Disasters and Public Health:Learning from Recent History

Richard Keller, PhD

Dept. of Medical History and Bioethics

University of Wisconsin-Madisonrckeller@wisc.edu

Public Health and the History of Disasters

• What can we learn about public health by studying recent natural and environmental disasters?

• What do disasters teach us about risk and vulnerability?

• What about this research is “translatable” to public health practice?

Poll Question

In your opinion, are there any practical things that can be done to enhance a community’s resilience prior to the experience of a disaster?

A. Yes

B. No

Examples

• Bhopal: 3 December 1984

• Chernobyl: 26 April 1986

• Chicago heat wave: July 1995

• European heat wave: August 2003

• Hurricane Katrina: August–September 2005

• Each with important lessons on risk, vulnerability, and coupling of human-natural systems

Objectives

This presentation will help participants:

Develop the ability to recognize social dimensions of risk

Understand how environmental and technological hazards are often linked to poor health outcomes

Define policy initiatives that could promote greater resilience among vulnerable populations

Vulnerability and Resentment

Bhopal and Katrina

Disaster in a Social Frame

Much study of disaster is conducted in fields such as physical geography, geology, seismology, volcanology, meteorology, toxicology.

Great Sumatra/ Andaman Earthquake

But…

Recent episodes demonstrate importance of understanding social and cultural dimensions of disaster.

Hurricane Katrina

Bhopal

• Internationalization of risk and responsibility

• Critical factors Uncontrolled urbanization Outsourcing of risk Engineered unpreparedness

• Outcomes Unclear m&m Nonexistent management Aimless litigation and

resentment

Hurricane Katrina

• Revelation of unequal burden of vulnerability

• Poor management

• Public health consequences ongoing

• Q: Who is a disaster victim?

Poll Question

In your opinion, which of the following are victims of a disaster?

A. Someone stranded on a rooftop by a flood

B. Someone who drowns in a flood

C. Someone displaced by a flood, who commits suicide years later

D. All of the above

Cities and Vulnerability

Mapping Resilience and Vulnerability

• Neighborhood studies

• Corollary to epidemiological case-control studies How does one neighborhood experience relatively

little damage or bounce back quickly, while a nearby neighborhood experiences utter devastation?

• Examples Fire in Southern California

Heat in Chicago

Heat in Paris

Fire in Greater Los Angeles (Davis 1999)

• Malibu Regular wildfires; insurance and federal/state

programs cover damage and ensure rapid response

• Downtown LA Regular building fires; poorly funded fire stations,

disregard for building codes, absence of funding mean greater aggregate damage and failure of state to respond

• Movie stars vs. immigrants, ethnic minorities Socioeconomic, cultural, and political inequality

Heat Wave in Chicago, July 1995 (Klinenberg 2002)

• ~700 excess deaths, mostly African-American, very few whites and Latinos

• City, public health officials offer dubious cultural explanation for divergent mortality

Latinos more habituated to heat

Latinos have closer family ties, therefore less isolated (questionable)

Neighborhood Study

• Qualitative analysis of two neighborhoods

North Lawndale (African-American)

Little Village (Latino)

• Abutting communities

• Identical microclimates

• Similar socioeconomic conditions

• Similar age of populations

North Lawndale

• Degraded infrastructure and decaying housing stock: Economic decline in aftermath of “white flight” and industrial relocation

• Aging and unfit population: High rates of obesity, hypertension, heart disease

• Drug trafficking, gang warfare, high crime rate creates climate of fear

• Result: Difficult for aging populations to leave home, poor social integration of most vulnerable populations

• Isolation in brick apartments/houses, with windows shut out of fear

Little Village

• Similar population size, income level, age, lower, significant crime rate and gang activity

• Less white flight

• Most important: Significant economic/commercial activity and street life

• Result: Vulnerable populations leave apartments, even at night, for air-conditioned/cooler locations, lowering risk factors

• Not ethnic protection factor: Lower mortality even among whites in Little Village

• Not socioeconomic: More a function of different behavior than one of different incomes

Poll Question

In your opinion, which of the following goals of public policy is most important to your local community’s resilience in the face of a disaster?

