Building Human Resilience
The Role of Public Health Preparedness and Response As an
Adaptation to Climate Change
Mark E. Keim, MD
Abstract: Global climate change will increase the probability of extreme weather events, including
heatwaves, drought, wildﬁre, cyclones, and heavy precipitation that could cause ﬂoods and
landslides. Such events create signiﬁcant public health needs that can exceed local capacity
to respond, resulting in excess morbidity or mortality and in the declaration of disasters.
Human vulnerability to any disaster is a complex phenomenon with social, economic,
health, and cultural dimensions. Vulnerability to natural disasters has two sides: the degree
of exposure to dangerous hazards (susceptibility) and the capacity to cope with or recover
from disaster consequences (resilience). Vulnerability reduction programs reduce suscep-
tibility and increase resilience. Susceptibility to disasters is reduced largely by prevention
and mitigation of emergencies. Emergency preparedness and response and recovery
activities—including those that address climate change—increase disaster resilience.
Because adaptation must occur at the community level, local public health agencies are
uniquely placed to build human resilience to climate-related disasters. This article discusses
the role of public health in reducing human vulnerability to climate change within the
context of select examples for emergency preparedness and response.
(Am J Prev Med 2008;35(5):508–516) Published by Elsevier Inc. on behalf of American Journal of
Climate Change and Extreme Weather Events
Global climate change will increase the probabil-
ity of extreme weather events
(Table 1), which
may be associated either with high precipita-
tion (i.e., storms, ﬂoods, and landslides) or with low
precipitation (i.e., heat, drought, wildﬁre).
events often overwhelm the capacity of communities
and local governments to respond, requiring outside
assistance. Such mismatches between needs and re-
sources often result in declarations of disaster.
High-precipitation events, which are likely to in-
crease in frequency, will compound the risk of ﬂood
and landslide disasters. According to the UN Intergov-
ernmental Panel on Climate Change (IPCC): “Many
millions more people are projected to be ﬂooded every
year due to sea-level rise by the 2080s. In some areas
heatwaves are expected to increase in severity and
frequency, expanding drought affected areas.”
latitude regions, crop productivity is expected to de-
crease, thus increasing the risk for hunger, particularly
in Africa and small island developing States. “By 2020,
between 75 and 250 million people are projected to be
exposed to an increase in water stress.”
The Public Health Impact of Extreme Weather Events
By 2008, the cost of natural disasters, in mortality and in
public resources, had exceeded that of previous periods for
which data were available.
In particular, climate-related
(hydrologic and meteorologic) hazards affected an increas-
ing number of people and caused increasingly large eco-
Between 1970 and 1999, climate-related
events accounted for 90% of the world’s disaster-related
with the world’s poor disproportionately affected.
The literature thoroughly describes how climate change
affects natural disaster–related health risk.
nants of population health, such as education, health care,
public health prevention efforts, and infrastructure, play a
major role in vulnerability and resiliency.
Table 2 compares the public health emergencies asso-
ciated with the six climate-related hazards mentioned
above: storms, ﬂoods, landslides, heat, drought, and wild-
ﬁre. Such disasters result in public health needs that often
exceed local response capacity. This article focuses on the
ﬁve natural disasters other than heatwave, which is dis-
cussed in detail elsewhere in this journal issue.
Building Human Resilience As an Adaptation to
Human Vulnerability and Disaster Risk
and the WHO
deﬁne a disaster as “a serious
disruption of the functioning of a community or a
From the National Center for Environmental Health, Agency for
Toxic Substances and Disease Registry, CDC, Atlanta, Georgia
Address correspondence and reprint requests to: Mark E. Keim,
MD, NCEH, CDC, 4770 Buford Highway, MS-F29, Atlanta GA 30341-
3724. E-mail: email@example.com.
508 Am J Prev Med 2008;35(5) 0749-3797/08/$–see front matter
Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine doi:10.1016/j.amepre.2008.08.022
society causing widespread human, material, economic
or environmental losses which exceed the ability of the
affected community or society to cope using its own
Thus, the disaster consists of the interac-
tion between the hazard and the vulnerability of those
affected, not the mere fact of the hazard’s occur-
For any given hazard, disaster risk varies ac-
cording to a population’s vulnerability (e.g., age, gen-
der, health status, SES).
Disaster Risk Management
Recently, the international approach to emergencies
and disasters has shifted from largely post-impact activ-
ities (i.e., ad hoc relief and reconstruction) to a more
systematic and comprehensive risk management pro-
As described by disaster experts Lisa Schipper
and Mark Pelling, “Disaster risk management includes
both pre-impact disaster risk reduction—prevention,
preparedness, and mitigation—as well as ‘response and
recovery’ post-impact crisis management activities.”
Preparedness is deﬁned as “activities and measures
taken in advance to ensure effective response to the
impact of hazards.” Mitigation is the “structural and
nonstructural measures undertaken to limit the adverse
impact of natural hazards, environmental degradation
and technologic hazards.”
