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uilding Human Resilience he Role of Public Health Preparedness and Response As an daptation to Climate Change ark E. Keim, MD

bstract: Global climate change will increase the probability of extreme weather events, including heatwaves, drought, wildfire, cyclones, and heavy precipitation that could cause floods and landslides. Such events create significant public health needs that can exceed local capacity to respond, resulting in excess morbidity or mortality and in the declaration of disasters. Human vulnerability to any disaster is a complex phenomenon with social, economic, health, and cultural dimensions. Vulnerability to natural disasters has two sides: the degree of exposure to dangerous hazards (susceptibility) and the capacity to cope with or recover from disaster consequences (resilience). Vulnerability reduction programs reduce suscep- tibility and increase resilience. Susceptibility to disasters is reduced largely by prevention and mitigation of emergencies. Emergency preparedness and response and recovery activities—including those that address climate change—increase disaster resilience. Because adaptation must occur at the community level, local public health agencies are uniquely placed to build human resilience to climate-related disasters. This article discusses the role of public health in reducing human vulnerability to climate change within the context of select examples for emergency preparedness and response. (Am J Prev Med 2008;35(5):508 –516) Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine.

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limate Change and Extreme Weather Events

lobal climate change will increase the probabil- ity of extreme weather events1 (Table 1), which may be associated either with high precipita-

ion (i.e., storms, floods, and landslides) or with low recipitation (i.e., heat, drought, wildfire).1 These vents often overwhelm the capacity of communities nd local governments to respond, requiring outside ssistance. Such mismatches between needs and re- ources often result in declarations of disaster.

High-precipitation events, which are likely to in- rease in frequency, will compound the risk of flood nd landslide disasters. According to the UN Intergov- rnmental Panel on Climate Change (IPCC): “Many illions more people are projected to be flooded every

ear due to sea-level rise by the 2080s. In some areas eatwaves are expected to increase in severity and

requency, expanding drought affected areas.”1 In low- atitude regions, crop productivity is expected to de- rease, thus increasing the risk for hunger, particularly n Africa and small island developing States. “By 2020, etween 75 and 250 million people are projected to be xposed to an increase in water stress.”1

rom the National Center for Environmental Health, Agency for oxic Substances and Disease Registry, CDC, Atlanta, Georgia Address correspondence and reprint requests to: Mark E. Keim,

d D, NCEH, CDC, 4770 Buford Highway, MS-F29, Atlanta GA 30341-

724. E-mail: [email protected].

08 Am J Prev Med 2008;35(5) Published by Elsevier Inc. on behalf of American Journal of

he Public Health Impact of Extreme Weather Events

y 2008, the cost of natural disasters, in mortality and in ublic resources, had exceeded that of previous periods for hich data were available.2 In particular, climate-related hydrologic and meteorologic) hazards affected an increas- ng number of people and caused increasingly large eco- omic losses.3 Between 1970 and 1999, climate-related vents accounted for 90% of the world’s disaster-related atalities,2 with the world’s poor disproportionately affected.4

The literature thoroughly describes how climate change ffects natural disaster–related health risk.1,3,5–12 Determi- ants of population health, such as education, health care, ublic health prevention efforts, and infrastructure, play a ajor role in vulnerability and resiliency.1

Table 2 compares the public health emergencies asso- iated with the six climate-related hazards mentioned bove: storms, floods, landslides, heat, drought, and wild- re. Such disasters result in public health needs that often xceed local response capacity. This article focuses on the ve natural disasters other than heatwave, which is dis- ussed in detail elsewhere in this journal issue.13

uilding Human Resilience As an Adaptation to limate Change uman Vulnerability and Disaster Risk

he UN2 and the WHO3 define a disaster as “a serious

isruption of the functioning of a community or a

0749-3797/08/$–see front matter Preventive Medicine doi:10.1016/j.amepre.2008.08.022

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ociety causing widespread human, material, economic r environmental losses which exceed the ability of the ffected community or society to cope using its own esources.”14 Thus, the disaster consists of the interac- ion between the hazard and the vulnerability of those ffected, not the mere fact of the hazard’s occur- ence.15 For any given hazard, disaster risk varies ac- ording to a population’s vulnerability (e.g., age, gen- er, health status, SES).

isaster Risk Management

ecently, the international approach to emergencies nd disasters has shifted from largely post-impact activ- ties (i.e., ad hoc relief and reconstruction) to a more ystematic and comprehensive risk management pro- ess.16,17 As described by disaster experts Lisa Schipper nd Mark Pelling, “Disaster risk management includes oth pre-impact disaster risk reduction—prevention, reparedness, and mitigation—as well as ‘response and ecovery’ post-impact crisis management activities.”18

reparedness is defined as “activities and measures aken in advance to ensure effective response to the mpact of hazards.” Mitigation is the “structural and onstructural measures undertaken to limit the adverse

mpact of natural hazards, environmental degradation nd technologic hazards.”18 (This definition of mitiga- ion is not to be confused with “mitigation” used in the limate change context, which refers to reduction of reenhouse gas emissions.) Figure 1 provides an over- iew of the four phases of the disaster risk management ycle. These concepts are very applicable to climate hange.19

