32 Post Disaster Relief and Health Care Management

Lakshman Lakshman

 Objectives

• To understand the processes involved in providing post disaster relief
• To gain a basic understanding of humanitarian logistics
• To look into public health care management post disasters based on public health and humanitarian logistics perspective

    Rationale

This chapter delves into the process through which the post disaster relief and health care management reaches the affected people. It is extremely important for us to understand the humanitarian supply chain to completely absorb the complexities associated in post disaster relief management. The module also provides an overview of the public health processes and explains in details about the processes governing public health care management after any disaster event to elaborate disaster relief processes properly.

Learning objective

Unit 1 – Post disaster relief – Process

Disaster relief is “the provision of assistance during or immediately after a disaster to meet the life preservation and basic subsistence needs of the people affected by any disaster event . It can be of an immediate, short-term, or protracted duration.” (WHO, 2007) But the provision of relief appropriate to the needs of the community, and to ensure last mile connectivity is not a simple and straight forward activity. It involves multiple interlinked processes and strategies. Based on the needs and loss assessment, the material and service requirements are assessed and the procurement (in certain cases), transportation, warehousing and distribution of relief materials are planned and implemented. This flow of activities from procurement to distribution is governed by the principles of humanitarian logistics and supply chain management. This section will elaborate these processes associated with post disaster relief provisioning.

Relief cycle

The relief requirements in a post disaster operation can be segregated into four distinctive phases:

1. Assessment – This phase is carried out immediately after the disaster strikes to identify and assess the immediate material and resource needs of the affected people. During this phase, there is no significant movement of resources or materials.

2. Deployment–In the deployment phase, the relief reaching the affected area and the associated activities goes through a sudden spike and a ramping up of processes .

3. Sustainment –During this phase, the relief reaching the affected area and the associated activities is sustained at a stable level.

4. Reconfiguration–During this phase the operations are reduced, and the relief provided also reduces following a ramp down function and gradually terminated with the responding agency having fulfilled mandate or have ran out of resources.

The Relief Cycle is observed in all relief operations and any organization responding to a disaster scenario will be following these phases. After the reconfiguration phase, depending on the developmental requirements, another similar cycle can start, but it is beyond the purview of this module.

Figure 1 Relief Cycle- Resources vs Time

Figure: Relief Mission Cycle

  Source: Thomas 2002, taken from Beamon, 2004

What is Humanitarian Supply Chain?

Commercially, supply chain is defined as the network of entities through which material flows.(Lummus and Alber, 1997). It consists of all activities associated with moving goods from the stage of raw-materials to the final stage where it reaches the end user. These activities include procurement & sourcing, production planning, production, inventory/ stock management, transportation/logistics, warehousing& storage and customer service.The management of the entire process is called supply chain management. (Ellram and Cooper, 1993)

Supply chain in disasters specialize in organizing the procurement, transport, storage and delivery of required supplies in case of disasters to the affected people. Commercial supply chains are often disrupted after the disaster. To fill the space while addressing the sudden spike in demands and probably the sudden shortage of supply, the formulation of a humanitarian supply chain focused towards alleviating the sufferings of the disaster affected community is required. The objective is to address the demand and supply uncertainty and satisfy beneficiary requirements in a timely manner at an acceptable cost. The humanitarian supply chain differs from a commercial supply chain in the following aspects:

• Unpredictable and unstable demand from previously unknown locations
• Usually production phase is not considered in humanitarian supply chain
• The cost of supply-demand gap is very high in the humanitarian supply chain (often life-and-death)
• Due to the involvement of multiple stakeholders and the ultimate motive of providing essentials to affected community, there is little performance measurement built in the system.
• Variable levels of enabling technology , especially if the operations are from a developed nation organization working in developing/ under-developed nation

    Disaster Relief Network:

The following diagram represents a typical disaster relief chain configuration. Disaster Relief Network shows the flow of goods from the source to the beneficiaries in a humanitarian relief operation.

Figure –Relief Logistics Network

(Source – Balciket.al., 2009)

Based on the post disaster rapid assessments, the supply of relief in the disaster affected area is initiated . The prepositioned materials (materials strategically stored in certain pre-planned locations for ready utilization in case of contingencies/ disasters) are mobilized; while materials which need to be procured from local and global sources, there could also be the supply of donated items in response to the appeals from various forums. All these materials are collected and transported to distribution centres. This section of the supply chain is known as the supply acquisition/procurement phase.

From the distribution centres, prepositioned materials as well as materials received as donations are transported to intermediary stocking and distribution points. This section is thus linked with prepositioning and warehousing of the relief materials. Often the ports and principal transport terminals serve intermediary stocking and distribution points.

