Prevention is Better than Cure

A disaster not only brings suffering or injuries at the time it strikes  but afterward, too, in the form of psychological effects and infectious disease. The mental and emotional effects of natural disasters may not be apparent at first. This is because the first reaction is to take care of the physical damage while on the other hand, the agents of infectious disease find favorable conditions after a catastrophe and can easily spread if nothing is done to prevent them.

"PREVENTION OF MENTAL HEALTH PROBLEMS"

Typically, in a state of emergency, people need to be rescued and their physical safety is of first concern. Efforts are focused on cleaning up, rebuilding and providing shelter, etc. Because there are so many things that need to be taken care of, many people have to put their emotions on the back burner while they deal with the physical damage..

Mental health phases after disaster

There are two main things needed to be done on the victims:

1. Prompt treatment

Every single psychiatry symptoms finding should be considered as important signal as a psychopathology condition. Can be like people who appear to keep on being silent or hysterical cry or shouts.

2. Regular evaluation

Evaluation of the mental status of disaster- affected people should be done routinely. The procedures can be started right after the triage is done and continue thoroughly.

I've discussed about the clinical emergency response on physically and psychologically in my previous post. Welcome to read it back :)

Meanwhile, the prevention measurements should also being intervened towards the staff in charge for the psychological managements. They may be are already trained to do the job, nonetheless, they are also human with limitation of strength. Hence, it's recommended that these workers are placed in disaster affected area in less than 2 weeks. They have to avoid from experiencing psychiatric morbidity protecting them from any flaws on their emotion, energy, and even activities so they can be a truly good support group for the victims.

"PREVENTION OF INFECTIOUS DISEASE"

Lots of people are in close proximity during a time that challenges the ability practice normal hygiene, with strained bathroom facilities and diaper changes occurring in close quarters. Worst when they can't get clean water sources. It can also due to problems finding fresh clothes and laundry facilities and disposing of trash. It's not uncommon for people in the refugee camp to suffer diarrhea, nausea and respiratory illnesses, including colds.

The general safeguards which can be done and yes; can be explained to the refugees for them to really practice may include:

• Water must be boiled or treated with iodine or chlorine before using it to clean, cook with or drink.
• Fully cook food.
• Wounds need to be cleaned as soon as possible and care should be taken to avoid new ones. Make sure they know who and where that they can get a treatment from.
• Hygiene is one of the best infectious disease preventions. The victims notwithstanding, may not be able to care on this by themselves. There are so many of them and they have their own problems to deal with.. It's mostly (yes, not 100%) our responsible. Staff or volunteers to the the sanitary procedures are very important.

Here is the example of good management which support the prevention of infectious disease in the refugee camp on the Merapi eruption victims :)

Click to enlarge

That describes the condition of Posko SD Gambiranom, Manukan, Condongcatur, Depok (it's actually a school. Read the whole story for full details). One of the best statement to be highlighted is, 

"Secara umum, di posko ini, pengungsi dan relawan bekerjasama agar kondisi pengungsian tetap bersih dan rapi."

Translated: "In general, in this post, refugees and volunteers working for the refugee condition is kept clean and tidy."
 

Crystal clear, right?
The responsible for these preventions measurement goes to everyone involving in the circumstances :)

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Reference:

• "Disaster Management in Mental health", lecture by dr. Bambang Hastha Yoga, Sp. KJ
• "Disaster Surveillance", Guest lecture: Dinkes Propinsi DIY

P.T.S.D

I believe this is quite a big topic in disaster as most victims experiencing trauma; can be as little as they can easily and independently overcome it, or as complicated and tough as it becomes severe.

PTSD, stands for post-traumatic stress disorder, is an anxiety disorder that can develop to become a significant stress after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened. According to MERCK, PTSD causes recurring, intrusive recollections of an overwhelming traumatic incident that persist more than 1 months, as well as emotional numbing and hyperarousal.

 "How PTSD occurs?"

It starts with trauma, where the initial normal reflections of a person are fear or worry represented by the characteristics of being anxious. The feelings collectively produce personal response which can be either realistic or unrealistic. The unrealistic responses are what is called PTSD.

"Time course and PTSD subtypes"

"Will everyone experience PTSD?"