educing Human Vulnerability As an Adaptation to limate Change

itigation policies focus on reducing the hazard, either y controlling the emissions of greenhouse gases or by apturing and sequestering those emissions. Adapta- ion policies focus on reducing the vulnerability, by

able 1. Trends of extreme weather events predicted to occ

henomenon and direction f trend

Likelihood that the trend occurred in the late 20th century

ncreased incidence of heatwaves

66–90 (likely)

ncreased incidence of heavy precipitation events

66–90

ore areas affected by drought

66–90

ncreased incidence and severity of cyclones

66–90

ncreased incidence of extremely high sea levels

66–90

dapted from IPCC Working Group II Report. Impacts, Adaptation,

aking steps to make social and environmental systems o

ovember 2008

ore resilient to the effects of climate-related hazards. ffective climate policy necessarily requires a combina-

ion of mitigation and adaptation policies, although ublic support and funding for adaptation have been

imited.20

Reducing human vulnerability is a key aspect of educing climate change risk.18 The 2002 Yokohama trategy and Plan of Action for a Safer World led to a hange in the UN’s approach to mitigating disasters to reating human actions and vulnerabilities as the main auses of disasters.17

uman Resilience As a Means for ulnerability Reduction

any economists believe that measures directed to- ard the underlying macro-level causes of climate hange vulnerability should be broadly integrated nto development policy, not confined to climate hange adaptation strategies.21 Human vulnerability o disasters is a complex phenomenon that includes ocial, economic, health, and cultural factors. Vul- erability to natural disasters has two sides: the egree of exposure to dangerous hazards (suscepti- ility) and the capacity to cope with or recover from he consequences of disasters (resilience). Vulnera- ility reduction programs reduce susceptibility and

ncrease resilience. Susceptibility to disasters de- reases through activities such as prevention, and hrough mitigation measures that prevent or limit a opulation’s exposure to the hazard.22 Preparedness, esponse, and recovery activities all increase resil- ence. Resilience has two components: that provided y nature, and that provided through human action. n example of resilience provided by nature is the anner in which porous soil allows more rapid

rainage of flood water than more occlusive soil. An xample of human action that affects resilience is ocial organization that facilitates (or hinders) re- ponse and recovery. Disaster resilience is composed

a result of climate change (%)

kelihood of human ntribution to trend

Likelihood of future trends based on projections for 21st century

–66 (more likely than not) 90–99 (very likely)

–66 90–99

–66 66–90

–66 66–90

–90 66–90

ulnerability, 2007.1 www.ipcc.ch/ipccreports/ar4-wg2.htm

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Am J Prev Med 2008;35(5) 509

Table 2. The relative public health impact of the six natural disasters expected to worsen with climate change

Public health impact

High-precipitation events Low-precipitation events

Storms Floods Landslides Heat Drought Wildfire

Number of deaths Few, but can be many in low-income countries

Few, but can be many in flash floods

Few to moderate

Moderate to many in high-income countries

Few, but can be many in low-income countries

Few to moderate

Risk of an associated epidemic

Unlikely Unlikely, except for low-income countries

Unlikely Unlikely Unlikely, except for low- income countries

Unlikely

Severe injuries Few Few Few to moderate

Moderate to many cases of heat stroke

Unlikely Few to moderate

Loss of clean water Widespread Focal to widespread Focal Unlikely Widespread Focal Loss of shelter Widespread Focal to widespread Focal Focal to widespread Focal to widespread Focal Loss of personal and

household goods Widespread Focal to widespread Focal None Unlikely among

displaced populations Likely among displaced

populations Permanent migration Unlikely Unlikely Unlikely Unlikely Likely Unlikely Loss of sanitation Widespread Focal to widespread Focal Unlikely Likely among displaced

populations Likely among displaced

populations Loss of routine hygiene Widespread Focal to widespread Focal Unlikely Likely among displaced

populations Likely among displaced

populations Disruption of solid waste

management Widespread Focal to widespread Focal Unlikely Likely among displaced

populations Likely among displaced

populations Public risk perception High High High Moderate to high Moderate to high High Increased pests and vectors Widespread Widespread Unlikely Unlikely Possible Unlikely Loss and/or damage of

healthcare system Widespread Focal to widespread Focal Unlikely Unlikely Focal

Worsening of existing chronic illnesses

Widespread Focal to widespread Focal Widespread Widespread Focal to widespread

Toxic exposures Possibly air, water, food Possibly air, water, food

Possibly air, water

Possibly air Possibly water Likely air

Food scarcity Uncommon except in low-lying remote islands

Uncommon Unlikely Unlikely Common Possible

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city, and (3) response to the event and recovery from he damage sustained.22

uilding Resilience to Extreme Weather Events hrough Public Health Preparedness and esponse

daptation to disaster occurs at the community level. ublic health is uniquely placed at the community level o build human resilience to climate-related disasters. By focusing on vulnerability and the ability of individ- als and communities to recover (resilience), vulnera- ility reduction places the individuals at risk at center tage and tasks the responsible authorities with enhanc- ng social equity and promoting community cohesive- ess, alongside a heightened sense of individual re- ponsibility.”23 By promoting safety and health, public ealth works to reduce the pre-existing burden of isease, build social capital, and strengthen community esilience to a wide range of health hazards, including xtreme weather events. Community public health and medical institutions can

