CJ455

January – March 2002 http://pdm.medicine.wisc.edu Prehospital and Disaster Medicine

SPECIAL REPORT

Abstract The prediction of future disasters drives the priorities, urgencies, and per- ceived adequacies of disaster management, public policy, and government funding. Disasters always arise from some fundamental dysequilibrium between hazards in the environment and the vulnerabilities of human com- munities. Understanding the major factors that will tend to produce hazards and vulnerabilities in the future plays a key role in disaster risk assessment.

The factors tending to produce hazards in the 21st Century include pop- ulation growth, environmental degradation, infectious agents (including biological warfare agents), hazardous materials (industrial chemicals, chem- ical warfare agents, nuclear materials, and hazardous waste), economic imbalance (usually within countries), and cultural tribalism. The factors tending to generate vulnerabilities to hazardous events include population growth, aging populations, poverty, maldistribution of populations to disas- ter-prone areas, urbanization, marginalization of populations to informal settlements within urban areas, and structural vulnerability.

An increasing global interconnectedness also will bring hazards and vul- nerabilities together in unique ways to produce familiar disasters in unfa- miliar forms and unfamiliar disasters in forms not yet imagined. Despite concerns about novel disasters, many of the disasters common today also will be common tomorrow.

The risk of any given disaster is modifiable through its manageability. Effective disaster management has the potential to counter many of the fac- tors tending to produce future hazards and vulnerabilities. Hazard mitigation and vulnerability reduction based on a clear understanding of the complex causal chains that comprise disasters will be critical in the complex world of the 21st Century.

Arnold JL: Disaster medicine in the 21st Century: Future hazards, vulner- abilities, and risks. Prehosp Disast Med 2002;17(1):3–11.

Department of Emergency Medicine, Baystate Medical Center, Tufts University School of Medicine, Springfield, Massachusetts USA

Correspondence: Jeffrey L. Arnold, MD Department of Emergency Medicine Baystate Medical Center Tufts University School of Medicine Springfield, MA 01199 USA Email: [email protected]

Keywords: 21st Century; 9-11; aging population; Amazon; anthrax letter attack; anthrax; armed conflict; Bhopal; biological warfare agent; chemical dis- aster; chemical warfare agent; Chenobyl; civil war; complex emer- gency; cyclone; deforestation; disaster medicine; Disaster; disaster-prone; drought; earthquake; economic; El Nino; environmental degradation; flood; future; global warming; global- ization; hazard; hazardous material; hazardous waste; industrial chemical; infectious disease; influenza; informal settlements; interconnectedness; Iraq; landslide; Love Canal; maldistribution; marginalization; Minamata; natural disaster; nuclear disaster; nuclear mate- rial; nuclear release; nuclear terrorism; nuclear waste; nuclear weapon; pan- demic; plague; population density; pop- ulation growth; poverty; proliferation; risk assessment; risk; sarin; smallpox; structural vulnerability; terrorism; Tokyo subway; tribalism; urbanization; volcano; vulnerability

Abbreviations: BWA = biological warfare agents HSEE = hazardous substance emer-

gency events

Disaster Medicine in the 21st Century: Future Hazards, Vulnerabilities, and Risk

Jeffrey L. Arnold, MD

Presented at the 6th Asian-Pacific Conference on Disaster Medicine, Fukuoka, Japan, 19–22 February 2002

Received: 03 March 2002 Accepted: 28 March 2002 Web Publication: 09 August 2002

Introduction With the new century only in its sec- ond year, the world already has wit- nessed the largest coordinated terrorist attack in modern history in New York City and Washington, DC, which left 3,082 dead or missing and untold thousands seeking emergency care.1,2 On its heels came the anthrax letter attacks in the eastern US, the largest bioterrorist attack to date, which

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4 Disaster Medicine in the 21st Century

Mexico), the total world population is estimated to jump from 5.7 billion in 1995 to 9.3 billion in 2050.16–18 An expanding world population will cause more environmen- tal stress, consume more resources, create more and larger human settlements, and produce more socioeconomic pres- sures to coexist.17,19,20 Accordingly, there will be more nat- ural and anthropogenic disasters of every type, as well as some not yet imagined.

