Disaster Epidemiology Lessons From Bam

Earthquake Dec 26, 2003 Iran

Part 7: Health sector in Bam

earthquake A. Ardalan MD, MPH, PhD student in

Epidemiology1

Learning objectives:

To view the structure of health system in Bam

To understand the barriers of efficient health

services delivery in Bam

To learn about mental health interventions in Bam

To learn about surveillance system in Bam

To learn about health related concerns in Bam

2

Health

service

structure

Geographic

classification

Physical space

Instruments

Workforce composition

Duration of activities

Workforce tasks

Strategies for

service delivery

Workforce training

Volunteer peoples 3

Population movement after the earthquake

Zones

Earthquake-stricken area

4

Population Movement

Major concern and barrier for effective services delivery in Bam

1) Invasion of poor people from neighboring

areas to Bam

110,000

Population

before the

earthquake

40,000

Number of

death

90,000

Population at

the 1.5

months after the

earthquake

- = (?)

5

The most important reasons:

Poor environmental health condition of previous living

zone (85%)

Lack of accessibility to latrines (73%)

Recurrent referral of health personnel for census

(54%)

Being interested in being in front of their own

damaged house (49%)

Lack of sufficient environmental space for living (26%)

Population Movement

2) Changing living places inside the bam

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Water forsanitaryusage

Bath room Latrine Detergents

1th day

2nd day

3-5 days

> 5 days

7

Cumulative percent of the first time health services delivery to the earthquake-stricken households in Bam

till 20th days of post-disaster period

The overall satisfaction of the earthquake-stricken people from health services delivery

0%10%20%30%40%50%60%70%80%90%

Water forsanitaryusage

Bath room Latrine Detergents

High Moderate Low 8

The needs (expressed demands) of Bam earthquake-stricken households on 19th and

20th days of post-disaster periodBath room

74 %Food 69 %

Clothes 68 %

Heaters 62 %

Security 60 %

Latrine 49 %

Money 47 %

Others

9

10Addiction

10Irregular menstrual bleeding

13Movement disability

15Nausea / Vomiting

20 Oral & teeth problem

51Depression

60Acute respiratory infection

%IllnessIllness %

Suicide thought 5

Pregnancy 3

Low back pain 2

GI bleeding 1.5

Bloody diarrhea 1.5

Suicide attempt 1

The frequency of illnesses in the earthquake-stricken households till 19th and 20th days of

post-disaster period

10

29%26% 25%

23%20%

14%12%

0%

5%

10%

15%

20%

25%

30%

11

The needs (expressed demands) of Bam earthquake-stricken householdson19th and 20th days of post-disaster period

22%

15%

12%

9%7%

0%

5%

10%

15%

20%

25% Transportation

Unavailability of required servicesUnfamiliarity with health and medical centersDissatisfied from

previous servicesInappropriate

time

12

Main barriers in health services delivery in Bam earthquake-stricken households,

during first 20 days of post-disaster period

Some points about accommodation status of population

Determinants of aggregation places

Distances of tents

Risk of injuries

Cultural values

13

Social problems of earthquake-stricken households

in Bam till 20th days of post-disaster period

67%

56%

3%

0%

10%

20%

30%

40%

50%

60%

70%

Steeling Violance Sexual violance

Violence: Physical or psychological aggression 14

67%

14%9%

4%0.50%

6.00%

0%

10%

20%

30%

40%

50%

60%

70%

15

Substance abuse in Bam

Opium abuse

Prevalence before the earthquake: 30 % male, 5% female (anecdotal evidence)

Norm culture

A major problem in the treatment

of hospitalized patients

16

Opium odor

High price of

opium

Heroin

Injection

Low price of heroin

Lack of money

Security concern

Psychological

consequences

of earthquake

Unemployment

Inadequate withdrawal

services

17

Changing the pattern of substance abuse in Bam

Psychological Problems in Bam earthquake

A major consequence of disaster:

40% PTSD

Comprehensive Mental Health program by

Office of MH at MOH

MH and Social Working interventions

by State Welfare Organization

18

Mental health interventions in Bam

Office of Mental Health at Iranian MOH has

valuable experiences on MH interventions

in disaster situations, based on previous

earthquakes in Iran.

They are covering all population in Bam

by holding “Relief groups” to deal with

PTSD, Depression and Suicide.19

20

21

22

Between families had asked for news

about their relatives after the

earthquake and used from provided

list by governmental organization,

23% had found their response.

Public address system: Psychological importance

23

Mass Graves in Bam Myths and Realities

Political environment

Bad odor

Cultural beliefs

24

Current response

 Modify the

system

Collection of additional

data

Additional analyses

Disseminating the result

Further action

Evaluation the action

Iterative process

Surveillance System

25

Evaluation of Designing Steps of the Surveillance System in Bam

Establishment of objectives

Development of case definitions

Determining data sources

Development of data-collection instruments

Testing the field

Development and testing of analysis strategy

Development of dissemination mechanism

Usefulness assessment of system 26

Pre-requirements of Surveillance System in disasters

Stable health management in crises

EpidemiologicKnowledge

Well-trained field-team

Network communication system

27

28

Some comments on the Disease Surveillance System in Bam

Necessity of effective training program

Improving effective communication system, especially internet

Surrounding area should not be missed

Integration of a JIT Outbreak Investigation System

Using available data on referrals to clinics and health centers instead of the population for denominator of the indicators accompany by providing necessary information on referral pattern of people. 29

Future Potential Risk Factors of Outbreaks in Bam

Hot weather

Re-establishment of pipe-water supplies

Low access to bathing facilities and risk of pediculosis and other cutaneous diseases

Past history of epidemics of typhoid fever and cholera

Endemicity of malaria and coetaneous leshmaniasis 30

Final Conclusion of the lecture:

Bam earthquake was a major disaster,

resulting in mass destruction and a very

high toll on human lives and health.

These losses cannot be justified in light

of existing scientific knowledge and

expertise in disaster management. 31

Final Conclusion of the lecture:

The necessity of research-based

information and better multi-disciplinary

coordination was evident for more efficient

service deliveries to poor people.

Most of what can be done to mitigate

injuries must be done before an

earthquake occurs. 32

Final Conclusion of the lecture:

Because structural collapse is the single

greatest risk factor, priority should be given to

seismic safety in land-use planning and in the

design and construction of safer buildings.

The reconstruction of buildings according to

modern standards will take decades to

accomplish and will absorb a considerable part

of the country's resources.33

Final Conclusion of the lecture:

In disaster-prone areas, training and education in

basic first aid and rescue methods should be an

integral part of any community preparedness

program.

Better epidemiologic knowledge of risk factors

for death and the type of injuries and illnesses

caused by earthquakes is clearly an essential

requirement for determining what relief

supplies, equipment, and personnel are

needed to respond effectively to earthquakes. 34

Final Conclusion of the lecture:

The integration of epidemiologic studies

with those of other disciplines such as

engineering, architecture, the social

sciences and other medical sciences is

essential for improved understanding of

consequences following earthquakes. 35