lay an active part in reducing human vulnerability to limate-related disasters through promotion of “healthy eople, healthy homes and healthy communities.”24

ealthy people are less likely to suffer disaster-related orbidity or mortality and are therefore more disaster-

esilient. Healthy homes are disaster-resilient; they are esigned and built to stay safe during extreme weather vents. Healthy “communities minimize exposure of peo- le and property to natural disasters. Sustainable commu- ities are disaster-resilient communities.”25 Public health

igure 1. A diagram of the disaster risk management cycle co above) to crisis-management measures (below)

reparedness and response activities build community m

ovember 2008

resilience and reduce hu- man vulnerability, includ- ing vulnerability to climate change.

Preparedness is defined as “activities and measures taken in advance to en- sure effective response to the impact of hazards.”26

Emergency response be- gins with the impact of an event. During a cyclone, flood, wildfire, or landslide event, the onset of the di- saster impact is quite clear; during times of drought, however, it may be more insidious. The re- sponse phase usually be- gins with ad hoc local emergency response fol- lowed some time later by a formal declaration of di- saster and external assis- tance and emergency relief.

esilience-Building Strategies for Extreme Weather vents Related to Climate Change rought

he public health impact of drought disasters. Drought s usually defined as a “period of abnormally dry weather hat is sufficiently prolonged so that the lack of water auses a serious hydrologic imbalance in the affected rea.”27 Ironically, very few people die of thirst or dehy- ration during a drought, even in low-income countries. rought-related deaths are generally secondary to the

gricultural, economic, and health effects of drought, uch as famine, malnutrition, poverty, poor public health ractices, contamination of existing water supplies, infec-

ious diseases, social strife, and heat-related illness.2 In ddition to increasing the likelihood of food insecurity nd famine, a drought can have catastrophic effects on he regional or national economy.28 The predominant sychosocial impacts of drought include decreased quality f life, major changes in lifestyle, and increasing conflict ver water resources.

reparing for drought-related public health emergen- ies. Public health preparedness for drought emergen- ies should begin with a risk assessment. This assessment hould focus on critical health needs such as food security, ater, sanitation, and shelter, as well as on the psychoso- ial, political, and economic impact of the drought. ccurate short- and long-term forecasting and early warn-

ng may improve preparedness and may guide develop-

ing risk-reduction measures

mpar

ent over the long term. Drought emergency plans

Am J Prev Med 2008;35(5) 511

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hould specifically include contingencies for long-term, ustained emergency operations, for an insidious onset and therefore a difficult-to-identify threshold for decla- ation and implementation of emergency measures), and or population displacement. Public education about lo- ally relevant water use, health risks, and behaviors that rotect health also represents a key component of public ealth preparedness. A well-established capability for ep-

demiologic investigation and disease surveillance can uide the need for evidence-based interventions.

esponding to drought-related public health emergen- ies. Public health responses to drought emergencies are deally based on locally developed plans, which in turn are ased on national and international guidance. The most ignificant risks for drought-related hunger, disease, and opulation displacement occur in low-income countries. uring a drought emergency response, the principal xpected interventions relate to the public need for:

food security safe water and adequate sanitation hygiene infection control in healthcare settings surveillance temporary shelter for displaced populations

In high-income countries, the economic impact from he higher cost of food and safe water will likely utweigh the direct risk of famine or epidemic, yet that

mpact will significantly hinder economic growth and evelopment. During other types of disasters, water hortages have been reported to affect a wide range of ospital services, including food preparation, environ- ental control, toilet availability, housekeeping, laun-

ry, infection control, renal dialysis, and fire safety.29

ildfire

he public health impact of wildfire disasters. Wildfire s defined as “a sweeping and destructive conflagration, specially in a wilderness or a rural area.”30 At the turn f the twentieth century, three major wildfire disasters ccurred in the U.S., each resulting in about 1000 atalities.31 Since that time, advances in information issemination, warning systems, and firefighting equip- ent and control capabilities have reduced wildfire-

elated mortality in the U.S. In 2007, California wild- res caused over $1 billion in damage, destroyed over 500 homes, and affected over 1 million people, yet ery few deaths and injuries were reported.32 As has also een the case for floods and cyclones, developed ations such as the U.S. have been able to achieve a onsiderable impact in reducing wildfire-related mor- ality through enhancement of local preparedness and esponse activities.

