promoting communicable disease transmission interact synergistically in complex emergencies. These factors include mass population movements and resettlement in temporary shelters, overcrowding, environmental degradation, lack of safe water and poor sanitation and waste management. In 2012 alone, more than 2 million internally displaced persons due to massive floods were registered in Nigeria.  Additionally, the collapse or overwhelming of public health infrastructure and absence of health services hamper prevention and control programmes with consequent risk in vector-borne diseases - malaria, yellow fever and vaccine preventable diseases such as measles,  [Figure 2].
When infectious diseases occur after a disaster they tend to be endemic and common e.g. typhus in Burndi. So, when responding to disasters, it is vital to have reliable information on health needs of survivors. It is also crucial to have an early warning system for epidemics (epidemiologic surveillance). Data are obtained to identify and plan for the initial and evolving needs of the affected population, to detect epidemics and to prioritize interventions and importantly to investigate the quality, coverage and effectiveness of response and programmes. Basically, three types of data are obtained: (i) Rapid health assessment (initial overview of immediate effect and needs); (ii) surveys (focused assessments that gather population-based health data); and (iii) surveillance (ongoing, systematic gathering, analysis and interpretation of health data). Crude mortality rate and under-5 mortality rate are the most commonly reported mortality rates in complex emergencies. However, during epidemics, attack rates and case-fatality rates will need to be calculated. 
The major vaccines used in emergency situations are against measles, meningococcal meningitis, poliomyelitis and yellow fever. Measles immunization should be implemented immediately in all complex emergency situation if vaccine coverage rates are <90% and should not await a single case. Measles campaigns are one of the most cost-effective public health interventions  and where possible such campaigns should be combined with administration of Vitamin A. Measles accounted for 32% of case-fatality rate among children in Wad Kowli camp in the Sudan in 1985.  Cholera is re-emerging as a thread on the global public health and the number of reported cases worldwide is back at peak level observed two decades ago. Cholera-related morbidity and mortality are particularly high during humanitarian crises; Rwandan refugees in Goma (1994), Zimbabwe (2008-2009), Haiti (2011) and now Sierra Leone (2012). , Cholera and other water-related diseases may be partly controlled by improved water supply and provision of adequate, culturally appropriate sanitation facilities. The recent WHO strategy of stockpiling oral cholera vaccine for use in outbreak response as an adjunct to established prevention and control measures is a welcome development.
Food shortages due to breakdowns in storage and distribution system are exacerbated when large areas of land are unproductive through landmines, deliberate use of atrocities and terror as in Sierra Leone.  Complex emergencies are often characterized by a high prevalence of acute malnutrition (wasting and nutritional edema) and micronutrient deficiency. The earliest efforts to estimate the extent and severity of the problem of malnutrition occurred during the Nigerian civil war in Biafra, the famines in Ethiopia and among Cambodian refugees in Thailand. , The average minimum requirement for E for a population with typical developing country demographic profile is 2100 kcal per person per day.  In children, to calculate acute malnutrition weight-for-height (W/H) is better than weight-for-age which is more suited to longer-term growth monitoring and indicates stunting rather than acute malnutrition. The mid-upper-arm circumference (MUAC) is a useful rapid technique for assessing new arrivals and gives a rough estimate of nutritional status. However, care and training of the health personnel to conduct the exercise is required. Different agencies have used different cut-offs  of MUAC to indicate malnutrition but a meta-analysis  provided the following cut-offs: MUAC < 125 mm = global acute malnutrition (roughly equating to W/H of < 80% W/H or − 2 standard deviation [SD]); MUAC < 110 mm ± oedema = severe acute malnutrition (roughly equating to W/H < 70% or − 3 SD).
The general food ration should satisfy not only the population's nutritional requirements but also qualitative criteria of cultural acceptability, safety, digestibility, ease of preparation and storage. The air-dropping of humanitarian daily rations in militarized contexts  has been considered inappropriate in complex emergencies.
Some disasters give rise to increases in the populations of vectors or nuisance species usually insects or rodents. Floods may create new mosquito breeding sites in disaster rubble and stagnant pools. Malaria is one of the five leading causes of mortality in emergency situations. Others are diarrhoeal diseases, measles, acute respiratory infections and malnutrition. The vectors likely to be present in emergency settlements and diseases  they carry are shown in [Table 3].
|Table 3: Vectors and diseases likely to be present in emergency settlements|
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Examples of vector control interventions that have been implemented in complex emergencies include insecticide-treated nets (ITNs), indoor residual spraying for malaria and traps for tsetse flies. In malaria endemic areas of Africa, ITNs are the most effective public health intervention especially in young children, substantially reducing mortality by up to 60% and morbidity by 54% in trials in the Gambia. ,,
Emergency preparedness and response is a programme of long-term development activities whose goals are to strengthen the overall capacity and capability of a country to manage efficiently all types of emergency and bring about an orderly transition from relief through recovery and back to sustainable development.  The individuals are responsible for maintaining their wellbeing and disaster preparedness is an ongoing multi-sectoral activity. It forms an integral part of the national system responsible for developing plans and programmes for disaster management. It is essential for instance, to consider the healthcare delivery system and the public health infrastructure as an integrated whole in planning for, responding to or recovering from large-scale disasters. We can do better by applying lessons learnt from previous disasters to the planning for future events. Even though experience is the best teacher, basic science can and should form disaster policy.
