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Emergency Health and Risk Management in Sub-Saharan Africa: A Lesson from the Embassy Bombings in Tanzania and Kenya

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Abstract

In 1998, terrorists simultaneously bombed United States Embassies in Dar es Salaam, Tanzania and Nairobi, Kenya. The local response to these bombings was unorganized and ad hoc, indicating the need for basic disaster preparedness and improvement of emergency management capabilities in both countries. In this context, risk and risk management are defined and are related to the health hazards affecting Tanzanians and Kenyans. In addition, the growing number of injuries in Tanzania is addressed and the relationship between risk management and injury is explored. Also, an emergency medicine-based strategy for injury control and prevention is proposed. Implications of implementing such a protocol in developing nations also are discussed.
April – June 2002 http://pdm.medicine.wisc.edu Prehospital and Disaster Medicine
ORIGINAL RESEARCH
Abstract
In 1998, terrorists simultaneously bombed United States Embassies in Dar
es Salaam, Tanzania and Nairobi, Kenya.The local response to these bomb-
ings was unorganized and ad hoc, indicating the need for basic disaster pre-
paredness and improvement of emergency management capabilities in both
countries.
In this context, risk and risk management are defined and are related to
the health hazards affecting Tanzanians and Kenyans. In addition, the grow-
ing number of injuries in Tanzania is addressed and the relationship between
risk management and injury is explored. Also, an emergency medicine-based
strategy for injury control and prevention is proposed. Implications of
implementing such a protocol in developing nations also are discussed.
Clack ZA, Keim ME, Macintyre AG, Kevin Yeskey K: Africa: A lesson
from the Embassy bombings in Tanzania and Kenya. Prehosp Disast Med
2002;17(2):nnn–mmm.
1. Assistant Professor, Emory University,
Department of Emergency Medicine
2. Emergency Preparedness and Response
Branch, Division of Emergency and
Environmental Health Services, National
Center for Environmental Health, Centers
for Disease Control & Prevention
3. Assistant Professor, George Washington
University,Department of Emergency
Medicine
4. Associate Director for Science,Division of
Emergency and Environmental Health
Services, National Center for
Environmental Health, Centers for Disease
Control and Prevention
Correspondence:
Mark Keim, MD
National Center for Environmental
Health
Centers for Disease Control &
Prevention
4770 Buford Highway,MS-F38
Atlanta, GA 30341-3724 USA
Keywords: bombing; emergency
health; global health; Kenya;injuries;
international emergency medicine; risk
management; Tanzania; U.S. Embassy.
Abbreviations:
Received:
Revisions received:
Posted on Webpage:
Emergency Health and Risk Management in
Sub-Saharan Africa: A Lesson from the
Embassy Bombings in Tanzania and Kenya
Zoanne A. Clack, MD;1Mark E. Keim,MD;2Anthony G. Macintyre, MD;3
Kevin Yeskey, MD4
Background
On 07 August 1998, terrorist bomb-
ings targeted United States
Embassies in Dar es Salaam,
Tanzania and Nairobi, Kenya during
the morning business hours. In
Nairobi, 213 people were killed,
including 12 U.S. citizens and 32
Foreign Service Nationals. Approx-
imately 5,000 others, including 13
U.S. citizens, were injured.1Initial
rescue efforts were hampered by lim-
ited experience with incident com-
mand organizational management,
mass casualty management, and
search and rescue procedures.
Controlling the scene was difficult,
since all roads to the downtown area
were jammed with traffic moving
towards the explosion. Thousands of
people converged on the site to inves-
tigate the cause of the explosion,
which initially was believed to be the
result of civil unrest. As a few U.S.
Marines worked to establish a secure
perimeter around the embassy,
Kenyan riot police set up a wider
perimeter to push people back from
the site. This interfered with rescue
efforts. Most of the injured received
no pre-hospital care, and most who
sought treatment at hospitals did so
without assistance from the formal
responders on the scene. Hospitals
soon were overwhelmed by casualties
and flooded by citizens seeking news
of relatives and friends. These crowds
hindered patient access to the facili-
ties. Many citizens in Nairobi volun-
teered to give blood at these institu-
tions, but these efforts were restricted
by the limited capacity to store or
process the blood. Limited mortuary
capacity hindered forensic investiga-
tion.