The public health impact of wildfires may include: i

12 American Journal of Preventive Medicine, Volume 35, Num

burn injuries exacerbations of chronic obstructive pulmonary dis- ease and asthma population displacement resulting in a need for humanitarian assistance that includes safe shelter, water and food, security, sanitation, and health care

In 1991, grass wildfires in Alameda County CA re- ulted in 26 deaths and �225 injuries.33 Emergency epartment records showed that more than twice as any people sought treatment for smoke-related prob-

ems as for other traumatic injuries.34

reparing for wildfire-related public health emergen- ies. The first step in a community-based risk assess- ent for wildfire should be a fire hazard evaluation. oreover, emergency plans that detail the local, state,

nd federal responses to wildfire should incorporate his risk assessment. Once developed, the plans should e validated through regularly scheduled exercises and rills. These plans and exercises should include contin- encies for population evacuation and for mass care nd shelter. The public should be educated as to the otential risk of wildfire and, in the case of a wildfire isaster, what protective steps to take (i.e., evacuation r shelter-in-place). Further studies are needed to

dentify risk factors for short- and long-term wildfire- elated morbidity and mortality and to establish best ractices for public health risk management of wildfire isasters.

esponding to wildfire-related public health emergen- ies. Immediately after the disaster-impact phase, rapid eeds assessments of an affected community are con- ucted to identify gaps among health, medical needs, and vailable resources. Mass casualties are very rare in the ase of wildfires, especially in high-income countries. To nsure safe and healthy living conditions, public health is ften involved in shelter and resettlement decisions. Pub-

ic health also plays a role in healthcare delivery, in nspections of food, in air safety and water quality, and in ssessment of sanitation and hygiene in mass-care shelters. f wildfire threatens manufactured hazardous materials, ublic health may also be called upon to perform hazard isk analysis or to promote the occupational health and afety of responders. Also, health-related public informa- ion campaigns can encourage family-based prepared- ess, inform vulnerable populations, and promote evacu- tion preparedness.

loods

he public health impact of floods. Floods are defined s “the overflow of areas that are not normally sub- erged with water or a stream that has broken its

ormal confines or has accumulated due to lack of rainage.”35 Floods may be caused by natural processes hat are either fluvial (an abundance of rainfall, melt-

ng snow) or coastal (a hurricane-related storm surge,

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oastal inundation, or seismically induced tsunami) in rigin. Since tsunamis are not associated with climate hange, this article will not consider flooding from this ause. Worldwide, floods are the most common natural isaster— during the decade from 1996 to 2005 floods ccounted for 42% of all natural disasters.18 During hat same decade, 1.3 billion people were affected by oods, and over 90,000 of them died. That decade also

aw floods cause more damage than any other natural isaster, accounting for one third of all disaster-related osts.36

Public health impacts of flooding include:

damage to homes and consequent displacement of occupants compromised personal hygiene contamination of water sources disruption of sewage service and solid-waste collection injuries sustained during cleanup stress-related mental health and substance abuse problems deaths, mostly caused by drowning37

reparing for public health emergencies caused by ood. Meteorologic forecasting and early warnings ave decreased mortality from flash floods by �50%.38

imilarly, public health emergency response planning hould address key precautionary flood-related health ssues, such as those associated with potential loss of helter, sanitation, hygiene, and health care among ffected populations, as well as exacerbations of hronic disease, toxic exposures, mental illness, family iolence, and loss of healthcare services.37 Drills and xercises should include contingencies for population rotection as well as alert/notification systems for pub-

ic health and medical staff and for special populations. ublic health communications can encourage pre- aredness in the home, in schools, in the work place, nd at healthcare facilities; health communications can lso raise public awareness of evacuation routes, flood ones, and community response plans. Development of obust public health surveillance systems helps to pre- are for rapid needs assessments and for surveillance of ood-related morbidity and mortality. Power genera-

ors and water pumps are examples of equipment ommonly useful during flood emergencies. These evices help to maintain critical health and medical

nfrastructure, including public health departments, ospitals, nursing homes, schools, and outpatient linics.

esponding to flood-related public health emergen- ies. Some evidence indicates that the way a flood isaster response is handled by community and profes- ional agencies can have a significant effect on mental ealth outcomes, which in turn are strongly associated ith physical health.39 Strategies that minimize popu-

ation displacement and favor an early return of victims o

ovember 2008

o routine activities of daily living are known to lessen he health impact of flood disasters.

As a natural disaster evolves, the demands for environ- ental health services and consultation often rise.40 Al-

hough communicable disease outbreaks after flood di- asters are rare in the U.S., some potential disease ransmission does exist, and affected communities should herefore remain under close surveillance.41 Moreover, tudies of flood disasters have shown that outbreaks of accine-preventable diseases rarely result42; thus mass mmunization in absence of a documented outbreak iverts limited human resources and materials from other ore effective and urgent measures.42– 44 In preventing

otential spread of infectious disease by floodwaters, basic ules of hygiene and sanitation are far more important han are immunizations.45

In many parts of the world, floods are often followed y a proliferation of mosquitoes. The relationship etween flooding and vectorborne disease is complex. evere weather can either increase or decrease the ransmission of vectorborne illness.46 In the U.S. as ompared to other regions of the world, floods rarely esult in outbreaks of arboviral disease, which is attrib- table mostly to the relatively low prior prevalence of ectorborne diseases in the region.45,46 Furthermore, iven that most flood-related injuries are minor soft issue injuries, trauma care teams are usually not re- uired.40 Community-based primary care outreach ac- ivities are often necessary to overcome the barriers to ealthcare access encountered by flood victims. During ood disasters, evacuation of special populations, such s those in hospitals, schools, prisons, and nursing omes, as well as migrants, tourists, and people with isabilities, can create the need for a major public ealth intervention.

