||PREFACE TO ONLINE EDITION
It has been gratifying that since it was published in 1989, Disaster
Response: Principles of Preparation and Coordination has been widely used by the disaster
management and disaster medicine communities, both in the United States and abroad. It
appears to have been successful in informing planners and clinicians about some of the
important findings from the disaster research literature.
Since the book went out of print, I have received numerous inquiries by
those still wanting to obtain a copy. Two years ago I had the pleasure of traveling and
teaching in the South Pacific with fellow emergency physician and disaster medicine
specialist, Maj. Patricia Hastings of the Center of Excellence in Disaster Management and
Humanitarian Assistance at Tripler Army Medical Center in Honolulu. She had used the text
as a teaching resource in the Center's work throughout the Pacific Basin and was also
concerned about the dwindling supply of copies. At that time we began to discuss the
possibility of collaborating in the development of a digital version of the text. It is
our intent to make this version of the book available gratis via the Internet, so the
process of knowledge dissemination can continue to grow.
While much of the information contained in the text is just as relevant as
it was a decade ago, we are also looking forward to updating the material and adding new
chapters to cover many of the important subject areas that were not included in the
original version. Fortunately, compared to a print version, updating the digital edition
will be relatively easy and can be done relatively frequently as each new chapter is
We are pleased to offer this first version of the electronic edition and
hope that it will continue to offer valuable assistance to those involved in disaster
planning, preparedness, mitigation, and response.
Erik Auf der Heide, MD, MPH, FACEP
PREFACE TO BOOK
Disaster Response: Principles of Preparation and Coordination grew out of a
relatively modest project-to create a triage training program for emergency medical
technicians in which I became involved in the spring of 1982. 1 was then director of the
advanced life support ambulance base station at the University of California, Davis
Medical Center, and served as a disaster planning committee member at the medical center,
for the local medical society, and for the County of Sacramento. Although I was unable to
develop the program while at the university, my interest was stimulated. I later carried
out an extensive survey of the medical and allied medical literature on triage and on
disaster management. There were two things that impressed me in this material.
First, many of the recommendations made in the available literature were not grounded in
rigorous, scientifically-based observations. Rather, most of the articles gave advice
without producing evidence to show that the advice was correct. In fact, much of the
literature did not even examine actual disasters, but only described disaster drills or
Second, as I read about a number of disasters, it became clear that in too many cases the
same mistakes were being repeated by different communities. Sometimes, the same community
repeated its own errors in successive disasters. This pattern generated concerns about the
usefulness of existent disaster literature. Either the suggestions were not very
effective, or people were ignoring them. If the advice was being ignored, why was this the
As I continued my research, I discovered a body of written material on disasters that
existed outside the medical literature. There is, in fact, a large collection of
research on disasters that has been carried out by sociologists, psychologists, and those
involved in the study of public administration and fire science. I found that the most
useful material for my purposes resided in the sociological literature.
As I explored this wealth of research, I learned there are often problems affecting the
hospital that are the result of actions or omissions by people at the disaster site; this
is an area over which the hospital has little control. A common example is the tendency to
transport most of the injured victims, frequently by non-ambulance vehicles, to the
nearest hospital while other nearby hospitals remain unused. This is but one illustration
of how one organization suffers the consequences of actions carried out by another group
It became apparent that disaster problems cross disciplinary lines. One cannot effectively
address disaster management difficulties by focusing on the isolated problems of a single
type of organization such as a hospital. Hospitals (as well as many other organizations)
are influenced by the activities of a host of other independent agencies including
ambulance services, police departments, fire departments, military personnel, the media,
etc., whose actions can have a profound impact on their ability to function in a disaster.
In light of these observations, I became convinced that a program to teach triage, by
itself, would accomplish very little unless these other more fundamental issues in
disaster management were also addressed. I therefore redirected my efforts to deal with
the more general problems of disaster response and to take a more interdisciplinary
perspective. This perspective is a much needed approach, because, while disaster problems
cross disciplinary and organizational boundaries, disaster planning typically does not. On
the contrary, the multitude of organizations that may become involved in a disaster
response often plan in isolation.
