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.
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.
Disaster Agents / Epidemiology of Disaster
Ø Primary Agents:
It includes falling of buildings, heat wind rising waters and smoke.
Ø Secondary Agents:
It includes bacteria and viruses that produce contamination or infection after the primary agent has caused injury or destruction.
· Primary or secondary agent will vary according to the type of disaster.
For example: - A hurricane with rising water can cause flooding and high winds, these are primary agents. The secondary agents would include damaged buildings and bacteria or viruses that thrive as a result of the disaster. In an epidemic the bacteria or virus causing a disease is the primary agent rather than the secondary agent.
Factors affecting disaster
In the epidemiological frame work as applied to disaster the host is human-kind. Host factors are those characteristics of humans that influence the severity of the disaster effect. Host factors include
Ø Immunization status
Ø Degree of mobility
Ø Emotional stability
1. Physical Factors
Weather conditions, the availability of food, time when the disaster occurs, the availability of water and the functioning of utilities such as electricity and telephone service.
2. Chemical Factors
Influencing disaster outcome include leakage of stored chemicals into the air, soil, ground water or food supplies.
Eg: - Bhopal Gas Tragedy.
3. Biological Factors:
Are those that occur or increase as result of contaminated water, improper waste disposal, insect or rodent proliferations improper food storage or lack of refrigeration due to interrupted electrical services.
Bioterrorism: Release of viruses, bacteria or other agents caused illness or death.
4. Social Factors:
Are those that contribute to the individual social support systems. Loss of family members, changes in roles and the questioning of religious beliefs are social factors to be examined after a disaster.
5. Psychological Factors:
Psychological factors are closely related to agents, host and environmental conditions. The nature and severity of the disaster affect the psychological distress experienced by the victims.
Phases of Disaster
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.
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.
Risk reduction phase before a disaster
Recovery phase after a disaster
Disaster impact and response
Medical treatment for large number of casualties is likely to be needed only after certain types of disaster. Most injuries are sustained during the impact, and thus, the greatest need for emergency care occurs in the first few hours. The management of mass casualties can be further divided into search and rescue, first aid, triage and stabilization of victims, hospital treatment and redistribution of patients to other hospitals if necessary.
Search, rescue and first aid
After a major disaster, the need for search, rescue and first aid is likely to be so great that organized relief services will be able to meet only a small fraction of the demand. Most immediate help comes from the uninjured survivors.
Most injured persons converge spontaneously to health facilities, using whatever tansport is available, regardless of the facilities, operating status. Providing proper care to casualties requires, that the health service resources be redirected to this new priority. Bed availability and surgical services should be maximized. Provisions should be made for food and shelter. A centre should be established to respond to inquiries from patient's relatives and friends. Priority should be given to victim's identification and adequate mortuary space should be provided.
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.
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.
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).
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.
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.
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:
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.
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.
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 Abuse-Physical, sexual (E.g. rape) or psychological
Ø Terrorist attack
Ø Prisoner of war
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 Proximity to the stressful event
Ø Resilince readily recovering from set backs.
8. High risk group for PTSD
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
“Hyper vigilance” - close attention to and anticipation of approaching
“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".
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
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.
Understanding the experience of stress
1. Behavioural symptoms
Ø Loss of interest in life
Ø Reduced activity, no energy
Ø Over activity and inability to rest (restlessness)
Ø Difficulty in concentration
Ø Sleep disturbances and problem
Ø Feel as though I cannot breathe
Ø Flash backs
Ø Taking intoxicants or drugs.
2. Physical symptoms
Ø Tense muscles
Ø Palpitation/irregular heart beat
Ø Poor appetite, pain in abdomen, vomiting sensation
Ø Unidentifiable pain in arms, leg, chest or all over the body.
3. Emotional symptoms
Ø Fear, vigilance & anxiety
Ø Helplessness, sadness and guilt
Ø Repeated thoughts about the same thing
Ø Moods keep changing - poor concentration, forgetfulness & suicidal thoughts.