2. Environmental Degradation Another factor tending to produce hazards in the 21st Century is environmental degradation, which parallels population growth, and is due largely to unchecked human activity. Global warming, one of the most serious forms of environmental degradation, impacts large regions, if not the entire planet.17,21–24

3. Global Warming Global warming has two primary causes: 1) over-produc- tion of greenhouse gases due to fossil fuel consumption; and 2) under-absorption of carbon dioxide from a shrink- ing global carbon sink.17,22 The net result has been an increase in the global mean surface temperature of 0.2–0.6°C over the last century.22,24 Furthermore, the warming appears to be accelerating — the 1990s were the warmest decade ever recorded, 1998 was the warmest year ever, and 2001 was the second warmest year ever.24

Global warming has been accompanied by increased rainfall in mid to high latitude countries, with many instances of flooding, and increased frequency and intensi- ty of droughts in parts of Asia and Africa.17,22 In addition, since the 1970s, the El Niño phenomenon has become more frequent, intense, and persistent.22,25 In 1997–1998, El Niño was associated with at least 22 natural events that resulted in disasters including several floods in South America and droughts and vegetation fires in Indonesia.21

By 2100, the mean value for the global surface temper- atures is expected to rise another 1.4–5.8°C, not only increasing the risk of extreme weather events, but also rais- ing the mean value for global sea levels by at least 9.88 cm, if not higher.22,24,26 The areas most vulnerable to inunda- tion from a rising sea level include the Nile delta, the Ganges-Brahmaputra delta in Bangladesh, and many small island states, particularly in Micronesia.22,23 In these and other low-lying areas, fresh water supplies may be compro- mised, food production undermined, and disease-causing insect vector populations (e.g., mosquitoes) redistributed to highland areas with weak public health infrastructures and lower levels of herd immunity (e.g., East Africa, Papua New Guinea).22

4. Deforestation Deforestation, another serious form of environmental degradation, is occurring at an alarming pace in many regions of the world.17,27,28 For example, during the past 30 years, the Brazilian portion of Amazonia (the world’s largest tropical forest) has been disappearing at the rate of 0.5% per year.28 Deforestation not only leads to global warming (through the burning off of forests and the loss of carbon fixation capacity), but also causes soil erosion,

resulted in five deaths, and >32,000 persons being placed on prophylactic antibiotics.3–7 Are these events just ran- dom blips in the historical record, or are they portents of catastrophe to come? Can we find a dangerous trend in just two instances? Can we find reassurance in the fact that even larger events did not occur? Can we possibly predict what types of disasters the 21st century will bring?

These questions are not merely academic. Predicting the future drives national and international public policy, government legislation, and the distribution of enormous sums of public money.8 For example, in requesting $11 bil- lion for biodefense in 2003–2004,4 the Bush administra- tion has weighed in with its answer to the question of whether bioterrorism will be a future threat.9 From the perspective of disaster management, predicting the future drives the urgencies of disaster mitigation, the perceived adequacies of disaster preparedness and planning, and the priorities for disaster response.

With so much at stake, how can we possibly begin to know the future? To understand the next century of disas- ters, we must begin by understanding exactly what is a dis- aster. According to Gunn, a disaster results from “a vast ecological breakdown in the relations between man and their environment, a serious and sudden event (or slow, as in a drought) on such a scale that the stricken community needs extraordinary efforts to cope with it, often with out- side help or international aid”.10 This suggests that disasters are the consequence of some fundamental dysequilibrium between various phenomena or hazards encountered by human populations and the resistance of human populations to these hazards. Whenever the hazard is too great or the resistance too low, then a disaster seems to occur. This trade- off between hazards and vulnerabilities not only defines individual disasters, but presages future risk.11–15 If we want to embark on the slippery task of disaster risk assessment, then we must have a firm grip on future hazards and vulner- abilities.

Thus, the question about what types of disasters will occur in the 21st Century must be subdivided: What fac- tors will tend to produce the hazards in the 21st Century (natural and anthropogenic)? And equally important, what factors will tend to produce vulnerabilities to hazardous events? Each of these questions must be considered, and their answers ultimately must be integrated into the larger framework of future risk.

