Responding to Catastrophes: A Public Health Perspective

I. INTRODUCTION From a public health perspective, it is difficult to define exactly what a catastrophe is. Catastrophes can be of sudden onset or they can develop slowly; they can be the result of natural causes, such as hurricanes, droughts, or earthquakes, or they can be man-made, a consequence of war or of terrorist acts. Some would say that the distinction between these is not totally clear-even in earthquakes, for example, mortality rates are predictably higher among the poor, those who live in housing that does not conform to local construction standards. The Indian Ocean tsunami of December 2004 did not spare anyone on the basis of socioeconomic status, but those with means were able to rebuild, rehabilitate, and reconstruct their lives much more rapidly and more completely than those who had only minimal assets. Finally, the plight of the poor left behind in the wake of Hurricane Katrina, one of the world's most recent major catastrophes, was visible on televisions around the world. The blurriness of the lines between these categories, acute versus slow onset and natural versus man-made disaster, has led some to coin the term "complex emergency." The global response to complex emergencies has become a subject of relatively recent study and many of its medical, engineering, and even legal ramifications are still being refined. Unfortunately, there is no universally accepted definition of exactly what constitutes a complex emergency. One common description, initially promulgated by the Centers for Disease Control and Prevention, the lead public health agency of the United States government, contends that complex emergencies are "situations affecting large civilian populations that usually involve a combination of factors including war or civil strife, food shortages, and population displacement, resulting in significant excess mortality."1 This definition is obviously imprecise, but it is clear that events such as the outpouring of hundreds of thousands of Hutus into neighboring Tanzania and Zaire (now the Democratic Republic of Congo) in the wake of the 1994 genocide in Rwanda generally fit the definition. The displacement of villagers in the Darfur region of Sudan, fleeing both to more southern parts of that country and over the border to Chad, is another clear-cut example of a complex emergency. Other aspects of these catastrophes are highlighted in a different definition of a complex emergency: "a humanitarian crisis in a country, region or society where there is total or considerable breakdown of authority resulting from internal or external conflict and which requires an international response that goes beyond the mandate or capacity of any single agency and/or the ongoing United Nations country programs."2 This definition does not characterize the situation as much as it does the nature of the response, which needs to be "humanitarian" and requires a team of government, nongovernmental, and United Nations agencies to work in the absence of a functional state (such as in Somalia and Kosovo) or in the face of an unwilling governmental partner (as is the case in Sudan or Burma). Because of the imprecision of these and other definitions, the response to complex emergencies is somewhat unpredictable. Some have gone so far as to suggest that a reasonable definition of a catastrophe that requires response on the part of the "humanitarian community"3 is an event that is widely covered by CNN and/or other news media. Certainly, the political response to complex emergencies, especially when concerns of national security are not paramount, can be heavily influenced by the media. The 1991 US military incursion in Somalia is widely cited as a case in point. Without clear objectives, until about twenty years ago, emergency relief was based primarily on good intentions. For example, generous people and organizations were moved to action by photographs of starving babies in Europe after the Second World War; in Biafra during the war of secession in Nigeria in the late 1960s; and in Thailand, Somalia, and Ethiopia during the late 1970s and 1980s. …