This complements the disaster preparedness and response activities. It involves measures designed either to prevent hazards from causing emergency or to lessen the likely effects of emergencies. Among others, it includes flood mitigation works, land use planning and improved building codes. Medical casualties can be drastically reduced by improving the structural quality of houses, schools and other public infrastructures.
The "new" dimensions
Terrorism and use of WMD have arrived the continent of Africa with its attendant public health challenges. This will certainly overwhelm the already weakenedhealthcare infrastructures. HIV/AIDS was ignored for many years in complex emergencies, but in many African and some Asian countries, AIDS may be the major underlying cause of mortality. Depending on local epidemiological factors, complex emergencies may hinder or accelerate the transmission of HIV during the acute phase of the crisis. There is need for wider access to voluntary counseling and testing for HIV and appropriate care. Finally, three critical areas have emerged for intervention in complex emergencies; reproductive health, mental health and disaster training. In reproductive health, the minimum initial services package which includes condoms, universal precautions and designation of a reproductive coordinator has been a major advance in camp situations.  Mental health problems are a common consequence of disasters. The prevalence of posttraumatic stress disorder and depression has been reported to be very high among flooded populations. , Loss or injury to loved ones, separation, highly disrupted neighbourhoods and severely damaged property represent extreme stressors for many people. These pose even greater risks for children, adolescents and people with preexisting psychological or behavioural problems.Bereavement, property loss and social disruption may increase the risk of depression and mental health problems.  Unfortunately, globally, most regions have serious shortages of resources for addressing such problems. There is a need for introducing curriculum for disaster training at undergraduate medical and allied sciences levels. As communities become more vulnerable to disasters and political discontent leads to wars resulting in complex emergencies, training in risk reduction, preparedness and response has become necessary as well as addressing the root causes of the discontentment through dialogue, equity, social justice, accountability and transparency.
Disasters both natural and man-made and technological are now quite common occurrence in Africa. Most hospitals lack the capacity and capability for "medical surge capacity." Management of such disasters and complex emergencies is sub-optimal in the context of sustainable development.
| Conclusion|| |
All disasters are unique in that each affected region of the world has different social, economic and health backgrounds. At the background especially in the last few decades is the rapid rate of urbanization and increasing numbers of mega-cities. This rapid urbanization poses a challenge to environmental health because it creates conditions that increase human vulnerability to disasters. Most of this rapid urbanization has taken place in Africa against the background of a weakened public health care systems and social infrastructures. Medical responses as part of complex emergencies or disasters is a huge public health challenge that the medical personnel must be prepared to engage. Proper preparation and planning (EPR) enable the affected community and nation to deal better with the devastation and death in the wake of such situations. There is an urgent need for hospitals to have disaster management committee with a robust and flexible disaster management plan. Training in disaster management needs to be introduced into the curriculum of tertiary institutions in Africa.
| References|| |
Office of Foreign Disaster Assistance. Significant Disasters from 1990-1995 - World Disaster Report. Washington DC: Office of Foreign Disaster Assistance; 1996. p. 86.
Logue JN. Disasters, the environment, and public health: Improving our response. Am J Public Health 1996;86:1207-10.
Cieslak TJ, Lillibridge SR, Sharp TW, Christopher GW, Eitzen EM. Categorical public health sciences; Disaster preparedness and response. In: Wallace RB, Last JM. Maxcy-Rosenau-Last. Public Health and Preventive Medicine;2007.15 th
ed, McGraw Hill, New York-USA.
Wasley A. Epidemiology in the Disaster setting. Curr Issues Public Health 1995;1:131-5.
International Federation of Red Cross and Crescent Societies. World Disaster Report 1996. NY: Oxford University Press; 1996.
Lillibridge SR, Burkle FM Jr, Noji EK. Disaster mitigation and humanitarian assistance training for uniformed service medical personnel. Mil Med 1994;159:397-403.
Toole MJ. Mass population displacement. A global public health challenge. Infect Dis Clin North Am 1995;9:353-66.
Olapade-Olaopa EO. Developing disaster management strategies in Sub-Saharan Africa. Arch Ib Med 2006;7:79-84.
International Federation of Red Cross and Crescent. World Disaster Report; 2006.
Schultz CH, Koenig KL, Noji EK. A medical disaster response to reduce immediate mortality after an earthquake. N Engl J Med 1996;334:438-44.
United States Mission to United Nations. Global Humanitarian Emergencies. New York: ESCOC Section of the United States Mission to the United Nations; 1996.
