QUESTION

1. QUESTION • Do you keep abreast with the local and international news? • Do we agree with the remarks of that great 19th century German pathologist- Rudolph Virhow- that ‘medicine is a social science, and politics is nothing but medicine on a larger scale’?

2. A LECTURE BY PROFESSOR HAMIDU AHMED, OON CONSULTANT PAEDIATRICIAN UDUS/UDUTH, SOKOTO, NIGERIA DELIVERED DURING THE NMA (KEBBI STATE CHAPTER) SCIENTIFIC MEETING AT THE FEDERAL MEDICAL CENTRE (FMC) AUDITORIUM, BIRNIN-KEBBI ON SATURDAY, 12TH JANUARY, 2013 DISASTER MEDICINE AND EMERGENCY PREPAREDNESS: AN OVERVIEW OF CURRENT CONCEPTS AND THE SITUATION IN NIGERIA

3. Outline of the Lecture • Definition/explanation of concepts • Classification of disasters • Common disasters in Nigeria • Common consequences of disasters • Some details on common disasters in Nigeria • Disaster management and emergency preparedness: the role of the health services • Disaster management in Nigeria • Conclusions • Further Reading for Doctors, Managers and Policy-makers

4. 1) DEFINITION OF CONCEPTS • Disaster: A disaster can be defined as any occurrence that causes damage, ecological disruption, loss of human life or deterioration of health and health services on a scale sufficient to warrant extraordinary response from outside the affected community or area (WHO 1995) • Disasters are not confined to a particular part of the world. They can occur anywhere and at any time. • Emergencies: An emergency can be defined as a sudden occurrence demanding immediate action that may be due to epidemic, natural, or technological catastrophe or to strife or other man-made causes (WHO 1995). • Emergencies arise everyday world-wide. • Emergencies and disasters do not affect only health and wellbeing, frequently they cause greater risk of epidemic , and considerable economic harm.

5. Disasters are the extreme end of the spectrum of harmful events. • Some disasters are extreme examples of normal processes, e. g: • The normal seasonal hunger turns into famine; • The annual flood reaches its 20-year high point, • or the normal rises and fall of economic fortune plummets into economic collapse (IFRCRCS , World Disaster Report 1994)

6. Disaster Medicine Disaster medicine is concerned with: 1) Alleviation of the suffering of people affected by disasters 2) Rapid health assessment for emergencies 3) Emergency preparedness, including identification of warning signs, e g for epidemics. Disaster medicine is multidisciplinary field involving health personnel (doctors, nurses, pharmacists other health workers, other experts: engineers, administrators, security agents, e t c).

7. The Concept of Rapid Health Assessment for Emergencies • In disaster management, assessment means collecting information in order to measure damage and identify those basic needs of the affected population that require immediate response (WHO, 1999a) • The assessment is always meant to be rapid, as it must be performed in limited time, during or in the immediate aftermath of a disaster • The purpose of a rapid assessment is to: • confirm the emergency; • describe the type, impact and possible evolution of the emergency; • measure the present and potential health impact of the disaster • assess the adequacy of existing response capacity and immediate additional needs; • recommend priority action for immediate response

8. The Concept of Emergency Preparedness • Recall that disasters cause great harm to people, communities and countries, affecting current population and existing infrastructure and threatening the future of sustainable development • Therefore, neither communities nor governments can afford to wait for emergencies and disasters to occur before responding to them. • The suffering caused by injuries and deaths, social and economic disruption, and the destruction of environment can be reduced through various measures designed to reduce vulnerability • What is emergency preparedness? Emergency preparedness is a programme of long term development activities, whose goals are to strengthen the overall capacity and capability of a country to manage efficiently all types of emergency and bring about an orderly transition from relief through recovery and back to sustained development (WHO 1999b)

9. 2) CLASSIFICATION OF DISASTERS

10. CLASSIFICATION OF DISASTERS

11. A) Examples of Sudden-impact Natural Disasters • Cyclones • Hurricanes • Gales • Tornadoes • Tidal Waves • Storm Surges • Tsunamis • Flash Floods* • Fires (large-scale devastating forest fires, e.g. in Australia, USA) • Earthquakes • Landslides • Avalanches • Volcanic Eruptions