Most disaster response problems are not failures of the individual. More often, they are systems
problems. That is, the usual organizational systems (procedures, management
structures, and designation of responsibilities) established by various organizations to
cope with routine, daily emergencies, are not well adapted for use in disasters.
Accordingly, this text emphasizes not so much what the individual can do to influence
disaster response, but what can be done on an organizational and inter-organizational
level. While famil-iarity with the material in the book will allow emergency medical
technicians, firefighters, police officers, or physicians, to see how they fit into the
overall picture, it will be of most use to those with organizational management, planning,
and policy-making responsibilities.
Addressing the interdisciplinary aspects of disaster response management does not change
the fact that emergency medical care is an important focus of this text. This not only
reflects my own background and training as an emer-gency medicine specialist, but also the
importance that society places on the numbers of deaths and injuries caused by disasters.
Disasters are, in fact, often defined in terms of the numbers of dead and injured.
The material in this text is derived from the research on peacetime, natural, and
technological disasters. Disasters of social conflict such as civil distur-bances, riots,
terrorism, and war are markedly different phenomena, and the conclusions derived in this
book may not be applicable in those types of events. Caution also must be taken when
comparing the United States to foreign countries where different levels of development,
different cultures, and differ-ent styles of government may require different approaches.
For the most part, therefore, the studies referred to in this book are those that have
been carried out in the United States. Applying these studies to disasters that involve
tens and hundreds of thousands of casualties must also be interpreted with caution.
Peacetime disasters of such magnitude from which we might draw conclusions have simply not
occurred in the United States.
The writing style
Although examples of how to manage specific disaster problems are given, the text is not
intended to be a manual, "cookbook," or "how-to" book on disaster
management. It is intended to be a basic principles-oriented text. The emphasis is not so
much on how, as it is on why.
This book was written with the intention of being an authoritative and well-documented
work. Extensive references have been provided to show the sources of data on which
conclusions may be derived and principles based. The thorough referencing will also be of
help to those who wish to learn more about specific topics. While I have located a large
number of useful studies on disasters, many have been difficult to find. Some are
unpublished or out-of-print, while others are from diverse and rather esoteric journals,
books, and other publications. When possible, addresses are provided. Material that is no
longer in print can often be obtained from your local library.
The reader will notice that a number of the facts and conclusions that appear in this book
seem contrary to the "conventional wisdom" about disasters. This is because many
traditional beliefs have been disproved when subjected to careful examination and
well-designed study. It may be that others will chal-lenge some of these conclusions,
offer supplemental observations, or derive alternative interpretations. To the extent that
this can be successfully accomplished, it will only improve our understanding, and is,
Examples are used extensively in this text, many from actual disasters, to illustrate what
happens in these events and how the problems have been successfully or ineffectively
approached. Where "conventional wisdom" has been refuted or contradicted, I have
tried to provide multiple examples and documentation to support my contentions.
As I live in California, it is natural that I am most familiar with the way things are
done there. To the extent possible, I have tried to use examples from other parts of the
country and to avoid a west coast bias. Nonetheless, any tendency toward California
examples is not intended to suggest that California is any better or worse than other
parts of the country, but merely reflects my predomi-nant geographical exposure. In
particular, some have expressed the opinion that my emphasis on the Incident Command
System (Chapter 7) reflects such a bias. However, to my knowledge, although other
management systems exist, none has been accepted on a national basis to the extent that
the Incident Command System has.
There is an increasing sensitivity in recent times toward the use of words that express
gender. Unfortunately, the English language has not kept pace by avoiding an array of
non-gender-specific third person, singular pronouns. Rather than taking the awkward stance
of using he/she, etc., or avoiding the use of any pronouns expressing gender at all, I
have chosen to use "he," "his," and "him" in the generic
sense. Please understand that I am referring to both the masculine and the feminine