Queensland University of Technology University of Technology Faculty of Health Institute of Health and Biomedical Innovation School of Public Health Human Health and Wellbeing Domain

Policy Analysis of Health Management in

Weiwei Du BA, BEc (Peking University)

A THESIS SUBMITTED IN FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY

November, 2010

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Supervisory Team

Principal Supervisor: Prof. Gerard FitzGerald MB, BS (Qld), BHA (NSW), MD (QLD), FACEM, FRACMA, FCHSE School of Public Health, Queensland University of Technology, , Phone: 61 7 3138 3935 Email: [email protected]

Associate Supervisor: Dr. Xiang-Yu Hou BM ( Uni), MD (Peking Uni), PhD (QUT) School of Public Health, Queensland University of Technology, Brisbane, Australia Phone: 61 7 3138 5596 Email: [email protected]

Associate Supervisor: Prof. Michele Clark BOccThy (Hons), BA, PhD School of Public Health, Queensland University of Technology, Brisbane, Australia Phone: 61 7 3138 3525 Email: [email protected]

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Certificate of Originality

The work contained in this thesis has not been previously submitted to meet requirements for an award at this or any other higher education institution. To the best of my knowledge and belief, the thesis contains no material previously published or written by another person except where due reference is made.

Signed:

Mr. Weiwei Du Date: November 8th, 2010

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Keywords

Disaster Medicine Disaster Health Management in China Disaster Policy Policy Analysis Health Consequences of Case Study of

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Abstract

Humankind has been dealing with all kinds of since the dawn of time. The risk and impact of disasters producing mass casualties worldwide is increasing, due partly to global warming as well as to increased population growth, increased density and the aging population. China, as a country with a large population, vast territory, and complex climatic and geographical conditions, has been plagued by all kinds of disasters. Disaster health management has traditionally been a relatively arcane discipline within public health. However, SARS, Avian Influenza, and and floods, along with the need to be better prepared for the Olympic Games in China has brought disasters, their management and their potential for large scale health consequences on populations to the attention of the public, the government and the international community alike. As a result significant improvements were made to the disaster management policy framework, as well as changes to systems and structures to incorporate an improved disaster management focus. This involved the upgrade of the Centres for Disease Control and Prevention (CDC) throughout China to monitor and better control the health consequences particularly of infectious disease outbreaks. However, as can be seen in the Southern China Snow and Wenchuan in 2008, there remains a lack of integrated disaster management and efficient medical rescue, which has been costly in terms of economics and health for China. In the context of a very large and complex country, there is a need to better understand whether these changes have resulted in effective management of the health impacts of such incidents. To date, the health consequences of disasters, particularly in China, have not been a major focus of study. The aim of this study is to analyse and evaluate disaster health management policy in China and in particular, its ability to effectively manage the health consequences of disasters. Flood has been selected for this study as it is a common and significant disaster type in China and throughout the world. This information will then be used to guide conceptual understanding of the health consequences of floods. A secondary aim of the study is to compare disaster health management in China and Australia as these countries differ in their length of experience in having a formalised policy response. The final aim of the study is to determine the extent to which Walt and Gilson’s (1994) model of policy explains how disaster

VIII management policy in China was developed and implemented after SARS in 2003 to the present day. This study has utilised a case study methodology. A document analysis and literature search of Chinese and English sources was undertaken to analyse and produce a chronology of disaster health management policy in China. Additionally, three detailed case studies of flood health management in China were undertaken along with three case studies in Australia in order to examine the policy response and any health consequences stemming from the floods. A total of 30 key international disaster health management experts were surveyed to identify fundamental elements and principles of a successful policy framework for disaster health management. Key policy ingredients were identified from the literature, the case-studies and the survey of experts. Walt and Gilson (1994)’s policy model that focuses on the actors, content, context and process of policy was found to be a useful model for analysing disaster health management policy development and implementation in China. This thesis is divided into four parts. Part 1 is a brief overview of the issues and context to set the scene. Part 2 examines the conceptual and operational context including the international literature, government documents and the operational environment for disaster health management in China. Part 3 examines primary sources of information to inform the analysis. This involves two key studies: • A comparative analysis of the management of floods in China and Australia • A survey of international experts in the field of disaster management so as to inform the evaluation of the policy framework in existence in China and the criteria upon which the expression of that policy could be evaluated Part 4 describes the key outcomes of this research which include: • A conceptual framework for describing the health consequences of floods • A conceptual framework for disaster health management • An evaluation of the disaster health management policy and its implementation in China.