12. B) Examples of Epidemics ofInfectious Origin • Epidemic Meningococcal Meningitis* • Cholera* • Yellow Fever Epidemic* • Lassa Fever* • Ebola • Dengue • Other Hemorrhagic Fevers • Influenza Epidemic • HIV/AIDS • SARS • Avian Influenza Epidemic, etc

13. C) Examples of Other Natural Disasters • Drought* • Locust Invasion* • Famine* • Both drought & locust invasion can lead to loss of crops & famine

14. Examples of Man-made Disasters • Wars • Strife • Generalized violence • Chemical emergencies • Air disasters • Terrorist bombings • Fires • Nuclear Disasters

15. 3) COMMON DISASTERS IN NIGERIA Natural: Sudden-impact natural disasters • Floods* Epidemics of Infectious Origin • Epidemic Meningococcal Meningitis* • Cholera • Yellow Fever Epidemic • Lassa Fever Other Natural Disasters • Drought* • Locust Invasion • Famine • Both drought & locust invasion can lead to loss of crops & famine • * Some details are given on these in the discourse

16. Common Disasters in Nigeria- Cont’d Man-made: • Strife* • Generalized violence* • Chemical emergencies* • Air disasters* • Fires* • Terrorist bombings* * Some details are given on these in the discourse

17. 4) COMMON CONSEQUENCESOF DISASTERS DISASTERS NATURAL MAN-MADE 1- Sudden population displacement 2- Nutritional emergencies (famine) 3- Outbreak of epidemics due to overcrowding, poor sanitation, inadequate safe supply of water.

18. Common Consequences of Sudden-impact Natural Disasters • Kill a large number of people (mortality increases) • Injure a large number of people (morbidity increases) • Cause extensive • social damage • economic damage • Often create an immediate obstacle to response by disrupting vital services, e.g. - water supply - health services - security services - communication - transportation

19. Common Consequences of Man-made Disasters • Wars, strife and generalized violence kill a large number of people (mortality increases). They also cause injury to a large number of people –causing mass surgical casualties • Air disasters and terrorist bombings usually deliver few intensive care patients, since only a small percentage of these patients have delayed deaths. This is a reflection of the mechanism of injury. The majority of patients from these situations will have either injuries producing immediate deaths, obviously mortal injuries, or minor to mild injuries (See Frykberg & Tepas 1988, 1989) • Chemical disasters such as toxic fumes, smoke inhalations from high-rise structure fires and nuclear radiation exposures are medical mass-casualty incidents which are less frequent but more likely to deliver many patients to the intensive care unit (Ferguson el al 1992) • Recall the recent incidence of acute, severe, large-scale lead poisoning in children in Zamfara State, north-western Nigeria, in which thousands of children were affected, with hundreds of deaths (MSF, 2012)

20. 5) SOME DETAILS ON SELECTED COMMON DISASTERS IN NIGERIA Brief discourse on: • Natural disasters • Floods • Epidemic meningococcal meningitis • Drought and famine • Man-made disasters: • Strife and generalized violence • Terrorist bombings and air disasters • Fires and chemical disasters

21. Floods • Flooding is the most common of all environmental hazards. It is estimated that it claims over 20,000 lives per year and adversely affects about 75 million people world-wide (Etuonovbe, 2011). • Other estimates indicated that from 1993 to 2002 flood disasters affected about 140 million people per year, which is more than all other natural or technological disasters put together (IFRCRCS 2003) • In Nigeria, flooding in various parts of the country have forced millions of people from their homes, destroyed business, polluted water resources and increased the risk of disease • Mortality and morbidity are due to drowning, near-drowning, collapse of buildings and water pollution.

