The Costs of Relief in International Disasters

Does rescue and medical intervention in foreign disasters cost too much? Is it effective and efficient? It is remarkable how little debate there is about these questions and how few data are available on which to base one's judgements.

In assessing costs, it is necessary to distinguish between search and rescue (SAR) and urban search and rescue (USAR). The former includes mountain and sea rescue, lost climbers, search for lost children and Alzheimer's patients and is usually focussed on one or two individuals, or a single boat. USAR involves searching damaged buildings after earthquakes, explosions and structural collapses.

SAR costs are highly variable. The cost of using helicopters depends on the type and availability of the aircraft, its range and crewing requirements (from a single pilot to a full medical team, copilot and winchman). In general it is around €2,500 per hour of search.

International USAR may involve travel over very long distances (for example from Taiwan to Haiti). It may also involve one or two teams of 58 members, up to 28 tonnes of equipment, and possibly also two or three rescue dogs (FEMA 1996). USAR teams inscribed in the UN register INSARAG are required to maintain 72 hours' total autonomy wherever they work, which necessitates bringing food and water supplies with them. However, it is very difficult to be autonomous with regard to local transportation in a foreign country.

In the USA a USAR team costs about $1.8-$2.2 million per year to maintain. For accredited teams, the US Federal Government contributes about $1 million per task force per year, a total of $28 million. Although in 20 years the cost to US taxpayers went up seven times, they have fallen back recently (Bea 2010, p. 1).

The number of foreign rescuers that arrive in a disaster area after a major, internationally declared catastrophe usually varies from 1,200 to about 2,300, with a mean somewhere around 1,600. Almost no one arrives within the first 24-36 hours and almost all usually arrive within 72 hours. On occasion delays have been experienced by failure to get through immigration and quarantine, or by lack of transport on the ground. The teams usually stay for 4-7 days.

The "golden period" for rescuing trapped survivors is 6-12 hours after a sudden impact disaster that causes buildings to collapse (and definitely well within the first 24 hours). However, most foreign rescuers arrive later than this, and the number of people rescued is usually very small. The teams are thus restricted to recovering bodies from the rubble. In Bam the 57 members of Rapid-UK rescued no one at all. In Haiti, 134 people were rescued (bearing in mind that the death toll was probably in excess of 250,000 and no one ever counted the plethora of injured people). Of these 134 people only nine were rescued after the fourth day. Yet the EU alone mobilised 12 USAR teams, and at least 24 others arrived from different countries in Europe, Asia and the Americas. Whilst one is of course grateful that anyone was rescued, one is forced to conclude that overwhelming inputs thus produced very small results. Similarly, 40 USAR teams participated in the response to the Bam, Iran, earthquake of 2003, but only five of them arrived within the first 24 hours (Abolghasemi et al. 2006).

The maximum survival time for an uninjured person trapped under rubble is 14-15 days, but the proportion of people who last more than five days is absolutely insignificant. In the Tanghsan, China, earthquake of 1976, the worst such disaster in the 20th century, 5,500 people were rescued on the first day, but by the fifth day there were only 34 new survivors.

The cost of sending teams across the globe and putting them to work for a week is seldom, if ever, quoted. Rumour has it that the cost per life saved is about US$1 million, although accurate estimates have, to my knowledge, never been made. Clearly, if all search and rescue could be conducted by well-equipped, numerous, well trained local forces, then costs would be very much smaller. However, it is as well to remember that in the response to the 1985 Mexico City earthquake, 135 rescuers died, 65 of them when searching confined spaces that flooded (Casper and Murphy 2003, p. 367). Safety training and personal protective equipment are thus absolutely necessary. In Mexico City, as elsewhere, four fifths of survivors were rescued within one day of the disaster (Olson and Olson 1987).

A second problem concerns foreign field hospitals (FFHs). In the aftermath of the Bam earthquake, the estimated cost of deploying 14 foreign field hospitals for an average of two months each was $12 million, or about 40 per cent of the cost of rebuilding Bam's two damaged and unserviceable hospitals. Deployment was more rapid than it had been in the Gujarat earthquake two years previously (24-48 hours as against 5-7 days), but nevertheless, by the time the first field hospitals were active, injured patients had either died or been airlifted by medivac to other cities. The field hospitals were used to provide routine medical care in substitution for the damaged permanent medical structures. Hence, it is hardly surprising that when Von Schreeb et al (2008) looked at four major mass-casualty disasters, they found evidence of substantial over-supply of medical aid and rates of utilisation of field hospitals that fell below 50 per cent. In the final analysis, the logistical costs of deploying field hospitals may be so high that they are sometimes left behind at the end of operations and donated to the host country--i.e. written off.

The upshot of these considerations about USAR and FFHs is that there is no substitute for resilient, local rescue and medical response to disasters. The costs of foreign intervention are very high, the benefits are small and from this point of view the international relief system is extremely inefficient.