From the intermediary stocking and distribution points, the relief is moved to the local distribution points, which are often located very close to the affected area but not in the close vicinity of the affected area. Depending on the nature and scale of disasters, the location of the distribution point varies. From the local distribution points, the relief is moved to the beneficiaries located in the affected area, which is often termed as the last mile. This composes the last mile distribution component.

The transportation component links all these sections together. First the procured materials are transported to the distribution centers and then from distribution centers they are taken to the distribution points and finally to the beneficiaries. Fleet management in relief scenarios plays a significant role in deciding the effectiveness of the relief programme. Depending on the contextual requirements, the mode of transportation and other parameters are also determined.

The configuration is highly dynamic and often one or few of the components might not exist in the configuration or certain components might get appended.

International Best Practices

The emergency products to be supplied in a post disaster scenario largely depend on the type of disaster and context of the affected region. There are multiple categorizations to identify the products sets to be supplied in disaster affected regions. One of them is the IFRC emergency items catalogue. The International Federation of Red Cross and Red Crescent Societies (IFRC) and the International Committee of the Red Cross (ICRC) supported by National Societies have coordinated joint efforts towards the need for improved standardization of emergency relief and medical items. This harmonization has been due to their experience over the years of responding to emergency situations across the globe. The

  IFRC has developed a catalogue intending to facilitate procurement of suitable items with standardization.

The standardization in relief materials is intended to facilitate field operations and support logistics, improving quality of insurance, communication and reporting. It would also avoid inappropriate donations. Their catalogue provides generic technical specifications for essential items.

The catalogue provides guidance and assistance to:

1. Operation requesters, operational users and decision makers and also donors and national authorities concerned with planning, budgeting and execution of assistance programmes in emergency situations.

2.  Purchasers and suppliers involved with the supply of emergency items.

The catalogue classifies products in the following product groups:

• Warehouse and Administration
• Relief and Logistics Kits, ERU, RDU
• Personnel security equipment
• Radio and Telecommunication
• Power supply and electrical equipment
• Tools and Hardware
• Food
• Household
• Shelter and construction materials
• Livelihood
• Vehicles and consumables
• Water and Sanitation
• Drug products
• Medical disposable supplies
• Medical equipment
• Cold chain
• Laboratory
• Physical Rehabilitation
• Basic health care ERU
• Emergency care and triage
• Rapid Deployment Emergency Hospital
• Referral hospital ERU
• Surgical hospital, weapon wounds
• Medical kits
• Feeding and nutrition Kits
• Medical sets
• Surgical instruments and sets

The Sphere Handbook, of Humanitarian Charter and Minimum Standards in Humanitarian Response, is one of the most widely known and internationally acknowledged sets of common principles and universal minimum standards in life-saving areas of humanitarian response.

Sphere Handbook is broadly accepted by the humanitarian sector and is followed in the humanitarian response.

The Sphere Handbook puts the rights of disaster-affected population to life with dignity, and to protection and assistance as the core of humanitarian action. It promotes the active participation of affected populations as well as of local and national authorities, and is used to negotiate humanitarian space and resources with authorities in disaster-preparedness work.

The Handbook provides ethical and legal backdrop to the Protection Principles, as well as to the core and minimum standards, thereby setting the stage for appropriate interpretation and implementation. Founded on the principle of humanity and the humanitarian imperative, these include the rights to life with dignity; to right to receive humanitarian assistance; and the right to protection and security. The Charter emphasizes the importance of responding agency’s accountability to affected communities. The Core Standards and minimum standards are articulations of what these principles and obligations mean in practice.

The minimum standards cover four primary life-saving areas of humanitarian aid:

1.     Water supply ,sanitation and hygiene promotion

2.     Food security and nutrition

3.     Shelter, settlement and non-food items

4.     Health action

Logistics Strategies

Many logistics strategies for relief supply chains have been proposed based on different parameters. Here we consider disaster logistics strategies based on time and location based disaster classification. Disasters may be classified based on a combination of geographic dispersion and speed of onset. Based on this , different logistics strategy for each classification is identified.

Dispersed and sudden onset – These types of disasters tend to be the most catastrophic because of the lack of warning before onset and the large geographic area covered. These disasters span over nations and require international assistance. Severe capacity constraints on flow of inbound supplies arise after these kinds of disasters. e.g. Indian Ocean tsunami

Localized and sudden onset – Creates difficulties lesser than dispersed and sudden onset event, but still overwhelms the local capacities. These are limited to the national or regional boundary. These sudden events do not provide time to prepare for the event. The situation gets worse if pre existing socio economic and institutional vulnerability exist. e.g. Haiti earthquake

Localized and slow onset – These types of disasters provide preparation time. They are also limited to regional or national boundaries. Compared to the other four categories of disasters, these are the easiest to address. But even these events can affect significant no. of population due to poor planning and infrastructural failure post disaster. e.g. Hurricane Katrina

Dispersed and slow onset – When a disaster is slow but a significant area is affected, it requires substantial planning, resource allocation and co ordination between the different actors. Though slow onset disasters provide lead time, planning and effective implementation of the plan becomes crucial. e.g. 2009 Influenza epidemic

Based on the type of disaster, four fundamental strategies can be employed:

(1) Pre positioning – It is the most desirable logistics strategy for disaster events where it would shorten the lead-time to provide supplies. But the primary issue with prepositioning is investment in such inventories could be large. Stores of prepositioned stocks should be secure else prepositioning is ineffective.