Ø Relational changes - Disagreement and argument, unpleasantness, lack of emotion. Too much dependence on others for decisions and support
Understanding the stages of symptoms reactions:
Ø Immediately after the event, i.e. within few hours to a few days - Panic, tension, anxiety
Shock or numbness (like a robot)
Normal reaction: Outcry Denial Intrusion Working through Abnormal reaction: Overwhelmed panic/exhaustion
Extreme avoidance Flooded states
Relief, elation, euphoria among the survivors
Ø Survivors guilt
Ø Depression - restlessness, confusion, sleeplessness, repeated experiences of the events, nightmares and arousal symptoms may come up.
Ø As the days pass by (within 1 to 6 months) new reactions appear, these are seen in about 40-50% of the population in the form of
- lack of response to others
- inhibition of outward activity
- physical symptoms of anxiety
Ø Delayed reactions manifest after 6 months and may be seen as an intensification of the reactions seen earlier, in about 30% of the population
Other delayed reactions - Loss of productivity
Increased vulnerability to stress
Poor physical health
Role of rehabilitation:
1. Spectrum of care would cover issues related to
Housing and livelihood
Rights and justice
2. Role of CLH
Understanding the changes that they experience in their body & mind. Decreasing the physical emotional effects by listening, relaxation, external ization of interests and activities
Support and rebuild their sheltered lives in the areas of housing, work, health & community.
Ø Active listening
Ø Social support
Ø Externaliation of interests
Ø Life style choices
Ø Relaxation & recreation
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 Group participation for rebuilding efforts
Ø Sensitisation process
Rehabilitation of special groups:
1. Aged people can be helped by
Ø Keeping them with their near & dear ones
Ø Visiting them regularly & spending time with them
Ø Touching them & allowing them to cry
Ø Reestablishing their daily routines
Ø Making them feel responsible by giving them some work to carry out which is not too difficult
Ø Getting them involved in relief work by requesting for their suggestion & advice etc.
Ø Keeping them informed of positive news
Ø Attending to their medical ailments
Ø Organising small group prayer meetings.
2. Disabled people
Ø Removing them to places of safety
Ø Keeping them informed what is happening
Ø Getting them involved in activities
Ø Integrate them in group discussions
Ø Attend to their specific needs (wheel chairs, hearing aids)
Ø Helping them overcome their feeling of insecurity
Ø Taking cognizance of the fact that mentally challenged people, especially the women & children are vulnerable to sexual abuse, & help them.
Ø Help them to be with their families
Ø Keep informing them what is happening
Ø Involve them in activities
Ø Involving them in relief & rehabilitation activities
Ø Initiating self-help formation
Ø Involve them in recreation
Ø Making them to spend time with young widows or people who have lost their children & supporting them.
Ø Letting him/her to be close to adults who are loved & familiar
Ø Reestablishing some sort of a routine for them like eating, sleeping, Going for programs
Ø Actions like touching, hugging, reassuring them verbally
Ø Allowing them to take about the event
Ø Encourage them to play
Ø Involve them in activities like painting & drawing, where then can express their emotions.
Ø Organise story telling sessions, singing, songs and games.
Ø Praising coping behaviour
Ø Provide referral if required
Ø Spending time on their studies once they return to school.
Referral for any of these issues:
Ø Livelihood issues-procurement of materials & grants
Ø Children education needs, adoption or fostering & financial assistance
Ø Paralegal issues like compensation, reassessment of homes & FIRs
Ø Medical issues - health problem, special needs of crutches or pregnancy related issues
Ø Housing plans, like assessing & getting construction
Ø Women support group, like special needs of a material single parent who faced violence, rape victims
Ø Emotional issues
Disaster mitigation in health sector
Emergency prevention and mitigation involves measures designed either to prevent hazards from causing emergency or to lessen the likely effects of emergencies. These measures include flood mitigation works, appropriate land-use planning, improved building codes, and reduction or protection of vulnerable population and structures.
In most cases mitigation measures aim to reduce the vulnerability of the system. Medical casualties can be drastically reduced by improving the structural quality of houses, schools and other public and private buildings. Although mitigation in these sectors has clear health implications, the direct responsibility of the health sector is limited to ensuring the safety of health facilities and public health services, including water supply and sewerage systems. When water supplies are contaminated or interrupted, in addition to the social cost of such damage, the cost of rehabilitation and reconstruction severely strains the economy. Mitigation complements the disaster preparedness and disaster response activities.
