Our country is among the leading countries in the world in terms of losses caused by earthquakes. In addition to the enormous economic losses they cause, earthquakes also have a profound impact on public health. The application of epidemiology study discipline in health management in disasters, which is one of the most critical issues in the field of public health, is called earthquake epidemiology. Earthquake epidemiology examines in detail the extent of losses caused by earthquakes to public health, the conditions of their occurrence and the cause-effect relationships of these phenomena, and provides very useful information for minimizing losses. In other words, the main objective of disaster epidemiology is to identify and measure the effects of disasters on health. Earthquake epidemiology includes the earthquake-specific part of this. Since Turkey is considered one of the most risky countries in the world in terms of earthquakes, this issue becomes even more of a priority for us.
Before the adoption of earthquake prevention and control measures and the implementation of relief activities around the world, even a single earthquake caused tens of thousands of deaths, serious injuries and severe economic losses. Among the components that determine the damage caused by earthquakes are factors that we cannot change, such as the structure of the ground and environmental factors, as well as features that can be changed by humans. These include variables such as people’s settlements and behavior, the availability of warning, and preparedness for disasters. For this reason, the scientific results of earthquake epidemiology are of great importance in determining the fate of the society during and after a disaster.
All layers of society have certain duties and responsibilities in earthquake preparedness. The responsibility of the society in general will be to be prepared for disasters and to raise awareness in this sense. The responsibilities specific to health professionals include making health service structures the most resilient and safe for all disasters so that they can immediately intervene in the community when they are most needed, reaching the disaster area from other regions as quickly as possible, making services accessible to the vulnerable groups of the society without ignoring them, providing routine health services without interruption in the first days of the disaster and in the following phases until life returns to normal, epidemics that are likely to occur, etc. protection of society from such situations. It is important to remember that in the organization of services such as health care, which are very complex and require a matrix organization, it is important that communication between health teams, with each other, with the teams of other service sectors and finally with the sick, injured and healthy people is very strong. Another part of the responsibility is to ensure that health and health service records are kept up-to-date, accurate and complete in all cases and delivered to the authorities on a daily basis.
Earthquake epidemiology studies are of great benefit to health professionals in fulfilling these responsibilities and play an indispensable role in meeting the health education needs of the public and making them more prepared and conscious for disasters. This review article was written in the aftermath of the 1999 Marmara Earthquake and contains information that is necessary and useful for us today.
More epidemiological information on the causes of deaths and types of injuries caused by earthquakes is needed in order to fully understand what kind of relief supplies are available, what kind of equipment and personnel are needed, and to provide the necessary services. The main objective of the epidemiology of disasters is to identify and quantify their health impacts. In doing so, it seeks to understand the needs of disaster survivors, allocate resources efficiently and appropriately, eliminate unintended health impacts, assess program effectiveness, and plan a contingency scenario. Before the adaptation of earthquake prevention and control measures and the implementation of relief activities around the world, even a single earthquake caused tens of thousands of deaths, very serious injuries and severe economic losses (1). As in other service areas, it is of great importance to adapt the experiences gained in health services to the policies to be put forward in the next disaster. The Marmara earthquake of August 1999 revealed the great deficiencies in the organization of health services in our country regarding the measures to be taken in disasters. The epidemiology of earthquakes is particularly important for health planners and health administrators in Turkey, as our country is at a higher risk of earthquakes than many other countries in the world.
Elements to Understand the Effects of Earthquakes
The extent of deaths and injuries in an earthquake varies depending on (2):
- Earthquake intensity
- Distance from the center of the earthquake
- Ground structure
- Features of buildings
- Features of other man-made structures
- Density and distribution of the population in the region
- Environmental conditions
- Human settlements and behavior
- Whether there is an opportunity to warn
- Preparedness against disasters
- What time of day earthquakes occur
- On which day of the week there is an earthquake
Mahoney states that “death is observed when earthquakes exceeding 6.0 on the Richter Scale occur near settlements” (3). In the last 20 years, more than one million people have died in earthquakes alone (4). More than 80% of earthquake deaths in this century occurred in 9 countries, including Turkey, and 50% in a single country – China. In 1976, a magnitude 7.8 earthquake struck Tangshan, a city of one million people in northern China. Within seconds, the city was reduced to rubble and more than 240,000 people were killed (5). Other seismically active urbanized areas with populations of 20 000 – 60 000 per square kilometer are always vulnerable to this level of earthquake-related catastrophic death and injury (4).