Factors Likely to Produce Hazards The 10 factors that are most likely to produce hazards dur- ing this 21st Century include: 1) Population growth; 2) Environmental degradation; 3) Global warming; 4) Deforestation; 5) Infectious diseases; 6) Hazardous materi- als; 7) Chemical warfare; 8) Nuclear materials; 9) Economic imbalance; and 10) Cultural tribalism. Each of these factors is discussed below.

1. Population Growth The single most important factor tending to produce haz- ards in the future is continued world population growth. With the world population increasing at the present rate of 85 million per year (equivalent to the population of

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100,000 industrial chemicals in the workplace today are increasing by an estimated 1,000 per year.45 At least 50,000 chemicals are considered hazardous to humans, with only a handful having antidotes.46

In the US, chemicals are produced, consumed, or stored at an estimated 850,000 sites.47 During the period from 1993–1998, the number of hazardous substance emergency events (HSEE) increased, the number of substances released increased, and the number of deaths due to HSEE increased.48 In 1998, 79% of the HSEE occurred during production or storage at fixed-facilities (42% in so-called process vessels), while the remainder occurred during transport (82% during ground transport).49 Although the vast majority of chemical releases are minor (e.g., currently 3.5 chemical releases per day in Texas alone), the potential continues for larger releases to cause disasters.49,50 In 1984, the largest chemical event in history occurred in Bhopal when an explosion at the Union Carbide India pesticide plant released 27–40 tons of methylisocyanate gas, expos- ing 250,000–500,000 persons, killing an estimated 2,500–3,000 persons, and leaving many uncounted with chronic pulmonary and neurological disease.51–54

The accumulation of hazardous materials also translates into the accumulation of hazardous waste and the potential for slow-onset events.55,56 There have been many instances of hazardous waste remaining unrecognized in communities until irreversible environmental and human damage has occurred (e.g., Love Canal, USA and Minimata, Japan).57–61

7. Chemical Warfare Chemical warfare agents also remain a continuing problem despite international attempts to control their proliferation. In recent years, a number of countries either have produced or attempted to produce chemical weapons, including Egypt, Iran, Iraq, Libya, North Korea, Sudan, and Syria.34,35 As a prime example, the Iraqi military deployed nerve agents and mustards against several Iranian villages during 1984–1988.62,63 During 1995, the Aum Shin Rikyo cult shocked the world, when it released sarin vapor on five Tokyo subway trains, killing 13 persons, sending 5,500 per- sons to hospitals, and demonstrating that a well-financed, terrorist organization can produce a chemical weapon of mass destruction using common chemical precursors and manufacturing technology.64–68 The relative ease of pro- duction and dissemination of chemical warfare agents makes chemical terrorism the most likely type of terrorism in the future after bombings and multiple shootings.69–71

8. Nuclear Materials During the 21st Century, nuclear material likely will create a number of serious hazards.72–81 Despite the international attempts to control the proliferation of nuclear weapons, eight nations now have an estimated 31,000 nuclear weapons.73 Russia and the United States, with 95% of the world's stock, have a combined 1,750 metric tons of weapon-grade uranium and 225 metric tons of weapons- grade plutonium.73 In recent years, Israel, India, and Pakistan have produced nuclear weapons outside the Nuclear Non-Proliferation Treaty (Israel has an estimat- ed 200, India has 95, and Pakistan has 50), and many are

which in turn, is a factor in landslides, floods, and food and fuel scarcity.17,28

5. Infectious Diseases Another flash point for the generation of natural hazards is the interface between the human and the microbial world. Whether considering new, emerging, or re-emerging infec- tious diseases, the potential exists for the development of infectious disease pandemics.29–32 During the past 20 years, >30 new disease-causing organisms have been iden- tified, including the HIV, Ebola virus, Hepatitis C, han- tavirus, and rotavirus.30,32 Meanwhile, numerous infectious diseases have re-emerged, including cholera, diphtheria, malaria, plague, and yellow fever, due to environmental fac- tors (e.g., deforestation and the settling of virgin areas), demographic factors (e.g., increased urbanization), and markedly increased international commerce and travel.29,32

