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their success is assessed by the fact that nothing happened that could have
happened. They could be assessed by extent to which they produce intangi-
ble values (i.e., basic trust, security etc.).

REFERENCES
1. Thompson D (ed): The Concise Oxford Dictionary of Current English.
9th ed, Oxford: Oxford University Press: 1995, p 969.
2. Ibid., p 432.
3. Øvretveit J: Evaluating Health Interventions: An Introduction to
Evaluation of Health Treatments, Services, Policies, and Organizational
Interventions. Philadelphia: Open University Press, 1998, pp 152–154.
4. Thompson, Dictionary, p120.
5. Berckmans P, Dawans V, Schmets G, Vandenbergh D: Inappropriate
drug-donation practices in Bosnia and Herzegovina, 1992–1996. N Engl
J Med 1997;337:1842–1845.
6. Autier P, Ferir MC, Hairapetien A, et al: Drug supply in the aftermath
of the 1988 Armenian earthquake. Lancet 1990;335:1388–1390.
7. Ali HM, Homieda MM, Abdeen MA: “Drug dumping” in donations to
Sudan. Lancet 1988;335:538–539.
8. Offerhaus L: Russia: Emergency drug aid goes awry. Lancet 1990;336:745.
9. World Health Organization, Regional Office for Europe, Zagreb Area
Office: Medical Supplies Donor Guidelines: WHO Humanitarian
Assistance for Former Yugoslavia. Version 3.01.09.94. Zagreb, Croatia:
World Health Organization, 1994.
10. Øvretveit, Evaluating, pp 110–117.
11. Ibid., pp 105–117.

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 Interventions, Effects, Outcomes, Benefits, and Costs

S S S
Chapter Seven
RESPONSES, RELIEF, AND RECOVERY

ABSTRACT
All damage requires some response. Responses are directed towards the
mitigation of further damage once the impact of an event has begun and/or
correcting the functional deficits created by the primary and secondary
events, and restoring the functionality of the damaged elements to their
respective pre-event state. Disaster responses are directed towards search and
rescue, relief, recovery, and/or rehabilitation. Responses must be directed at
satisfying all or part of defined needs. Implementation of responses must be
coordinated through a Coordination and Control Center. Thus, all responses
must be driven by clearly stated goals and objectives directed towards specif-
ic needs. The Disaster Critical Control Point (DCCP) is the time at which the
available supplies balance all of the needs. Selection of appropriate indicators
that reflect the severity of the damage and the effectiveness of the response in
meeting its goals and objectives and the benefit to society that results is cru-
cial. Use of appropriate indicators eventually will result in the evolution of
minimum and optimum standards, and definition of functional and critical
thresholds. Evolution of such standards and thresholds will lead to the devel-
opment of critical pathways (process evaluation) and guidelines to be used in
optimizing future responses. All of the steps from preparedness to recovery
that are undertaken to minimize the damage and restore the pre-event status
are the tasks of disaster management.
Keywords: critical pathways; damage, disaster; function; goals; impact; indi-
cators; management; objectives; preparedness; recovery; rehabilitation; relief;
rescue; response; severity; standards; thresholds

TFQCDM/WADEM: Health Disaster Management: Guidelines for

Evaluation and Research in the “Utstein Style”. Chapter 7: Responses,
relief, and recovery. Prehosp Disast Med 2002;17(Suppl 3):113–127.

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A LL DAMAGE, regardless of its magnitude, requires some type of

response. Responses are directed towards the mitigation of further
damage once the impact of an event has begun and/or at correct-
ing the functional deficits created and restoring the functionality of damaged
elements to their pre-event state. For most damaged elements, the latter is a
reasonable goal. However, this may not always be possible, i.e., when the dam-
age is sustained by biological entities like humans or animals or, in many
instances, the environment. However, the objective of returning the society to
its pre-event state remains a primary goal.