(This deﬁnition of mitiga-
tion is not to be confused with “mitigation” used in the
climate change context, which refers to reduction of
greenhouse gas emissions.) Figure 1 provides an over-
view of the four phases of the disaster risk management
cycle. These concepts are very applicable to climate
Reducing Human Vulnerability As an Adaptation to
Mitigation policies focus on reducing the hazard,either
by controlling the emissions of greenhouse gases or by
capturing and sequestering those emissions. Adapta-
tion policies focus on reducing the vulnerability,by
taking steps to make social and environmental systems
more resilient to the effects of climate-related hazards.
Effective climate policy necessarily requires a combina-
tion of mitigation and adaptation policies, although
public support and funding for adaptation have been
Reducing human vulnerability is a key aspect of
reducing climate change risk.
The 2002 Yokohama
Strategy and Plan of Action for a Safer World led to a
change in the UN’s approach to mitigating disasters to
treating human actions and vulnerabilities as the main
causes of disasters.
Human Resilience As a Means for
Many economists believe that measures directed to-
ward the underlying macro-level causes of climate
change vulnerability should be broadly integrated
into development policy, not conﬁned to climate
change adaptation strategies.
to disasters is a complex phenomenon that includes
social, economic, health, and cultural factors. Vul-
nerability to natural disasters has two sides: the
degree of exposure to dangerous hazards (suscepti-
bility) and the capacity to cope with or recover from
the consequences of disasters (resilience). Vulnera-
bility reduction programs reduce susceptibility and
increase resilience. Susceptibility to disasters de-
creases through activities such as prevention, and
through mitigation measures that prevent or limit a
population’s exposure to the hazard.
response, and recovery activities all increase resil-
ience. Resilience has two components: that provided
by nature, and that provided through human action.
An example of resilience provided by nature is the
manner in which porous soil allows more rapid
drainage of ﬂood water than more occlusive soil. An
example of human action that affects resilience is
social organization that facilitates (or hinders) re-
sponse and recovery. Disaster resilience is composed
of (1) the absorbing capacity, (2) the buffering cap-
Table 1. Trends of extreme weather events predicted to occur as a result of climate change (%)
Phenomenon and direction
Likelihood that the trend
occurred in the late 20th
Likelihood of human
contribution to trend
Likelihood of future trends
based on projections for
Increased incidence of
66–90 (likely) 51–66 (more likely than not) 90–99 (very likely)
Increased incidence of heavy
66–90 51–66 90–99
More areas affected by
66–90 51–66 66–90
Increased incidence and
severity of cyclones
66–90 51–66 66–90
Increased incidence of
extremely high sea levels
66–90 66–90 66–90
Adapted from IPCC Working Group II Report. Impacts, Adaptation, and Vulnerability, 2007.
November 2008 Am J Prev Med 2008;35(5) 509
Table 2. The relative public health impact of the six natural disasters expected to worsen with climate change
Public health impact
High-precipitation events Low-precipitation events
Storms Floods Landslides Heat Drought Wildﬁre
Number of deaths Few, but can be many in
Few, but can be many
in ﬂash ﬂoods
Moderate to many
Few, but can be many in
Few to moderate
Risk of an associated
Unlikely Unlikely, except for
Unlikely Unlikely Unlikely, except for low-
Severe injuries Few Few Few to
Moderate to many
cases of heat
Unlikely Few to moderate
Loss of clean water Widespread Focal to widespread Focal Unlikely Widespread Focal
Loss of shelter Widespread Focal to widespread Focal Focal to widespread Focal to widespread Focal
Loss of personal and
Widespread Focal to widespread Focal None Unlikely among
Likely among displaced
Permanent migration Unlikely Unlikely Unlikely Unlikely Likely Unlikely
Loss of sanitation Widespread Focal to widespread Focal Unlikely Likely among displaced
Likely among displaced
Loss of routine hygiene Widespread Focal to widespread Focal Unlikely Likely among displaced
Likely among displaced
Disruption of solid waste
Widespread Focal to widespread Focal Unlikely Likely among displaced
Likely among displaced
Public risk perception High High High Moderate to high Moderate to high High
Increased pests and vectors Widespread Widespread Unlikely Unlikely Possible Unlikely
Loss and/or damage of
Widespread Focal to widespread Focal Unlikely Unlikely Focal
Worsening of existing
Widespread Focal to widespread Focal Widespread Widespread Focal to widespread
Toxic exposures Possibly air, water, food Possibly air, water,
Possibly air Possibly water Likely air
Food scarcity Uncommon except in
Uncommon Unlikely Unlikely Common Possible
510 American Journal of Preventive Medicine, Volume 35, Number 5 www.ajpm-online.net
acity, and (3) response to the event and recovery from
the damage sustained.
Building Resilience to Extreme Weather Events
Through Public Health Preparedness and
Adaptation to disaster occurs at the community level.
Public health is uniquely placed at the community level
to build human resilience to climate-related disasters.
“By focusing on vulnerability and the ability of individ-
uals and communities to recover (resilience), vulnera-
bility reduction places the individuals at risk at center
stage and tasks the responsible authorities with enhanc-
ing social equity and promoting community cohesive-
ness, alongside a heightened sense of individual re-
By promoting safety and health, public
health works to reduce the pre-existing burden of
disease, build social capital, and strengthen community
resilience to a wide range of health hazards, including
extreme weather events.