ropical Cyclones

he public health impact of tropical cyclones. Tropical yclones are low-pressure weather systems that develop ver the warm waters of the oceans, typically between he latitudes of 30°N and 30°S.47 In the past 2 centuries, ropical cyclones have caused an estimated 1.9 million eaths worldwide, and 16 of the 18 deadliest occurred

n the Asia–Pacific region.36

Storm surge is the unusually high ocean level caused y pressure differentials and surface winds along coast-

ines in advance of a cyclone landfall. Absent early arning and evacuation measures, drowning from

torm surge can cause an estimated 90% of cyclone- ttributable mortality.47,48 In low-income countries ithout critical preparedness measures, storm surge emains the primary cause of mortality following trop- cal cyclones.49,50

Injury is the major cause of tropical cyclone morbidity.51

ome researchers have also noted an increased incidence

f animal and insect bites in the aftermath of tropical

Am J Prev Med 2008;35(5) 513

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yclones.52,53 However, the increased incidence of insect ites has not been associated with increases in vector- orne disease. Chronic diseases such as asthma and mphysema are exacerbated after tropical cyclones, as is a otential for exposure to hazardous substances—such as old— during cleanup and recovery efforts. Outbreaks of

nfectious diseases following tropical cyclones are rare, ut both waterborne and arthropodborne diseases have een reported in low-income countries.54 –57 As of yet, here is no clearly defined common etiology for this ncidence. Behavioral health effects are among the most ignificant long-term adverse health outcomes of tropical yclones.58 – 64

reparing for public health emergencies caused by ropical cyclones. Weather monitoring and forecasting re clearly essential components of an early warning ystem for cyclones. Accurate weather monitoring and arly warning allow for timely implementation of a safe vacuation, thus preventing drowning—the leading ause of cyclone death. Emergency operations plans hould take into consideration the priority public ealth needs experienced after cyclones, which most ften include at-risk population evacuation and provi- ion of adequate shelter, as well as food, water, sanita- ion, and health care. Public education can encourage reparedness in the home, in schools, at the workplace, nd at healthcare facilities. Such education can raise ublic awareness of evacuation routes, storm surge, and iverine flood zones, and community response plans. It an also assist in development of public health surveil- ance assistance when preparing rapid needs assess-

ents and when conducting post-impact surveillance of yclone-related morbidity and mortality. With regard to quipment, power generators are critical for maintain- ng health and medical infrastructure, such as public ealth departments, hospitals, nursing homes, schools, nd outpatient clinics.29

esponding to public health emergencies caused by yclones. The public health effects of cyclones are ostly secondary to the loss of access to shelter and

ervices (e.g., food safety, electricity, water sanitation, nd health care). In the event of population displace- ent and resettlement, public health is often called

pon to evaluate the need for these health and medical ervices, and possibly to deliver them. Health informa- ion systems and public health surveillance data moni- or the health and safety of the flood-affected popula- ions, as well as that of relief and recovery workers.41

In a cyclone’s wake, clinical care typically involves reatment of soft tissue injuries incurred during evacu- tion and cleanup, rashes, chronic disease and mental llness exacerbations, and self-limited respiratory and astrointestinal infections.37,65– 67 After cyclones, multi- ystem trauma is rare; thus, external assistance such as urgical ships or mobile hospitals is usually unneces-

ary. In absence of a documented outbreak or a mass p

14 American Journal of Preventive Medicine, Volume 35, Num

asualty event, public health interventions involving ector control, immunization, and trauma care are arely necessary and can divert limited human re- ources and materials from other, more effective and ore urgently needed measures.43,44,46 Research has

ndicated, however, that providing increased social upport after cyclone disasters can significantly lower llness burdens.39 Moreover, the appropriate use of ersonal protection equipment among disaster recov- ry workers can help to prevent toxic exposures from hemicals or mold.68

andslides (Debris Flows)

he public health impact of landslides. Landslides nclude all types of gravity-induced ground movements, anging from rock falls through slides/slumps, ava- anches, and flows, triggered mainly by precipitation including snowmelt), seismic activity, and volcanic ruptions.68,69 A debris flow is a rapidly moving mass of ater and material that is mainly composed of sand, ravel, and cobbles, but typically includes such items as rees, cars, and even small buildings. Most debris flows ave the consistency of wet concrete and move at peeds in excess of 35 miles per hour.70

Landslides occur in every U.S. state and territory. In he U.S. alone, landslides cost an estimated $1–$3 illion per year.71 Landslides are associated with high ates of traumatic injury and mortality, with mortality argely due to trauma and asphyxiation. Landslide

orbidity is generally associated with traumatic inju- ies, wound infections, and disruptions of water, sani- ation, and shelter, as well as disruption of the affected opulation’s locally grown food supply.72,73 Arthros- ores can be dispersed in dust clouds, as occurred uring landslides triggered by the 1994 Northridge arthquake in California, when an outbreak of 203 ases of coccidioidomycosis resulted.74 Debris flows ssociated with 1999 floods in Venezuela killed 30,000 eople, then came dangerously close to causing a azardous chemical release with the potential to affect 0,000 nearby residents, as well as that country’s largest irport and second largest seaport.75,76

reparing for public health emergencies caused by andslides. Rainfall monitoring, together with warning nd population evacuation, can reduce potential loss of ife due to landslides. Early warning systems based on eather forecasts and rainfall information can substan-

ially improve emergency warning for and evacuation of hreatened communities.70 In advance of heavy rains, ublic health information campaigns can communicate isk and protective behaviors. The public health commu- ity should become educated about hazard awareness, as ell as emergency preparedness and mitigation and re-

ponse measures.77 Public health can also play a part in

romoting development of safe and healthy communi-

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ies, where the terrain remains well-drained and stabilized hrough land use regulation and building codes.

