Health Effects of the 1991 Bangladesh Cyclone: Report of a UNICEF Evaluation Team

To assess the impact on health of the cyclone and tidal wave that struck the southern coast of Bangladesh on the evening of 29 April 1991, a team of health professionals visited cyclone affected areas from 4–27 June, 1991. Team members met with health workers and officials of the Government of Bangladesh and with staff pom nongovernmental organizations, and conducted field surveys in two severely affected areas.
Mortality among the 135 households surveyed (pre-cyclone population 1,123) was 14 per cent. At highest risk of deaths were children of less than 10 years (26 per cent mortality) and women of more than 40 (31 per cent mortality). Almost all deaths occurred as a result of drowning from the tidal wave that accompanied the cyclone. Although 95 per cent of the population surveyed had received warning of the cyclone four or more hours before it struck, the 300 existing cyclone shelters had capacity for only 450,000 of the 5,000,000 people affected by the cyclone. Deaths following the cyclone were few. Diarrhea caused by Vibrio cholerae and Shigella dysenteria type 1, both of which are endemic in Bangladesh, occurred in the post-cyclone period. Reports by the national Diarrhea Surveillance System of large increases in diarrheal incidence following the cyclone were difficult to assess because of inconsistencies in pre-and post-cyclone reporting methods. No increase in other infectious diseases was identified.
Although water availability had been a major concern following the cyclone, the tubewell system was functioning well in the area that was surveyed. Distribution of relief assistance by the Government of Bangladesh and by non-governmental organizations was good, with 95 per cent of families surveyed receiving food aid within five days of the cyclone.
The major health effect of this cyclone was acute deaths due to drowning. Preventing deaths during future cyclones will require increasing accessible shelter.     

Changes in HIV/AIDS/STI knowledge, attitudes and practices among commercial sex workers and military forces in Port Loko, Sierra Leone

Sierra Leone suffered from 11 years of civil war (1991-2002) resulting in tens of thousands of deaths and mutilations together with massive population displacement. In 2001, ARC International, Sierra Leone conducted a baseline survey of 201 commercial sex workers (CSWs) and 202 military respondents on the knowledge, attitudes and practices surrounding HIV/AIDS and STIs in Port Loko, Sierra Leone. In 2003, a comparable post-intervention survey of 202 CSWs and 205 military respondents was performed. Comparison of baseline and post-intervention results showed that HIV/AIDS knowledge increased among both groups, with those able to name three effective means of avoiding AIDS increasing from 5 per cent to 70 per cent among CSWs, and 11 to 75 per cent among the military. Reported condom use during last sex increased among CSWs from 38 to 68 per cent and among military from 39 to 68 per cent. These results demonstrate that, despite the challenges inherent in a post-conflict country, good-quality AIDS-prevention programmes can be effective.     

Severe drought and the vitamin A status of rural pre-school children in India

A community-based cross-sectional study was carried out in six drought-affected areas of India in 2003 to assess the impact of drought on the vitamin A status of 3,657 rural pre-school children. The prevalence of Bitot's spots was found to be significantly (p < 0.01) higher (1.8 per cent) during drought (odds ratio (OR) = 2.0; 95 per cent confidence interval: 1.6 -2.7). The dietary intake of vitamin A was lower during drought and in 81 per cent of households it was less than 50 per cent of the recommended rate. Severe drought has an adverse impact on the vitamin A status of rural pre-school children, particularly those with illiterate mothers and belonging to an older age group (p < 0.01). Communities need to be sensitised, therefore, to vitamin A deficiency through health and nutrition education, and there needs to be wider coverage of vitamin A supplementation, particularly among children in drought-affected and drought-prone areas.     

Epidemiological assessment of food aid in the Bosnian conflict, 1994-97

Surveys in emergency settings are important for the accountability of food aid. Four household surveys conducted between 1994 and 1997 measured the performance of the Bosnia food aid programme, covering a random sample of clusters in Bosnia and Herzegovina and the Republica Srpska. The team calculated coverage, exclusion and inclusion errors, programme misses, and under-supply. Despite intended universal coverage from 1994-96, 15, 19, and 31 per cent, respectively, did not receive food across the three-year time frame. Households categorised as vulnerable were somewhat more likely to receive food. Programme misses were rare, whereas under-supply fell from 30 per cent in 1994 to four per cent in 1997, as the availability of other food increased. Extrapolation suggested that 61 per cent of the food distributed did not reach households. The programme introduced priority categories for targeting in 1997, yet nearly one-half of the highest priority households did not receive food. Incomplete coverage and weak targeting were related to political constraints.     