Perhaps the most chilling example of the devastation that a simple virus can cause is the 1918 global influenza pandemic, which in a matter of a few months, left 20–100 million persons dead (500,000 deaths in the US).33 The worldwide crude mortality rate in this pandemic was 2.5% (as great as 20% in regions such as Western Samoa).33 In contrast, World War I left 9.2 million persons dead, World War II, 15.9 million persons dead, and, as of 1997, AIDS had killed 11.7 million worldwide.33 Although the 1918 flu virus DNA recently was isolated from a victim found buried in the Alaskan permafrost, the mechanism respon- sible for its increased virulence during that period remains unknown.33 To be sure, mortality rates would improve with antibiotics against secondary pneumonia, better supportive care, and immunizations. The fact remains that the largest disaster of the 20th Century was caused by an infectious organism of which little is known.

The intentional accumulation of infectious agents as biological warfare agents (BWA) is another factor. In recent years, a number of countries have been implicated either as producing or seeking to produce biological weapons, including Iran, Iraq, Libya, North Korea, Sudan, and Syria.34,35 Of the many human biological pathogens used in biological weapons, Variola and Yersinia pestis are the most likely to cause contagious pandemic disasters in civilian populations, since only these spread person-to-person by respiratory droplet.36,37 Although the deliberate deploy- ment of biological warfare agents as weapons of mass destruction by bioterrorists or a rogue government is feared most widely, repositories of BWAs in non-terrorist nations may lead to similar results. In this respect, it is important to remember that the last known case of smallpox in the world resulted from a laboratory accident in 1978.38,39 Furthermore, the Ames anthrax strain implicated in the 2001 anthrax letter attacks is suspected of originating from a US BWA research laboratory.40–42

6. Hazardous Materials Hazardous materials are another factor likely to produce human-conceived disasters in the future.17,43 During the past two decades, the number of disasters caused by indus- trial chemical spills, gas leaks, industrial explosions, and fires, has increased across the world.44 Moreover, the

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10. Cultural Tribalism Another major factor in producing armed conflict is cultur- al tribalism, which describes the banding together of a single ethnic or cultural group in order to replace the existing polit- ical structure with one based on ethnic or cultural homo- geneity.86,88 Consequences of unchecked tribalism include civil war, terrorism, population displacement, economic dis- location, dissolution of existing political structures, and ulti- mately, disintegration of the larger nation-state.86,88 For example, the disintegration of Yugoslavia led to the creation of four independent nations, two nation fragments, and many years of intermittent civil war. Of the 38 armed con- flicts in the world in 1999 as reported by the Humanitarian Law Project, cultural tribalism appeares to have been in every one.91

Cultural tribalism, in turn, appears to have two major underlying factors. First, with >6,000 cultural groups in the world (i.e., Indonesia has at least 350), most countries are culturally or ethnically heterogenous.86,92 Only 20 countries truly are homogenous, and relatively few are immune to the pressures of heterogeneity (e.g., Canada has Quebec, Japan has Okinawa, and Spain has its Basque region).86 Secondly, cultural tribalism gathers its impetus as a direct reaction to globalization.86 In this respect, globalization describes the spread of transnational economic interests, such as corpora- tions, banks, trade organizations, and the media, in order to open markets, establish free trade, and ultimately earn transnational profits (Table 1). Today, cultural tribalism plays a major role in the current conflict between Islamic fundamentalism and the West.86,93 Such clashes between parochial and global interests are likely to become more entrenched in future years, making complex emergencies more common and longer lasting than they already are.86,94

Factors Tending to Produce Vulnerabilities Factors that likely will contribute to increasing the vulner- ability of the world's population during this century include: 1) Population growth; 2) Aging; 3) Poverty; 4) Population maldistribution; 5) Urbanization; and 6) Structural and functional failures. Each of these factors is discussed below.