Emergency preparedness 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. It should bring about an orderly transition from relief through recovery, and back to sustained development” (1).
The objective of disaster preparedness is to ensure that appropriate systems, procedures and resources are in place to provide prompt effective assistance to disaster victims, thus facilitating relief measures and rehabilitation of services.
The individuals are responsible for maintaining their well-being. Community members, resources, organizations, and administration should be the cornerstone of an emergency preparedness programme. The reasons of community preparedness are: (a) Members of the community have the most to lose from being vulnerable to disasters and the most to gain from an effective and appropriate emergency preparedness programme; (b) Those who first respond to an emergency come from within the community. When transport and communications are disrupted, an external emergency response may not arrive for days; (c) Resources is most easily pooled at the community level and every community possesses capabilities. Failure to exploit these capabilities is poor resource management; (d) Sustained development is best achieved by allowing emergency-affected communities to design, manage, and implement internal and external assistance programme (2).
Disaster preparedness is an on going multisectoral activity. It forms an integral part of the national system responsible for developing plans and programmes for disaster management, prevention, mitigation, preparedness, response, rehabilitation and reconstruction. The system, known by a variety of names depending on the country, depends on the coordination of a variety of sectors to carry out the following tasks (5):
1. Evaluate the risk of the country or particular region to disaster;
2. Adopt standards and regulations;
3. Organize communication, information and warning systems;
4. Ensure coordination and response mechanisms;
5. Adopt measures to ensure that financial and other ' resources are available for increased readiness and can ' be mobilized in disaster situation ;
6. Develop public education programmes;
7. Coordinate information sessions with news media; and
8. Organize disaster simulation excercises thai test response mechanisms.
The emergency preparedness and emergency management do not exist in a vaccum. To succeed, emergency programmes must be appropriate to their context. This context will vary from country to country and from community to community.
Policy development (2)
The policy development is “the formal statement of a course of action”. Policy is strategic in nature and performs the following functions:
a. establish long - term goals;
b. asign responsibilities for achieving goals;
c. establish recommended work practice; and
d. determine criteria for decision making.
While policies tend to be “top – down” that is authorized by higher levels, implementation of the strategies that arise from a policy tend to be “bottom-up”, with the higher levels assisting lower levels. The form of emergency preparedness policy varies from country to country. Six sectors are required for response and recovery strategies. These sectors are communication, health, social welfare, police and security, search and rescue and transport.
Personal protection in different types of emergencies (2)
In addition to considering action by rescuers, thought must be given to personal protection measures in different types of emergencies. Making people aware of what is expected of them in case of an emergency can make large difference to the organized management efforts. By taking precautions, the individual assists the collective effort to reduce the effects of an emergency.
A number of measures must be observed by all persons in all types of emergency:
- Do not use the telephone, except to call for help, so as to leave telephone lines free for the organization of response.
- Listen to the messages broadcast by radio and the various media so as to be informed of development.
- Carry out the official instructions given over the radio or by loudspeaker.
- Keep a family emergency kit ready. In all the different types of emergency, it is better:
- To be prepared than to get hurt;
- To get information so as to get organized;
- To wait rather than act too hastily.
What to do beforehand
While town planning is a government responsibility, individuals should find out about risks in the area where they live. For example, people who live in areas downstream from a dam should know the special signals (such as foghorns) used when a cam threatens to break. Small floods can be foreseen by watching the water level after heavy rains and regularly listening to the weather forecasts.
Forecasting of floods or tidal waves is very difficult, but hurricanes and cyclones often occur at the same time of year, when particular vigilance must be exercised. They are often announced several hours or days before they arrive.
During a flood
- Turn off the electricity to reduce the risk of electrocution.
- Protect people and property:
- as soon as the flood begins, take any vulnerable people (children, the old, the sick, and the disabled) to an upper floor;
- whenever possible, move personal belonging upstairs or go to raised shelters provided for use in floods.