In Dar es Salaam, the affected area
was largely residential, and as a result,
there were fewer victims. Eleven peo-
ple were killed in the explosion; seven
were embassy employees, though
none of these were U.S. citizens. At
Prehospital and Disaster Medicine http://pdm.medicine.wisc.edu Vol.17,No.2
2Emergency Health and Risk Management in Sub-Saharan Africa
Defining Risk and Risk Management
The World Health Organization has defined a disaster as
“a serious disruption of the functioning of a society, caus-
ing widespread human, material, or environmental losses
which exceed the ability of affected society to cope using
only its own resources.”2An event that does not exceed a
society’s capacities to cope is then classified as an emer-
gency — “a sudden and usually unforeseen event that calls
for immediate measures to minimize its adverse conse-
quences”.2Thus, emergencies and disasters are part of a
relative continuum of events that occurs when a population
is both exposed and vulnerable to a “threatening event or
potentially damaging phenomenon”, referred to as hazard.2
When a vulnerable population becomes exposed to any
hazard, there are “lives lost, persons injured,property dam-
aged and economic activity ... disrupted”. These events are
defined as risk. Thus,risk is the product of hazard and vul-
nerability.
Risk management is a comprehensive system of actions
that includes prevention, mitigation, response and recovery
from the tragic event (Table 2).3The greater the capacity a
population has to manage emergencies, the less likely that
unforeseen events will develop to an extent that would
overwhelm local resources. Additionally, effective disaster
management activities strengthen the ability of a popula-
tion to respond to those everyday emergencies that occur in
all societies. Thus, the more that Kenyan and Tanzanian
officials can build a basic public health and medical system,
the less vulnerable their populations will be to health haz-
ards. Health officials will be able to respond more effec-
tively to emergencies and disasters than they have in the
past, and ultimately the quality of life of the nation’s citi-
zens will improve.
Hazards Affecting Tanzanians and Kenyans
Describing risk as being caused by natural or technologic
phenomena is limiting. Instead, effective strategies should
seek to broaden the scope of risk management to include
an all-hazard approach. Some of the factors related to the
vulnerabilities common to both Kenyans and Tanzanians
are listed in Table 1.
Poverty is one of the most significant hazards con-
tributing to all disasters. Poverty limits the resources avail-
able to populations for management efforts in prevention,
preparedness, mitigation, response, and recovery. Poverty
also may be an additional causative factor by generating
economic inequality and conflict, and ultimately, world
instability. Unfortunately, poverty rarely is recognized as a
major hazard associated with risk for disasters, and miti-
gating this hazard can be difficult for many reasons.
Table 3 lists other significant hazards that have occurred
in this region of eastern Africa. The most frequent disasters
for both Tanzania and Kenya have been droughts and
floods. Floods caused 38% of all disasters recorded in
Tanzania from 1872 through 1990.4 Droughts affected
about 6 million Kenyans from 1964–1994.4Epidemics
have caused the most-reported mass mortality events in
Tanzania during the period 1964–1994. These events
already have received attention from the international relief
community. Now,injury represents one of the most preva-
least 100 people were reported injured by the blast, most of
whom were treated at Muhimbili Hospital in Dar es
Salaam. Tanzania, however, is a much poorer nation than
Kenya. Access to medical care is much more limited in Dar
es Salaam as compared to that of Nairobi. Per capita
national health care expenditures in Tanzania are a fraction
of that spent for Kenyan healthcare. Thus,the vulnerabili-
ty of the population was much higher in Tanzania than in
the population in Kenya. Search and rescue efforts did not
require outside assistance because there was no massive
structural failure, as there had been in Nairobi.Scene man-
agement lacked coordination. Most victims were transport-
ed by private vehicles and commercial minibuses. Even
though Muhimbili Hospital had received a large shipment
of medical supplies before the explosion, and despite the
availability of staff during weekday work hours, capacities
were quickly overwhelmed and many victims received less
than adequate acute or definitive medical care.