Economic evaluation of measles catch-up and follow-up campaigns in Afghanistan in 2002 and 2003

This paper assesses the cost-effectiveness of, and the return on the investment in, the 2002 catch-up and the 2003 follow-up measles campaigns in Afghanistan from the perspective of the donor. The catch-up campaign targeted nearly 12 million children aged between six months and 12 years, while the follow-up campaign targeted over five million children aged between 9 and 59 months. Both campaigns successfully vaccinated approximately 96 per cent of the respective target populations, and are expected to avert an estimated 301,000 measles deaths over the next 10 years. The average cost per dose of measles vaccine delivered was USD 0.40. The cost per death prevented is USD 23.6, assuming a case fatality rate of 10 per cent and a discount rate of three per cent. With more than 42,000 measles deaths avoided for every one million US dollars spent, the campaigns are an excellent public health investment for precluding childhood mortality in a country affected by a complex emergency.     

Mortality,violence and lack of access to healthcare in the Democratic Republic of Congo

The people of the Democratic Republic of Congo for decades have been living in a situation of chronic crisis. Violence, population displacement and the destruction of infrastructure and health services have devastated the health of the population. In 2001, Médicins Sans Frontières conducted a survey in five areas of western and central DRC to assess mortality, access to health-care, vaccination coverage and exposure to violence. High mortality rates were found in front-line zones, mainly due to malnutrition and infectious diseases. In Basankusu approximately 10 per cent of the total population and 25 per cent of the under-five population had perished in the year before the survey. Humanitarian needs remain acute across the country, particularly near the front line. Infectious-disease control and treatment are a priority, as is increasing access to health-care. Humanitarian assistance must be increased considerably, especially in rural areas and zones that have been affected directly by conflict.     

Determinants of coverage in Community‐based Therapeutic Care programmes: towards a joint quantitative and qualitative analysis

One of the most important elements behind the success of Community‐based Therapeutic Care (CTC) programmes for the treatment of severe acute malnutrition has been their ability to achieve high levels of coverage. In CTC, coverage is measured using the Centric System Area Sampling (CSAS) method, which provides accurate and reliable estimates of programme coverage as well as information on the primary reasons for non‐attendance. Another important feature of CTC programmes is their use of socio‐cultural assessments to determine potential barriers to access and to develop context‐specific responses. By analysing data on non‐attendance provided by CSAS surveys, in conjunction with data from socio‐cultural assessments, it is possible to identify common factors responsible for failures in programme coverage. This paper focuses on an analysis of data from 12 CTC programmes across five African countries. It pinpoints three common factors (distance to sites, community awareness of the programme, and the way in which rejections are handled at the sites) that, together, account for approximately 75 per cent of non‐attendance.     

Long-Term Effects of Hurricane Andrew: Revisiting Mental Health Indicators

Two population-based surveys of South Dade County, Florida, were conducted after Hurricane Andrew to compare hurricane-related symptoms of mental distress and describe the impact of mental health outreach teams. Households were selected by three-stage cluster sampling and findings from the two surveys, 13 months apart, were compared. Response rates were 75 per cent and 84 per cent. The prevalence of symptoms of mental distress decreased over time. However, in the households contacted by the teams (25 per cent of sample), the prevalence of symptoms (50 per cent) did not differ from households not contacted (43 per cent). Households contacted by teams that reported symptoms were just as likely to have been referred for help by the teams (72 per cent) as those without symptoms (68 per cent). Households reporting symptoms were equally likely to get counselling regardless of whether the teams visited. Mental health teams had no significant impact on mental health symptoms or the use of mental health services. Alternative approaches to mental health outreach teams need to be explored.     

Barriers to the long‐term recovery of individuals with disabilities following a disaster

This study examines how pre‐existing disabling conditions influenced the recovery process of survivors of Hurricane Katrina. It focuses specifically on the barriers that hindered the recovery process in these individuals. Focus groups were convened in four Gulf Coast states with 31 individuals with disabilities who lived in or around New Orleans, Louisiana, prior to Hurricane Katrina in August 2005. Qualitative data were analysed using grounded theory methodology. Five themes emerged as the most significant barriers to recovery: housing; transportation; employment; physical and mental health; and accessing recovery services. While these barriers to recovery were probably common to most survivors of the disaster, the research results suggest that disability status enhanced the challenges that participants experienced in negotiating the recovery process and in acquiring resources that accommodated their disabilities. The findings indicate that, when disaster recovery services and resources did not accommodate the needs of individuals with disabilities, recovery was hindered. Recovery efforts should include building accessible infrastructure and services that will allow for participation by all.     