A. Robust local economic/commercial activity

B. Equity of social and physical infrastructures

C. Community cohesion and social integration

D. Clear plans for disaster response

Heat Wave in Paris: Beaugrenelle

Heat Wave in Paris: Auteuil

Deaths from Heat Wave

Deaths by Age and Sex, 1–20 August 2003

Source: INSERM

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

44 andunder

45–74 75 andover

Total

Women

Men

Total

Ile-de-France

• 32.9% of excess mortality concentrated in one region (4866 unanticipated deaths)

• Paris: 7.2% (1066)

• But only roughly 3.33% of French population

• Other hard-hit areas: Hauts-de-Seine (5.4%)

Val-de-Marne (5.1%)

Seine-Saint-Denis (3.9%)

Why Did They Die?

• Poor thermoregulation

• Lower perception of thirst

• Highest risk groups: those over 75 years of age and psychiatric/neurological patients

Risk Factors: Socioeconomic Status

Source: InVS

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

Management, executive

Middle management

Employee

Artisan, skilled labor

Worker, other

Risk Factors: SES and Its Markers

2.47None

1.49Bath

0.86Shower and bath

1.00Shower

Odds ratioBath facilities

1.39No elevator

2.33Top floor

1.12Other than top floor

Odds ratioHousing situation

Source: InVS

Risk Factors: Behavior During Heat Wave

0.47Media exposure: TV/Radio

20.76Never

15.61Weekly

12.09Every other day

3.14Daily

1.00More than daily

Odds ratioShower/bath frequency

4.97Grocery delivery

3.90Rare (weekly or less)

0.54Seeking a cool place

1.00Regular, no reason specified

Odds ratioDeparture from home

Source: InVS

Risk Factors: Social Integration

ORFrequency of visitors

1.00Never or rarely

2.812–4 x weekly

3.60Daily or more

6.12No social activity

0.59Living alone

ORDegree of social interaction

Poverty, Isolation, Accumulation of Risk

3.64SES: Worker/other

2.47No bath facilities

2.33Top floor of building

6.12No social interaction

3.90Rare departure

ORRisk factor

Marginalization and Social Citizenship

“You know, the elderly, they don’t have very good memories, often from one moment to another, so the preventive messages that we could air…well, they’d forget them the same day!” —Jean-François Mattéi 15 August 2003

Source: INA

A Science of Resilience: Critical Themes and Concepts

• Integrating social scientific and humanistic knowledge in disaster risk reduction and assessments of vulnerability and resilience

• Mapping resilience and vulnerability

• Intersections of health, citizenship, and resilience

• Violence and vulnerability: Research problems and possibilities

• Goal: A societal resilience index?

Political/Social Dimensions of Resilience

Problem: “Biological citizenship” and cultures of reparation

Claims to citizenship based on vulnerability

Chernobyl

Chernobyl memorial, Vilnius. Photo: Alma Pater

Other Examples

• Bhopal

• Brazil’s AIDS program

• What potential mechanisms can ensure other forms of security to avoid replication of such patterns, particularly in developing countries?

Opportunity?

• Relative dearth of research on basic social factors promoting vulnerability or resilience Ultimate vs. proximate causes

• Importance of civic, economic, political, and practical equality as components of resilient societies, vs. prevalence of structural violence (economic, social, political marginalization; inhibited agency) as critical factor determining vulnerability

Goal: A Societal Resilience Index?

• Building on models of vulnerability Can we determine an index of resilience

To what uses can this index be put (insurance, resource allocation)?

• Critical variables Age, personal wealth, ethnicity, occupation, and

infrastructure dependence

Density of the built environment, housing stock, and tenancy

Coupling of technological systems

We are now going to open the phone lines and ask people to verbally share one thing you might do differently in your practice in light of today’s discussion.

Simply raise your hand by clicking on the “hand raise” icon. We will call on you.

Conclusions