Both Kenya and Tanzania have a limited capacity to
deal with disasters of any kind. The response on the part of
the people, government, medical personnel, and volunteer
organizations to this tragedy was commendable, given the
lack of basic disaster preparedness and the deficiencies in
their emergency medical management capabilities. These
deficiencies exist despite the high level of vulnerability of
the population, and the relatively high risks in this area of
the world for acute onset of both manmade and natural
events.
As part of the U.S. government’s response to the bomb-
ing of its embassies, both acute response and long-term
recovery efforts were explored. The risks faced by Kenyans
and Tanzanians are predicated on a variety of factors (Table
1). The international relief community has worked exten-
sively within this region to address many of these vulnera-
bilities. However, public health issues associated with
emergency healthcare and injury prevention and control
largely have not been addressed. Using the Embassy bomb-
ings as a context, the nature and magnitude of these public
health issues is described, and possible interventions for
addressing these issues are discussed.
Childhood
Gender
Disability
Lack of information and education
Lack of experience and process
Inadequate healthcare
Geographical location / isolation
Lack of integration and coordination
Malnutrition
Inappropriate developmental policies
Food insecurity
Societal stratification
Poor water and food quality
Limited state and local resources
Political perceptions
Social implications: graft, corruption, competition
Table 1—Factors that increase vulnerability to health
emergencies in developing nations
Prehospital and Disaster Medicine ©2002 Clack
April – June 2002 http://pdm.medicine.wisc.edu Prehospital and Disaster Medicine
Clack et al 3
the city of Arusha is located). Results of the study indicat-
ed that injuries were the third most common cause of death
for men in both Dar es Salaam and Morogoro, and the sec-
ond leading cause of death for men in the Hai district.5
Injury was listed among the top 10 causes of death in all
areas. Among adults aged 15–59 years, injury contributed
to 11.5% and 2.3% of overall deaths among males and
females respectivelyin Dar es Salaam, 20.0% and 7.8% for
males and females in the Hai district, and 13.9% and 3.1%
for males and females in Morogoro. The probability of
dying from injuries before age 60 years for a 15-year-old
girl in the three areas was 1.2 to 2.4 times the rate for a 15-
year-old girl in the United Kingdom. For boys aged 15
years, the probability was three to 45 times that for boys of
lent daily emergencies causing death and disability for peo-
ple living in this region.
Injuries in Tanzania
Health statistics for Tanzania indicate that injury has a
major impact on public health in Tanzania. Injury is among
the five leading causes of death among men aged 15–59
years, accounting for more deaths in Dar es Salaam than
malaria and acute diarrhea combined.4
In a study conducted by the United Kingdom’s
Department for International Development (UK DFID)
and the Government of the United Republic of Tanzania,
three areas were examined: one city (Dar es Salaam) and
two rural districts (Morogoro and the Hai district, where
1. Primary Prevention Seeks to prevent adverse events from ever occurring. Not possible in all cases.
2. Secondary Prevention Takes measures in advance that will decrease or eliminate the impact of risks. (Mitigation)
3. Response Undertakes actions to minimize loss of life and damage. Organizes the temporary removal
of people and property from the threat and facilitates timely rescue, relief and rehabilitation.
Includes persons knowing what to do and how to respond after risk has occurred.
4. Recovery Initiates procedures directed towards returning to normal function.
Table 2—Phases of risk management Prehospital and Disaster Medicine ©2002 Clack
Hazard Type Category Hazard
Human-Made Economic setting Poverty
World economic patterns
Violence Interpersonal
Civil conflict
Warfare
Terrorism
Settlement Patterns Displaced populations
Flood plains
Population density
Environmental Degradation Deforestation
Improper utilization
Overgrazing
Desertification
Hazardous Materials
Transportation Traffic
Marine and shipping
Private
Occupation
Natural Ecological Setting Precipitation
Drought
Flood
Soil infertility
Storms Cyclones,
Hailstorms
Seismic threats Earthquakes
Volcanoes
Landslides
Disease
Pests
Wildfire
Table 3—Hazards affecting Kenya and Tanzania Prehospital and Disaster Medicine ©2002 Clack
Prehospital and Disaster Medicine http://pdm.medicine.wisc.edu Vol.17,No.2
4Emergency Health and Risk Management in Sub-Saharan Africa
involved in fatal injuries. Young people (aged 18–37 years)
had the highest rate of injury among all age groups.10
The leading types of home injuries in Arusha were
burns, fractures, and poisonings. Fractures most common-
ly were attributed to falls and the most vulnerable group
was children. Of those injured, 64% were three to five years
of age. These types of injuries can be attributed to poor
environmental conditions, and but they also can be associ-
ated with the rapid urbanization occurring in Tanzania.