Usually the death/injury ratio is around 1 / 3-4. However, this ratio manifests itself as more deaths/less injuries in settlements near the epicenter and less deaths/more injuries in settlements relatively far from the epicenter. For example, in Tangshan (China) there were 3 deaths for every 2 injuries and in Whittier Narrows, California (USA) there were 1 death for every 450 injuries (2).
The number of deaths and injuries is directly related to variables such as the number of severely damaged buildings, the number of people who were able to escape from buildings, the effectiveness/availability/availability of medical services immediately after the earthquake, and the efficiency of search and rescue activities. The amount of building damage is an inevitable consequence of the extent to which a society has invested in disaster situations in the past. In general, it can be said that in developed countries, injury and death rates in disasters are lower than in undeveloped countries because there are resources allocated in advance for disaster situations and a system that can be used accordingly.
The most important secondary disaster that can follow an earthquake is fire. With a few tremors, stoves, heating appliances, light fixtures, etc. may topple over, sparks may fly and flames may engulf the area. In Japan, 10 times more deaths were recorded in city earthquakes with fires than without fires(6). After the 1906 San Francisco earthquake, the fire killed many more people than the earthquake itself. Closer to the present day, the 1994 Northridge earthquake in California showed that strong tremors can rupture underground fuel oil pipes or gas joints, causing flammable explosive materials to spread and ignite and start fires. Moreover, as the city’s water supply network was damaged, the ability to extinguish these fires was severely compromised (1).
Dams are also in danger of collapse, putting communities at risk of flooding. In all earthquakes after a certain magnitude, dams in the vicinity should be checked immediately and sudden drops in the water level accumulated behind the dams should suggest that the dam may have suffered structural damage (4,7).
In many earthquakes, arguably the most common cause of death and injury is the partial or total collapse of man-made structures (4). In this century, 75% of the deaths attributed to earthquakes are the result of the collapse of buildings built with inadequate earthquake resistance, inappropriate materials or construction errors (7). Most of the deaths occurred in supported buildings, such as adobe, briquette or rough stone houses, or in unsupported buildings, such as clay bricks and reinforced concrete blocks, which can collapse even at very low intensity shaking and collapse very quickly at high intensity shaking. In many highly seismic regions of the world (such as Iran, Pakistan, Turkey, Latin American countries), buildings have not only collapse-prone walls but also heavy roofs (8). This facilitates collapse and ultimately death.
Earthquake Planning Scenarios
It is very likely that the immediate aftermath of a major earthquake would be chaos. Cut off from the outside world, residents must first help themselves and their neighbors. People will be able to make the most useful assistance efforts if they have a plan for what to do in the most likely case scenarios and have practiced its implementation before. Medical preparedness plans can similarly be based on scenario calculations based on the number of buildings that may be affected, population density and settlement characteristics, the size and character of the earthquake expected in the region, and the medical services available in the region. Such a regional damage study, including accident scenarios, provides specific training for medical and rescue personnel, as well as the opportunity to procure the necessary equipment without an earthquake.
Since there will never be enough rescue and medical personnel in major disasters, earthquake-prone communities should conduct public education on what to do in such situations. In these training activities, topics such as first aid, basic rescue information, fire information should be addressed. Voluntary organizations, fire departments and hospitals can be contacted and simulation studies can be conducted. These trainings will also help observers to better understand what to do in larger-scale emergencies (1).