Without early warning systems or evacuation and shel- er programs, landslides can cause high rates of traumatic njury and mortality.72 After the landslide occurs, it is ften too late for response activities to have a significant ffect on morbidity and mortality. Response operations ith the most potential to save lives and prevent injuries egin before the landslide—whenever heavy rainfall or lope instability is detected—with population evacuation nd temporary resettlement out of high-hazard zones.

In the immediate aftermath of a landslide disaster, the rst responses are life-saving search and rescue efforts and rst aid for immediate, life-threatening traumatic injuries. ccupational health and safety are also important con-

erns for landslide responders who work in and around nstable debris flows.77 In addition to injury, the public ealth effects of landslides are secondary to the popula-

ion’s loss of access to shelter and loss of public services, uch as food safety, electricity, water, sewer, and health are. After a landslide occurs, and especially in the event f population displacement, public health is often called pon to evaluate the need for, or to assist in, the delivery f health and medical services.

ummary

limate change is predicted to result in an increased umber of extreme weather events, including heatwaves, rought, wildfire, tropical cyclones, and heavy precipitation vents resulting in floods and landslides. The consequences f these events are expected to include significant public ealth needs, which in turn will necessitate disaster eclarations. Community-based risk-reduction activities lessen human

ulnerability to the vagaries of natural disasters, especially hose activities that integrate public health, disaster manage-

ent, and climate change. Sustainable adaptations to cli- ate change, along with community-based public health

reparedness and response activities, build human resilience nd lessen human vulnerability. Such local adaptation activ- ties are also enhanced by a supportive policy environment at he national and international levels.70

o financial disclosures were reported by the author of this paper.

eferences 1. Intergovernmental Panel on Climate Change. Climate change 2007: impacts,

adaptation and vulnerability. Contribution of Working Group II to the Fourth Assessment Report of the Intergovernmental Panel on Climate Change. Parry ML, Canziani OF, Palutikof JP, van der Linden PJ, Hanson CE, eds. Cambridge UK: Cambridge University Press, 2007. www.ipcc.ch/ipccreports/ar4-wg2.htm.

2. Center for Research on the Epidemiology of Disasters (CRED). EM-DAT: The International Disaster Database. Ecole se Sante Publique, Universite Catholique de Louvain. Brussels Belgium, 2005. www.emdat.be/.

3. Thomalla F. Reducing hazard vulnerability: towards a common approach

between disaster risk reduction and climate adaptation. Disasters 2006; 30:39 – 48.

3

ovember 2008

4. Munich Re Group. Annual review: natural catastrophes. Munich Re Group, Munich Germany 2002. www.munichre.com.

5. Van Aalst M. The impacts of climate change on the risk of natural disasters. Disasters 2006;30:5–18.

6. Mitchell J, Lowe J, Wood R, et al. Extreme events due to human-induced climate change. Phil Trans Soc A 2006;364:2117–33.

7. Woodruff R, McMichael T, Butler C. Action on climate change: the health risks of procrastinating. Aus and NZ J Pub Hlth 2006;30:567–71.

8. Woodruff R, McMichael T, Hales S. Climate change and human health: review of the evidence. Lancet 2006;367:859 – 69.

9. Huppert H, Sparks S. Extreme natural hazards: population growth, glob- alization and environmental change. Phil Trans Soc A 2006;364:1875– 88.

0. Zell R. Global climate change and the emergence/re-emergence of infec- tious diseases. Int J Med Microbiol 2004;293(37S):16 –26.

1. Parkinson A, Butler J. Potential impacts of climate change on infectious diseases in the Arctic. Int J Circumpolar Health 2005;64:478 – 86.

2. Morrissey S, Reser J. Natural disasters, climate change and mental health considerations for rural Australia. Aust J Rural Health 2007;15:120 –5.

3. Luber G, McGeehin M. Climate change and extreme heat events. Am J Prev Med 2008;35:429 –35.

4. WHO. Health Sector Emergency Preparedness Guide. Tazmania: WHO, Geneva. 1998.

5. deVille de Goyet C, Lechat M. Health aspects in natural disasters. Tropical Doctor 1976;6:152–7.

6. Clack Z, Keim M, Macintyre A, et al. Emergency health and risk manage- ment in sub-Saharan Africa: a lesson from the embassy bombings in Tanzania and Kenya. Prehosp Dis Med 2002;17:59 – 66.

7. UN ISDR World Summit on Sustainable Development. Geneva: UN, International Strategy for Disaster Reduction, 2002. www.worldsummit2002.org.