The trend toward urbanization now is occurring among
most developing nations throughout the world. However,
injury mortality not only is a product of industrialization.
In fact, rates in developing countries often exceed those in
developed countries. For instance, overall mortality rates
due to injury in Tanzania were 2.5 to 4 times higher than
were those for either England orWales.4The probability
that a 15-year-old male would die from an injury before
reaching an age of 60 years was 3 to 4.5 times higher for
areas in Tanzania than for all of England.
The impact of injuries on African society is even more
profound considering the years of potential-life-lost
(YPLL), disability-adjusted life-years-lost (DALY),
health-care costs (including treatment and rehabilitation),
and wages lost.11 In 1990, injuries were responsible for
more DALYs lost than any other single health condition in
sub-Saharan Africa,12 and throughout the world, injuries
rank among the leading causes of lost years of productive
life.13
Risk Management and Injuries
Injuries are the most common cause of mortality resulting
from disasters of acute onset events. The greatest numbers
of fatalities from earthquakes during this century have
occurred in developing countries.14 However,until recent-
ly, disaster planning and relief efforts in Kenya and
Tanzania have involved mostly management of disasters
that are of slow onset or chronic in nature.15 Despite the
significant public health threat caused by injuries in
Tanzania, little attention has been given to the impact of
disaster-related injuries. There are no major programs
among donor nations, international organizations, or non-
governmental organizations that address the problem of
injuries despite the enormous impact they have on Kenya
and Tanzania. Tanzanian nurses and physicians are not
specifically trained in the skills required to manage injuries,
nor does injury prevention and control exist as a specific
program within either the Kenyan or Tanzanian Ministries
of Health.
Risk management, injury prevention and control, and
trauma care are new concepts in the public health sector
worldwide. The health implications of injuries and their
causes have been studied and identified with a focus on
prevention only recently. Merely educating people to be
more careful is not sufficient. Instead, the fundamental
paradigm of injury prevention and control should be based
on the premise that injuries do not occur in a random man-
ner.15 Haddon recognizes that injuries can be placed in the
same epidemiologic context as other diseases.16
Investigation into the root causes of injury indicates that
causes are multi-factorial, and effective interventions
the same age in the United Kingdom.5,6
Most injuries reported were caused by road traffic
crashes.7These injuries have been attributed to the recent
urbanization of the country. It has been shown that the
majority of crashes with injuries involved local commuter
buses (known as daladalas).8
The number of road traffic crashes appears to be
increasing. In Dar es Salaam, the number of road traffic
crashes from 1973 through 1978 was 12 times higher than
it was from 1958 through 1962.8The number of registered
cars also increased by a factor of 4.6, from 238 in 1990 to
1,086 in 1992. 7Compared with rates in other developed
countries, the rates of traffic fatalities and injuries in
Tanzania and Africa are high (Table 4).9Most cars driven
in Arusha, Tanzania were not registered there, and road
intersections were found to be inadequate for vehicle-tim-
ing movements.The Arusha road network had deteriorated
and was out-of-date, traffic-control facilities were inade-
quate, and the municipality was found to be poorly planned,
overpopulated, bankrupt, and disintegrating.7
Most other injuries reported were occupational or home
injuries. As the Tanzanian economy continues to industri-
alize, the population is experiencing unfamiliar working
conditions and environments. Increases in the number of
people in the workforce (from about 700,000 people in
1987 to about 762,000 in 1990), and the diversity of
imported technologies have contributed to the rise in the
number of industrial injuries. For instance, there has been
a 25% increase in the number of occupational injuries per
1000 workers.10 Injuries at mines and quarries, construc-
tion work sites, and in the manufacturing industry were
major contributors to this increase.10 In the Arusha munic-
ipality, the most frequently reported occupational injuries
occurred in textile mill industries.7The most common
causes of occupational injury resulted from falls or striking
objects, involvement in powered transmission machinery,
crime-related violence, and transportation. The average
number of workdays lost due to injury, was 31 in
1987–1988 and 27 during 1989–1990. The injuries tended
to be more severe in community services, trade, building
construction, and transport. The number of reports of fatal
injuries increased from 94 in 1987 to 128 in 1990. People
employed as farm laborers, railway and road-vehicle load-
ers, and plant and machine operators most frequently were
No COUNTRY KILLED INJURED
1United Kingdom 6 311
2Canada 7 224
3Australia 8 200
4Japan 9 294
5Kenya 55 500
6Tanzania 56 643
7Uganda 103 1326
8Nigeria 125 1750
Table 4—Morbidity and mortality per 10,000 registered
vehicles, 1985 (Adapted from Nordberg E: Injuries in
Africa: A review. East Africa Med J 1994;7(6):339–345)
[Authors Do we have copyright permission for
reprint?]