RESPONSES
A response is an answer, reply, or a reaction to some perceived question or
need.1,2 In the context of this discussion, responses constitute reactions to the
damage, whether related to the primary event or to secondary event(s). Thus,
responses are a reaction or a set of reactions. Responses may be local, regional,
national, or international; they may be immediate or delayed. In general, the
initial, local responses are part of effecting preparedness. For example, the
reaction to the event by the local emergency medical services is part of pre-
paredness. In the case of a disaster, by definition, local resources are over-
whelmed, and the responses are supplemented by personnel, materials,
and/or equipment from outside of the affected area. Search and rescue teams
from other countries that respond to assist the affected society with recovery
of trapped survivors or bodies of the dead are examples of such responses.
Disaster Responses may be directed at search and rescue, relief, recovery,
and/or rehabilitation. Responses that elevate the functional status of any BSF
or its components beyond rehabilitation (return to pre-event status), are clas-
sified as development. Responses aimed at improving a society’s capability to
absorb (mitigate) future events (i.e., new building codes), should be based on
evaluations of the factors that were responsible for the damage. Search and
rescue efforts need no definition. However, the timing of these efforts relative
to the primary and secondary events is critical, and their usefulness seems to
differ significantly between different scenarios. For example, in some earth-
quakes, search and rescue activities have provided significant assistance in
extricating survivors even on the fifth day after the quake. In other settings,
their activity could have been terminated 48 hours after the quake, and the
resources could have been redirected towards assisting the survivors.3-8
Reliable information to guide these different approaches that require deci-

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sions by management, as of yet, are not properly substantiated, since all exist-
ing reports are differently structured and focused.3-8
Relief efforts are directed at the alleviation of pain or distress.9 They
consist of assistance with materials, facilities, and personal needs and servic-
es provided to needy persons or communities without which they would suf-
fer.10 Such relief efforts often receive much attention from the media. The
effectiveness, efficiency, efficacy, benefits, and costs of such efforts remain to
be demonstrated in the overall context of resource utilization.
During disasters, responses must be directed at satisfying all or part of
a need or needs identified by assessments of needs. In disaster settings,
responses must provide the resources that are required to deal with specific
needs. A response may be directed at decreasing a need (e.g., proper clothing
may reduce the consumption of heating devices and fuel) or by increasing
the supply of the resources needed. Resources typically come in the form of
goods and services (personnel, equipment, supplies, or money). Even in a
sudden-onset disaster, ALL responses should be coordinated by a single
Coordination and Control Center, and should be directed at specific, identi-
fied needs. This may be difficult during the immediate response when care is
provided by uninjured bystanders, as has been demonstrated repeatedly. All
professional responses must be coordinated and controlled through a Grand
Pooh-Bah.i
In the early stages of a sudden-onset disaster, the ability to respond is
a function of the level of preparedness of the local community. Some of the
resources required during this immediate period may be greater than the
quantities that were required during the pre-event period. For example, the
amount of emergency medical services required may increase during and/or
following an event due to the number of associated casualties (conditional
needs). Thus, preparedness and response plans should delineate how this
conditional increase in needs will be managed.8,14-17 When these local
resources (civil society) are insufficient to meet the augmented needs,
responses may be provided by regional national, and possibly international
sources by governmental, inter-governmental (IGO), and/or non-govern-
mental (NGO) organizations. Some disaster responses have been poorly
coordinated, have provided unneeded personnel, equipment, and/or sup-
plies, and the responses actually may have detracted from the ability to meet