Community public health and medical institutions can
play an active part in reducing human vulnerability to
climate-related disasters through promotion of “healthy
people, healthy homes and healthy communities.”
Healthy people are less likely to suffer disaster-related
morbidity or mortality and are therefore more disaster-
resilient. Healthy homes are disaster-resilient; they are
designed and built to stay safe during extreme weather
events. Healthy “communities minimize exposure of peo-
ple and property to natural disasters. Sustainable commu-
nities are disaster-resilient communities.”
preparedness and response activities build community
resilience and reduce hu-
man vulnerability, includ-
ing vulnerability to climate
Preparedness is deﬁned
as “activities and measures
taken in advance to en-
sure effective response to
the impact of hazards.”
Emergency response be-
gins with the impact of an
event. During a cyclone,
ﬂood, wildﬁre, or landslide
event, the onset of the di-
saster impact is quite
clear; during times of
drought, however, it may
be more insidious. The re-
sponse phase usually be-
gins with ad hoc local
emergency response fol-
lowed some time later by a
formal declaration of di-
saster and external assis-
tance and emergency relief.
Resilience-Building Strategies for Extreme Weather
Events Related to Climate Change
The public health impact of drought disasters. Drought
is usually deﬁned as a “period of abnormally dry weather
that is sufﬁciently prolonged so that the lack of water
causes a serious hydrologic imbalance in the affected
Ironically, very few people die of thirst or dehy-
dration during a drought, even in low-income countries.
Drought-related deaths are generally secondary to the
agricultural, economic, and health effects of drought,
such as famine, malnutrition, poverty, poor public health
practices, contamination of existing water supplies, infec-
tious diseases, social strife, and heat-related illness.
addition to increasing the likelihood of food insecurity
and famine, a drought can have catastrophic effects on
the regional or national economy.
psychosocial impacts of drought include decreased quality
of life, major changes in lifestyle, and increasing conﬂict
over water resources.
Preparing for drought-related public health emergen-
cies. Public health preparedness for drought emergen-
cies should begin with a risk assessment. This assessment
should focus on critical health needs such as food security,
water, sanitation, and shelter, as well as on the psychoso-
cial, political, and economic impact of the drought.
Accurate short- and long-term forecasting and early warn-
ing may improve preparedness and may guide develop-
ment over the long term. Drought emergency plans
Figure 1. A diagram of the disaster risk management cycle comparing risk-reduction measures
(above) to crisis-management measures (below)
November 2008 Am J Prev Med 2008;35(5) 511
should speciﬁcally include contingencies for long-term,
sustained emergency operations, for an insidious onset
(and therefore a difﬁcult-to-identify threshold for decla-
ration and implementation of emergency measures), and
for population displacement. Public education about lo-
cally relevant water use, health risks, and behaviors that
protect health also represents a key component of public
health preparedness. A well-established capability for ep-
idemiologic investigation and disease surveillance can
guide the need for evidence-based interventions.
Responding to drought-related public health emergen-
cies. Public health responses to drought emergencies are
ideally based on locally developed plans, which in turn are
based on national and international guidance. The most
signiﬁcant risks for drought-related hunger, disease, and
population displacement occur in low-income countries.
During a drought emergency response, the principal
expected interventions relate to the public need for:
●safe water and adequate sanitation
●infection control in healthcare settings
●temporary shelter for displaced populations
In high-income countries, the economic impact from
the higher cost of food and safe water will likely
outweigh the direct risk of famine or epidemic, yet that
impact will signiﬁcantly hinder economic growth and
development. During other types of disasters, water
shortages have been reported to affect a wide range of
hospital services, including food preparation, environ-
mental control, toilet availability, housekeeping, laun-
dry, infection control, renal dialysis, and ﬁre safety.
The public health impact of wildﬁre disasters. Wildﬁre
is deﬁned as “a sweeping and destructive conﬂagration,
especially in a wilderness or a rural area.”
At the turn
of the twentieth century, three major wildﬁre disasters
occurred in the U.S., each resulting in about 1000
Since that time, advances in information
dissemination, warning systems, and ﬁreﬁghting equip-
ment and control capabilities have reduced wildﬁre-
related mortality in the U.S. In 2007, California wild-
ﬁres caused over $1 billion in damage, destroyed over
1500 homes, and affected over 1 million people, yet
very few deaths and injuries were reported.
As has also
been the case for ﬂoods and cyclones, developed
nations such as the U.S. have been able to achieve a
considerable impact in reducing wildﬁre-related mor-
tality through enhancement of local preparedness and
The public health impact of wildﬁres may include:
●exacerbations of chronic obstructive pulmonary dis-
ease and asthma
●population displacement resulting in a need for
humanitarian assistance that includes safe shelter,
water and food, security, sanitation, and health care
In 1991, grass wildﬁres in Alameda County CA re-
sulted in 26 deaths and !225 injuries.
department records showed that more than twice as
many people sought treatment for smoke-related prob-
lems as for other traumatic injuries.
Preparing for wildﬁre-related public health emergen-
cies. The ﬁrst step in a community-based risk assess-
ment for wildﬁre should be a ﬁre hazard evaluation.