Prehospital and Disaster Medicine ©2002 Clack
April – June 2002 http://pdm.medicine.wisc.edu Prehospital and Disaster Medicine
Clack et al 5
conditions or death. For example, simple and inexpensive
suturing of a lacerated tendon of a limb may prevent life-
long disability.Emergency care-providers also may identi-
fy patterns of environmental and social hazards (e.g., poi-
soning, chronic respiratory disease, burns, or violence-
related injuries).
Many survivors of terrorist bombings also may have
non-life-threatening injuries. Survivors often have pene-
trating and blunt soft-tissue injuries, many of which can be
managed in an emergency department setting. Key clinical
skills would include basic wound care (e.g., debridement,
delayed primary closure, and tendon repair). These injuries
also can be treated with the use of basic clinical laboratory
analysis and plain film radiography.
Most importantly, emergency physicians often play
major roles in disaster-relief operations.16 As Rothman et
al noted, “Although other specialties participate, emergency
physicians are ideally suited to function as key players in
disaster medical preparedness and response by virtue of
their breadth of knowledge, developed critical care exper-
tise, familiarity with working under conditions of stress and
uncertainty and their role in the development of emergency
medical services.”17 Emergency care providers are well-
suited to provide the medical care that is required after
acute onset disasters.18 The medical staff often fulfills an
important role involving incident management, medical
control, and caring for casualties.
Proposed Priorities for Emergency Health
1. Promote the development of surveillance systems for
injuries and environmental illness among developing
nations.
To r educe injuries in developing countries, public health
officials must collect and analyze data to identify the extent
and nature of the most significant injury problems and to
set prevention priorities. In addition, risk factors involving
the host, agent and environment should be assessed to
identify effective interventions.11 These assessments are
needed to identify hazards and to evaluate the vulnerabili-
ties of the population. Surveillance and trauma registries
are needed to track trends over time and to measure the
effectiveness of any subsequent interventions. On the basis
of findings delineated previously about injuries in Sub-
Saharan Africa, groups at risk and particular high hazard
environments can be chosen as sites for initial intervention.
Cross-sectoral working and reference groups should be
established with private (for example, industry) and public
(for example, government) sources.
2. Improve access to decentralized emergency medical ser-
vices at the community-level.
The basic principles of emergency and disaster medical
care often are time-dependent, with the most lives saved by
early intervention that may be available only when provid-
ed by the community itself. Community-based interven-
tion also takes advantage of the many important resources
available at that level. It also promotes buy-in and accep-
tance of governmental planning initiatives.
Community based intervention should maintain the
basic structure of healthcare system as much as possible. It
require integration across many sectors of the society and
government.
Development, Emergency Medicine and Strategies
for Risk Management
One reason for the relatively recent public health emphasis
on injuries is that, as nutrition and infection-related death
rates have fallen, injury has become a leading cause of
death and years of productive life lost. The challenge for
public health involving emergencies and disasters then, is
to focus limited health resources on the most efficient, sus-
tainable, and cost-effective means of minimizing risk. It is
impossible to prevent and mitigate emergencies and disas-
ters to the point of zero risk.