22. FLOODS- CONT’D Causes of Flooding in Nigeria • Natural causes • Heavy/torrential rain • Ocean storms and tidal waves • Types of Flooding in Nigeria • Man-made • Dam burst • Dam spills Coastal flooding River flooding Flash floods Urban fld Dam b&s

23. Types of Flooding in Nigeria

24. Types of Flooding in Nigeria

25. Medical Consequences of Flood Disasters • Mortality is high only in the case of sudden flooding- flash floods, the collapse of dams, or tidal waves • Morbidity: fractures, injuries, bruises; and in cold weather accidental hypothermia may occur (WHO, 1989)

26. Examples of Deleterious Effects of Flooding in Nigeria

27. Examples of Deleterious Effects of Flooding in Nigeria

28. Examples of Deleterious Effects of Flooding in Nigeria

29. EPIDEMIC MENINGOCOCCAL MENINGITIS(For more details see Ahmed H, 2007(a); WHO,1999(a)

30. Meningitis belt lies within 300mm to 1,100mm of annual rainfall i.e. • corresponds to Sudan and Sahel Savannah of Africa ( northern part of sub-Saharan Africa). • - In this belt short severe epidemics occur every 5-10 year • - Mortality: 3-20% - with mortality tending to fall as the epidemic progresses. • Last major epidemic reported by WHO – 1996; 300,000 cases. Most affected countries: Nigeria, Niger, B/Faso and Mali. Recent epidemic: Feb. – May 2008 and March-May, 2009 • - In Nigeria epidemics have occurred rarely outside the meningitis belt. • - Remember that: • Meningococcal meningitis in its epidemic form occurs worldwide. • In this case the predominant serogroup depends on geographical • location. • Serogroup A is the predominant cause of the disease in Africa during both • endemic (sporadic cases) and epidemic periods. • Serogroup B – major cause of disease and small outbreaks (in winter and • spring) in Europe. • - Serogroup C – can also cause disease and epidemics – especially in Africa. • The major group causing epidemics i.e. A, B and C can be sub-typed into • clones for epidemiological study. • Clonal analysis is based on eletrophoretic variation of the bacterial • cytoplasmic isoenzymes and major outer membrane proteins.

31. MENINGITIS BELT OF AFRICA= THE AFRICAN MENINGOCOCCAL MENINGITIS BELT The area enclosed within the bold lines approximately corresponds to the sudan savannah and sahel regions where meningococcal meningitis epidemics occur at fairly regular 10-year intervals. Map is modified from Lapeysonnie (1963) and Achtman (1991)

32. Serogroup A: can be divided into several groups: AI, AII, AIII, AIV, AV, AVI. Each subgroup has several clones. numbered 1 – 4 e.g. serogroup AIII has the following clones: AIII-1, AIII-2, AIII-3 and AIII-4. This sub-grouping is important in studying epidemics: Note: each wave of a given epidemic of group A disease is caused by a particular clone. By using clonal analysis the origins of an epidemic (or pandemic) of group A meningococcal infection can be traced and the spread of this particular epidemic from country to country can be followed. Age Distribution of Meningococcal Disease Non-epidemic periods : Mostly 3 months – 5 yeas (>50% cases) Epidemics: (Africa): 5 – 14 years (Europe and N. America): Young children are mostly affected

33. People prone to infection during epidemics: • Children living in crowded conditions, e.g. • - pupils in traditional Qur’anic schools; • Young people in closed communities; • - boarding schools • - military recruits • . Any crowded living conditions can increase likelihood of infection • during epidemics. • Pointers to epidemic outbreaks. The immediate pointer to an • epidemic outbreak is the attack rate. • When the attack rate exceeds 15 cases per 100,000 population for 2 weeks in a row, it is likely that an epidemic of meningococcal infection is on. • In one epidemic of meningococcal disease in Zaria, Northern Nigeria, the overall attack rate reached 360 per 100,000. This is extremely high. • Note: In the meningitis belt, there is seasonal variation in incidence of BM. Outside the belt there is no variation in incidence. • - Humans are the reservoir of meningococci. • - Not every person exposed to pathogenic meningococci develops clinical • symptoms. • - Healthy individuals can carry meningococci in the nasopharynx.