References

Abolghasemi, H., M.H. Radfar, M. Khatami, M. S. Nia, A. Amid and S.M. Briggs 2006. International medical response to a natural disaster: lessons learned from the Bam earthquake experience. Prehospital and Disaster Medicine 21(3): 141-148.

Bea, K. 2010. Urban Search and Rescue Task Forces: Facts and Issues. Congressional Research Service, Washington, DC, 41 pp.

Casper, J. and R.R. Murphy 2003. 2003. Human–robot interactions during the robot-assisted urban search and rescue response at the World Trade Center. IEEE Transactions on Systems, Man, and Cybernetics. Part B: Cybernetics 33(3): 367-385.

FEMA 1996. Technical Rescue Program Development Manual. FA-159. US Federal Emergency Management Agency, Washington, DC, 252 pp.

Olson, R.S. and R.A. Olson 1987. Urban heavy rescue. Earthquake Spectra 3(4): 645-658.

Von Schreeb, J., L. Riddez, H. Samnegσrd, H. Rosling and C. de Ville de Goyet 2008. Foreign field hospitals in the recent sudden-impact disasters in Iran, Haiti, Indonesia, and Pakistan. Prehospital and Disaster Medicine 23(2): 144-153.

Integrated Emergency Response

Configuration of resources in disaster preparedness

Towards a common language and culture of civil protection

At least 35 disciplines and professions have relevance to civil protection. When disaster strikes or incidents occur, their practitioners must work together efficiently and effectively. Many of the greatest problems of emergency co-ordination occur, not within, but between organisations and groups, for people must work together who are not accustomed to doing so, or at least not in the way that emergency situations demand.

Stated simply, during an emergency the priorities are to save and protect lives, rescue and evacuate people, make environments safe, and restore acceptable conditions as soon as possible. These objectives require programmes, plans, protocols, procedures, norms, regulations and a legal framework. In its essence, planning is not about procedures, it is about co-ordinating inter-agency work according to particular scenarios of event and response. Thus, a common language and a universal culture of civil protection are needed. Indeed, one of the greatest challenges of the 21st century is to involve the general public in this process, and encourage them to know and evaluate the risks they face, generate personal plans, and support civil protection initiatives.

The need for both professionalism and multidisciplinary competence means that members of the civil protection community must consider the consequences of actions outside the compass of single disciplines (Comfort 1985). For example, to achieve greater integration in the field, non-medical rescuers must learn to appreciate the needs and modus operandi of medical, sanitary and epidemiological emergency responders.

When disaster strikes, we face three sets of challenges connected with different spheres of action: domestic, international and intercontinental. Whereas in the past these have involved three distinct communities of responders (local civil protection operatives, national ones and international humanitarian agencies), as world integration gathers pace there is an increasing tendency towards convergence and the involvement in each field of all three constituencies.

The organisation of civil protection systems

With regard to domestic emergency response, there are four main groups of protagonists: public administration (in general, the civil protection services of government at all levels), 'blue-light' services (police, fire, ambulance and technical specialists), civil society organisations (especially volunteer services), and military and paramilitary forces in their roles as providers of military assistance to civil communities. This diverse set of protagonists requires careful organisation in order to ensure rapid and timely response to disasters, and guarantee a well-organised, carefully targeted reaction that is based on scenarios of what is likely to happen. The key words are command, co-ordination and collaboration. Generally, as information and communications technology (ICT) has opened up new opportunities, there has been a shift in emphasis from the first of these to the second and third (Green 2001). With respect to models of emergency control developed in previous eras, ICT has thus had the effect of flattening the chain of command. A rigid hierarchy is no longer needed when what is required is a flexible approach to the evolution of problems in the field that draws benefit from techniques of adaptive management. Hence, parallel task forces have tended to replace the earlier militaristic forms of centralised command [1], and their roles have been enhanced by digital information sharing. Rapid communication has facilitated the apportionment and conduct of emergency response tasks.

There is no universal model of command that is valid and appropriate for all circumstances. Instead there are two basic themes: the command principle and the support function principle. Both require a lead agency, or in other words a central organisation that takes a directional role in emergency situations and also functions as a point of reference for the diverse forces that respond to incidents and disasters. This is usually a 'blue-light' service but which one it is depends on the country involved. For instance, in the United Kingdom, where emergencies are seen primarily as a question of public order, it is the police service. In Italy, where the primary requirement is for technical intervention, the fire brigades are the lead agency; while in Iran, where mass casualties are feared on huge scale, it is the national Red Crescent Society.

The command principle divides emergency functions vertically into policy (and ethical), strategic, tactical and operational levels (PESTO). Alternatively, the support function principle divides command by creating corresponding units that manage functions (such as communications, transportation, material supplies, and shelter) at different levels and in different organisations. Unfortunately, the two principles seem not to be compatible to the extent that a hybrid system can be made out of the best features of both.