Early and Rapid Investigation of the Impact of an Earthquake
The rapid rescue of victims under the rubble and the appropriate treatment of those with life-threatening injuries will increase the impact of our work. Therefore, early and rapid investigation of the extent of injury and damage is crucial so that resources can be sent directly to where they are most needed. Unfortunately, disasters that cause massive injuries often block communication and transportation routes and reduce the opportunities for medical assistance (1).
In the Italian study, 93% of 3619 people were rescued in the first 24 hours and 95% of those who died under the rubble were still alive but died because they could not be reached. Estimates from the China and Turkey earthquakes suggest that in the first 2-6 hours after a building collapse, less than 50% of those under the rubble are still alive. Based on these data, it is understood that if teams with special expertise in search and rescue, first aid teams and medical aid teams reach the region more than a few days later, these teams will not contribute much to changing the severe consequences of large earthquakes (9).
If we exclude neighboring countries in the same geographical region, foreign aid can only reach the earthquake zone after most of the rescue work has been carried out by domestic aid teams. For example, in the 1980 earthquake in southern Italy, 90% of those pulled from the rubble were rescued by untrained survivors using bare hands and simple tools such as picks and shovels. Similarly, in the 1976 Tangshan earthquake, 200,000 to 300,000 people emerged from the rubble and immediately set about rescuing others. These people have rescued more than 80% of all rescued people. Most of the lifesaving activities are left to the relatively uninjured and untrained people among the earthquake victims, local fire brigades and other local professionals (1,9).
As with effective search and rescue operations, medical services need to act very quickly. The greatest demand is in the first 24 hours. Safar, who worked on the 1980 earthquake in Italy, concluded that if early first aid and medical responders had arrived quickly, they could have saved 25-50% of the people who were injured and died over time. According to today’s data, injured people need emergency medical services only in the first 3-5 days after the earthquake, after which hospital services are almost normalized. An equipped field hospital that arrives at the scene a week later is too late. For example, in the Egyptian earthquake, more than 70% of people with earthquake-related injuries and illnesses received medical care in the first 36 hours (1,7).
The damage from major earthquakes can also extend to public health and medical services. Hospitals, clinics, medical supply depots, etc. in the earthquake zone. may have collapsed. A total of 4397 hospital beds (one in every four beds) were lost in the 1985 Mexico City earthquake, which killed nearly 7000 people (1,3,4). Similarly, in the Marmara earthquake of August 1999, almost all regional hospitals were rendered unusable. In earthquake zones, hospital emergency plans should cover the removal of patients from wards, the safe transportation of critical supplies from places such as operating rooms and radiology units, and the restoration of routine services. The fact that hospitals in our country are far from conducting such studies reveals the need to initiate studies on this issue as soon as possible.
Public Health Dimension of Disaster Management
There is a direct relationship between health problems and the type of disaster. Some disasters have a more direct impact on human life and health than others. Such impacts require immediate action.
One of the indirect effects of a disaster is the spread of infectious diseases. When people’s homes are destroyed, they will start looking for shelter. Overcrowding in relatively manageable places, water shortages, food shortages and personal and environmental pollution will increase the risk of disease and outbreaks will occur.
In general, public health problems of disasters in the short term can be summarized as follows (10):
- Deaths and bodies that need to be properly removed
- Severe injuries requiring urgent and comprehensive medical attention
- Moderate and mild injuries that do not require special action
- Outbreaks of infectious diseases
- Psychosocial impacts of the disaster-affected community
- Mass migrations.
Priority Operations of Coordinated Health Services in Emergency/Temporary Settlements
The issues to be prioritized in the health services to be coordinated in the shelters urgently provided to the disaster victims can be listed as follows (11):
- Protection from natural and man-made hazards
- Establishment of population detection/census systems
- Provision of sufficient quantities of water that can reasonably be considered clean
- Adequate food supply at the recommended nutritional value
- Ensure that people in need of protection have access to appropriate food or, if malnutrition occurs, implement supportive nutrition programs
- Provide appropriate housing
- Cooling culturally appropriate and functioning sanitation and hygiene systems, (toilets and bathrooms, chlorine and soap, etc.)