The research outcomes clearly identified that the most significant improvements are to be derived from improvements in the generic management of disasters, rather than

IX the health aspects alone. Thus, the key findings and recommendations tend to focus on generic issues. The key findings of this research include the following: • The health consequences of floods may be described in terms of time as ‘immediate’, ‘medium term’ and ‘long term’ and also in relation to causation as ‘direct’ and ‘indirect’ consequences of the flood. These two aspects form a matrix which in turn guides management responses. • Disaster health management in China requires a more comprehensive response throughout the cycle of prevention, preparedness, response and recovery but it also requires a more concentrated effort on policy implementation to ensure the translation of the policy framework into effective incident management. • The policy framework in China is largely of international standard with a sound legislative base. In addition the development of the Centres for Disease Control and Prevention has provided the basis for a systematic approach to health consequence management. However, the key weaknesses in the current system include: o The lack of a key central structure to provide the infrastructure with vital support for policy development, implementation and evaluation. o The lack of well-prepared local response teams similar to local government based volunteer groups in Australia. • The system lacks structures to coordinate government action at the local level. The result of this is a poorly coordinated local response and lack of clarity regarding the point at which escalation of the response to higher levels of government is advisable. These result in higher levels of risk and negative health impacts.

The key recommendations arising from this study are: 1. Disaster health management policy in China should be enhanced by incorporating disaster management considerations into policy development, and by requiring a disaster management risk analysis and disaster management impact statement for development proposals. 2. China should transform existing organizations to establish a central organisation similar to the Federal Agency (FEMA) in the USA or the Emergency Management Australia (EMA) in Australia. This organization would be responsible for leading nationwide preparedness through planning, standards

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development, education and incident evaluation and to provide operational support to the national and local government bodies in the event of a major incident. 3. China should review national and local plans to reflect consistency in planning, and to emphasize the advantages of the integrated planning process. 4. Enhance through community education and the development of a local volunteer organization. China should develop a national strategy which sets direction and standards in regard to education and training, and requires system testing through exercises. Other initiatives may include the development of a local volunteer capability with appropriate training to assist professional response agencies such as police and services in a major incident. An existing organisation such as the Communist Party may be an appropriate structure to provide this response in a cost effective manner. 5. Continue development of professional emergency services, particularly ambulance, to ensure an effective infrastructure is in place to support the emergency response in disasters. 6. Funding for disaster health management should be enhanced, not only from government, but also from other sources such as donations and insurance. It is necessary to provide a more transparent mechanism to ensure the funding is disseminated according to the needs of the people affected. 7. Emphasis should be placed on prevention and preparedness, especially on effective disaster warnings. 8. China should develop local disaster health management infrastructure utilising existing resources wherever possible. Strategies for enhancing local infrastructure could include the identification of local resources (including military resources) which could be made available to support disaster responses. It should develop operational procedures to access those resources.

Implementation of these recommendations should better position China to reduce the significant health consequences experienced each year from major incidents such as floods and to provide an increased level of confidence to the community about the country’s capacity to manage such events.

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Acknowledgement

I take this special opportunity to express my deep gratitude to my supervisors: Prof. Gerry FitzGerald, Dr. Xiang-Yu Hou, and Prof. Michele Clark, whose invaluable guidance, support and encouragement have nourished this research project. Their vision, professionalism, friendship and kindness in both research and daily life are much appreciated. Their expertise areas have also formed the tile of the thesis: policy analysis (Michele) of disaster health management (Gerry) in China (Xiang-Yu). I would also like to acknowledge Queensland University of Technology and China Scholarship Council and for their joint scholarship, on which this research is based. I am most grateful to the 30 experts in disaster health management and the 15 local managers in the three case studies in China who kindly accepted my interviews or surveys. Your involvement has flagged key strategic disaster management issues that helped shape and inform the disaster health management policy framework in China in this thesis. Special thanks also go to Dr. Cynthia Cliff, Ms. Susan Mahon, Dr. Rooks Pillay, Prof. Marylou Fleming, Ms. Mary FitzGerald and Ms. Elinor Davis for their kind support both academically and in daily life throughout the process of this study, especially Ms. Mary FitzGerald who did proof-reading and became the first reader of the thesis. Lastly, I express my gratitude and appreciation to my family and friends for their unlimited love, support and sacrifices. I would also like to thank Ms. Li Na for her support in all phases of this PhD study.