i a person who holds many offices simultaneously11

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the real needs, whereas others have been poorly documented, prohibiting
substantiated conclusions.8,14-17 Such occurrences mandate that the indica-
tors selected must incorporate the ability to assess adequate function even
though the requirements are augmented.18 Indicators should inform both of
the appropriateness and timelines of the response provided, and preferably
before they can be measured as increased Crude Mortality Rate.
The overall objective of disaster responses is to return the affected
society to its pre-event status, and thus, balance available supplies
(resources) with defined needs. Interim responses are directed first to saving
lives and reducing morbidity. Thereafter, responses are directed toward
improving the functional status of the societal elements (recovery) described
earlier. Initial efforts are directed towards raising the functional state of all of
the elements that have a critical threshold, to levels above their respective
critical thresholds. The next priority is to raise the functional states above
functional threshold so that they are able to meet their basic roles in the
affected society. Lastly, responses are directed to returning the functional sta-
tus of the society to its pre-event status. However, if this pre-event status
includes supplies considered as surplus, external assistance could be termi-
nated at the discretion of Coordination and Control, and the resources redi-
rected to other Basic Societal Functions still operating below their respective
functional threshold(s).
It is essential here, to stress that the basic societal functions (BSF) are
highly interdependent upon one another. For example, it may not be possi-
ble to improve the water supply without the public works and transportation
functions first being returned to a higher functional state. Coordination and
Control will be unable to establish priorities without communications and
accurate and timely information, and so on.

GOALS AND OBJECTIVES

Although any response in a disaster is directed toward increasing the
resources to reduce a specific identified need or set of needs, the goals and
objectives of the response in meeting the need(s) must be identified in order
to define any desired or undesired outcomes of the response. Thus, the pur-
pose and intent of a response must be defined prior to the action.20 This is
similar to the definition of end-points in quantitative research projects.
Without clearly stated goals and objectives, it is not possible for the
Coordination and Control Center for the disaster to assign any priority to

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the responses. Actually, donation of money often may be the best resource
for disaster relief. When financial resources are made available, the Coor-
dination and Control Center can acquire needed resources with the highest
priority at a given time, and then direct them to where they are needed,
rather than trying to make other donations fit into priorities that may not
have temporal relevance. The Independent Commission on International
Humanitarian Issues (ICIHI) proposes that during a famine, money should
be given directly to the victims as they know their needs even better than do
the central authorities.21 Then, the merchant society would be expected to
arrange all of the necessary logistics.
The Coordination and Control Center also must have the ability to
request, receive, warehouse, and distribute relief supplies and equipment.
Several systems have been developed to assist with this function, the most
notable being Supply Management (SUMA), an activity of PAHO/WHO
that coordinates the levels of supplies available with the demonstrated
needs.22 The utility of SUMA in such circumstances, has been demonstrated
repeatedly during the last decade.
On occasion, some responses may be directed primarily towards meet-
ing needs and goals of the donor organizations rather than the defined needs
of the affected populations.18,19,23-27 Such activities may serve to preserve or
enhance the capabilities of the donor organizations, but, in fact, may be dele-
terious to the overall relief and rehabilitation efforts.14,18 Careful evaluations
of response efforts should detect such situations.
Substantial responsibility falls upon the Coordination and Control
agency in terms of selection and prioritization of responses. In its requests
for assistance, the Coordination and Control agency must define exactly
what is needed, how much, where, and when. Requesting assistance without
direction may be responsible for confusion and frustration at both the donor
and recipient levels. Requesting assistance has been considered humiliating
by some recipient countries.28,29 In some circumstances, requests for assis-
tance have been made indirectly through distribution of situation reports
without directly asking for assistance. Such indirect requests infer that spon-
taneous gifts would not be rejected and provide little guidance for correct
decision-making.30
An important key point in time is the Disaster Critical Control Point
(DCCP). The DCCP is defined as the time at which the available supplies
balance all of the needs in terms of the function or sub-function being eval-

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uated. Identification of this time is crucial to avoid inappropriate oversup-

ply, and requires accurate and ongoing re-assessment of needs and available
supplies. Furthermore, it is important to recognize that the preceding dis-
cussion relates to needs and supplies, and does not relate to the demands
requested by the stricken community. It has been demonstrated that needs
and demands often are non-congruous, and great care must be taken in eval-
uations to separate the needs from the demands.31
Lastly, it is important for responding agencies to have established
explicit indicators of effectiveness and benefit for their activities prior to ini-
tiating action. Without such indicators, there will be little objective evidence
that the assigned task has been accomplished either entirely or in part—the
outcome will be elusive.