- Beware of water contamination - if the taste, colour, or smell of the water is suspicious, it is vital to use some means of purification.
- Evacuate danger zones as ordered by the local authorities it is essential to comply strictly with the evacuation advice given. Authorities will recommend that families take with them the emergency supplies they have prepared.
After a flood
When a flood is over, it is important that people do not return home until told to do so by the local authorities, who will have ensured that buildings have not been undermined by water. From then on it is essential to:
- wait until the water is declared safe before drinking any that is untreated;
- clean and disinfect any room that has been flooded;
- sterilize or wash with boiling water all dishes and kitchen utensils;
- get rid of any food that has been in or near the water, including canned foods and any food kept in refrigerators and freezers;
- get rid of all consumables (drinks, medicines, cosmetics, etc.).
STORMS, HURRICANES AND TORNADOES
What to do beforehand
Above all, it is vital that people find out about the kinds of storm liable to strike their region so that they can take optimum preventive measures, and:
- choose a shelter in advance, before the emergency occurs - a cellar, a basement, or an alcove may be perfectly suitable;
- minimize the effects of the storm - fell dead trees, prune tree branches, regularly check the state of roofs, the state of the ground, and the drainage around houses;
- take measures against flooding;
- prepare a family emergency kit.
During an emergency
- Listen to the information and advice provided by the authorities.
- Do not go out in a car or a boat once the storm has been announced.
- Evacuate houses if the authorities request this, taking the family emergency package.
- If possible, tie down any object liable to be blown away by the wind; if there is time, nail planks to the doors and shutters, open the windows and doors slightly on the side opposite to the direction from which the wind is coming so as to reduce wind pressure on the house.
- If caught outside in a storm, take refuge as quickly as possible in a shelter; if there is no shelter, lie down flat in a ditch.
- In a thunderstorm keep away from doors, windows, and electrical conductors, unplug electrical appliances and television aerials. Do not use any electrical appliances or the telephone.
- Anyone who is outside should:
- look for shelter in a building (never under a tree);
- if out in a boat, get back to the shore;
- keep away from fences and electric cables;. .- - kneel down rather than remain standing.
After an emergency
After the storm has subsided:
- follow the instructions given by the authorities;
- stay indoors and do not go to the stricken areas;
- give the alert as quickly as possible;
- give first aid to the injured;
- make sure the water is safe to drink and check the contents of refrigerators and freezers;
- check the exterior of dwellings and call for assistance if there is a risk of falling objects (tiles, guttering, etc.).
What to do beforehand
The movement of the, ground in an earthquake is rarely the direct cause of injuries; most are caused by falling objects or collapsing buildings. Many earthquakes are followed (several hours or even days later) by further tremors, usually of progressively decreasing intensity. To reduce the destructive effects of earthquakes a number of precautions are essential for people living in risk areas:
- Build in accordance with urban planning regulations for risk areas.
- Ensure that all electrical and gas appliances in houses, together with all pipes connected to them, are firmly fixed.
- Avoid storing heavy objects and materials in high positions.
- Hold family evacuation drills and ensure that the whole family knows what to do in case of an earthquake.
- Prepare a family emergency kit.
During an earthquake
- Keep calm, do no panic.
- People who are indoors should stay there but move to the central part of the building.
- Keep away from the stairs, which might collapse suddenly.
- People who are outside should stay there, keeping away from buildings to avoid collapsing walls and away from electric cables.
- Anyone in a vehicle should park it, keeping away from bridges and buildings.
After an earthquake
- Obey the authorities instructions.
- Do not go back into damaged buildings since tremors may start again at any moment.
- Give first aid to the injured and alen the emergency services in case of fire, burst pipes, etc.
- Do not go simply to look at the stricken areas: this will hamper rescue work.
- Keep emergency packages and a radio near at hand.
- Make sure that water is safe to drink and food stored at home is fit to eat (in case of electricity cuts affecting refrigerators and freezers).
CLOUDS OF TOXIC FUMES
What to do beforehand
People in a risk area should:
- find out about evacuation plans and facilities;
- familiarize themselves with the alarm signals used in case of emergency;
- equip doors and windows with the tightest possible fastenings;
- prepare family emergency kits.