No. It depends on the vulnerability of each individual, which is influenced by several factors:

1. Pre trauma factors

i. Ability to be independent

Individual inner protective skills enables some people to be "protected" from get carried away too much by his/ her own feelings or emotions as to be an I- don't- care person.. Ignorance is bliss, eh?

ii. Family

Family "trainings" affect a lot on one's characteristic and yes, one's life. Remember when we were little, and our parents (or love- to- bully big brothers or sisters..) threaten us with things like, "If you go out alone, you'll be kidnapped!" or "If you go to that place, ghost will catch you!"? This actually consciously or subconsciously influenced our capability to face things truly boldly.

Other pre- trauma factors can be the presence of prior traumatization(s), pessimistic thoughts, hereditary, recent life stressors, and initial distress at the time of trauma.

2. Post trauma factors

i. Secondary victimization

This is very common to happen. Such as for the people to be the victim of the Merapi eruption disaster is their primary victimization, then there come another plight at the refugee camp.. Can be like, the staffs scold or even insult them when they don't queue properly in a line to take their foods or as the refugees sleep together in a very large number of people of variety background causing the high occurrence of sexual harassment or even abuse:(

ii. Ineffective coping

There are two types of refugees. One is grateful- type, they accept and appreciate with what they are given. Another type is the opposite's: Ungrateful and even keep complaining.. They should actually learn to adapt with the situations..

Other post- trauma factors can be the recovery environments and the lacking or ineffective treatments.

"Can PTSD be treated?"

Yes:) There are 2 types of management for PTSD: Pharmaceutical approach and Healing approach.

1. Pharmaceutical

Symptomatic drugs.

Examples:

• Benzodiazepines for anxiety or insomnia
• TCAs (Tricyclic antidepressants) for depression
• SSRIs (Selective serotonin reuptake inhibitors) for PTSD itself

2. Healing

These 7 principles of healing will indeed help the healing process of PTSD:

1. Starts by applying skills to manage PTSD symptoms

This includes skills to reduce distressing arousal and manage anger or intrusions. It's not curative, but reduce the troubling symptoms.

2. Healing occurs when traumatic memory is processed or integrated

The traumatic memory is connected to adaptive material be it the thoughts or emotions. Those can be released or expressed so the memory is connected to calmer, more supportive emotions as verbalizing helps to the memory together and be viewed more logical and realistic:)

3. Healing occurs when confronting replaces avoidance

Avoidance is the hallmark of anxiety disorder. Face it, don't run from it..

4. Healing occur in the climate of safety and pacing

Traumatized is a state of feeling unsafe. Progression is steadily yet slowly to remain in control.

5. Healing occurs when boundaries are intact 

Set up a firm, positive and realistic boundaries, then stay in the "safe zone":)

6. Kind awareness and acceptance of feeling aid the healing journey

Realizing that things happened for reason, and it's in the past though. Be optimistic. 

7. Balance in our lives is necessary

Not too much, not too least. Being too emotional or even too much of being an "I don't care anything" are not a good idea.

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Reference

• "Post Traumatic Stress Disorder Management", lecture by dr. Bambang Hasta Yoga, Sp. KJ 
• MERCK: Acute and Posttraumatic Stress Disorders (PTSD) 
• The Post-Traumatic Stress Disorder Sourcebook: A Guide to Healing, Recovery, and Growth

Disaster Surveillance

Disaster, be it the natural or man made ones are mostly preventable or at least predictable. Merapi eruption for example, where the geological expertise able to provide expected data on its condition. Disaster preparedness (and mitigation) is hence should be established as such a system will be very useful at all stages of disaster (go to my previous post on Preparedness, Response, and Recovery.

Disaster surveillance therefore is needed so any actions are in a good hand of management making sure that how, who, when, and what are involved are all in the correct lines.

1  

Why disaster surveillance is important? You see, effects of disasters are too wide; death, mild to severe injuries, psychosocial and economic effect, famine, and population movement. The potential indirect effects of disaster cause the increase of possible transmission of communicable disease because of the movement of the people into adjacent areas due to destruction dwelling. Overcrowding, lack of water supply, food shortage, and lack of sanitation facilities will lead to disease outbreaks because of the increase of the sensitivity to disease.