Moreover, emergency plans that detail the local, state,
and federal responses to wildﬁre should incorporate
this risk assessment. Once developed, the plans should
be validated through regularly scheduled exercises and
drills. These plans and exercises should include contin-
gencies for population evacuation and for mass care
and shelter. The public should be educated as to the
potential risk of wildﬁre and, in the case of a wildﬁre
disaster, what protective steps to take (i.e., evacuation
or shelter-in-place). Further studies are needed to
identify risk factors for short- and long-term wildﬁre-
related morbidity and mortality and to establish best
practices for public health risk management of wildﬁre
Responding to wildﬁre-related public health emergen-
cies. Immediately after the disaster-impact phase, rapid
needs assessments of an affected community are con-
ducted to identify gaps among health, medical needs, and
available resources. Mass casualties are very rare in the
case of wildﬁres, especially in high-income countries. To
ensure safe and healthy living conditions, public health is
often involved in shelter and resettlement decisions. Pub-
lic health also plays a role in healthcare delivery, in
inspections of food, in air safety and water quality, and in
assessment of sanitation and hygiene in mass-care shelters.
If wildﬁre threatens manufactured hazardous materials,
public health may also be called upon to perform hazard
risk analysis or to promote the occupational health and
safety of responders. Also, health-related public informa-
tion campaigns can encourage family-based prepared-
ness, inform vulnerable populations, and promote evacu-
The public health impact of ﬂoods. Floods are deﬁned
as “the overﬂow of areas that are not normally sub-
merged with water or a stream that has broken its
normal conﬁnes or has accumulated due to lack of
Floods may be caused by natural processes
that are either ﬂuvial (an abundance of rainfall, melt-
ing snow) or coastal (a hurricane-related storm surge,
512 American Journal of Preventive Medicine, Volume 35, Number 5 www.ajpm-online.net
coastal inundation, or seismically induced tsunami) in
origin. Since tsunamis are not associated with climate
change, this article will not consider ﬂooding from this
cause. Worldwide, ﬂoods are the most common natural
disaster—during the decade from 1996 to 2005 ﬂoods
accounted for 42% of all natural disasters.
that same decade, 1.3 billion people were affected by
ﬂoods, and over 90,000 of them died. That decade also
saw ﬂoods cause more damage than any other natural
disaster, accounting for one third of all disaster-related
Public health impacts of ﬂooding include:
●damage to homes and consequent displacement of
●compromised personal hygiene
●contamination of water sources
●disruption of sewage service and solid-waste collection
●injuries sustained during cleanup
●stress-related mental health and substance abuse
●deaths, mostly caused by drowning
Preparing for public health emergencies caused by
ﬂood. Meteorologic forecasting and early warnings
have decreased mortality from ﬂash ﬂoods by !50%.
Similarly, public health emergency response planning
should address key precautionary ﬂood-related health
issues, such as those associated with potential loss of
shelter, sanitation, hygiene, and health care among
affected populations, as well as exacerbations of
chronic disease, toxic exposures, mental illness, family
violence, and loss of healthcare services.
exercises should include contingencies for population
protection as well as alert/notiﬁcation systems for pub-
lic health and medical staff and for special populations.
Public health communications can encourage pre-
paredness in the home, in schools, in the work place,
and at healthcare facilities; health communications can
also raise public awareness of evacuation routes, ﬂood
zones, and community response plans. Development of
robust public health surveillance systems helps to pre-
pare for rapid needs assessments and for surveillance of
ﬂood-related morbidity and mortality. Power genera-
tors and water pumps are examples of equipment
commonly useful during ﬂood emergencies. These
devices help to maintain critical health and medical
infrastructure, including public health departments,
hospitals, nursing homes, schools, and outpatient
Responding to ﬂood-related public health emergen-
cies. Some evidence indicates that the way a ﬂood
disaster response is handled by community and profes-
sional agencies can have a signiﬁcant effect on mental
health outcomes, which in turn are strongly associated
with physical health.
Strategies that minimize popu-
lation displacement and favor an early return of victims
to routine activities of daily living are known to lessen
the health impact of ﬂood disasters.
As a natural disaster evolves, the demands for environ-
mental health services and consultation often rise.
though communicable disease outbreaks after ﬂood di-
sasters are rare in the U.S., some potential disease
transmission does exist, and affected communities should
therefore remain under close surveillance.
studies of ﬂood disasters have shown that outbreaks of
vaccine-preventable diseases rarely result
; thus mass
immunization in absence of a documented outbreak
diverts limited human resources and materials from other
more effective and urgent measures.
potential spread of infectious disease by ﬂoodwaters, basic
rules of hygiene and sanitation are far more important
than are immunizations.
In many parts of the world, ﬂoods are often followed
by a proliferation of mosquitoes. The relationship
between ﬂooding and vectorborne disease is complex.
Severe weather can either increase or decrease the
transmission of vectorborne illness.