1. Population growth The growing human population not only will generate more hazards, the growth will result in increasing the pop- ulation's vulnerability to hazardous events.17 Population growth is exacerbated further by an estimated 80 million unwanted pregnancies in the world every year. Underlying this are the estimated 120 million couples in the develop- ing world still lacking access to adequate contraception.95

2. Aging The world population also is aging. By the year 2050, for the first time in history, the number of older persons (≥60 years of age) is predicted to surpass the number of those who are younger.96 Concomitantly, the current median value for the age world's population of 26 years is expected to increase to 36 years by 2050.96 Although today, most developing countries have relatively young population structures (e.g., the median value for the ages of the popu-

suspected of developing production capacity.34 Radioactive material also can be deployed with conventional explosives in so-called “dirty bombs”, such as the type tested by Iraq before the Gulf War.34,72

Despite concerns about nuclear weapons, nuclear events most likely will occur as a result of nuclear power plant accidents.77 Although releases of nuclear materials are rare, their impact can be massive, as suggested by the release at Chernobyl in 1986, which led to 30 deaths from acute radi- ation sickness, evacuations of 100,000 persons, and at least 2,000 delayed cases of childhood thyroid cancer.82–83 During this new century, as world fossil fuel reserves dwin- dle (or as global warming worsens), the world will experi- ence an unprecedented increase in demand for nuclear energy, with a consequent increase in the number of nuclear reactors. Although new reactors will be designed to operate more safely, many old reactors will be pressed into continued service.74 For example, Russia still has in opera- tion three Chernobyl-like, plutonium-producing reactors without containment vessels or emergency core-cooling systems.76 Two of the 104 commercial power reactors in the US already have been approved by the Nuclear Regulatory Commission for an additional 20 years of ser- vice beyond their original 40 year limit.74,85 Increased nuclear energy also translates into increases in uranium mining, the production of highly enriched uranium, and the re-processing, transportation, and storage of nuclear waste. How fast will this occur? Today, the US and Canada comprise only 5.4% of the world’s population, but consume 26.9% of the world’s energy. As only one example, if the Chinese public began driving automobiles at the same rate Americans currently do, then the world’s fossil fuel reserves would be gone within five years.86

The potential for nuclear terrorism also exists, either through the detonation of a nuclear weapon or dirty bomb (acquired or manufactured) or the direct attack on a nuclear power plant.75,80,81 There is compelling evidence that some terrorist groups have been trying to obtain weapons grade uranium. Since 1993, police in the Czech Republic, Germany, and Turkey each have seized uranium caches in the 0.4–4 kg range, while the International Atomic Energy Agency has reported 175 cases of nuclear trafficking.80 In recent years, Al-Qaeda agents tried (albeit unsuccessfully) to purchase uranium from South Africa as well as from three central Asian countries.80,87

9. Economic Imbalance Economic imbalance will continue to produce armed con- flict within this Century (with resulting complex emergen- cies).88 A number of hypotheses have been advanced for this, including economic inequalities within a country (e.g., Bosnia), personal greed of political leaders (e.g., Liberia), failure of the social contract (such as high employment), and extreme poverty or economic stagnation (e.g., Rwanda).88 The overall incidence of armed conflict and complex emer- gencies has been increasing since 1950, with most conflict taking place within countries.89 Armed conflict dispropor- tionately affects the least developed countries—eight of the world’s 10 poorest countries recently have suffered or are suffering from armed conflict.88,90

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more catastrophic disasters.22 Even developed countries may fail to discourage population growth in disaster prone areas, such as in seismically active California or Japan.

5. Urbanization Increasing urbanization also will increase the vulnerability to hazardous events. In 2007, the number of urban dwellers in the world is expected to surpass the number of rural dwellers for the first time in history, and sometime between 2010–2020, the urban population in the developing world will surpass its rural population.113 Meanwhile, the num- ber of megacities (population >10 million) and large urban agglomerations (population >5 million) in the world is expected to increase further.113 For example, only eight large urban agglomerations existed in the world in 1950, 41 existed in 2000, and 59 are projected for 2015 (with only 11 of these in developed countries).113 The most rapid rates of urbanization will take place in the currently least urbanized regions, such as Africa and Asia.113

From a disaster management perspective, greater urban population density concentrates populations at risk. A clas- sic example is the greater number of casualties that occur when an earthquake strikes an urban area, particularly when buildings are densely concentrated and building occupancies are high.107 In many developing countries, rapid urbanization outstrips the development of an ade- quate public health infrastructure, predisposing popula- tions at risk, such as the poor, women, and children, to human-conceived disasters like complex-emergencies.92

Poverty and urbanization are interrelated: half of the poor people in the developing world today live in urban slums, which often consist of informal settlements or squatter developments in marginal areas of cities other- wise unsuitable for residential use.114,115 Known as favelas in Brazil, jhuggie settlements in India, and gecekondu in Turkey, informal settlements share a number of character- istics that predispose their inhabitants to suffer a range of human-conceived and natural events (Table 2).114,115 From the 1984 Bhopal catastrophe to the recent landslides in Caracas, informal settlements represent a major locus of hazard vulnerability. The marginalization of the urban poor of the developing world into informal settlements will be a growing international concern as poverty and urbanization continue in the 21st Century.