 Under normal circumstances, the existing National disease surveillance system serves the following purpose: early warning, situation and trend assessment, and evaluation of the effectiveness of health promotion and disease prevention programs.

Keys in Disaster Surveillance: 

Governance & Coordination 

The target is to integrate all resource and activities to become synergistic power, to tackle health problems in emergencies and disaster efficiently and effectively.

Simply put, "governance" means: the process of decision-making and the process by which decisions are implemented or not implemented (source: UNESCAP). To this, coordination plays a major role throughout this process.

  

Coordination are the backbone of the health programs integration in handling disaster which branches into 8 main scopes: basic and specialist health care, nutrition, immunization, reproductive care, vector control, sanitation and environment, health promotion, and logistic aids.

The management requires effective organization, proactive leadership, and critical mindset. Collaboration with government is also important besides having a good human relation. Obviously, interdisciplinary collaborative efforts is indeed very important in the design of disaster surveillance.

In many of my other posts, I'm sure you notice that I've been talking a lot about the importance of coordination. Indeed, I believe that in any action or plan which involves more than a single party truly requires a good coordination to work on.

United we stand, divided we fall!

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Reference: "Disaster Surveillance", Guest lecture: Dinkes Propinsi DIY

Good Shield for Good Yield

Disaster management cycle can be
decomposed into 4 stages: prevention and mitigation, preparedness, response and rehabilitation.

Prevention and mitigation deal with the proactive social component of emergencies. This includes mechanisms and regulations that lessen the vulnerability of the population and enhance their resilience toward disaster.

"Preparedness"   

Putting the response mechanisms in place to counter factors that a community has not been able to mitigate. The planning and organization of emergency preparedness should be a task for a multidisciplinary planning team involved at the community level, and one which should be integrated into hazard assessment, risk reduction and emergency response.

In a developing country like Indonesia, the management of casualties it is now well recognized that medical teams from outside may take at least 3 days to arrive at the scene of disaster. As most preventable deaths occur within the first 24 to 48 hours, such assistance will arrive too late:( Thus it is at the local level that emergency preparedness should be focused, so that the community itself has the means to begin rescue and relief actions immediately after an event.

Part of the plans which I can include in the preparedness lists are:

1. Information and communication needs 

• Providing adequate information to the public (eg. provide early warning system for evacuation)
  
• Communications systems between the different emergency services at the local and national levels
• Stockpiling emergency food and water supplies in households 

2. Command and control and emergency communications 

The designation of the emergency service in charge, and the constitution of a disaster coordinating team.

 

3. The hospital major incident plan 

Hospitals should have specific plans for dealing with a sudden large influx of casualties, and there should be provision for a hospital flying squad to go to the scene to work with search and rescue teams in extricating trapped victims or to undertake field triage of large numbers of casualties.There's a compulsory need for a hospital in the disaster- prone area to set up a Contingency Plan. 

Contingency plan refers to the alternative plan of the hospitals in case their primary plan isn’t working that well i.e. “Plan B” for any possibilities of handling matters. Contingency plan is a realistic method. Those personnel or individuals involved were already being trained and this plan has its respected evaluation time to time. 

4. Emergency equipment 

5. Emergency response plans

• The separate emergency services and the health care sector, including public health, occupational health and environmental health practitioners.
• The management of evacuees, the location of evacuation centers and the appropriate preventive health measure (Eg. staff to do the sanitary jobs).
• The need for emergency stress management to prevent stress disorders in victims and emergency workers.

6. Training and education

This is very important as besides their knowledge and certified competency, medical staff and other health care professionals at the hospital and primary care level are similar to the community of the  disaster- prone area of which they are likely to be unfamiliar with working in disasters.

 

"Response"

Response includes the provision of assistance, support or intervention during or immediate actions after a disaster to meet the life preservation and basic subsistence needs of those people affected. This can be in the form of an immediate, short-term, or protracted duration. 

This takes place during the disaster. It includes the principles of disaster management, clinical emergency during disaster, and also includes:

• rescue and evacuation of casualties and property 
• fulfillment of basic needs 
• protection 
• management of refugee 
• rescue, and recovery of infrastructure and facilities

In emergency, according to PAHO- WHO (2001), LOGISTICS are required to support the organization and implementation or response operation in order to ensure their timelines and efficiency.