In the U.S. as
compared to other regions of the world, ﬂoods rarely
result in outbreaks of arboviral disease, which is attrib-
utable mostly to the relatively low prior prevalence of
vectorborne diseases in the region.
given that most ﬂood-related injuries are minor soft
tissue injuries, trauma care teams are usually not re-
Community-based primary care outreach ac-
tivities are often necessary to overcome the barriers to
healthcare access encountered by ﬂood victims. During
ﬂood disasters, evacuation of special populations, such
as those in hospitals, schools, prisons, and nursing
homes, as well as migrants, tourists, and people with
disabilities, can create the need for a major public
The public health impact of tropical cyclones. Tropical
cyclones are low-pressure weather systems that develop
over the warm waters of the oceans, typically between
the latitudes of 30°N and 30°S.
In the past 2 centuries,
tropical cyclones have caused an estimated 1.9 million
deaths worldwide, and 16 of the 18 deadliest occurred
in the Asia–Paciﬁc region.
Storm surge is the unusually high ocean level caused
by pressure differentials and surface winds along coast-
lines in advance of a cyclone landfall. Absent early
warning and evacuation measures, drowning from
storm surge can cause an estimated 90% of cyclone-
In low-income countries
without critical preparedness measures, storm surge
remains the primary cause of mortality following trop-
Injury is the major cause of tropical cyclone morbidity.
Some researchers have also noted an increased incidence
of animal and insect bites in the aftermath of tropical
November 2008 Am J Prev Med 2008;35(5) 513
However, the increased incidence of insect
bites has not been associated with increases in vector-
borne disease. Chronic diseases such as asthma and
emphysema are exacerbated after tropical cyclones, as is a
potential for exposure to hazardous substances—such as
mold—during cleanup and recovery efforts. Outbreaks of
infectious diseases following tropical cyclones are rare,
but both waterborne and arthropodborne diseases have
been reported in low-income countries.
As of yet,
there is no clearly deﬁned common etiology for this
incidence. Behavioral health effects are among the most
signiﬁcant long-term adverse health outcomes of tropical
Preparing for public health emergencies caused by
tropical cyclones. Weather monitoring and forecasting
are clearly essential components of an early warning
system for cyclones. Accurate weather monitoring and
early warning allow for timely implementation of a safe
evacuation, thus preventing drowning—the leading
cause of cyclone death. Emergency operations plans
should take into consideration the priority public
health needs experienced after cyclones, which most
often include at-risk population evacuation and provi-
sion of adequate shelter, as well as food, water, sanita-
tion, and health care. Public education can encourage
preparedness in the home, in schools, at the workplace,
and at healthcare facilities. Such education can raise
public awareness of evacuation routes, storm surge, and
riverine ﬂood zones, and community response plans. It
can also assist in development of public health surveil-
lance assistance when preparing rapid needs assess-
ments and when conducting post-impact surveillance of
cyclone-related morbidity and mortality. With regard to
equipment, power generators are critical for maintain-
ing health and medical infrastructure, such as public
health departments, hospitals, nursing homes, schools,
and outpatient clinics.
Responding to public health emergencies caused by
cyclones. The public health effects of cyclones are
mostly secondary to the loss of access to shelter and
services (e.g., food safety, electricity, water sanitation,
and health care). In the event of population displace-
ment and resettlement, public health is often called
upon to evaluate the need for these health and medical
services, and possibly to deliver them. Health informa-
tion systems and public health surveillance data moni-
tor the health and safety of the ﬂood-affected popula-
tions, as well as that of relief and recovery workers.
In a cyclone’s wake, clinical care typically involves
treatment of soft tissue injuries incurred during evacu-
ation and cleanup, rashes, chronic disease and mental
illness exacerbations, and self-limited respiratory and
After cyclones, multi-
system trauma is rare; thus, external assistance such as
surgical ships or mobile hospitals is usually unneces-
sary. In absence of a documented outbreak or a mass
casualty event, public health interventions involving
vector control, immunization, and trauma care are
rarely necessary and can divert limited human re-
sources and materials from other, more effective and
more urgently needed measures.
indicated, however, that providing increased social
support after cyclone disasters can signiﬁcantly lower
Moreover, the appropriate use of
personal protection equipment among disaster recov-
ery workers can help to prevent toxic exposures from
chemicals or mold.
Landslides (Debris Flows)
The public health impact of landslides. Landslides
include all types of gravity-induced ground movements,
ranging from rock falls through slides/slumps, ava-
lanches, and ﬂows, triggered mainly by precipitation
(including snowmelt), seismic activity, and volcanic
A debris ﬂow is a rapidly moving mass of
water and material that is mainly composed of sand,
gravel, and cobbles, but typically includes such items as
trees, cars, and even small buildings. Most debris ﬂows
have the consistency of wet concrete and move at
speeds in excess of 35 miles per hour.
Landslides occur in every U.S. state and territory. In
the U.S. alone, landslides cost an estimated $1–$3
billion per year.
Landslides are associated with high
rates of traumatic injury and mortality, with mortality
largely due to trauma and asphyxiation. Landslide
morbidity is generally associated with traumatic inju-
ries, wound infections, and disruptions of water, sani-
tation, and shelter, as well as disruption of the affected
population’s locally grown food supply.
pores can be dispersed in dust clouds, as occurred
during landslides triggered by the 1994 Northridge
earthquake in California, when an outbreak of 203
cases of coccidioidomycosis resulted.
associated with 1999 ﬂoods in Venezuela killed 30,000
people, then came dangerously close to causing a
hazardous chemical release with the potential to affect
80,000 nearby residents, as well as that country’s largest
airport and second largest seaport.