During an emergency
- Do not use the telephone; leave lines free for rescue services.
- Listen to the messages given by radio and other media.
- Carry out the instructions transmitted by radio or loudspeaker.
- Close doors and windows.
- Stop up air intakes.
- Seal any cracks or gaps around windows and doors with adhesive tape.
- Organize a reserve of water (by filling wash basins, baths, etc.).
- Turn off ventilators and air conditioners.
After an emergency
- Comply with the authorities' instructions and do not go out until there is no longer any risk.
- Carry out necessary decontamination measures.
MAN MADE DISASTERS
There are many disasters which have large elements of human causation either accidental or intended. These can also be divided into three categories, (a) sudden disasters such as Bhopal Gas Tragedy in India on 3rd December 1984 in which a leakage in the storage tank of Union Carbide Pesticide Plant released tons of methyl isocyanate into the air. Wind conditions and an atmospheric inversion, along with delayed warning and a population that had not been taught the nature of risks and the appropriate response increased the impact. About 2 million people were exposed to the gas leaving about 3000 dead. People are still suffering from the adverse effects of the gas. The second example is the accident at reactor 4 of the Chernobyl nuclear power station in the Soviet Union on April 26, 1986, which resulted in the largest reported accidental release of radioactive material in the history of nuclear power. It deposited more than 7 million curies of Iodine 131, Cesium 134 and 137, Strontium 90 and other isotopes throughout the northern hemisphere, (3); (b) Insidious disasters, such as insidious chemical exposure and insidious radiation exposure, as in nuclear weapons production factories, research laboratories resulting in release of radioactive substances into the air, soil and underground water. Chemical plants releasing their toxic by-products into rivers and other water sources is another example. Other form of long term and continuing human-made disaster include global warming (the “green house effect”) caused by the heat-trapping gases in the atmosphere released by burning of fossil fuels, and depletion of ozone layer due to the use of the aerosolized chlorofluorohydrocarbons etc. ; and (c) Wars and civil conflicts. The latest example is the attack on twin buildings of World Trade Centre in New York in which about 6000 people lost their lives and thousands were injured.
Since World War II, there have been about 127 wars and 21.8 million war-related deaths involving more than 50 per cent of civilians (3). Recently the proportion of civilians among dead has been increasing. Air-borne power and wide-ranging nature of modern war puts an entire population at risk, disrupting food production and supply routes, imperiling fragile ecosystem and forcing refugees by hundred of thousands to flee. More than half of the civilian deaths in current hostilities resulted from war-related famines. As for causes of most wars, most frequent objectives were gain of land assets, and independence. However, civil wars, representing power conflicts within nations, have increased sharply in the twentieth century, and are now, by far the major form of warfare.
The public health response to man-made disaster is the primary prevention, i.e., prevention of occurrence of the disaster. Much can be done to prevent not only the consequences but also the occurrences of fires, explosions, crashes, and sudden chemical and radiation exposures. This includes tighter regulations of chemical plants and other hazardous facilities and insistance that the chemical plants be built away from dense populous areas. Other measures include appropriate engineering and technological measures (like building codes, dam designs, containment of toxic materials), early warning, if possible, and protection against human errors.
During the first half of the twentieth century, two world wars and many regional conflicts provided the experience for governments, to develop civil defence programmes. They were reshaped after the introduction of nuclear weapons and massive air attacks occurring with little warning. Weapons of mass destruction are indiscriminate, killing and injuring civilians as well as military personnel, and destroying and contaminating ecosystem over wide areas. People around the world have turned towards efforts to stop the arms race and prevent nuclear war.
Disasters in India
With a wide range of topographic and climatic conditions, India is the highly disaster-prone country in Asia-Pacific region with an average of 8 major natural calamities a year. While floods, cyclones, draughts, earthquakes and epidemics are frequent from time to time, major accidents happen in railways, mines and factories causing extensive damage to human life and property.