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Associated Publications and Presentations

Du, W., FitzGerald, G., Hou, X.-Y., & Clark, M. (2010). Health Impacts of floods. Prehospital and , 25(3), 265-272.

FitzGerald, G., Du, W., Jamal, A., Clark, M., & Hou, X.-Y. (2010). Flood fatalities in contemporary Australia (1997-2008). Emergency Medicine Australasia, 22(2), 180-186.

FitzGerald, G., Du, W., Jamal, A., Clark, M., & Hou, X.-Y. (2009, 23-24 July). Flood Fatalities in Contemporary Australia (1997-2008). Paper presented at the Public Health Association of Australia Queensland State Conference, Brisbane, Australia.

Du, W., Hou, X.-Y., Xu, A., Lei, J., Clark, M., & FitzGerald, G. (2009). Characteristics of disaster management in China—A preliminary evaluation of flood management in Jinan, 2007. Paper presented at the 16th World Congress on Disaster and Emergency Medicine, Victoria, BC, . Prehospital and Disaster Medicine, 24(Supplement 1), s18.

Du, W., FitzGerald, G., Hou, X.-Y., & Clark, M. (2009). Health consequences of flooding in China and Australia. Paper presented at the 16th World Congress on Disaster and Emergency Medicine, Victoria, BC, Canada. Prehospital and Disaster Medicine, 24(Supplement 1), s148.

Du, W. (2010). Preventing flood death and injury in Queensland—issue paper. Brisbane: Queensland Department of Community Safety.

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Contents

SUPERVISORY TEAM ...... III

CERTIFICATE OF ORIGINALITY ...... V

KEYWORDS ...... VII

ABSTRACT ...... VIII

ACKNOWLEDGEMENT ...... XII

ASSOCIATED PUBLICATIONS AND PRESENTATIONS ...... XIII

CONTENTS ...... XIV

LIST OF TABLES ...... XX

LIST OF FIGURES ...... XXI

ABBREVIATIONS ...... XXIV

PART I INTRODUCTION ...... ‐ 1 ‐

CHAPTER ONE: OVERVIEW ...... ‐ 1 ‐

1.1 BACKGROUND AND JUSTIFICATION ...... ‐ 2 ‐ 1.1.1 An Overview of Disasters ...... ‐ 2 ‐ 1.1.2 Disaster Management ...... ‐ 4 ‐ 1.1.3 Disaster Profile and Disaster Health Policy Development in China ...... ‐ 5 ‐ 1.1.4 Floods ...... ‐ 6 ‐ 1.2 RESEARCH AIM AND OBJECTIVES ...... ‐ 6 ‐ 1.3 RESEARCH QUESTIONS ...... ‐ 7 ‐ 1.4 RESEARCH SCOPE AND METHODS ...... ‐ 8 ‐ 1.5 THESIS STRUCTURE ...... ‐ 9 ‐ PART II BACKGROUND AND LITERATURE ...... ‐ 13 ‐

CHAPTER TWO: DISASTER CONCEPTS AND PROFILE ...... ‐ 13 ‐

2.1 DISASTER CONCEPTS ...... ‐ 13 ‐ 2.1.1 Definition of Disasters ...... ‐ 13 ‐ 2.1.2 Disaster Classification ...... ‐ 15 ‐ 2.1.3 Disaster Related Terms ...... ‐ 18 ‐ 2.1.4 Disaster Cycle and Impact ...... ‐ 19 ‐ 2.2 RECENT DISASTER PROFILE ...... ‐ 20 ‐ 2.2.1 Global Disaster Profile ...... ‐ 20 ‐ 2.2.2 Disaster Profile in China ...... ‐ 25 ‐ 2.2.3 Disaster Profile in Australia ...... ‐ 27 ‐ CHAPTER THREE: HEALTH CONSEQUENCES OF DISASTERS ...... ‐ 29 ‐