34. Mode of spread of meningococci (whatever the serogroup) is fromperson to person by direct contact with respiratory droplets of infected person. • All humans are susceptible to meningococcal disease, but disease risk is higher in persons with: • - Terminal complement deficiency (C5 – C9), splenectomy, patients with sickle cell disease • Incubation period • 1-10 days with a mean of 4 days. • - The organism initially colonizes the nasopharynx. • Under special conditions – e.g. under-nutrition, overcrowding and reduced immunity to a particular clone (reduced herd immunity) there is spread via the blood stream to other parts of the body and the meninges.

35. Prevention and control: • Mass vaccination during epidemics of meningococcal disease. Bivalent A&C vaccines used during epidemics in the meningitis belt • Chemoprophylaxis of contacts for limited outbreaks among closed populations (household, boarding schools, day-care centres) • Chemoprophylaxis is however not warranted as a control measure against spread of meningococcal meningitis in severe epidemics. For such epidemics mass immunization is more appropriate. Treatment under difficult circumstances • Under difficult circumstances, when health workers are overwhelmed by multitude of patients in an epidemic of meningococcal meningitis, long-acting chloramphenicol or other forms of short-course antibiotic regime can be used in the treatment of the disease

36. Medical Consequences of Droughts • If famine occurs mortality is high in such areas. • Morbidity is increased due to increase in PEM- marasmus, kwashiorkor • Incidence of vitamin A deficiency increases in children causing xerophthalmia, blindness and reduced immunity in children. • In the conditions of famine, measles, respiratory infections and diarrhoea can bring massive increase in morbidity and mortality • Population displacement with overcrowding and poor hygiene may facilitate the spread of endemic communicable diseases- e .g., tuberculosis, parasitic diseases and malaria (WHO, 1989)

37. Strife and Generalized Violence: The Nigerian Situation: Review of Some Historical Aspects • I have prepared a catalogue of strife and generalized violence from 15th century when the area, to be known later as Nigeria, was the target for British and Portuguese economic exploitation including extensive slaving, to the period of gradual British control (1861-1914), to the 1965 western Nigerian post-election violence, the Nigerian civil war, up to the current security situations in the Niger Delta, Plateaux State, and the terrorist bombings and armed attacks in northern Nigeria (see Copley RG 2006, and various news reports from 2007-2012). • I have summarized the effects of such man-made disasters in subsequent discourse, with special reference to the current Nigerian situation.

38. Strife and Generalized Violence: The Nigerian Situation: Review of Some Historical Aspects

39. Strife and Generalized Violence: The Nigerian Situation: Review of Some Historical Aspects

40. Strife and Generalized Violence: The Nigerian Situation: Review of Some Historical Aspects

41. Strife and Generalized Violence: The Nigerian Situation: Review of Some Historical Aspects

42. Strife and Generalized Violence: The Nigerian Situation: Review of Some Historical Aspects

43. Strife and Generalized Violence: The Nigerian Situation: Review of Some Historical Aspects

44. Strife and Generalized Violence- The Nigerian Situation: Age of Terrorist Bombings • In the last 2 years northern Nigeria has been adversely affected by regular terrorist bombings and armed attacks on : • churches • mosques • public squares • public buildings • parking spaces • markets • banks • residential areas • police stations • police posts • universities • primary schools • prison yards • bridges • several villages and communities

45. Terrorist bombings and Complex Emergencies • Every disaster, whether natural or man-made, creates problems for maintaining law and order and performing day-to-day police functions • Law and order must be maintained even during disasters and emergencies. This may prove difficult since police may be heavily committed to emergency operations • Police organizations will need to develop operational plans that ensure sufficient resources for normal policing and security (WHO 1999b) • However, the recent terrorist bombings in northern Nigeria are creating complex emergencies, since the security agents are also the target of attacks. • Complex emergencies are situations where the cause of the emergency as well as assistance to the afflicted are bound by intense level of political considerations (WHO, 1999a)