Northern mountain regions, including the foot hills are prone to snow-storms, land slides and earthquakes. The eastern coastal areas are prone to severe floods and cyclones (Andhra Pradesh, West Bengal, Orissa, etc.). Bihar, Assam and Uttar Pradesh get major floods almost every year. Western desert areas are prone to draughts. There is hardly a year when some or the other part of the country does not face the spectre of drought, floods or cyclone. Orissa had super cyclone on 29th October 1999, when thousands lost their lives and many more became homeless. Gujarat had a severe earthquake in which about 16480 people died and lacs became homeless. More recently, Tsunami killed more than 200,000 persons in India in Dec. 2004 and major earthquake in Jamrnu & Kashmir (7.4 RS) left 2100 dead and 30,000 injured. India also saw world's worst man-made disaster in 1984, when methyl ifocyanate gas leaked at Union Carbide Pesticide Plant in Bhopal killing about 3000 people. People are still suffering from variety of diseases, as an after effect of this tragedy.
Some of the natural disasters and the effects they had on human population during 2000-2001 are shown in Table 2. During that period about 416.24 lac people were affected by natural disasters and about 19262 persons lost their lives (6).
Disaster impact in some states in India 2000-2001
Type of disaster
Population affected (000)
Human lives lost
Heavy rains/floods/land slides
In the federal structure of India, the state governments are responsible for the execution of relief work in wake of natural disasters. Government of India plays a supportive role, in terms of supplementation of final resources to the states. An administrative system has been developed to combat and minimize the adverse impact of the natural disasters. At the centre, the Ministry of Agriculture is the nodal ministry for coordination of all activities during a natural disaster. Since health is an important part of disaster management, in the DGHS under the ministry of Health and Family Welfare there is a special wing called the Emergency Medical Relief Wing which coordinates all activities related to health.
In a vast country like India, it is not practicable for the government machinery alone, to undertake disaster reduction programmes without involvement of NGOs. Public education and community involvement plays a vital role here. As part of the International Decade for Natural Disaster Reduction activities, every year, the second Wednesday of October has been designated as World Disaster Reduction Day.
Indian Meteorological Department (IMD) plays a key role in forwarning the disaster. It has five centres in Kolkata, Bhubaneshwar, Vishakhapatnam, Chennai and Mumbai for detection and tracing of cyclone storms. Satellite imagery facilities and cyclone warning radars are provided to various Cyclone Warning Centres. In addition, it has 31 special observation posts set up along east coast of India. For all ships out at sea, warnings are issued six times a day. Insat Disaster Warning System (DWS) receivers have been installed primarily in the coastal areas of Tamil Nadu and Andhra Pradesh. This has proved very reliable for.n of communication system. The Snow and Avalanche Study Establishment (SASE) in Manali has been issuing warning to people about avalanches 24 to 48 hours in advance.
MAN MADE DISASTERS INTERNATIONAL AGENCIES PROVIDING HEALTH HUMANITARIAN ASSISTANCE
Every country is a potential source of health humanitarian assistance for some other disaster-striken nation. Bilateral assistance, whether personnel, supplies or cash is probably the most important source of external aid. Several international or r regional agencies have established special funds, procedures and offices to provide humanitarian assistance. United Nation's Agencies are United Nations Office for the Coordination of Humanitarian Affairs (OCHAj, World Health Organization (WHO), UNICEF, World Food Programme (WFP), Food and Agriculture Organization (FAO). Inter-governmental organizations are European Community “Humanitarian Office (ECHO), Organization of American States (OAS), Centre of Coordination for Prevention of Natural Disasters in Central America, Caribbean Disaster Emergency Response Agency. Some Non-Governmental Organizations are CARE, International Committee of Red Cross, International Council of Voluntary Agencies (1CVA), International Federation of Red Cross and Red Crescent 2 Societies (IFRC) etc.