6. Structural/functional vulnerability

lation in Yemen is 15 years versus 41 years in Japan), aging is occurring most rapidly in the developing world, suggest- ing that these developing countries will have less time to adjust to its consequences.96 The elderly constitute a unique population at risk in disasters, since they tend to be more susceptible to illness and injury, have chronic medical problems requiring ongoing access to medical care, be homebound, and depend upon the care of others.97

3. Poverty Poverty represents another major area of vulnerability to hazards.98 An estimated 1 billion people in the world already live on [US]≤$1 per day or less, and half the world’s population subsists on ≤$2 per day.99,100 Some of the poor- est nations are so marginalized by a lack of resources that they have fallen into inextricable cycles of poverty and dis- ease, in which one problem begets the other ad infini- tum.101,102 Poverty drives hazard vulnerability at the household level, determining the location and type of housing as well as the resources available for disaster recov- ery.103 Accordingly, poor populations and developing countries are more susceptible to natural events, like drought and flooding, and anthropogenic disasters, like complex emergencies and technological disas- ters.22,50,92,103–105 Of the approximate 80,000 deaths per year in the world from natural disasters, 95% occurred in “poor” countries.105,106 For example, Hurricane Mitch in 1998, left 7,500 dead in Honduras, Nicaragua, Guatemala, and El Salvador, led to the evacuation of half the popula- tion, and left 75% of Hondurans without clean water. In China in 1998, flooding resulted in 4,000 deaths and the destruction of 7 million homes. In Orissa, India in 1999, a tropical cyclone killed 10,000 and affected 10–15 million. In Mozambique in 2000, flooding caused 500 deaths and created 330,000 homeless persons.22

4. Population Maldistribution Hand-in-hand with overpopulation and poverty is the mald- istribution of human populations to disaster-prone areas. Many countries strapped for resources turn a blind eye when human settlements expand near natural hazards, including low lying coastal areas (cyclones, tsunamis), floodplains, seis- mic areas, landslide-prone areas, and volcanoes.107–112 With 50% of the world's population already living within 60 km of the sea (and continuing to grow), this trend is unlikely to be reversed without the wholesale intervention of yet

Characteristic Cultural Tribalism Globalization Scope Local, parochial Global, cosmopolitan Historical perspective Antimodern Modern Culture Monocultural Multicultural Logic Mystical Rational Problem-solving Traditional Experimental Value system Absolute Relative Political goal Political totalism Economic totalism Freedom cherished Self determination Free trade Political system Often religious fundamental Secular

Table 1—Characteristics of cultural tribalism and globalization (after Barber)86 Prehospital and Disaster Medicine  2002 Arnold

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tors tending to produce vulnerabilities including popula- tions that are increasing in magnitude, aging, impoverished, maldistributed to disaster-prone regions, more urbanized, marginalized within urban areas, and poorly sheltered. Underlying all of this is the vast common denominator of an expanding world population chasing limited resources (Table 3).

The increasing interconnectedness of the world also must be considered. Global interconnectedness will bring together hazards and vulnerabilities more rapidly, efficient- ly, and with greater tangible and intangible consequences. Already, environmental degradation affects large regions, infectious disease is promptly distributed by international travel, civil wars spill across borders, and acts of terrorism impact the entire world. The offspring of this global eco- logical interdependence will be old disasters in unprece- dented forms and new disasters in ways not yet envisioned.