The general concept of injury control and prevention
emphasizes the importance of developing interventions
designed to: 1) prevent injury-causing events; 2) reduce or
prevent injuries during potentially hazardous events that
do occur; and 3) enhance survival and minimize adverse
outcomes when injury does occur.14 For instance, refrain-
ing from alcohol consumption before driving is an example
of “pre-event” countermeasures.Those elements that focus
on reducing the rate of energy transfer and the likelihood
of injury and its severity are referred to as “event phase”
measures. Such strategies include the use of safety belts and
airbags. “Post-event” or “tertiary” prevention measures
include the treatment and rehabilitation phase for injuries
after they occur.The emergency care of fractures and head
injuries illustrates this aspect.
An effective strategy for reducing the impact injuries
has on society has been to enhance secondary and tertiary
prevention. One way to do so is to implement appropriate
informal and formal emergency medical care and emer-
gency medical service systems. The contribution of emer-
gency medicine among developed nations is not based sole-
ly on trauma care. Emergency medical care also provides an
organizational framework for the development of prehos-
pital care that may increase patient access to care for a vari-
ety of medical and surgical complaints. In addition, emer-
gency medical care provides a basis for the time-critical
resuscitation of patients involving a wide variety of illness-
es such as malaria, pneumonia, or diarrhea.
Providing emergency medical services does not always
involve treating critically ill patients. In fact, most care pro-
vided in many nations in emergency departments does not
constitute an emergency. Rather, emergency medical ser-
vices offer a way to expedite access to acute care that may
involve a wide variety of potential specialties, such as
surgery,obstetrics and cardiac care. In this sense, the emer-
gency care provider becomes a generalist specializing in
rapid diagnosis and acute care. Patients may receive obstet-
rical, pediatric, occupational,medical, or surgical care from
a single source. The abilities of the caregivers are not lim-
ited to primary care; but they also may care for those with
more serious illnesses. Thus,these caregivers must be able
to extend a level of care that normally would require hos-
pital admission or the services of several physicians.
In addition, emergency care providers reduce the mor-
bidity and mortality associated with illnesses and injuries
that could result in progression to more serious or disabling
Prehospital and Disaster Medicine http://pdm.medicine.wisc.edu Vol.17,No.2
6Emergency Health and Risk Management in Sub-Saharan Africa
means of communication. This common phenomenon may
lead to the relative isolation of some communities from the
assessment, reporting, and coordination efforts at the
national level. These resources for communication, assess-
ment, and reporting should be integrated formally into the
national and ministry level organizational efforts.
3. Promote the development of community-based injury
prevention and disaster mitigation strategies
The most cost-efficient use of healthcare resources is to
prevent or lessen the effects of an emergency before it hap-
pens. This may be accomplished through methods that also
have been employed for prevention of other causes of
adverse human health effects. These methods also are
applicable to emergency prevention and control measures,
and include engineering controls, educational controls, and
legislative controls.
Engineering controls—Facilities, homes, and communities
may be designed or located within areas that may minimize
or lessen vulnerability and risk. Examples of these measures
include safe highways, seismic, flood, or high wind hazard-
specific architectural designs, flood plain management
engineering projects, counter-terrorist security measures,
and fire-resistant structures. Land may also be developed
and maintained in a manner that will minimize risk for
seismic activity,landslide, lahars, or flood.
Education controls—Public education can promote general
hazard awareness, and can guide individual management of
risk. It can serve to identify hazards, prioritize risk, offer
prevention strategies, discourage development within high
hazard areas, and promote safe conduct. Student education
within the school system also offers a unique opportunity
for instilling a lifelong awareness of emergency and disas-
ter prevention measures.
Legislative controls—Legislative controls restrict and
encourage behavior served to prevent disasters among vul-
nerable populations. These include controls involving
industrial, commercial, and construction practices that may
prevent technological disasters, such as hazardous material
may include a cadre of local volunteers trained to provide
basic first aid, in addition to the existing resource of tradi-
tional or modern healers. It should follow a normal medical
referral process utilizing the services of existing primary care
workers, dispensaries, and super-dispensaries. It also should
seek to utilize other community assets such as local facilities
that may include churches, schools, and private homes.