Logistics is the management of the flow of the goods, information and other resources in a repair cycle between the point of origin and the point of consumption in order to meet the requirements of customers (Wikipedia), of which in a disaster; the requirements of the victims or the scene.

"Recovery"

It’s a post- disaster rehabilitation and reconstruction of which the process, policies and procedures related to preparing for recovery or continuation of technology infrastructure critical to an organization after a natural or human induced disaster take place.

Recovery process is influenced by how much the hazard causes impacts to occur. While the impacts depends on the vulnerability of the community and the area itself. Mitigation (preparedness) is the source of capacity. A better n higher preparedness, the higher the capacity.

 DISASTER RISK REDUCTION

 

 

Briefly explained, risks can be reduced when capacity increases (i.e more preventive efforts are done or improved).

Disaster Risk Reduction (DRR) is formula of mitigating impacts of disaster through prescriptions of preventive measure as the capacity.

Click to read the book :)

Indonesia's government’s commitment in disaster management based on this DRR is described in this book: NATIONAL ACTION PLAN FOR DISASTER RISK REDUCTION.

You can also read books of  countries which also plan for DRR at Strategic National Action Plan (SNAP) for Disaster Risk Reduction website.

Semoga Bermanfaat :)

*Hopefully useful* 

Referring to Carter (1991), the decomposition of disaster management into 4 stages does not mean that activities during a disaster are divided from each other and separated in time. Often they overlap. (cited at Russell,2005)

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References:

• "Preparedness, Response, and Recovery", lecture by dr. Belladona, M. Kes
• "Logistic Management Support", lecture by dr. Sulanto Saleh- Danu, Sp. FK
• "Earthquake in Yogyakarta (Natural disaster)", GROUP 8 TUTORIAL SESSIONS (Week 6)
• "Multiprofessional Team in Disaster Management", Panel Discussion.

Goodies Delivery~

I was reading through online updates on Merapi eruption and came across this post on one blog:

Bis Mania Community blog

And I was pathetically questioned myself: "What is logistics?"

It embarrassed me as after we had a lecture on logistics management I discovered that eventually, one of the critical success factors on disaster management is an effective logistics management. Plus, UNDP (1993) stated that logistics is often the largest and most complex element of relief operations.

Relief/Humanitarian Logistics:

Humanitarian logistics involves delivering the right supplies to the right people, at the right place, at the right time, and in the right quantities. (Cottam, Roe, & Challacombe, 2004)

Mobilizing the staff, equipment and goods of humanitarian assistance organizations, the evacuation of the injured or the resettlement of those directly affected by the disaster, requires a logistics system to maximize effectiveness.

We can say that logistics serves as a bridge between disaster preparedness and response.

Emergency situation like disaster requires emergency supplies. Several most important emergency supplies usually are medicines, water and environmental health, health supplies or kits, food, shelter, electrical, construction, logistics or administration, personal needs, education, human resources, agriculture or livestock and many others of which we must never pay only one eye to.

Lists of important necessities of the refugee in Posko Maguworhajo, Yogyakarta. Photos courtesy of Intermed07

The flow of supplies logistic in Indonesia shown below will also help to know the coordination of authorities responsibled in  logistics (medical) management.

Flow of supplies logistics (DepKesRI, 2007)

The organization and command system is at most the responsibility of the Ministry of Health and the national board involves BNPB (Badan Nasional Penanggulan Bencana) directed to BPBP (Governor), then to BPBK/ KT (Bupati or Mayor).

The typical network structure of relief logistics is as below:

Relief Logistics Network Structure

"Transportation" 

As we can see in the image above, transportation plays a big role in the whole network structure. Transportation makes it possible for assistance to reach those in need.

For example, during the Tsunami (2004), an illustrative relief shipment could have arrived in Indonesia in Jakarta through commercial transport by sea from Singapore. From Jakarta, it was flown by charter aircraft to Medan in Sumatra and stored in an organizations regional warehouse. When it was needed, the shipment was loaded on an International Organization for Migration (IOM) caravan headed to Banda Aceh. In  Banda Aceh, it was unloaded from the large IOM trucks and delivered by smaller vehicles to the beneficiaries (victims).