In assessing the risk for future disasters, a major caveat is to remember the critical role played by manageability. Disasters are not fait accompli. Disaster risk is dynamic. The likelihood of any given disaster is significantly modifiable through the management of its various component hazards and vulnerabilities.11–13,117 Using the following equation,

Risk = Hazard X Vulnerability Equation 1 Manageability

it should be apparent that increasing disaster manageability decreases disaster risk — usually through the mitigation of hazards or the reduction of vulnerabilities. In the past, many underdeveloped and under-funded nations have suffered from a sense of fatalism — “There is nothing we can do about it anyway.” (e.g., Mekong River flooding), develop- ing nations have remained indifferent until after a disaster strikes — “Other problems are the priority” (e.g., 1999 JiJi earthquake in Taiwan), and developed nations have had a sense of invulnerability — “It can’t happen to us!” (e.g., 2001 World Trade Center attack).119 In the future, the cen- tral role of disaster manageability must be stressed at all dis- aster management, policy-making, and funding levels, from local community agencies to transnational organizations.

A second caveat is that common things are common. The four ancient elements — earth, fire, water, and wind — will continue to figure as the roots of earthquakes, veg- etation fires, floods, and tropical cyclones (although in many cases, the reasons will be more complicated and the

Structural vulnerability to natural forces will continue to affect homes, workplaces, schools, and critical infrastruc- ture, particularly in developing countries.116,117 Over the past 20 years, natural events have rendered an estimated one billion people homeless, with 14 million losing their homes in a single event, the 1998 floods in China.116 Whether due to poor design, improper construction tech- niques, or the use of inferior materials, structural failure is a major determinant of morbidity and mortality from nat- ural events (as well as from spontaneous structural col- lapse). Foundations give way in floods and landslides, walls topple in cyclones and earthquakes, and roofs cave in under the weight of volcanic ash.107–112 Structural vulnerability is perpetuated in poor countries by recurrent events, which lead to further under-development.116 In many countries, nonexistent, ineffective, or corrupt government regulation also may play a role. As a recent example, many of the 43 deaths in the Sultandagi earthquake in Turkey in February 2002 already have been blamed on building practices unchanged since the two earthquakes in 1999 killed 18,000 persons.118

The structural and functional vulnerability of critical infrastructure to intentional physical damage by terrorism or armed conflict also will be a future concern. Such infra- structure is involved in ensuring the security of water, food, sanitation, energy, transportation, communication, and information storage for a population. For example, a 1982 study by the US Department of Energy found that if a jet airliner crashed into a nuclear reactor, igniting only 1% of its fuel, the resulting explosion could compromise the integrity of the reactor containment building.80 The struc- tures that house spent fuel rods at nuclear power plants (with five times more radioactive material than a reactor core) also are vulnerable to deliberate destruction.80

Caveats and Conclusions There is an estimated one disaster-producing event per day somewhere in the world.90 With an increasing number and scope of hazards and vulnerabilities, this number likely will increase. At the heart of this trend are several interrelated factors tending to produce hazards, including population growth, environmental degradation, infectious agents, haz- ardous materials, economic dysequilibrium, and cultural tribalism. Equally relevant are a number of interrelated fac-

Characteristic Growing population Overcrowding (increased population density) Poverty Increased populations at risk: women, children Higher baseline incidence of disease Adjacent to technological hazards (e.g., industrial complexes, solid-waste disposal sites) Adjacent to natural hazards (e.g., flood plains, landslide-prone areas, earthquake faults) Homes structurally vulnerable Inadequate public health infrastructure Fresh water, food, sanitation, and energy insecurity Lack of government regulation Lack of home ownership

Table 2—Characteristics of informal settlements that predispose to disasters115 Prehospital and Disaster Medicine  2002 Arnold

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7. CDC: Update on anthrax investigations with Drs. Jim Hughes and Julie Gerberding. November 14, 2001. Centers for Disease Control Web site. Available at: www.cdc.gov/od/oc/media/transcripts/t011114.htm. Accessed 09 March, 2002.

8. Sarewitz, D, Pielke RA Jr.: Prediction in science and policy. In: Sarewitz D, Pielke RA Jr., Byelry R Jr., eds.: Prediction. Science, Decision-Making and the Future of Nature. 1st ed. Washington, DC; Island Press; 2000: pp 11–22.

9. Miller J: Bush to request a major increase in bioterror funds. The New York Times 04 February, 2002;A1.

10. Gunn SW: Multilingual dictionary of disaster medicine and international relief. Prehospital and Disaster Medicine Web site. Available at http://pdm.medicine.wisc.edu/vocab.htm. Accessed 07 March, 2002.