46. Terrorist bombings and Complex Emergencies • Complex emergencies are characterized by varying degrees of instability and even collapse of national authority • This leads to loss of administrative control and to the inability to provide vital services and protection to the civilian population • One main feature of complex emergencies is the actual or potential generalized violence against human beings, the environment, infrastructure and property • Violence has a direct impact in term of deaths, physical and psychological trauma and disabilities • In conflicts characterized by rapidly shifting zones of combat, as is today happening in northern Nigeria, where government is confronted with low-level insurgency by faceless organizations supported by fleeing Chadian rebels and other foreigners, civilians often find themselves under cross fire. • In many instances in complex emergencies, civilians become primary targets of ethnic and religious cleansing, murder, sexual abuse, torture and mutilation

47. Terrorist bombings, Armed Attacks and Complex Emergencies: Possible Effects on Public Health The other effects of conflict on public health are mediated by a variety of circumstances that include: • Population displacement with concentration in camps, public buildings or other settlements. This causes an increase in the risk of acute respiratory infection, diarrhoea, dysentery, measles and other epidemics. The dependence on food rations entails risk of malnutrition. • The loss of opportunities and instruments of production, food stocks, and purchasing power due to destruction or interference of commercial network can result in food shortages and population migration. • Armed attacks and bombings, in addition to targeting civilian population, can damage infrastructures such as roads, water plants, communications and even health facilities. • The general economic crisis due to decreased production, loss of capital and increased military expenditure can force cuts in the budgets for social sector including health • Insecurity and military operations may restrict access to affected areas and limit the delivery of health services and recovery operations

48. Fire Disasters • In Nigeria fire incidents affecting individual homes, markets, government offices, petrol stations and private business enterprises are too numerous to catalogue • Data obtained from the Nigeria Fire Service for the year 2010 indicated that there were 7129 incidents of fire in the country that destroyed 990 lives and property worth over N53 billion (See Ojo 2011) • Fires, of disaster magnitude, arising from deliberate or accidental rupture of petroleum pipelines, are also not uncommon; so are fires affecting large markets from Lagos to Sokoto • In recent years fires from air disasters and terrorist bombings have compounded the problem • WHO (1999b) recognizes search and rescue as one of the six major sectors in disaster management and emergency preparedness. The other five sectors include: communication, health and medical, social welfare, police and security, and transport and lifelines. • With regards to search and rescue, it is suggested that the Head of this sector should be the Chief of fire department (WHO, 1999b)

49. Fire Disasters • It is also recommended that the role of the Fire Service (or Fire Department) in disaster situations is fire fighting, rescue work, clearing rubble, protection of individuals and property (WHO, 1999b) • The fire department cooperates with other rescue services, public or private companies and utilities (water and electricity) in achieving these goals Fire Service in Nigeria: Brief Historical Review and the Current Status • Recall that the Nigeria Fire Service (NFS) is over one hundred years old. It started operations in1906 under the Lagos Police Fire Department. Subsequently, it became the Federal Fire Service (FFS) under a Controller-General. Furthermore, currently each state of the federation has also State Fire Service. • It is asserted that of all the disaster management agencies, the Nigeria Fire Service is the least equipped and staffed to play its vital role (Ojo, 2011) • Information from the Controller- General of FFS in 2010 indicated that the country needed 5,000 fire service stations to effectively fight fire outbreaks. However, Nigeria has only 269 of such stations nationwide.

50. Fire Disasters Fire Service in Nigeria: Brief Historical Review and the Current Status (Cont’d) • Furthermore, in the vast majority of the fire stations functional trucks for dispensing water are not available. Similarly, modern equipment for fire fighting is rarely available. There is paucity of water, air breathing apparatus, fire-resistant garments, fire blankets, megaphones, first aid kits and helicopters (Ojo, 2011) • Other challenges faced by the NFS both at federal and state levels include: absence of water hydrants at street corners in large cities, lack of fire escape for high-rise structures, non-enforcement of fire-prevention laws at petrol stations, lack of recruitment of new staff and poor funding. Recall that the last time FFS recruited was in 2001 (11 years ago!) • Fire disasters are one of the commonest man-made emergencies in Nigeria; therefore, the need for improvement in our fire-fighting capability is urgent.