Civil protection can only function well if it is generated and organised at the local level, for when emergencies occur the local area is almost always the "theatre of operations". In fact, given distances, route blockages, shortages of resources and the press of time, there is no substitute for locally-organised preparedness. As a result of this, other levels of government or administrative hierarchy should harmonise and co-ordinate, not supplant, local efforts. The importance of this cannot be overstated: many studies have proved that local resources and organisation are paramount when disaster strikes (Waugh and Tierney 2007). In fact, perhaps 90 per cent of emergency resources deployed during the early stages of sudden-impact disaster are likely to be of local origin (Gillespie 1991).

This implies 'bottom-up' organisation, but paradoxically it still requires 'top-down' harmonisation to ensure compatibility between different levels of administration and geographical areas. Generally, local preparedness has been fostered by decentralisation, and by applying the principle of subsidiarity in government. However, there is a risk that the resulting mosaic of jurisdictions will be exceedingly heterogeneous in terms of the degree of preparedness and the kinds of measures adopted. If that is so, the result will be incompatibility, and disasters are no respecters of political boundaries. Thus, one of the greatest challenges in civil protection is to ensure local self-sufficiency and at the same time guarantee compatibility.

Integration is not easy to achieve. For example, with respect only to medical emergency response, there is a need to integrate intra-hospital plans with plans for both inter-hospital response and the whole medical system (Auf der Heide 1995). The results must in turn be compatible with other civil protection plans, for example for municipalities, regions, airports and factories. At the simplest level it is merely a question of reading through plans in a comparative way and trying to ensure that there are no glaring inconsistencies between them. However, there are many other aspects. One of the greatest problems in emergency situations is to ensure adequate communication, not merely within groups, but between different organisations. This is both a technical matter, for example in terms of radio frequency compatibilities, and a socio-organisational one, regarding the protocols, priorities and command procedures utilised. The solution is to design systems in a parallel manner to be technically workable and robust, and also to have clear and acceptable chains of command. However, it is not easy to get particular organisations to accept overall command by members of other, possibly rival, institutions (Sylves 1991).

In the interests of creating a common language and culture, there is a question of whether to opt for standards and standardisation procedures (Alexander 2005). Standardised language need not involve absolute definitions, but should at least aim for acceptable working definitions of commonly used terms. These can be derived from any of more than a dozen glossaries of emergency management that are currently available on line or in print. Common language and culture also means familiarity with the faces, personalities and modus operandi of people in different organisations. This can be achieved by general field exercises, but these take much time and many resources to organise. They are also disruptive of routine. Frequent conferences and meetings, as well as table-top exercises and discussions, are needed. In any case, despite the increasing prevalence of information technology, which tends to remove people from direct contact with one another, the human aspect of emergency management cannot be overemphasised and is fundamental to any attempt to achieve integration of methodologies and resources.

In reality, technology and human organisation (i.e. management) both have a role to play in the achievement of greater integration in emergency management. Terrestrial Trunked Radio (TETRA), for example, has the ability to overcome the disjuncture of frequencies between organisations and emergency responders (Tattersall 2001). The Incident Command System (ICS) offers a flexible, modular way of ensuring overall control of an event without necessarily interfering with each organisation's internal mechanisms of command (Buck et al. 2006). It is no coincidence that ICS has become popular as information technology has made it more attractive and at the same time created the conditions for its more efficient application.

Humanitarian relief

Special attention needs to be devoted to the problems of integrated emergency response for large disasters in the international arena. Gradually over the last 60 years the world community has evolved a sophisticated system of relief for major sudden-impact disasters (Dore and Etkin 2003). It has been widely exercised: indeed, it has had to react to increasing numbers of deadly events. However, it is far from being efficient.

When a major flood, storm or earthquake causes a massive death toll and leaves survivors trapped, homeless or hungry rescue teams take to the skies and various branches of the United Nations send aircraft full of basic goods. The mobilisation of foreign search-and-rescue teams involves a series of stages. First they need to be alerted, and the early information coming out of major disaster areas is frequently as incomplete as it is inaccurate. Secondly, they must mobilise and find transport for personnel, equipment and, where appropriate, search dogs to the affected area. Thirdly, they must navigate customs, importation and quarantine regulations in order to gain entry to the country where the disaster has occurred. Finally, they must obtain transport and logistical support in order to reach the area. Many governments are not prepared in terms of policy or bureaucracy to waive or accelerate entry requirements. Commonly the realisation that this must be done is belated, or so is the realisation that the help should not be staved off.