This level of planning should involve community stan-
dards and societal norms. It should seek to identify authen-
tic community leadership and to enlist their support and
guidance. It should involve a broad base of community
assets including neighborhood and village volunteers.
These persons may be mobilized and organized in the form
of community brigades under the direction of local,
authentic leadership.
The chain of emergency health begins in the individual
home and extends up to the national Ministry of Health.
In order for a service and plan to be used effectively by the
community, it first must be communicated effectively to
the community. Communication also should occur in both
directions. Healthcare planners should enlist and incorpo-
rate community input into the disaster plan and exercises.
Community-based emergency response first-aid teams
or brigades also may serve as effective extensions of the
national health planning apparatus. They may be appoint-
ed for each village, and would serve as a first responder to
assist their neighbors in times of emergency. These
brigades may assist in the organization of community-level
planning as well as emergency response to involve essential
job elements such as the following:
Direction and Control
Communications
Warning and Emergency Public Information
Evacuation and Mass Shelter
Health and Medical
Emergency Census and Search and Rescue
Resource Management
Damage Assessment
Also, disasters frequently damage or destroy existing
Course Content Potential Trainees (and Future Trainers)
Emergency Operations Planning Planning coordinator
Planning committee members
Incident Management Systems Planning coordinator
General Principles of Disaster Management Planning committee members
Disaster Communications Emergency medical care providers
Fire department staff
Public safety / Law enforcement staff
Search & rescue personnel
Ministry of Health operational staff
Mass Casualty Management Planning coordinator
Emergency medical care providers
Physicians & nurses
Search & rescue personnel
Ministry of Health operational staff
Hazardous Materials Emergency Response Planning coordinator
Fire department staff
Emergency medical care providers
Table 5—Recommendations for emergency health and medical curriculum content Prehospital and Disaster Medicine ©2002 Clack
April – June 2002 http://pdm.medicine.wisc.edu Prehospital and Disaster Medicine
Clack et al 7
7. Mushi S, Mgonja AS: Assessment of types of accidents and their associated
factors in Arusha municipality between 1990 and 1992. Disasters, Accidents,
Violence, and Health in Africa. [Au—any more info available????]
8. Museru LM, Leshabari MT,Grob U, Lisokotola LN: The pattern of injuries
seen in patients in the orthopaedic/trauma wards of Muhimbili Medical
Centre. East and Central African Journal of Surgery [AU—need Date]
4(1):15–21.
9. Museru LM: Injuries in Africa, (personal correspondence, 1999)
10. Riwa PG, Kitunga LJ: Industrial accidents in Tanzania: An overview and
prospects for future interventions. Disasters, Accidents, Violence and Health
in Africa. [Au—any more info available????]
11. Rosenberg M, Brown S, Katz M, Berger L, Baer K: An international public
health perspective on injury control. Violence, Aggression and Terrorism
1988;2(4):357–372.
12. Forjuoh S, Zwi A, Mock C: Injury control in Africa: Getting governments
to do more. Tropical Medicine and International Health 1998;3(5):349–356.
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Morbidity and Mortality, End of Phase 1 Report August, 1997;Dar es Salaam,
Tanzania: Mack Printers, 1997.
6. Centers for Disease Control and Prevention (CDC): Cause-specific adult
mortality: evidence from community-based surveillance — Selected sites,
Tanzania, 1992–1998. Morbidity and Mortality Weekly Report (MMWR) 19
May 2000:49(19);416–419.
the most cost-effective first step. First, the infrastructure
must be modified so that the victims have adequate care
upon reaching their destination. A study done in Kuala
Lumpur, Malaysia found that extensive pre-hospital sys-
tems are expensive and resources would be better spent on
occupational safety,schools, or better roadways. According
to their estimations, there was no significant increase in
survival rates from improvement of the pre-hospital care
system.19 The University of New Mexico Division of
Emergency Medicine attempted to help develop an EMS
system in Costa Rica in 1990. Their conclusion was that
this was an overly optimistic goal due to the lack of an
effective infrastructure.20
In comparison, even experienced and developed EMS
systems often are overwhelmed during disasters. Most
recently, in an event similar to the embassy bombings, the
Murrah Building bombing reportedly overwhelmed the
Oklahoma City emergency medical services. Hogan et al
reported little to no documentation of on-scene triage of
casualties, and in fact, on-scene documentation of EMS
treatment was minimal. Of the known arrival modes, only
33% of patients arrived at hospitals transported by EMS;
and EMS was used largely for transport and not for pro-
viding clinical interventions.21
Conclusions
The recent US Embassy bombings have illustrated some of
the vulnerabilities shared by the people of Tanzania and
Kenya. Injuries comprise a key vulnerability and thus far,
have been neglected. Injuries result from combinations of
adverse environmental conditions, equipment, behavior,
and personal risk factors; many of which can be modified.