- Identifying and reporting the whereabouts of family members (essential for mental health)
- Communication and coordination with other sectors that require cooperation (such as food, transportation, communications and public works)
- Monitoring and evaluation, solving problems immediately
- Providing health care and medical services
- Public health surveillance (Nutrition surveillance/screening)
- Information on available health services
- Measles vaccination (later definition of GBP vaccines)
- Providing vitamin A if needed
- Selective nutrition in case of malnutrition (supportive and therapeutic)
- Provision of basic treatment services (especially ARI, diarrhea, malaria)
- Establishment and review of dispatch system, inspection and material distribution system
- Training and, where necessary, retraining of health personnel on the health problems and risks that may occur in emergency settlements and their solutions
- Providing health education programs to the public, including sexually transmitted diseases
- Provision of neonatal and pregnancy-birth-puerperium services
- Family planning services
- Closing the knowledge gap of health personnel on appropriate service provision in emergencies.
People at High Risk
In disaster situations, health managers need to make sure that services are delivered to all individuals. Service accessibility is always a specific issue in the management of health services and its importance increases in disaster situations. The following groups need to be specifically addressed and protected, as they are already inaccessible to services and could easily be overlooked in the event of a disaster. People at high risk in disaster situations include the following (12):
- Disabled people and individuals with special needs
- Infants and children who have lost their mother and/or father
- Pregnant and postpartum women
- Young women left alone (in terms of rape and other assaults)
- Chronically ill
- Foreigners who do not speak the local language (tourists, immigrants, etc.)
Importance of Communication
In order to provide timely and complete services, a fast communication channel must be established between health professionals. If possible, tools such as radios, cell phones, e-mail and social media groups should be used to create this channel. Health managers should clarify what kind of information should be reported and how often, to avoid unnecessary clogging of channels. Some problems such as diarrhea and pneumonia need to be monitored day by day. In addition, some priority services, such as vaccination activities, should be monitored on a day-to-day basis to establish links between problems and services provided and to use this information for new measures to address deficiencies. It is very important that the information obtained is recorded on a day-to-day basis, and as the routine record reporting system is often compromised, it is necessary to quickly establish a recording system to keep general information.
10 Actions Related to the Emergency Response of a Health Manager in Disasters
The issue of emergency response in disasters other than emergency medical intervention is very complex and the specific prioritization of each in the health field may vary, but the following priorities are generally valid in all cases (11):
- Quickly determine the health status of the community affected by the disaster.
- Establish disease surveillance and health information system immediately.
- Vaccinate all children between 0 months and 5 months against measles (sometimes the age group is extended to 14 years),
- In cases of malnutrition, give vitamin A supplementation.
- Establish a diarrhea control program.
- Provide basic sanitation and clean water.
- Provide suitable shelter, clothing and blankets.
- Provide at least 1 900 kcal/day for each person.
- Establish a treatment system based on a list of essential medicines with standardized protocols and ensure that it covers the entire population.
- Employ specialized community health workers, one for every 1,000 people.
- Coordinate local, national and international managers and volunteers.
Useful Questions for the Evaluation of Health Programs in Emergency Settlement Situations
The effectiveness of the service needs to be measured in some way in order to be able to determine exactly what actions to take in similar situations later on. The following questions are suggested as a basis for this measurement (13,14):
Relevance and cost-effectiveness of the service;
- What were the real needs of society?
- How were these investigated?
- Were the research methods appropriate?
- Was the intervention appropriate to meet the need?
- To what extent is the intervention acceptable, given the identified needs and available resources?
- If the same situation arises again in the future, how can needs be better met?
In terms of the scope of interventions;
- How is it targeted and determined who in the community will benefit from opportunities and how?