INDICATORS OF EFFECTIVENESS / BENEFIT

As noted above, the selection of appropriate indicators of effectiveness is of
key importance. The effectiveness of any intervention only can be judged by
the selection of an indicator or set of indicators that truly reflect the effec-
tiveness of the intervention instituted. The indicators identified for defining
the degree of function (Indicators of Function) of a specific component of
society may be different from those selected to reflect the effectiveness of an
intervention at meeting its goals and objectives. Indicators of effectiveness
must reflect the latter. Such indicators may be quantitative or qualitative.
Much of the data obtained in disaster research and evaluation are qualitative
or descriptive, and thus, cannot be analyzed directly using inferential statis-
tics. If the indicators chosen can be expressed numerically, then the use of
inferential statistics may add strength to the internal validity of the data
analysis. In order to judge the effectiveness, efficiency, and/or value of an
intervention (response) or an element of the absorbing capacity, it is neces-
sary to have other criteria against which the performance and effectiveness
can be compared. Initially, such criteria most often are implicitly defined, and
the results of an intervention are judged to determine if they have reached the
benchmark(s) previously determined within an indicator. Repeated confir-
mation of an indicator of effectiveness eventually may render the measure an
explicit, accepted mechanism for judging the effectiveness and efficiency of a
specific intervention. However, indicators of effectiveness only identify to
what extent an action is able to provide a certain kind of assistance, whereas
indicators of benefit, which often differ from indicators of effectiveness, will

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provide the extent to which this intervention really assisted the affected pop-
ulation. Identification of indicators that really define the value of an inter-
vention as to its benefit to a population is of critical importance, since such
indicators should signal alarm long before a deteriorating function results in
an increasing Crude Mortality Rate.
Appropriate indicators often are identified through the development of
consensus by a panel or congress of experts in the field. In the process of devel-
oping consensus, persons with experience and expertise, “teach” other panel
members in the area being studied. Then, discussions are conducted and
debate continues until a consensus is reached on the indicator(s) that most
likely will express the effectiveness and /or efficiency of the intervention. Such
an indicator or indicators then become indicators of effectiveness. Indicators
that express value32 of an intervention become indicators of benefit.
Crude Mortality Rate must be considered the ultimate, hard endpoint
indicator for any health disaster severity score, and for any damage, function,
intervention, commodity, or supply involved. Therefore sets of indicators

Reductions in
Feeling Circumference of Upper
Hungry Arm in Children

Unhappy with Reduced Increased

Monotonous Performance
Food Capacity CMR

A B C D E
Gravity of Situation

Figure 7.1—Example of applying different indicators for food supply or nutritional

status. Crude mortality rate is the ultimate hard endpoint, but the
introduction of other indicators will help to identify deterioration before
a society reaches the critical threshold. The example uses both
qualitative and quantitative indicators.

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must be defined that will enable us to identify any deterioration of functions

before it is measured by an increase in CMR. This is exemplified in Figure 7.1
where increasing seriousness is mirrored in different sets of scaled indicators,
(A) being the least serious, (B) and (C) are classified as intermediate, depicting,
together with level (D), an increasing deterioration until the critical threshold
is reached which is depicted as an increasing CMR. For each function or com-
modity, a similar method for grading of gravity must be developed, level A and
B constituting early warning indicators. The indicators suggested do not repre-
sent an endorsed scaling process, but serve as an example of how gravity can
be scaled through the combined use of qualitative and quantitative indica-
tors. When endorsed, they may be included in a scoring system.

STANDARDS, THRESHOLDS, AND INDICATORS

A standard is an object or quality or measure serving as a basis or example
or principle to which others conform or should conform or by which the
accuracy or quality of others is judged.33 Given the identification of the indi-
cators(s) used to determine the effectiveness of the intervention, standards
for these indicator(s) may be identified from previous research (explicit). If
no such standards can be identified, they may be estimated using the same
process that was used for identification of the indicator(s). In this manner,
minimal and optimal standards or benchmarks (i.e., thresholds) can be
defined for each indicator. The results of the research then are compared
against these standards. For those standards that have not been derived
mathematically, it is not possible to use inferential statistics in their analysis;
it only is possible to evaluate the data obtained against the standard.
For example, a group of experts has reviewed the medical literature
and reached the consensus that the amount of water supplied per person per
day is an important indicator of the effectiveness of an intervention.34 They
note that the available medical literature suggests that a minimum of 15
liters/day of potable water is required to meet all of the “essential” needs of
a human,34 and that a minimum intake of 2.5 liters/person/day is required
for the average human to survive in a temperate environment. Thus, the
indicator selected was the volume of water supplied per person per day, a
minimum standard to meet all of the requirements (functional threshold =
15 liters/person/day), and the volume necessary for survival (critical thresh-
old = 2.5 liters/person/day). Thus, damage assessments must determine the
actual volume of potable water available per person per day, and compare it

