Disasters and Public Health: Learning from Recent History

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Disasters and Public HealthLearning from Recent
History

• Richard Keller, PhD
• Dept. of Medical History and Bioethics
• University of Wisconsin-Madison
• rckeller_at_wisc.edu

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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?

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Poll Question

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

A. Yes B. No
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Examples

• Bhopal 3 December 1984
• Chernobyl 26 April 1986
• Chicago heat wave July 1995
• European heat wave August 2003
• Hurricane Katrina AugustSeptember 2005
• Each with important lessons on risk,
  vulnerability, and coupling of human-natural
  systems

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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

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Vulnerability and Resentment

• Bhopal and Katrina

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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
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But

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

Hurricane Katrina
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Bhopal

• Internationalization of risk and responsibility
• Critical factors
• Uncontrolled urbanization
• Outsourcing of risk
• Engineered unpreparedness
• Outcomes
• Unclear mm
• Nonexistent management
• Aimless litigation and resentment

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Hurricane Katrina

• Revelation of unequal burden of vulnerability
• Poor management
• Public health consequences ongoing
• Q Who is a disaster victim?

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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
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Cities and Vulnerability
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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

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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

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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)

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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

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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

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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

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Poll Question

• In your opinion, which of the following goals of
  public policy is most important to your local
  communitys 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
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Heat Wave in Paris Beaugrenelle
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Heat Wave in Paris Auteuil
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Deaths from Heat Wave
Deaths by Age and Sex, 120 August 2003
16,000
14,000
12,000
10,000
Women
8,000
Men
Total
6,000
4,000
2,000
0
44 and
4574
75 and
Total
under
over
Source INSERM
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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)

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Why Did They Die?

• Poor thermoregulation
• Lower perception of thirst
• Highest risk groups those over 75 years of age
  and psychiatric/neurological patients

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Risk Factors Socioeconomic Status
4.0
3.5
Management, executive
3.0
Middle management
2.5
Employee
2.0
1.5
Artisan, skilled labor
1.0
Worker, other
0.5
0.0
Source InVS
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Risk Factors SES and Its Markers
Odds ratio
Housing situation
1.12
Other than top floor
2.33
Top floor
1.39
No elevator
Odds ratio
Bath facilities
1.00
Shower
0.86
Shower and bath
1.49
Bath
2.47
None
Source InVS
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Risk Factors Behavior During Heat Wave
Odds ratio
Departure from home
1.00
Regular, no reason specified
0.54
Seeking a cool place
3.90
Rare (weekly or less)
4.97
Grocery delivery
Odds ratio
Shower/bath frequency
1.00
More than daily
3.14
Daily
12.09
Every other day
15.61
Weekly
20.76
Never
Source InVS
0.47
Media exposure TV/Radio
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Risk Factors Social Integration
OR
Degree of social interaction
0.59
Living alone
OR
Frequency of visitors
1.00
Never or rarely
2.81
24 x weekly
3.60
Daily or more
6.12
No social activity
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Poverty, Isolation, Accumulation of Risk
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Marginalization and Social Citizenship

• You know, the elderly, they dont have very good
  memories, often from one moment to another, so
  the preventive messages that we could airwell,
  theyd forget them the same day!
• Jean-François Mattéi 15
  August 2003

Source INA
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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?

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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
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Other Examples

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

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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

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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

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• 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 todays
  discussion.
• Simply raise your hand by clicking on the hand
  raise icon. We will call on you.

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Conclusions