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3.1 HEALTH IMPACT OF DISASTERS ...... ‐ 29 ‐ 3.1.1 Direct and Indirect Health Consequences ...... ‐ 31 ‐ 3.1.2 Tangible and Intangible Health Consequence ...... ‐ 32 ‐ 3.1.3 Immediate, Mid‐term, and Long‐term Health Consequences ...... ‐ 32 ‐ 3.2 HEALTH CONSEQUENCES OF FLOODS ...... ‐ 34 ‐ 3.2.1 Causes and Types of Floods ...... ‐ 35 ‐ 3.2.1.1 Precipitation ...... ‐ 36 ‐ 3.2.1.2 Rising Water Levels ...... ‐ 36 ‐ 3.2.1.3 Release of Stored Water ...... ‐ 37 ‐ 3.2.1.4 Failure of Natural Drainage ...... ‐ 37 ‐ 3.2.2 Factors that affect the health outcome of floods...... ‐ 38 ‐ 3.2.2.1 Flood Type ...... ‐ 38 ‐ 3.2.2.2 Geography ...... ‐ 38 ‐ 3.2.2.3 Demography ...... ‐ 39 ‐ 3.2.2.4 Community Infrastructure ...... ‐ 39 ‐ 3.2.2.5 Disaster Management System ...... ‐ 39 ‐ 3.2.3 Health Consequences of Floods ...... ‐ 40 ‐ 3.2.3.1 Immediate health effects: ...... ‐ 40 ‐ 3.2.3.2 Secondary Health Effects: ...... ‐ 42 ‐ 3.2.3.3 Longer term health consequences: ...... ‐ 44 ‐ CHAPTER FOUR: DISASTER MANAGEMENT ...... ‐ 47 ‐

4.1 INTRODUCTION TO DISASTER MANAGEMENT ...... ‐ 47 ‐ 4.1.1 The Evolution of Disaster Management ...... ‐ 47 ‐ 4.1.2 Disaster Management Concepts ...... ‐ 48 ‐ 4.1.3 Disaster Management Cycle ...... ‐ 50 ‐ 4.2 DISASTER HEALTH MANAGEMENT ...... ‐ 54 ‐ 4.2.1 EMS in Disaster Health Management ...... ‐ 55 ‐ 4.2.2 Hospitals in Disaster Health Management ...... ‐ 56 ‐ 4.2.3 Personnel in Disaster Health Management ...... ‐ 57 ‐ 4.2.4 Pharmaceuticals in Disaster Health Management...... ‐ 57 ‐ 4.2.5 Vulnerable population in Disaster Health Management ...... ‐ 58 ‐ 4.2.6 Public Health in Disaster Health Management ...... ‐ 59 ‐ 4.3 DISASTER MANAGEMENT IN DEVELOPED AND DEVELOPING COUNTRIES ...... ‐ 60 ‐ CHAPTER FIVE: POLICY AND DISASTER MANAGEMENT ...... ‐ 63 ‐

5.1 INTRODUCTION ...... ‐ 63 ‐ 5.2 POLICIES AND POLICY TYPES ...... ‐ 64 ‐ 5.3 TOP‐DOWN AND BOTTOM‐UP POLICY APPROACHES ...... ‐ 65 ‐ 5.4 MODELS OF POLICY AND POLICY MAKING ...... ‐ 66 ‐ 5.5 POLICY ELEMENTS ...... ‐ 67 ‐ 5.5.1 Context of Policy...... ‐ 68 ‐ 5.5.2 Process of Policy ...... ‐ 68 ‐ 5.5.3 Content of Policy ...... ‐ 73 ‐ 5.5.4 Actors in Policy ...... ‐ 74 ‐ CHAPTER SIX: DISASTER HEALTH MANAGEMENT IN CHINA ...... ‐ 77 ‐

6.1 BACKGROUND INFORMATION OF CHINA ...... ‐ 77 ‐ 6.1.1 Geography and Demography ...... ‐ 77 ‐ 6.1.2 Economy ...... ‐ 80 ‐ 6.1.3 Political System ...... ‐ 81 ‐ 6.2 DISASTERS IN CHINA ...... ‐ 83 ‐ 6.3 FLOODS IN CHINA ...... ‐ 84 ‐ 6.4 HEALTH CARE SYSTEM IN CHINA ...... ‐ 85 ‐