8. Schipper L, Pelling M. Disaster risk, climate change and international development: scope for, and challenges to, integration. Disasters 2006;30: 19 –38.

9. O’Brien G, O’Keefe P, Rose J, et al. Climate change and disaster manage- ment. Disasters 2006;30:64 – 80.

0. Bouwer L, Aerts J. Financing climate change adaptation. Disasters 2006;30: 49 – 63.

1. Watson R, Ackermann R. Poverty and climate change. Environment matters to the World Bank: annual review. Washington DC: World Bank, 2000.

2. de Boer J, Dubouloz M, ed. Handbook of disaster medicine. The Nether- lands: International Society of Disaster Medicine, 2000.

3. Werritty A. Sustainable flood management: oxymoron or new paradigm? Area 2006;38:16 –23.

4. Shobha Srinivasan LR, O’Fallon MA, Dearry A. Creating healthy communities, healthy homes, healthy people: initiating a research agenda on the built environment and public health. Am J Public Health 2003;93:1446 –50.

5. Beatley, Timothy. The vision of sustainable communities. In: Burby R, ed. Cooperating with nature. Washington DC: National Academy Press, 1998.

6. UN. Terminology: basic terms of disaster risk reduction. Geneva: UN, International Strategy for Disaster Reduction. www.unisdr.org/eng/library/ lib-terminology-eng%20home.htm.

7. Bailey G, Walker J. Heat related disasters. In: Hogan DE, Burstein JL, eds. Disaster Medicine. 2nd ed. Philadelphia: Lippincott, Williams and Wilkins, 2007.

8. Wilhite DA. Drought mitigation technologies in the United States: with future policy recommendations. International Drought Information Cen- ter technical report series 93-1, 1993.

9. Peters M. Hospitals respond to water lost during the Midwest floods in 1993: preparedness and improvisation. J Emerg Med 1996;14:345–50.

0. Merriam Webster Dictionary Online. www.m-w.com. 1. Sanderson L. Fires. In: Noji ER, ed. The public health consequences of

disasters. New York: Oxford, 1997;373–96. 2. Bolduan K. Outlook improves as firefighters make headway in wildfires.

CNN 2007 Oct 24. www.cnn.com. 3. Bedian K, Arcus A, Frankel-Cone C. Emergency medical response to the

Oakland-Berkeley Hills fire of October 1991. Sacramento CA: California Department of Health Services, 1994.

4. Shusterman D, Kaplan J, Canabarro C. Immediate health effects of an urban wildfire. West J Med 1993 Feb;158:133– 8.

5. Gunn SWA, Multilingual dictionary of disaster medicine and international relief. Dordrecht Nederlands: Kluwer Academic Publishers, 1990.

6. International Federation of Red Cross and Red Crescent Societies. World disaster report 2006. Bloomfield CT: Kumarian Press Inc., 2006:211– 8.

7. CDC. Tropical Storm Allison rapid needs assessment, Houston Texas, 2001. MMWR 2002;51:365–9.

Am J Prev Med 2008;35(5) 515

3

3

4

4

4

4

4 4

4

4

4

4

5

5

5

5

5

5

5

5

5

5

6

6

6

6

6

6

6

6

6

6

7

7

7

7

7

7

7

7

5

8. Poole J, Hogan D. Floods. In: Hogan D, Burstein J, eds. Disaster medicine. Philadelphia: Lippincott, Williams & Wilkins; 2007:214.

9. Tunstall S, Tapsell S, Green C, et al. The health effects of flooding: social research results from England and Wales. J Water and Health 2006;4:365– 80.

0. CDC. Morbidity surveillance following the midwest flood—Missouri, 1993. MMWR 1993;42:797– 8.

1. CDC. Outbreak of diarrheal illness associated with a natural disaster— Utah. MMWR 1983;32:662– 4.

2. CDC. Current trends flood disasters and immunization—California. MMWR 1983;32:171–2,178.

3. Malilay J. Floods. In: Noji ER, ed. The public health consequences of disasters. New York: Oxford University Press, 1997:287–300.

4. Noji E. Public health issues in disasters. Crit Care Med 2005;33:S29 –33. 5. Ivers LC, Ryan ET. Infectious diseases of severe weather-related and

flood-related natural disasters. Curr Opin Infect Dis 2006;19:408 –14. 6. CDC. Rapid assessment of vectorborne diseases during the midwest flood

United States, 1993 MMWR 1994;43:481–3. 7. Malilay J. Tropical cyclones. In: Noji EK, ed. The public health conse-

quences of disasters. New York: Oxford University Press, 1997:207–27. 8. CDC. Deaths associated with Hurricane Hugo—Puerto Rico. MMWR

1989;38:680 –2. 9. Chowdhury M, Choudhury Y, Bhuiya A, et al. Cyclone aftermath: research

and directions for the future. In: Hossain H, Dodge CP, Abed FH, eds. From crisis to development: coping with disasters in Bangladesh. Dhaka Bangladesh: University Press Ltd, 1992:101–33.

0. Diacon D. Typhoon resistant housing in the Philippines: the Core Shelter Project. Disasters 1992;16:266 –71.

1. Meredith JT, Bradley S. Hurricanes. In: Hogan DE, Burstein JL, eds. Disaster medicine. Philadelphia PA: Lippincott Williams & Wilkins, 2002:179 – 86.