Preparing for public health emergencies caused by
landslides. Rainfall monitoring, together with warning
and population evacuation, can reduce potential loss of
life due to landslides. Early warning systems based on
weather forecasts and rainfall information can substan-
tially improve emergency warning for and evacuation of
In advance of heavy rains,
public health information campaigns can communicate
risk and protective behaviors. The public health commu-
nity should become educated about hazard awareness, as
well as emergency preparedness and mitigation and re-
Public health can also play a part in
promoting development of safe and healthy communi-
514 American Journal of Preventive Medicine, Volume 35, Number 5 www.ajpm-online.net
ties, where the terrain remains well-drained and stabilized
through land use regulation and building codes.
Without early warning systems or evacuation and shel-
ter programs, landslides can cause high rates of traumatic
injury and mortality.
After the landslide occurs, it is
often too late for response activities to have a signiﬁcant
effect on morbidity and mortality. Response operations
with the most potential to save lives and prevent injuries
begin before the landslide—whenever heavy rainfall or
slope instability is detected—with population evacuation
and temporary resettlement out of high-hazard zones.
In the immediate aftermath of a landslide disaster, the
ﬁrst responses are life-saving search and rescue efforts and
ﬁrst aid for immediate, life-threatening traumatic injuries.
Occupational health and safety are also important con-
cerns for landslide responders who work in and around
unstable debris ﬂows.
In addition to injury, the public
health effects of landslides are secondary to the popula-
tion’s loss of access to shelter and loss of public services,
such as food safety, electricity, water, sewer, and health
care. After a landslide occurs, and especially in the event
of population displacement, public health is often called
upon to evaluate the need for, or to assist in, the delivery
of health and medical services.
Climate change is predicted to result in an increased
number of extreme weather events, including heatwaves,
drought, wildﬁre, tropical cyclones, and heavy precipitation
events resulting in ﬂoods and landslides. The consequences
of these events are expected to include signiﬁcant public
health needs, which in turn will necessitate disaster
Community-based risk-reduction activities lessen human
vulnerability to the vagaries of natural disasters, especially
those activities that integrate public health, disaster manage-
ment, and climate change. Sustainable adaptations to cli-
mate change, along with community-based public health
preparedness and response activities, build human resilience
and lessen human vulnerability. Such local adaptation activ-
ities are also enhanced by a supportive policy environment at
the national and international levels.
No ﬁnancial disclosures were reported by the author of this paper.
1. Intergovernmental Panel on Climate Change. Climate change 2007: impacts,
adaptation and vulnerability. Contribution of Working Group II to the Fourth
Assessment Reportof theIntergovernmentalPanelon ClimateChange. ParryML,
Canziani OF, Palutikof JP, van der Linden PJ, Hanson CE, eds. Cambridge UK:
Cambridge University Press, 2007. www.ipcc.ch/ipccreports/ar4-wg2.htm.
2. Center for Research on the Epidemiology of Disasters (CRED). EM-DAT:
The International Disaster Database. Ecole se Sante Publique, Universite
Catholique de Louvain. Brussels Belgium, 2005. www.emdat.be/.
3. Thomalla F. Reducing hazard vulnerability: towards a common approach
between disaster risk reduction and climate adaptation. Disasters 2006;
4. Munich Re Group. Annual review: natural catastrophes. Munich Re Group,
Munich Germany 2002. www.munichre.com.
5. Van Aalst M. The impacts of climate change on the risk of natural disasters.
6. Mitchell J, Lowe J, Wood R, et al. Extreme events due to human-induced
climate change. Phil Trans Soc A 2006;364:2117–33.
7. Woodruff R, McMichael T, Butler C. Action on climate change: the health
risks of procrastinating. Aus and NZ J Pub Hlth 2006;30:567–71.
8. Woodruff R, McMichael T, Hales S. Climate change and human health:
review of the evidence. Lancet 2006;367:859–69.
9. Huppert H, Sparks S. Extreme natural hazards: population growth, glob-
alization and environmental change. Phil Trans Soc A 2006;364:1875–88.
10. Zell R. Global climate change and the emergence/re-emergence of infec-
tious diseases. Int J Med Microbiol 2004;293(37S):16–26.
11. Parkinson A, Butler J. Potential impacts of climate change on infectious
diseases in the Arctic. Int J Circumpolar Health 2005;64:478–86.
12. Morrissey S, Reser J. Natural disasters, climate change and mental health
considerations for rural Australia. Aust J Rural Health 2007;15:120–5.
13. Luber G, McGeehin M. Climate change and extreme heat events. Am J Prev
14. WHO. Health Sector Emergency Preparedness Guide. Tazmania: WHO,
15. deVille de Goyet C, Lechat M. Health aspects in natural disasters. Tropical
16. Clack Z, Keim M, Macintyre A, et al. Emergency health and risk manage-
ment in sub-Saharan Africa: a lesson from the embassy bombings in
Tanzania and Kenya. Prehosp Dis Med 2002;17:59–66.