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6.4.1 Ministry of Health and Health Bureaus ...... ‐ 86 ‐ 6.4.2 Centre for Disease Control and Prevention (CDC) ...... ‐ 87 ‐ 6.4.3 Hospitals ...... ‐ 88 ‐ 6.5 DISASTER HEALTH MANAGEMENT STRUCTURE IN CHINA ...... ‐ 89 ‐ 6.5.1 General Disaster Management Structure...... ‐ 89 ‐ 6.5.2 Emergency Medical Services System (EMSS) ...... ‐ 94 ‐ 6.6 DISASTER SYSTEM AND POLICY DEVELOPMENT IN CHINA ...... ‐ 96 ‐ PART III RESEARCH METHODS AND RESULTS ...... 3‐ ‐10

CHAPTER SEVEN: RESEARCH METHODS ...... 3‐ ‐10

7.1 METHODOLOGY OVERVIEW ...... ‐ 103 ‐ 7.2 RESEARCH ETHICS REVIEW ...... ‐ 105 ‐ 7.3 CASE STUDY METHODOLOGY ...... ‐ 106 ‐ 7.3.1 Case Study Methodology Overview ...... 6‐ ‐10 7.3.2 Case Study Location Selection ...... 8‐ ‐10 7.3.3 Data Collection ...... 1‐ ‐11 7.3.4 Data Analysis ...... 2‐ ‐11 7.3.5 Validity and Reliability Issues ...... 3‐ ‐11 7.4 SURVEY OF EXPERTS ...... ‐ 113 ‐ 7.4.1 SELECTION OF EXPERTS ...... ‐ 114 ‐ 7.4.2 DATA COLLECTION ...... ‐ 114 ‐ 7.4.3 DATA ANALYSIS ...... ‐ 115 ‐ 7.4.4 VALIDITY AND RELIABILITY ISSUES ...... ‐ 116 ‐ CHAPTER EIGHT: CASE STUDIES OF FLOOD HEALTH MANAGEMENT IN CHINA ...... 9‐ ‐11

8.1 INTRODUCTION ...... ‐ 119 ‐ 8.2 CASE STUDIES—JINAN ...... ‐ 119 ‐ 8.2.1 The Context: Jinan ...... 9‐ ‐11 8.2.2 Case Description ...... 1‐ ‐12 8.2.3 The Impact of the Flood ...... 3‐ ‐12 8.2.4 The Health Management‐‐Prevention ...... 4‐ ‐12 8.2.5 The Health Management‐‐Preparedness ...... 5‐ ‐12 8.2.6 The Health Management‐‐Response ...... 6‐ ‐12 8.2.7 The Health Management‐‐Recovery ...... 7‐ ‐12 8.3 CASE STUDIES—PAN’AN ...... ‐ 128 ‐ 8.3.1 The Context: Pan’an ...... 8‐ ‐12 8.3.2 Case Description ...... 9‐ ‐12 8.3.3 The Impact of Flood ...... 0‐ ‐13 8.3.4 The Health Management‐‐Prevention ...... 1‐ ‐13 8.3.5 The Health Management‐‐Preparedness ...... 2‐ ‐13 8.3.6 The Health Management‐‐Response ...... 2‐ ‐13 8.3.7 The Health Management‐‐Recovery ...... 2‐ ‐13 8.4 CASE STUDIES—LENGSHUI ...... ‐ 133 ‐ 8.4.1 The Context: Lengshui ...... 3‐ ‐13 8.4.2 Case Description ...... 5‐ ‐13 8.4.3 The Impact of Flood ...... 5‐ ‐13 8.4.4 The Health Management‐‐Prevention ...... 5‐ ‐13 8.4.5 The Health Management‐‐Preparedness ...... 6‐ ‐13 8.4.6 The Health Management‐‐Response ...... 7‐ ‐13 8.4.7 The Health Management‐‐Recovery ...... 8‐ ‐13 8.5 ANALYSIS AND CONCLUSION ...... ‐ 138 ‐ 8.5.1 Policy Execution in the Local Level ...... 9‐ ‐13

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8.5.2 Construction as Mitigation ...... 0‐ ‐14 8.5.3 Media Dilemma ...... 0‐ ‐14 CHAPTER NINE: CASE STUDIES OF FLOOD HEALTH MANAGEMENT IN AUSTRALIA ...... 1‐ ‐14