2. CDC. Hurricanes and hospital emergency room visits—Mississippi, Rhode Island, Connecticut (Hurricanes Alicia and Gloria). MMWR 1986;34:765–70.

3. CDC. Morbidity and mortality associated with Hurricane Floyd—North Carolina. MMWR 2000;49:369 –72.

4. CDC. Needs assessment following Hurricane Georges—Dominican Repub- lic, 1998. MMWR 1999;48:93–5.

5. Guill CK, Shandera WX. The effects of Hurricane Mitch on a community in northern Honduras. Prehosp Disast Med 2001;16:124 –9.

6. WHO. The risk of disease outbreaks after natural disasters. WHO Chron 1979;33:214 –16.

7. Toole MJ. Communicable disease and disease control. In: Noji EK, ed. The public health consequences of disasters. New York: Oxford University Press, 1997:79 –100.

8. WHO. Psychosocial consequences of disasters: prevention and manage- ment. Report no. WHO/MNH/PSF/91.3. Geneva Switzerland: WHO, 1992.

9. Ursano RJ, Fullerton CS, McCaughey BG. Trauma and disaster. In: Ursano RJ, McCaughey BG, Fullerton CS, eds. Individual and community responses

to trauma and disaster: the structure of human chaos. Cambridge: Cam- bridge University Press, 1994:3–27.

16 American Journal of Preventive Medicine, Volume 35, Num

0. Krug EG, Kresnow M, Peddicord JP, et al. Suicide after natural disasters. N Engl J Med 1998;338:373– 8.

1. Keenan HT, Marshall SW, Nocera MA, et al. Increased incidence of inflicted traumatic brain injury in children after a natural disaster. Am J Prev Med 2004;26:189 –93.

2. Sattler DN, Preston AJ, Kaiser CF, et al. Hurricane Georges: a cross-national study examining preparedness, resource loss, and psychological distress in the U.S. Virgin Islands, Puerto Rico, Dominican Republic, and the United States. J Trauma Stress 2002;15:339 –50.

3. Caldera T, Palma L, Penayo U, et al. Psychological impact of the hurricane Mitch in Nicaragua in a one-year perspective. Soc Psychiatry Psychiatr Epidemiol 2001;36:108 –14.

4. Goenjian AK, Molina L, Steinberg AM, et al. Posttraumatic stress and depressive reactions among Nicaraguan adolescents after Hurricane Mitch. Am J Psychiatry 2001;158:788 –94.

5. Lutgendorf SK, Antoni MH, Ironson G, et al. Physical symptoms of chronic fatigue syndrome are exacerbated by the stress of Hurricane Andrew. Psychosom Med 1995;57:310 –23.

6. CDC. Morbidity and mortality associated with Hurricane Floyd—North Carolina. MMWR 2000;49:369 –72.

7. Lee LE, Fonseca V, Brett KM, et al. Active morbidity surveillance after Hurricane Andrew—Florida, 1992. JAMA 1993;270:591– 4.

8. CDC. Health concerns associated with mold in water damaged homes after hurricanes Katrina and Rita—New Orleans area, Louisiana, October 2005. MMWR 2006;55:41–5.

9. Varnes DJ. Slope movement types and processes. In: Schuster RL, Krizek RJ, eds. Landslides: analysis and control. Washington DC: Natl. Res. Council Transp Res Bd Spec Rpt 176;1978:11–33.

0. Cruden DM, Varnes DJ. Landslide types and processes. In: Turner AK, Schuster RL, eds. Landslides: investigation and mitigation. Washington DC: National Research Council Transp Res Bd Spec Rpt 247;1996:36 –75.

1. Larsen M, Wieczorek G, Eaton L, et al. Natural hazards on alluvial fans: the Venezuela debris flow and flash flood disaster. U.S. Geological Survey Fact Sheet 103-01. U.S. Department of the Interior. pubs.usgs.gov/fs/fs-0103- 01/fs-0103-01.pdf.

2. Keim M. Landslides. In: Ciottone G, ed. Disaster medicine. Philadelphia PA: Mosby-Elsevier; 2006.

3. UN Office for the Coordination of Humanitarian Affairs (OCHA), Tropi- cal Storm Chata’an, Federated States of Micronesia. OCHA Situation Report No. 2, July 16, 2004. www.pubs.er.usgs.gov.

4. CDC. Coccidioidomycosis following the Northridge earthquake—California, 1994. MMWR 1994;43:194 –5.

5. Keim M, Humphrey A, Dreyfus A, et al. Situation assessment report involving the hazardous material disaster site at LaGuaira Port, Venezuela. CDC Report to Office of Foreign Disaster Assistance, U.S. Agency for International Development, 2000.

6. Anonymous. Venezuela seeks contractors for hazardous cleanup. Hazard- ous Substances Spill Report 2000;3(2).

7. Segerstrom J. A dirty job: rescuers face the growing problem of debris flows,

mudslides and estuary rescues. Advanced Rescue Technology 2004:41–7.

ber 5 www.ajpm-online.net