- Which aspects of the interventions fell short in terms of principles?
- Was the subsequent work sufficient to address the shortcomings? If not enough, why not?
- Are the different interventions coordinated in a coherent way?
In terms of the effects and linkages of the intervention;
- What were the effects of the intervention on mortality and malnutrition rates, safety and precautions, and resolution mechanisms?
- How did the immediate response and assistance affect longer-term recovery efforts?
- How should emergency response and assistance be linked to longer-term recovery efforts in later situations?
Epidemiological evaluation of the effects of earthquakes, which are one of the biggest risk factors for our country in terms of geographical location, should be carried out meticulously. It is seen that we need to give more importance to earthquake preparedness activities and fulfill these preparations not only on paper but also in real life. The success epics written by search and rescue teams with great sacrifices, health, security, communication, infrastructure, etc. The self-sacrificing services provided by sector professionals have been greatly appreciated. Only by becoming more prepared can we minimize the negative effects of earthquakes, which are certain to continue to occur in our country. The February 2023 Kahramanmaraş Earthquake offers us many lessons to be learned. The discipline of epidemiology offers us a methodology to systematize these lessons in a logical sequence of measuring, evaluating, concluding and providing solutions.
- Noji E.K. The Epidemiology of Earthquakes: Implications for Vulnerability ReductionMitigation and Relief (Earthquakes and People’s Health. Proceedings of a WHO Symposium, Kobe, 27-30 Jan.1997).
- La Bourque L.B., Peek-Asa C. et al. Health Implications of Earthquakes: Physical and Emotional Injuries During and After the Northridge Earthquake(Earthquakes and People’s Health. Proceedings of a WHO Symposium, Kobe, 27-30 Jan.1997).
- Mahoney L.E. Catastrophic Disasters and the Design of Disaster Medical Care Systems. Annals of Emergency Medicine, 1987, 16: 1085-1091.
- Coburn A., Spence R. Earthquake protection. Chichester, John Wiley and Sons Ltd., 1992: 2-12, 74-80, 277-284.
- Chen Y., Tsoi K.L., Chen F., et al. The Great Tangshan Earthquake of 1976: an anatomy of disaster. Oxford, Pergamon Press, 1988.
- Coburn A., Murakami H.O., Ohta Y. Factors affecting fatalities and injury in eartquakes. Internal Report, Engineering Seismology and Earthquake Disaster Prevention Planning. Hokkaido, Hokkaido University, 1987.
- Coburn A., Spence R.J.S., Pomonis A. Factors determining human casualty levels in earthquakes: mortality, prediction in building collapse. In: Proceedings of the First International Forum on Earhquake-Related Casualties, Madrid, Spain, July 1992. Reston, V.A., U.S. Geological Survey, 1992.
- Mitchell W.A., Wolniewicz R., Kolars J.F. Predicting casualties and damages caused by earthquakes in Turkey. A preliminary report. Colorado Sprimgs, C.O., U.S. Air Force Academy, 1983.
- Ceciliano N., Pretto E., Watoh Y., et al. The earthquake in Turkey in 1992: a mortality study. Prehospital and Disaster Medicine, 1993, 8: S139.
- Mulyadi B. Disaster Management Experiences in Indonesia. (Earthquakes and People’s Health. Proceedings of a WHO Symposium, Kobe, 27-30 Jan.1997).
- Noji E.K., Burkholder B.T. Public Health Interventions (Humaniterian Crises. Ed: Leaning J., Briggs S. And Chen L.C. Harvard Un. Press, Massachusetts,1999).
- Saçaklıoğlu F. Risk Groups in Extraordinary Situations (Health Services in Extraordinary Situations. Ed: Amato Z., Elçi Ö.Ç. TTB-European Union, Ankara, 1995).
- WHO.Rapid Health Assessment Protocols for Emergencies,Geneva,1999.
- Refugee Health (Doctors Without Borders) MacMillan, Hong Kong, 1997.