References 1. Anon: Dead and missing. The New York Times February 26, 2002;A11. 2. CDC: Rapid assessment of injuries among survivors of the terrorist attack

on the World Trade Center – New York City, September 2001. MMWR 2002;51:1–5.

3. CDC: Update: investigation of bioterrorism-related anthrax – Connecticut, 2001. MMWR 2001;50:1077–1079.

4. CDC: Update: Investigation of bioterrorism-related anthrax, 2001. MMWR 2001;50:1008–1010.

5. CDC: Update: investigation of bioterrorism-related inhalational anthrax – Connecticut, 2001. MMWR 2001;50:1049–1054.

6. Jernigan JA, Stephens DS, Ashford DA, et al: Bioterrorism-related inhala- tional anthrax: the first 10 cases reported in the United States. Emerg Infect Diseases 2001;7:933–944.

security lapses, the capability of terrorists to commandeer and direct commercial jet liners, and the vulnerability of metropolitan airspace in the New York City and Washington, DC areas. But disasters always unmask hid- den problems in a community. Submerged issues invariably surface in some kind of Darwinian challenge to the eco- logical status quo. Defective chemical processing equip- ment fails, poorly built buildings fall down, or badly drawn political borders collapse. A deeper examination of 9-11 finds a knot of cause and effect, including millions of impov- erished, unemployed, and future-less Arab youth, the strate- gic dependence of most Western economies on fossil fuel, an Al Quaeda jihad against the Western globalization of the Islamic world, and a generation of failures to broker a mean- ingful peace in the Middle East. In analyzing the many fac- tors that will tend to promote future disasters, it is important to realize that every disaster is the result of some unique and complex causal chain.

Responsible disaster management in the 21st century translates into responsible disaster mitigation, which in turn will depend on the clearest possible understanding of the root causes of disasters. The identification and charac- terization of the factors contributing to the production of hazards and vulnerabilities will be central to this process. Risk assessment is the bridge that will take us from the post-disaster improvisation of the past to the pre-disaster preparedness of the future.

consequences more severe). Whether considering the risk of natural or anthropogenic disasters, it will be vitally important for disaster managers to remain interested in seemingly mundane hazards and vulnerabilities. Even though it will be relevant at times to address the potential for low risk, high impact events (e.g., a bioterrorist-con- ceived smallpox pandemic), ordinary high risk, high impact problems like the presence of hazardous material in a com- munity or population growth along an earthquake fault, must remain the focus of our ongoing energies.

A corollary to this is that common places also are com- mon. Disasters in the near next century, will continue to plague Asia and Africa, as they did in the late 20th century (due in part to differential population growth).120–122 For example, Asia has 58% of the total world population on 31% of the surface area, but has suffered 40-50% of all natural disasters and 70% of all disaster-related deaths since 1970 and 90% since 1990.123 With major hazards (seismic, meteorologic) and major vulnerabilities (more people, more maldistribution), Asia will continue to suffer a dispropor- tionate share of future world disasters.

A final caveat is that disasters are rarely the result of a simple cause, whether the events causing them are natural, human, or mechanical. Disasters always are complicated in origin and consequence. A superficial view holds that the 9-11 terrorist attacks resulted from a worldwide terrorist network against US interests, a string of intelligence and

Table 3—Factors tending to produce future hazards and vulnerabilities associated with disasters in the 21st century Prehospital and Disaster Medicine  2002 Arnold

Natural hazards Anthropogenic hazards Vulnerabilities Population Growth Population Growth Population Growth Environmental Degradation Hazardous Materials Populations Aging

Global Warming Industrial Chemicals Poverty Deforestation Hazardous Waste Population Maldistribution

Population Maldistribution Chemical Warfare Agents Urbanization Infectious Agents Nuclear Materials Urban Marginalization

New/Emerging Agents Neclear Waste Structural/Functional Vulnerability Re-emerging Agents Biological Warfare Agents

Industrial Chemicals Economic Imbalance Economic Inequality Personal Greed of Leaders Failure of the Social Contract Poverty

Cultural Tribalism Cultural Heterogeneity Reaction Against Globalization

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