Ultimately, any intervention to lessen human suffering
should reduce hazards, enhance local response resources,
and have the desired effect of sustainability. A proactive
and evidence-based approach for the prevention and con-
trol of acute-onset, health emergencies among developing
nations is proposed.
spills, building collapse, dam failure, or boat and plane
crashes. Legislative controls also may be applied to guide
behavior of vulnerable populations on an individual basis.
It may discourage counter-productive measures such as
home building within flood plains, ravines, and hillsides
prone to landslide or deforestation.
4. Promote the Education and Training of Emergency
Responders
In order to respond effectively to the challenges that face
the community, the emergency and disaster response work-
force requires additional training and education. Local
institutions assisted by others with extensive experience in
emergency health, medical services, and disaster manage-
ment, best provide this training.
The training itself should be simple. It should include
the most likely first responders to everyday emergency
responders (e.g., daladala and matatu bus drivers, police,
fire, ambulance, nurses, and doctors). A train-the-trainers
system also would allow developing nations to create a sus-
tainable capacity for self-sufficiency and facilitate the lega-
cy of this gain for future generations. The length of the
training sessions also should be brief, so as not to cause dis-
ruption of the attendees’ ongoing work and public service.
Table 5 lists recommendations for a training curriculum
content according to the potential target audience.
Steps for development should be prioritized and sequen-
tial. It should be noted that no recommendations are implied
for a first step of improving the existing ambulance systems
in most of Kenya and Tanzania. In these nations, the finan-
cial imbursement scheme for most ambulance services is
based upon a fee paid in advance of service rendered, and few
can afford ambulance transport. Most hospital emergency
patients are self-transported or carried by family members,
private vehicle, or public transportation. In developing
countries where the hospitals have inadequate equipment,
diagnostics, specialty consultants, and intensive care, the
action of improving formal ambulance systems may not be
Prehospital and Disaster Medicine http://pdm.medicine.wisc.edu Vol.17,No.2
8Emergency Health and Risk Management in Sub-Saharan Africa
17. Rottman SJ, Noji EK, [AU-need at least one more author] et al:Priorities in
medical response to disasters. Prehosp Disaster Med 1990;5:64–66.
18. SAEM Disaster Medicine White Paper Subcommittee on Disaster
Medicine: Current assessment and blueprint for the future. Academic
Emergency Medicine 1995;2(12):1068–1076.
19. Hauswald M, Yeoh E: Designing a prehospital system for a developing coun-
try: Estimated cost and benefits. American Journal of Emergency Medicine
1997;15(6):600–602.
20. Doezema D, Sklar DP, Roth PB, Rodolico MP, Key G: Development of
emergency services in Costa Rica: A collaborative project in international
health. JAMA 1991;265(2):188–190.
21. Hogan D, Waeckerle J, Dire D, et al:Emergency department impact of the
Oklahoma City terrorist bombing. Annals of Emergency Medicine
1999;34(2):160–167.
13. World Health Organization: Principles for Injury Prevention in Developing
Countries. proceedings of an international course organized by the John
Hopkins University School of Hygiene and Public Health and the World
Health Organization, 1985.
14. Barrs P, Smith G, Baker S, Mohan D: Injury prevention: An international per-
spective,New York:Oxford University Press, 1998.
15. Mutasingwa D: Vulnerability Analysis and Risk .anagement,paper present-
ed at the Disaster Management Workshop; Morogoro, Tanzania, 26–30
October, 1998.
16. Haddon W: Advances in the epidemiology of injuries as basis for public pol-
icy. Public Health Reports 1980;95:411–421.
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