A determination of the prevalence of gender-based violence among conflict-affected populations in East Timor

The Reproductive Health Response in Conflict (RHRC) Consortium designed a standardised questionnaire to measure gender-based violence (GBV) prevalence in conflict-affected settings. A preliminary field test was undertaken July-August 2002 in one urban and one rural district in East Timor to assess the prevalence of GBV among women 18-49 years of age during and after conflict. The field test used a cross-sectional survey design with a two-stage random selection process. During the year preceding East Timor's 1999 crisis, 23.8 per cent of respondents reported physical assault by an intimate partner; this rate was not significantly different in the year preceding the survey (24.8 per cent). Assault by perpetrators outside the family declined significantly from 24.2 per cent during the crisis to 5.8 per cent post-crisis for physical assault (p<.001) and 22.7 per cent during the crisis to 9.7 per cent post-crisis for sexual assault (p=0.046). The field test stimulated and informed additional research in East Timor, and the complementary findings of these research initiatives continue to be used to develop local policies and programming to prevent and address GBV.     

A multiple additive regression tree analysis of three exposure measures during Hurricane Katrina

This paper analyses structural and personal exposure to Hurricane Katrina. Structural exposure is measured by flood height and building damage; personal exposure is measured by the locations of 911 calls made during the response. Using these variables, this paper characterises the geography of exposure and also demonstrates the utility of a robust analytical approach in understanding health‐related challenges to disadvantaged populations during recovery. Analysis is conducted using a contemporary statistical approach, a multiple additive regression tree (MART), which displays considerable improvement over traditional regression analysis. By using MART, the percentage of improvement in R‐squares over standard multiple linear regression ranges from about 62 to more than 100 per cent. The most revealing finding is the modelled verification that African Americans experienced disproportionate exposure in both structural and personal contexts. Given the impact of exposure to health outcomes, this finding has implications for understanding the long‐term health challenges facing this population.     

Risk of flood-related mortality in Nepal

In July 1993, severe flooding devastated Sarlahi district in Nepal. The next month, a follow-up study of a large population cohort was undertaken. The study is unique in that a prospective research database was used to verify residency prior to the flood and to confirm vital status afterwards. It evaluated 41,501 children aged between two and nine years and adults aged 15-70 in 7,252 households. Flood-related fatality rates were 13.3 per 1,000 for girls and 9.4 per 1,000 for boys, 6.1 per 1,000 for women and 4.1 per 1,000 for men. Flood-related fatality rates for children were six times higher than mortality rates in the same villages a year before the flood (relative risk (RR) = 5.9, 95 per cent confidence interval (CI) 5.0-6.8). Flood-related fatality was associated with low socio-economic status preflood (RR = 6.4, 95 per cent CI 2.7-20.0), and having a house constructed of thatch (RR = 5.1, 95 per cent CI 1.7-24.5).     

Natural disasters and older US adults with disabilities: implications for evacuation

We analysed 2003 and 2004 Behavioral Risk Factor Surveillance System (BRFSS) data from New Orleans-Metairie-Kenner, LA to produce estimates of the number of community dwelling people aged 65 years or older with a disability and requiring special equipment.(4) Approximately, 47,840 (31.6 per cent) older adults with a disability and 24,938 (16.6 per cent) older adults requiring the use of special equipment were community dwelling and might require assistance to evacuate or a shelter that could accommodate special equipment. Older adults who need special equipment were likely to be female, unmarried and white, and to rate their health as fair or poor. Personnel who plan and prepare for evacuations and temporary shelter during disasters need baseline information on the number of older adults with a disability or who require special equipment. A surveillance system, such as the BRFSS, gathers information that planners can use to prepare for and to deliver services.     

Needs assessment of the displaced population following the August 1999 earthquake in Turkey

In August 1999 a major earthquake struck north-western Turkey. An assessment followed to identify the immediate needs of the displaced population. A random cluster sample of displaced families living in temporary shelter outside of organised relief camps was designed. Representatives of 230 households from the four communities worse affected by the earthquake were interviewed. Most families lived in makeshift shelters (84 per cent), used bottled water (91 per cent), obtained food from relief organisations (61 per cent), had access to latrines (90 per cent), had a member on routine medication (53 per cent) and obtained information by word of mouth (81 per cent). Many respondents reported having family members who were over the age of 65 (32 per cent) or under age three (20 per cent), who were pregnant (6 per cent), or who had been ill since the earthquake (64 per cent). The greatest immediate need reported by most families was shelter requirements (37 per cent), followed by food (23 per cent) and hygiene requirements (19 per cent). Ten days after the earthquake, basic environmental health needs of food, shelter and hygiene still predominated in this displaced population. Significant portions may have special needs due to age or illness.     