(2) Pro active deployment – Mobilizing materials in areas close to the expected disaster zone, when a disaster is anticipated. This reduces delivery time but is less effective in lead-time reduction than prepositioning. But this reduces cost involved in holding inventories.

(3) Phased deployment – It is the delivery of materials to a disaster area as it is needed and in the quantity in which it is needed. It prevents inundation of disaster-affected areas by unsolicited materials.

(4) Surge capacity – It refers to surge in transportation of manpower and materials from locations outside disaster zone once a disaster strikes. It is comparable to prepositioning of capacities.

The following shows the proposed policies for each type of disasters

Prepositioning as a strategy: It is the process of placing essential supplies at strategic locations before a disaster event occurs so that they may be available immediately after the event.(Rawls, 2008)

Positive Strategy

•  Key commodities are available in short time – reduction in lead time increasing speed of response
• Commodities are accessible because of strategic geographic positioning
• Goods available at right price through prior negotiation – extra cost of purchase post disaster due to high demand can be avoided
• Helps in maintaining the quality standards – Sphere standards
• Safety against emerging threats
• Aids decision making and emergency planning when information of available stocks is known

    Negative Strategy

• High costs involved in purchase and maintenance
• Expiration of unused materials and issues with disposal
• Hard to receive funds pre disaster to support large inventories
• Post disaster financial relaxations are not applicable in pre disaster purchase

In multiple cases it has been observed that prepositioning of materials have been largely successful in quick response. The concept of prepositioning is embedded in military planning operations. (Rawls, 2008) The success of IFRC response in Yogkarta was largely attributed to decentralized supply chain and its prepositioning strategy. (Jan Husdal, 2010) Even in Cyclone Nargis in Myanmar, the prepositioning approach helped. (IFRC, June, 2000)

India is a multi-hazard prone nation with multiple regions affected by disasters – both routine and rare. In case of routine hazard the response is often more costly than preparedness, and also the certainty factor is also high. As such prepositioning in this case should be considered. In case of rare hazard, uncertainty and magnitude is often a hindrance to design a prepositioning solution. But if the correct prepositioning strategy based on the product type and disaster location is used, then the negatives of prepositioning can be suitably handled.

Unit 2 – Post disaster health care management

Based on the above understanding, let’s look at the post disaster health care management. In this section, we will focus on public health and explore how public health issues in disasters can be addressed.

Public Health is an effort by the society to protect, promote, and restore health of the community. (Last, 2001) It is a combination of sciences, skills and beliefs directed at maintaining and improving health of the people through collective social actions. It aims at preventing diseases and addressing health needs of the population as a whole.

The following diagram shows the three fold mechanism of health care interventions. The people standing near the cliff are marching ahead. Without any protection, they might walk off the cliff, fall and be seriously injured. Through the health interventions, the primary barrier is erected at the cliff so that the people do not walk off the cliff, then a secondary prevention mechanism is laid in the form of a safety net and thirdly as tertiary prevention medical care is present at the ground to provide medical assistance in case of a fall.

Figure – Public Health Interventions    (Source – Jones)

Public health approach

The public health care approach to the community dwellers follows the following steps,

a. Define the problem – collection, analysis, and interpretation of data

b. Identify the risk – whether preventable, controllable, what is the priority

c. Identify the protective factors and prevention strategy

d. Identify the implementation mechanism and widespread adoption

    Disasters put special challenges to routine public health work as well as create some specific public health challenges.

The key challenges that public health faces due to disasters include:

a. Exposure to natural elements – Massive displacements and homelessness might result from disasters. This becomes a particular problem when disasters occur in areas with extreme temperature or weather. e.g Pakistan earthquake of 2005 ravaged villages leaving many homeless. Providing sufficient provisions to avoid the impact of the upcoming winter was a major concern.

b. Food and Nutrition – Shortage of food in the aftermath of a disaster due to the availability or access constraints put affected population under severe stress. Malnourishment, energy deficiency, reduced immunity are some of the major issues faced. Protein Energy Malnutrition, which affects children in poorer communities in most of the developing nations increase the susceptibility to many communicable diseases like malaria and tuberculosis.

c. Communicable diseases – The risk of diseases esp. communicable diseases in a post disaster scenario is dependent on the following factors:

1. Pre-existing diseases in the population – The risk of epidemic after a disaster is related to the endemic levels of diseases pre-existing in the population. These include various diseases like diarrhoea, dysentery, cholera, measles, tuberculosis, malaria, skin diseases and relapsing fever.