17. UN ISDR WorldSummit onSustainableDevelopment. Geneva: UN,International
Strategy for Disaster Reduction, 2002. www.worldsummit2002.org.
18. Schipper L, Pelling M. Disaster risk, climate change and international
development: scope for, and challenges to, integration. Disasters 2006;30:
19. O’Brien G, O’Keefe P, Rose J, et al. Climate change and disaster manage-
ment. Disasters 2006;30:64–80.
20. Bouwer L, Aerts J. Financing climate change adaptation. Disasters 2006;30:
21. Watson R, Ackermann R. Poverty and climate change. Environment
matters to the World Bank: annual review. Washington DC: World Bank,
22. de Boer J, Dubouloz M, ed. Handbook of disaster medicine. The Nether-
lands: International Society of Disaster Medicine, 2000.
23. Werritty A. Sustainable ﬂood management: oxymoron or new paradigm?
24. Shobha Srinivasan LR, O’Fallon MA, Dearry A. Creating healthy communities,
healthy homes, healthy people: initiating a research agenda on the built
environment and public health. Am J Public Health 2003;93:1446–50.
25. Beatley, Timothy. The vision of sustainable communities. In: Burby R, ed.
Cooperating with nature. Washington DC: National Academy Press, 1998.
26. UN. Terminology: basic terms of disaster risk reduction. Geneva: UN,
International Strategy for Disaster Reduction. www.unisdr.org/eng/library/
27. Bailey G, Walker J. Heat related disasters. In: Hogan DE, Burstein JL, eds.
Disaster Medicine. 2nd ed. Philadelphia: Lippincott, Williams and Wilkins,
28. Wilhite DA. Drought mitigation technologies in the United States: with
future policy recommendations. International Drought Information Cen-
ter technical report series 93-1, 1993.
29. Peters M. Hospitals respond to water lost during the Midwest ﬂoods in
1993: preparedness and improvisation. J Emerg Med 1996;14:345–50.
30. Merriam Webster Dictionary Online. www.m-w.com.
31. Sanderson L. Fires. In: Noji ER, ed. The public health consequences of
disasters. New York: Oxford, 1997;373–96.
32. Bolduan K. Outlook improves as ﬁreﬁghters make headway in wildﬁres.
CNN 2007 Oct 24. www.cnn.com.
33. Bedian K, Arcus A, Frankel-Cone C. Emergency medical response to the
Oakland-Berkeley Hills ﬁre of October 1991. Sacramento CA: California
Department of Health Services, 1994.
34. Shusterman D, Kaplan J, Canabarro C. Immediate health effects of an
urban wildﬁre. West J Med 1993 Feb;158:133–8.
35. Gunn SWA, Multilingual dictionary of disaster medicine and international
relief. Dordrecht Nederlands: Kluwer Academic Publishers, 1990.
36. International Federation of Red Cross and Red Crescent Societies. World
disaster report 2006. Bloomﬁeld CT: Kumarian Press Inc., 2006:211–8.
37. CDC. Tropical Storm Allison rapid needs assessment, Houston Texas, 2001.
November 2008 Am J Prev Med 2008;35(5) 515
38. Poole J, Hogan D. Floods. In: Hogan D, Burstein J, eds. Disaster medicine.
Philadelphia: Lippincott, Williams & Wilkins; 2007:214.
39. Tunstall S, Tapsell S, Green C, et al. The health effects of ﬂooding: social
research results from England and Wales. J Water and Health 2006;4:365–
40. CDC. Morbidity surveillance following the midwest ﬂood—Missouri, 1993.
41. CDC. Outbreak of diarrheal illness associated with a natural disaster—
Utah. MMWR 1983;32:662–4.
42. CDC. Current trends ﬂood disasters and immunization—California.
43. Malilay J. Floods. In: Noji ER, ed. The public health consequences of
disasters. New York: Oxford University Press, 1997:287–300.
44. Noji E. Public health issues in disasters. Crit Care Med 2005;33:S29–33.
45. Ivers LC, Ryan ET. Infectious diseases of severe weather-related and
ﬂood-related natural disasters. Curr Opin Infect Dis 2006;19:408–14.
46. CDC. Rapid assessment of vectorborne diseases during the midwest ﬂood
United States, 1993 MMWR 1994;43:481–3.
47. Malilay J. Tropical cyclones. In: Noji EK, ed. The public health conse-
quences of disasters. New York: Oxford University Press, 1997:207–27.
48. CDC. Deaths associated with Hurricane Hugo—Puerto Rico. MMWR
49. Chowdhury M, Choudhury Y, Bhuiya A, et al. Cyclone aftermath: research
and directions for the future. In: Hossain H, Dodge CP, Abed FH, eds.
From crisis to development: coping with disasters in Bangladesh. Dhaka
Bangladesh: University Press Ltd, 1992:101–33.
50. Diacon D. Typhoon resistant housing in the Philippines: the Core Shelter
Project. Disasters 1992;16:266–71.