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to the established minimum standards. Such a comparison constitutes a

needs assessment and identifies the minimum amount of water needed to
meet both the critical and functional requirements. In this circumstance, the
effectiveness of an intervention whose goal was to bring the average volume
of water available to the affected population to the functional threshold, was
assessed by determining how close the intervention came to meeting the
minimum standard of 15 liters of water per person per day.
In this example, the minimum standard and the functional threshold
were the same (15 L/person/day) and the functional indicator and the indi-
cator of effectiveness were identical: the volume of water available per person
per day. However, the indicators of function, and of effectiveness may not
always be the same. For example, if an intervention had as its goal to increase
the available water to 10 liters per person per day, and 10 liters were deliv-
ered, then the intervention was effective, it achieved its goal, even though the
supply was not sufficient to return to its functional threshold or pre-event
state. If only 8 liters/person/day was attained, the intervention would be
judged as reaching part of its goal. This was the process used to develop stan-
dards and indicators used in the Sphere Project.34 However, if a specific
amount of water is distributed, the degree to which a response is considered
to have reached its objective is determined, not only by the average amount
of available water per person per day, but the equality of its distribution to
persons in need. Although, in this example, numeric values have been used,
and hence, inferential statistical analysis of the data could be calculated, such
analyses may have little clinical relevance: the statistical results would not
reflect the benefit. The issue of whether the intervention being evaluated
produced a sufficient supply of water, cannot be determined by whether or
not there existed a statistically significant difference between the initial
assessment of the water supply and the amount available following the inter-
vention. Furthermore, the objective of the intervention may have been the
prevention of the supply of potable water per capita from falling below the
minimum!
It is noted that the standards selected also may represent the thresholds
described in previous sections of this document. Some of these standards (or
thresholds) may need to be defined experimentally, while others may be
defined only through experience. In the example used above, it would be
both unethical and immoral to conduct a study to define accurately the min-
imum amount of potable water necessary to sustain life. However, the use of

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retrospective, case-controlled methods to study populations in crisis may

provide more information about the actual minimum amount of potable
water per person per day necessary to sustain human life in a given setting.
Thus, future observations as well as conditional factors such as the climate
and activity levels of the affected population may lead to modification of
these standards.
Many standards already have been developed through use of the consen-
sus process. The American Heart Association and the European Resuscitation
Council used such processes to develop some of the measures of effectiveness
and “standards” used to judge the adequacy of responses to victims of sudden
cardiac death.35,36 It is worthwhile to note that the standards developed by con-
sensus of experts from these respective associations have differed.
A goal of disaster research/evaluations must be to provide enough
information (not just data) to facilitate the development of some indicators
and hence, evolve standards for future disaster interventions. Such measures
only can be derived by repeated evaluations and observations that lead to the
ability to gain consensus about the appropriateness, effectiveness, efficiency,
and/or value of disaster responses. For example, a question of the effective-
ness of a relief effort could be: “What is the average number of liters of
potable water/day/person available to the population affected?”; or even bet-
ter, “What proportion of the population affected by the disaster has access to
the established minimum standards of water per day compared to the stan-
dard?” Does the intervention being studied or compared, assist in increasing
or decreasing the proportion of the population whose water supply meets
the standard?
There is a profound need to develop indicators for the assessment of
disaster responses and analyses of the absorbing capacity. Indicators are
required for damage assessments, needs assessments, and evaluation of
interventions. Very few such indicators have been defined and universally
agreed upon. Our ability to understand what we do, how we do it, and the
impact produced is dependent upon the identification and validation of
appropriate indicators.