Strade G. The horror of landmines. Sci Am 1996;274:40-5.
WHO-Medi-Link journal April 2008;9:12-3.
Daily Trust 2012;29:31-3.
Newswatch January, 17, 2005;40:222-8.
Lillibridge SR. Managing the environmental health aspects of disasters. Water, Human excreta and shelter. In: Noji EK, editor. Public Health Consequences of Disasters. New York: Oxford University Press; 1991. p. 65-78.
Park K. Disaster management. In: Park′s Textbook of Preventive Social Medicine. India: Banarsidas Bhanot; 2002. p. 568-73.
Leaning J, Gulia-Sapir D. Natural disasters, armed conflict and public health. N Engl J Med 2013;369:1836-42.
Schultz CH, Koenig KL, Lewis RJ. Implications of hospital evacuation after the Northridge, California, earthquake. N Engl J Med 2003;348:1349-55.
Berman MA, Lazar EJ. Hospital emergency preparedness-lessons learned since Northridge. N Engl J Med 2003;348:1307-8.
Supe A, Satoskar R. Health services responses to disasters in Mumbai sharing experiences. Indian J Med Sci 2008;62:242-51.
VanRooyen M, Leaning J. After the tsunami - facing the public health challenges. N Engl J Med 2005;352:435-8.
Howarth J. A minimum data set for emergencies. Africa Health/ODA: Health care in-depth-health care in unstable situations. Afr Health 1996;18:17-24.
Newswatch, June, 2 012;55:12-9.
Waeckerle JF. Disaster planning and response. N Engl J Med 1991;324:815-21.
Mitchell JT, Grady B, editors. Emergency Services Stress: Guidelines for Preserving the Health and Careers of Emergency Services Personnel. Englewood Cliffs, N.J.: Brady; 1990.
Floret N, Viel JF, Mauny F, Hoen B, Piarroux R. Negligible risk for epidemics after geophysical disasters. Emerg Infect Dis 2006;12:543-8.
Piarroux R. Cholera: Epidemiology and transmission. Experience from several humanitarian interventions in Africa, Indian Ocean and Central America. Bull Soc Pathol Exot 2002;95:345-50.
Daily Trust; December, 2012;31:16:14-5.
Rivers JPW, Holt JF, Seaman JA, Bowden MR. Lessons for epidemiology from the Ethiopian famines. Ann Soc Belg Med Trop 1976;56:345-60.
Connolly MA, Gayer M, Ryan MJ, Salama P, Spiegel P, Heymann DL. Communicable diseases in complex emergencies: Impact and challenges. Lancet 2004;364:1974-83.
Toole MJ, Waldeman RJ. Prevention of excess mortality in refugees and displaced populations in developing countries. JAMA 1990;263:3296-302.
Goma Epidemiology Group. Public health impact of Rwandan refugee crisis: What happened in Goma, Zaire, in July 1994? Lancet, 1995;345:339-44.
Martin S, Costa A, Perea W. Stockpiling oral cholera vaccine. Bull World Health Organ 2012;90:714.
37. Young H, Borrel A, Holland D, Salama P. Public nutrition in complex emergencies. Lancet 2004;364:1899-909.
Macrae J, editor. The New Humanitarians: A Review of Trends in Global Humanitarian Action. Humanitarian Policy Group Report 11. London: Overseas Development Institute; 2002.
Yip R, Scanlon K. The burden of malnutrition: A population perspective. J Nutr 1994;124:2043S-6.
Sklaver B. Humanitarian Daily Rations: The need for evaluation and guidelines. Disasters 2003;27:259-71.
Wisner B, Adams J, editors. Environmental Health in Emergencies and Disasters. Malta: World Health Organization; 2002.
42. Alonso, PL, Lindsay SW, Armstrong JRM, de Francisco FC, Shenton BM, Greenwood M et al
. The effect of insecticide treated bed nets on the mortality of Gambian children. Lancet, 1991:337:1499-02.
Graves PM, Brabin BJ, Charlwood JD, Burkot TR, Cattani JA, Ginny M, Paino J, Gibson FD, Alpers MP. Reduction in incidence and prevalence of Plasmodium falciparum in under 5 year old children by permethrin impregnation of mosquito nets. Bull World Health Organ 1987:65:869-77.
United Nations High Commissioner for Refugees. Reproductive Health in Refugee Situations: An Interagency Field Manual. Geneva: UNHCR; 1996.
Warraich H, Zaidi AKM, Patel K. Floods in Pakistan: A public health crisis. Bull World Health Organ 2011;89:236-7.
Telles S, Singh N, Joshi M. Risk of posttraumatic stress disorder and depression among survivors of the floods in Bihar, India. Indian J Med Sci 2009;63:330-4.
Redlener I, Reilly MJ. Lessons from Sandy-Preparing Health Systems for Future Disasters. New Eng J Med. December, 2012;367:2269-71.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]