Disaster nursing refers to nursing services offered to the victims of disaster who experiences trauma caused by disaster Disaster produce several kinds of trauma.
a. Physical - Fractures, burns, injuries and infections.
b. Physiological - Shock and electrolyte imbalance
c. Psychological- Anxiety, depression, substance abuse, stress
d. Socio-economic- Unemployment, Homelessness, Environmental
The Symptoms related to Trauma Produced by disaster usualfy occurs in Five Phases.
a. Impact Phase: It includes event iself and is characterized by shock, extreme
b. Heroic Phase: Characterized by co-operative spirit exist between friends, neighbour and emergency teams. Constructive activity at this time can help to overcome feelings of anxiety and depression.
c. The honeymoon phase: It begins to appear one week to several months after the disaster, the need to help others is sustained, and the money, resources and support received from varying agencies allow life to begin again in the community.
d. Disillusionment phase: It last from two months to one year._ A time of disappointment, resentment, frustration and anger. Victims often begin to compare their neighbors with their own and may start to resent or show hostility towards others.
e. Reconstruction and reorganization phase: In this individual recognize that they must adjust with their own problems. They begin to rebuild their homes, business and lives in constructive fashion. This ... period may last for year after the disaster.
Ø Nurse along with the health team needs to utilize primary health care intervention in acute emergencies as follows:-
· Nursing Management
· Immunization and preventive health
· Management of diarrheas and dehydration.
· Management of acute respiratory infections.
· Setting up a health information system.
· Safe drinking water supply.
· Training and support for health workers.
· Other basic services.
In addition to above the following psychosocial intervention are provided by the nurses:
· Crises intervention / counseling
· Group work
· Telephone contact services.
· Disaster response managements
· Health education
· Community services like facilitation of self help groups etc.
Community measures in Disaster
Pre disaster phase, appropriate management of disaster requires advance planning. A nurse should be the part of the team for disaster planning.
a. Community Participation: It is the process by which individuals, families and communities assume the responsibility of promoting their own health and welfare. The community heath nurse maintains the link between professional group pf experts in disaster management and community.
b. Mock trails/training: The training of various inter-disciplinary forces like school children, voluntary organizations can be imparted by community health nurse and her team,
c. Mass awareness: The community should have the knowledge of all the Channel communication system, stand by equipment supplies and other resources; otherwise disaster preparedness will be failure.
d. Education: Mass awareness through media, booklets, panel discussion, films and televisions information is very essential.
Basic community Education should incorporate the following essentials:
a. Setting up the first aid post
b. Causality evaluation
c. Basic hygiene and sanitation
d. Safety measures
e. Maintenance of food and water supply
f. Maintenance of law and order.
g. Provision of shelters
h. Rescue streaming
i. Significance of traffic control and communication
j. Use of fire services
k. Hazards of radiation and preventive measures
l. Prevention of future disasters.
m. Grant in aid
Disasters are of different types which can happen any time ,any where, in the world causing tremendous after effects such as loss of human life ,economical imbalances, food scarecity epidemics , forced relocation of population etc. Disasters usually affect the developing countries comparing with the developed countries. While deserting the matter we could come to the conclusion that the adverse effects of natural disasters can be minimized by proper preventive measures alert technologies at high risk areas, proper mobilization of resources, decreased corruption in the field and also the mock training programmes in the community.
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2.Alexander,David;PRINCIPLES OF EMERGENCY PLANNING AND MANAGEMENT;2002;harpenden;Terra publishing;pp 1-1036.
3.Haddow,George D;Jane A Bullock;INTRODUCTION TO EMERGENCY MANAGEMENT;Amsterdam;Butterworth-Heinemann;pp 6-194.
4.WHO;COPING WITH NATURAL DISASTERS,THE ROLE OF LOCAL HEALTH PERSONNEL AND THE COMMUNITY;1989;WHO publishing;pp 10-225.
5.Maxy,R,Last;PUBLIC HEALTH AND PREVENTIVE MEDICINE;1992;13th edn;Massattussette;Mosby Inc;pp214-268.
6.WHO;COMMUNITY EMERGENCY PREPAREDNESS A MANUAL FOR MANAGERS AND POLICY MAKERS;1999;2nd edn;Geneva;WHO;pp 3-331.
1.Walker,Peter;International search and rescue teams,A league discussion paper;geneva;League of the Red Cross and Red Crecent societies;28:37:1998.
2.Singh J;72 hours kits,an article from home security guru;Indian Journal of public health;20:43:2002.