Most forms of entrapment involve relatively short survival times for injured people. A harsh climate and dangerous conditions of entrapment can drastically shorten the survival time for victims who are initially uninjured. Hence, although people can survive entrapment for up to 15 days, the cumulative curve of survival indicates that most victims will succumb under the rubble within 8-12 hours. In fact, after a day has elapsed the probability of being rescued alive diminishes to a value that may be statistically insignificant (Coburn and Spence 2002). Yet the international community is simply unable to import specialist search-and-rescue forces over intercontinental distances in such a way as to make a significant difference to the eventual survival rates. For example, after the Bam earthquake of 26 December 2003, about 1,600 foreign rescuers arrived in the Iranian Province of Kerman. Most arrived at Kerman, which is a significant distance from Bam. None had brought wood for buttressing tunnels into rubble, yet Bam is in a desert where there are only the most limited supplies of wood. Transport from Kerman to Bam was limited as well. The rescuers arrived during a time window that stretched approximately from 36 to 72 hours after the main earthquake. They succeeded in rescuing a total of 36 people, at a cost which probably reached about one million US dollars per life saved, if all the ancillary support is taken into account.

The problem of delay is exacerbated when national governments refuse to admit that they cannot cope. These include Myanmar in the 2008 hurricane and India in the Gujarat earthquake of 2001, both of which imposed restrictions on the arrival of foreign assistance. Even the United States was slow to accept international aid in 2005 after Hurricane Katrina.

There is no inherent reason why there should be one form of civil protection for the rich nations and another, inferior one for the poor countries. The cost of information and communications technology is falling, especially on a per capita basis, and much can be achieved by improvements in organisation, which are not necessarily costly. There is, however, a strong need to transfer expertise and training to the countries that are in the front line against disasters. This involves many different questions related to peace-building and sustainable development (White and Cliffe 2000).

Conclusion

In conclusion, how better to integrate emergency response is one of the leading questions of our time in civil protection (McLoughlin 1985, Ikeda et al. 2008). The increasing complexity both of emergency situations and of response capabilities has thrown this problem into high relief. For the sake of efficiency in emergency management it requires that considerable thought and effort be devoted to the search for a solution.

References

Alexander, D.E. 2005. Towards the development of a standard in emergency planning. Disaster Prevention and Management 14(2): 158-175.

Auf der Heide, E. 1995. Community Medical Disaster Planning and Evaluation Guide. American College of Emergency Physicians, Dallas, Texas, 182 pp.

Buck, D.A., J.E. Trainor and B.E. Aguirre 2006. A critical evaluation of the incident command system and NIMS. Journal of Homeland Security and Emergency Management 3(3): article 1. www.bepress.com/jhsem/

Coburn, A. and R. Spence 2002. Earthquake Protection (2nd edn). Wiley, Chichester, UK, 420 pp.

Comfort, L.K., 1985. Integrating organizational action in emergency management: strategies for change. Public Administration Review 45 (special issue): 155-164.

Dore, M.H.I. and D. Etkin 2003. Natural disasters, adaptive capacity and development in the twenty-first century. In M. Pelling (ed.) Natural Disasters and Development in a Globalizing World. Routledge, London: 75-91.

EMA 1998. Australian Emergency Management Glossary. Manual no. 3. Emergency Management Australia, Canberra, 133 pp.

Gillespie, D.F., 1991. Co-ordinating community resources. In Drabek, T.E. and Hoetmer, G.J., eds., Emergency Management: Principles and Practice for Local Government. International City Management Association, Washington, D.C.

Green III, W.G. 2001. E-emergency management in the USA: a preliminary survey of the operational state of the art. International Journal of Emergency Management 1(1): 70-81.

Ikeda, S., T. Sato and T. Fukuzono 2008. Towards an integrated management framework for emerging disaster risks in Japan. Natural Hazards 44(2): 267-280.

McLoughlin, D. 1985. A framework for integrated emergency management. Public Administration Review 45 (special issue): 165-172.

SIPROCI 2007. Glossary of Civil Protection for EU Citizens. SIPROCI Interregional Response to Natural and Man-Made Catastrophes, Ancona, Italy, 7 pp. http://www.siproci.net/

Sylves, R.T., 1991. Adopting integrated emergency management in the United States: political and cultural challenges. International Journal of Mass Emergencies and Disasters 9(3): 413-424.

Tattersall, P.T. 2001. Professional mobile radio: the BT Airwave public safety service and the path for technology and service evolution. BT Technology Journal 19(1): 142-148.

Waugh, W.L. Jr and K. Tierney 2007. Emergency Management: Principles and Practice for Local Government (2nd edn). ICMA Press, International City Management Association, Washington, D.C., 366 pp.

White, P. and Cliffe, L. 2000. Matching response to context in complex emergencies: 'relief', 'development', 'peace-building' or something in-between? Disasters 24(4): 314-342.

Note

[1] This is also true in the organisation of modern military forces, and hence there has been a general shift away from linear chains of command.