51. Meredith JT, Bradley S. Hurricanes. In: Hogan DE, Burstein JL, eds.
Disaster medicine. Philadelphia PA: Lippincott Williams & Wilkins,
52. CDC. Hurricanes and hospital emergency room visits—Mississippi, Rhode
Island, Connecticut (Hurricanes Alicia and Gloria). MMWR 1986;34:765–70.
53. CDC. Morbidity and mortality associated with Hurricane Floyd—North
Carolina. MMWR 2000;49:369–72.
54. CDC. Needs assessment following Hurricane Georges—Dominican Repub-
lic, 1998. MMWR 1999;48:93–5.
55. Guill CK, Shandera WX. The effects of Hurricane Mitch on a community
in northern Honduras. Prehosp Disast Med 2001;16:124–9.
56. WHO. The risk of disease outbreaks after natural disasters. WHO Chron
57. Toole MJ. Communicable disease and disease control. In: Noji EK, ed. The
public health consequences of disasters. New York: Oxford University Press,
58. WHO. Psychosocial consequences of disasters: prevention and manage-
ment. Report no. WHO/MNH/PSF/91.3. Geneva Switzerland: WHO,
59. Ursano RJ, Fullerton CS, McCaughey BG. Trauma and disaster. In: Ursano
RJ, McCaughey BG, Fullerton CS, eds. Individual and community responses
to trauma and disaster: the structure of human chaos. Cambridge: Cam-
bridge University Press, 1994:3–27.
60. Krug EG, Kresnow M, Peddicord JP, et al. Suicide after natural disasters.
N Engl J Med 1998;338:373–8.
61. Keenan HT, Marshall SW, Nocera MA, et al. Increased incidence of
inﬂicted traumatic brain injury in children after a natural disaster. Am J
Prev Med 2004;26:189–93.
62. Sattler DN, Preston AJ, Kaiser CF, et al. Hurricane Georges: a cross-national
study examining preparedness, resource loss, and psychological distress in
the U.S. Virgin Islands, Puerto Rico, Dominican Republic, and the United
States. J Trauma Stress 2002;15:339–50.
63. Caldera T, Palma L, Penayo U, et al. Psychological impact of the hurricane
Mitch in Nicaragua in a one-year perspective. Soc Psychiatry Psychiatr
64. Goenjian AK, Molina L, Steinberg AM, et al. Posttraumatic stress and
depressive reactions among Nicaraguan adolescents after Hurricane Mitch.
Am J Psychiatry 2001;158:788–94.
65. Lutgendorf SK, Antoni MH, Ironson G, et al. Physical symptoms of chronic
fatigue syndrome are exacerbated by the stress of Hurricane Andrew.
Psychosom Med 1995;57:310–23.
66. CDC. Morbidity and mortality associated with Hurricane Floyd—North
Carolina. MMWR 2000;49:369–72.
67. Lee LE, Fonseca V, Brett KM, et al. Active morbidity surveillance after
Hurricane Andrew—Florida, 1992. JAMA 1993;270:591–4.
68. CDC. Health concerns associated with mold in water damaged homes after
hurricanes Katrina and Rita—New Orleans area, Louisiana, October 2005.
69. Varnes DJ. Slope movement types and processes. In: Schuster RL, Krizek
RJ, eds. Landslides: analysis and control. Washington DC: Natl. Res.
Council Transp Res Bd Spec Rpt 176;1978:11–33.
70. Cruden DM, Varnes DJ. Landslide types and processes. In: Turner AK,
Schuster RL, eds. Landslides: investigation and mitigation. Washington DC:
National Research Council Transp Res Bd Spec Rpt 247;1996:36–75.
71. Larsen M, Wieczorek G, Eaton L, et al. Natural hazards on alluvial fans: the
Venezuela debris ﬂow and ﬂash ﬂood disaster. U.S. Geological Survey Fact
Sheet 103-01. U.S. Department of the Interior. pubs.usgs.gov/fs/fs-0103-
72. Keim M. Landslides. In: Ciottone G, ed. Disaster medicine. Philadelphia
PA: Mosby-Elsevier; 2006.
73. UN Ofﬁce for the Coordination of Humanitarian Affairs (OCHA), Tropi-
cal Storm Chata’an, Federated States of Micronesia. OCHA Situation
Report No. 2, July 16, 2004. www.pubs.er.usgs.gov.
74. CDC. Coccidioidomycosis following the Northridge earthquake—California,
1994. MMWR 1994;43:194–5.
75. Keim M, Humphrey A, Dreyfus A, et al. Situation assessment report
involving the hazardous material disaster site at LaGuaira Port, Venezuela.
CDC Report to Ofﬁce of Foreign Disaster Assistance, U.S. Agency for
International Development, 2000.
76. Anonymous. Venezuela seeks contractors for hazardous cleanup. Hazard-
ous Substances Spill Report 2000;3(2).
77. Segerstrom J. A dirty job: rescuers face the growing problem of debris ﬂows,
mudslides and estuary rescues. Advanced Rescue Technology 2004:41–7.
516 American Journal of Preventive Medicine, Volume 35, Number 5 www.ajpm-online.net