2. Diseases caused due to ecological changes – Natural disasters may alter the potential for disease transmission by altering the ecological conditions. Most important diseases are those transmitted by mosquito vectors and through water. The breakdown in living conditions following disasters may increase the hazard of transmission of such communicable diseases. The incidence of dog bite and risk of rabies may increase as neglected strays come in close contact with persons living in temporary shelters.

3. Population Movements – Increased population density in the disaster affected areas may cause burden on the water supply and other services. Further, the movement could also introduce susceptible population to a new disease or disease vector. Few of the potential disease outbreaks in the temporary settlements are diarrheal diseases and dysentery, viral hepatitis, measles, whooping cough, malaria, tuberculosis, scabies and other skin infections.

4. Damage to public Utilities– Damage to water supplies and sewage disposal systems may increase water borne and excremental diseases

5. Interruption of Public Health Services – The important services interrupted in this context are Vector control programme, which might lead to resurgence of malaria and other vector borne diseases. Routine immunization programme against measles, whooping cough, poliomyelitis, tuberculosis and diphtheria may also be interrupted.

   d. Social reactions which include spontaneous behaviour like panic and anxiety

Thus, a thorough understanding of the situation including the disaster and its corresponding impacts on the vulnerable population, the adaptive capacity and the catastrophic destruction of adaptive capacity, would help in providing life-saving medical care and preventive health care due to disease spread thereby aiding in the early recovery process. Once the immediate response starts to bring stability in the health of the disaster affected community, emergency health care must give way to a public health focused response for sustainable long-term arrangements.

The following table illustrates the type of impacts in different disasters:

Table 1 Public Health Impact of selected disasters (adapted from Sphere Handbook, 2013)

Depending on the type of impacts, health management processes post disasters would consist of –

Search, rescue and first aid-consist of searching for and rescuing the affected people, providing physical and psychological first aid.

Triage –If the quantity & severity of injuries is greater than the operating capacity of health facilities available at the site of disaster, a rapid classification of the injured on basis of severity of their injuries, and likelihood of their survival with prompt treatment is envisaged. Such a practice by medical professionals is termed as Triage. The following four colour code system is utilized

Field care–The provision of health care facilities at the disaster sites, including hospital beds, medical and surgical services along with the trained medical personnel to effectively respond to the demand.

Guidelines to address public health in post disaster situations :

1. Implement public health measures at the earliest after any disaster event so that the risk of disease transmission may be reduced.

2. Organization of a reliable and robust disease reporting system to identify outbreaks in disaster affected areas and to promptly initiate control measures

3. Disease surveillance mechanism to be established to investigate all reports of disease outbreaks rapidly with special focus on communicable diseases through water, air and other vector borne diseases

4. Nutrition – Infants, children, pregnant & lactating women, sick people’s needs must be taken care of in priority. Nutritional needs of the affected population, their daily food ration must be calculated and steps must be undertaken to ensure food relief by monitoring the nutritional status of the affected population.

5. Kitchen sanitation and personal hygiene of individuals involved in food preparation must be maintained.

6. Water supply – Survey of water sources and distribution system must be undertaken at the earliest to guage their physical integrity, remaining capacities, bacteriological & chemical quality. The need for Chlorination and other purification efforts must be met. Sanitation efforts must ensure wastes and excreta disposal occurs at a safe distance from water source.

7. Sanitation and hygiene efforts must also ensure that safe washing, cleaning and bathing facilities are available, emergency latrines are set up and efforts are channeled towards intensified vector control programmes.

Summary:

The relief requirements in a post disaster operation can be segregated in four distinctive phases: Assessment, Deployment, Sustainment, and Reconfiguration.

Supply chain in disasters specializes in organizing the procurement, transport, storage and delivery of required supplies in case of disasters to the affected people

Prepositioning is the process of placing essential supplies at strategic locations before a disaster event occurs so that they may be available immediately after the event. In multiple cases it has been observed that prepositioning of materials have been largely successful in quick response.

Public Health aims at preventing diseases and addressing health needs of the population as a whole. A thorough understanding of the situation including the disaster and its corresponding impacts on the vulnerable population, the adaptive capacity and the catastrophic destruction of adaptive capacity, would help in providing life-saving medical care and disease spread preventive health care thereby aiding in the early recovery process.

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