DEVELOPMENT OF CRITICAL PATHWAYS

(PROCESS EVALUATIONS)
It is important to point out that the two Associations noted above have
established “Guidelines” for how resuscitations should be conducted.35,36

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These “critical pathways” or algorithms, have become the “standards” to

which participants in an Advanced Cardiopulmonary Life Support (ACLS)
course have been held. These algorithms are examples of critical pathways.
Critical pathways may be defined by consensus that is obtained from
“experts” who combine what they know from the scientific literature with
their respective clinical experience. The process of defining pathways based
on clinical studies is called “evidence-based medicine” by some. The results
of consensus conferences are considered logical pathways through which the
majority of patients with a particular diagnosis or set of symptoms and signs
should proceed during their respective course of evaluation and treatment.
They represent a consensus of the best practice for the patient who fits the cri-
teria to be evaluated and treated. Thus, the ACLS algorithms represent the
best combination of science and clinical experience, and are especially cogent
when quantitative data are insufficient to provide explicit standards. Actual
performance then, is compared to the established guideline or critical path-
way. If evaluation of the victim’s course of recovery reveals a deviation from
the consensus-derived pathway, the reasons for the deviation should be
explored. A deviation from the critical pathway could result in a better out-
come, increased efficiency, and/or decreased cost. Thus, the deviant pathway
may become the new critical pathway. As such, the pathways are dynamic
processes that are improved continually.
The same type of guidelines could be developed for some aspects of
catastrophic events. As information about certain aspects of disaster re-
sponses gradually accumulates, critical pathways for some responses may
become possible. Evaluation of what actually occurred in a disaster response
will be compared with the pathway for the response.
The development of critical pathways should become an objective of
future research, since they may assist in evaluation of the responses.
Deviations from the pathway could be identified and studied with an eye to
improving future responses. Currently, no such pathways formally exist.
However, expectations in performance are a reality, and performance fre-
quently is judged by these informal expectations. Perhaps, a first step should
be the codification of these expectations.
The bottom line is that some standards and guidelines need to be
developed for the evaluation of disaster interventions. The development of
such standards must become an objective of future research into the medical
responses to disasters.

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RECOVERY
Recovery includes returning all of the societal components to their pre-event
status. In the previous examples, this would entail restoration of the available
supply of potable water to the pre-event status. Rehabilitation restores
function to a “normal” life and pre-event circumstances. Rehabilitation is ac-
complished through responses (including operations and decisions) that are
directed towards restoring the affected area, communities, families, and indi-
viduals to the former, pre-event living condition and encouraging and
facilitating the necessary adjustments to the changes resulting from the dis-
aster.37 Reconstruction includes reorganization of the affected territory and
may involve the removing of persons out of harm’s way, reconstruction of the
built environment, restoration of basic services, and the development of the
economy with a view to re-establishing the pre-disaster conditions.38
Reconstruction in known hazardous locations does not seem an appropriate
investment of resources.

MANAGEMENT
All of the steps (from preparedness to recovery) taken to minimize the dam-
age and restore the pre-event status are tasks of disaster management. Disas-
ter management has its roots in Coordination and Control and is a special
skill that requires specialized training and experience. Standards and quali-
fications for training must be established against which performance can be
evaluated.

SUMMARY
Responses to disasters are directed at meeting some defined needs detected
by needs assessments. All responses must be requested and coordinated by a
central Coordination and Control Center that is responsible for the overall
management of a disaster. Immediate relief efforts (responses) are directed
at providing those resources necessary to maintain or bring the supplies
above critical thresholds. Further responses aim at supporting the recovery
processes directed to restoration of the affected society as close as possible to
its pre-event status. A disaster no longer exists when the functions of the
stricken society have returned to their pre-event status. Rehabilitation serv-
ices may be required to restore some functions back toward their pre-event
status. However, deaths and disabilities elude this objective.

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