Concerns and future preparedness plans of a vulnerable population in New Jersey following Hurricane Sandy

Knowing how people prepare for disasters is essential to developing resiliency strategies. This study examined recalled concerns, evacuation experiences, and the future preparedness plans of a vulnerable population in New Jersey, United States, following Hurricane Sandy in 2012. Understanding the responses of minority communities is key to protecting them during forthcoming disasters. Overall, 35 per cent of respondents were not going to prepare for an event. Intended future preparedness actions were unrelated to respondents' ratings of personal impact. More Blacks and Hispanics planned on preparing than Whites (68 versus 55 per cent), and more Hispanics planned on evacuating than did others who were interviewed. A higher percentage of respondents who had trouble getting to health centres were going to prepare than others. Respondents' concerns were connected to safety and survival, protecting family and friends, and having enough food and medicine, whereas future actions included evacuating earlier and buying sufficient supplies to shelter in place.     

Epidemiology of tornado destruction in rural northern Bangladesh: risk factors for death and injury

The epidemiology of tornado-related disasters in the developing world is poorly understood. An August 2005 post-tornado cohort study in rural Bangladesh identified elevated levels of death and injury among the elderly (≥ 60 years of age) (adjusted odds ratio (AOR) = 8.9 (95 per cent confidence interval (CI): 3.9-20.2) and AOR = 1.6 (95 per cent CI: 1.4-1.8), respectively), as compared to 15-24 year-olds, and among those outdoors versus indoors during the tornado (AOR = 10.4 (95 per cent CI: 5.5-19.9) and AOR = 6.6 (95 per cent CI: 5.8-7.5), respectively). Females were 1.24 times (95 per cent CI: 1.15-1.33) more likely to be injured than males. Elevated risk of injury was significantly associated with structural damage to the house and tin construction materials. Seeking treatment was protective against death among the injured, odds ratio = 0.08 (95 per cent CI: 0.03-0.21). Further research is needed to develop injury prevention strategies and to address disparities in risk between age groups and between men and women.     

Hurricane Harvey and Greater Houston households: comparing pre-event preparedness with post-event health effects,event exposures,and recovery

Most disaster studies rely on convenience sampling and ‘after-only’ designs to assess impacts. This paper, focusing on Hurricane Harvey (2017) and leveraging a pre-/post-event sample of Greater Houston households (n=71) in the United States, establishes baselines for disaster preparedness and home structure flood hazard mitigation, explores household-level ramifications, and examines how preparedness and mitigation relate to health effects, event exposures, and recovery. Between 70 and 80 per cent of participants instituted preparedness measures. Mitigation actions varied: six per cent had interior drainage systems and 83 per cent had elevated indoor heating/cooling components. Sixty per cent reported home damage. One-half highlighted allergies and two-thirds indicated some level of post-traumatic stress (PTS). Three-quarters worried about family members/friends. The results of generalised linear models revealed that greater pre- event mitigation was associated with fewer physical health problems and adverse experiences, lower PTS, and faster recovery. The study design exposed the broad benefits of home structure flood hazard mitigation for households after Harvey.     

Impact of a commercial destocking relief intervention in Moyale district, southern Ethiopia

A commercial destocking intervention was piloted in southern Ethiopia during the drought of early 2006. The intervention led to the purchase of an estimated 20,000 cattle valued at USD 1.01 million. On average, destocked households received USD 186 from the sale of cattle--approximately 5,405 households were involved. In terms of aid investment, the approximate cost-benefit ratio was 41:1. During the drought, income from destocking accounted for 54.2 per cent of household income (n = 114 households), and was used to buy food, care for livestock, meet various domestic expenses, support relatives, and either pay off debts or augment savings. Seventy-nine per cent of the income derived from destocking was used to buy local goods or services. Expenditure on livestock care amounted to 36.5 per cent of local spending, and included the private transportation of livestock to better grazing areas. The buoyant livestock export trade was considered to be an important driver of commercial destocking, demonstrating a positive link between livestock and meat exports, and pastoral vulnerability during drought.     

Health effects of relocation following disaster: a systematic review of the literature

This paper reviews the literature on the effects of post-disaster relocation on physical and mental heath, and develops a conceptual framework to guide future research. Forty articles were selected for full-text review and incorporation into the conceptual framework. Twenty-four articles were reviewed for results and methodology. These overwhelmingly tracked mental health outcomes. Only four (16 per cent) focused on physical health. Eight of ten showed an association between relocation and psychological morbidity. Certain outcomes (such as mortality, injury and cardiovascular disease risk factors) revealed inconsistent results, but these were rarely studied. Despite the frequency of post-disaster relocation and evidence of its effect on psychological morbidity, there is a relative paucity of studies; the few examples in the literature reveal weak study designs, inconsistent results, and inattention to physical health impacts and the challenges facing vulnerable populations. Further research guided by theory is needed to inform emergency preparedness and recovery policy.