Counted how many types of the transportation mentioned already?

4- Ship, aircraft, trucks, smaller vehicles (may be cars or vans), and we' re not even counting based on quantities yet:)

"Stocking or Storage" 

This is under the inventory subsystem which includes different types of warehouses:

• Central warehouse
• Regional warehouse
• Entry point
• Collection site

"Distributions"

The beneficiaries receive the supplies at places there are gathered at, like the many number of posko provided for the refugee to stay in Merapi eruption disaster. The distributions of the goods are not necessarily done by significant authorities but also by the volunteers, even the students from UGM:)

"Problems"

Literature studies showed that the main problem occurred in the field of coordination (communication and organization) and logistical processes.

Take the earthquake in Bantul (2006) an an example, where it was reported that the preparations were quite systematic where the managements had good transportation, good communication, pre-existing of emergency services networking, and the presences of quick response of the local, regional and even international team. Unfortunately, there was no well- coordinated works between the managements related.

Nevertheless, I personally believe it's due to fact that the event was out of anyone’s expectation; it happened suddenly and huge. Plus, the involvement of large number of authorities (community itself, NGOs, private sectors, hospitals, individual volunteers, etc) in such a no- plan manner caused the rapid but yes, hectic uncoordinated works especially as they may have different approaches or goals.

But as what was told by dr. Hera Nirwati, the co- operation of the community of Bantul itself and the improvements of works coordination between the authorities helped the quick recovery process of Bantul. Let's pray for them:)

Now.. Another problem.

What do you think when you see this picture?

Heaps of clothes in Posko Manguwoharjo

This scenery are seen in almost all posko (source: Kompasiana) showing one of the ineffective managements in the logistical process. Believe me, the refugees are not to be blame fully on this matter the fact that they are thousands of them in one refugee camp; not everyone can behave in truly good manner. But if only there are more staffs provided, or there are schedule or terms and conditions for refugee to pick up the clothes which are best for them; things will be better..

Well.. May there will be more and better efforts to achieve the effective relief logistics management, and we are part of the contributors:)

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References:

• "Logistic Management Support", lecture by dr. Sulanto Saleh- Danu, Sp. FK 
• "Earthquake in Yogyakarta (Natural Disaster)": GROUP 8 TUTORIAL SESSIONS (Week 6)
• Scribd: Logistic Management in Disaster

As Every Detail Counts ii

Today's post is simply for me to continue my discussions on the characteristics to be determined for victim identification which is:

STATURE

Estimation of stature from skeletal measurements is of great interest in forensic anthropology. It's not a fixed value for any individual at any age but is influenced by different factors. Therefore, considerations regarding age, sex and ethnicity may be made when estimating stature from the skeleton. The fact is that an individual's stature is a result of both genetic and environmental (including nutritional, economic influences, etc) factors in a way which is quite complicated. Differences in skeletal body proportions in relation to stature may depend on each of these factors in combination.

Most methods of estimating stature from the skeleton are based on the long bones of the upper and lower extremities. The estimations from these long bones are based on least squares regression. It implies that the standard error is as small as possible from a mathematical point of view.

Okay, now let's do a little calculation together:)

A femur was taken from an individual leg which was separated from its belonged body. The measurement of femur's length (maximally taken from both tips of the femur) is 46 cm. The calculation goes as followed:

2.15 (Femur)  + 72. 57  +/-  3.80

= 2.15 (46cm) + 72. 57 +/-  3.80

= (171. 47 - 3.80) to (171. 47 + 3.80)

= 167. 67 to 175. 27

Hence, the estimated height for the person of which this femur belong to is in the range of 168cm to 175cm tall.

The estimation of stature will get even pronounced as we calculate other bones presence together and also with other types of analytical examinations like body structure analysis, documents of the dead victim, and environmental factors related (geographical, economical, cultural, nutritional values) to determine the age:)

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References:

• "Forensic Antropological Roles in Disaster Victim Identification", lecture by Prof. drg. Etty Indriati, Ph. D
• "Forensic Anthropological Identification of Disaster Victims", Practical Session guidelines in BLOCK 4.2 Lab. Manual Book: Health System & Disaster, UGM.
• CRANKSHAFT: Stature Estimation from The Skeleton