9.1 INTRODUCTION ...... ‐ 141 ‐ 9.2 DISASTER MANAGEMENT IN AUSTRALIA: POLICY FRAMEWORK AND STRUCTURE ...... ‐ 143 ‐ 9.2.1 National Level ...... 4‐ ‐14 9.2.1.1 National Legislation ...... ‐ 144 ‐ 9.2.1.2 National Structure ...... ‐ 145 ‐ 9.2.2 State Level (Queensland as an example)...... 7‐ ‐14 9.2.2.1 State Legislation ...... ‐ 147 ‐ 9.2.2.2 State Structures ...... ‐ 149 ‐ 9.2.3 District and Local Governments (Queensland as an Example) ...... 1‐ ‐15 9.3 FLOODS IN AUSTRALIA ...... ‐ 152 ‐ 9.3.1 Characteristics of flood in Australia ...... 3‐ ‐15 9.3.2 Government cooperation in flood management ...... 6‐ ‐15 9.3.3 Flood risk management and insurance ...... 7‐ ‐15 9.4 CASE STUDIES‐‐CHARLEVILLE...... ‐ 158 ‐ 9.4.1 Brief Introduction of Charleville ...... 8‐ ‐15 9.4.2 Charleville Flood Description ...... 8‐ ‐15 9.4.3 Prevention/ Mitigation ...... 0‐ ‐16 9.4.4 Preparedness ...... 1‐ ‐16 9.4.5 Response ...... 2‐ ‐16 9.4.6 Recovery ...... 3‐ ‐16 9.4.7 Results ...... 3‐ ‐16 9.5 CASE STUDIES‐‐EMERALD ...... ‐ 164 ‐ 9.5.1 Brief Introduction of Emerald ...... 4‐ ‐16 9.5.2 Emerald Flood Description ...... 5‐ ‐16 9.5.3 Prevention/ Mitigation ...... 7‐ ‐16 9.5.4 Preparedness ...... 7‐ ‐16 9.5.5 Response ...... 7‐ ‐16 9.5.6 Recovery ...... 8‐ ‐16 9.5.7 Results ...... 8‐ ‐16 9.6 CASE STUDIES‐‐MACKAY ...... ‐ 169 ‐ 9.6.1 Brief Introduction of Mackay ...... 9‐ ‐16 9.6.2 Mackay Flood Description ...... 9‐ ‐16 9.6.3 Prevention/ Mitigation ...... 1‐ ‐17 9.6.4 Preparedness ...... 2‐ ‐17 9.6.5 Response ...... 2‐ ‐17 9.6.6 Recovery ...... 2‐ ‐17 9.6.7 Results ...... 3‐ ‐17 9.7 CASE STUDY DISCUSSION ...... ‐ 173 ‐ CHAPTER TEN: COMPARATIVE CASE‐STUDY FINDINGS AND SYNTHESIS ...... 5‐ ‐17

10.1 INTRODUCTION...... ‐ 175 ‐ 10.2 FLOOD SCALES AND CONSEQUENCES IN CASE STUDIES ...... ‐ 175 ‐ 10.3 DISASTER HEALTH MANAGEMENT PROCEDURES COMPARISON IN AUSTRALIA AND CHINA ...... ‐ 179 ‐ 10.3.1 Prevention ...... ‐ 9 ‐17 10.3.2 Preparedness ...... ‐ 7 ‐18 10.3.3 Response ...... 0‐ ‐19 10.3.4 Recovery ...... 5‐ ‐19 10.4 COMPARATIVE CASE FINDINGS ...... ‐ 200 ‐ CHAPTER ELEVEN: FINDINGS OF INTERVIEWS AND SURVEYS WITH INTERNATIONAL EXPERTS3‐ ‐20

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11.1 INTRODUCTION ...... ‐ 203 ‐ 11.2 CHARACTERISTICS OF A CONCEPTUAL POLICY FRAMEWORK OF DISASTER HEALTH MANAGEMENT ..... ‐ 204 ‐ 11.3 ELEMENTS OF POLICY DEVELOPMENT ...... ‐ 208 ‐ 11.4 ELEMENTS OF POLICY IMPLEMENTATION ...... ‐ 212 ‐ 11.5 POLICY EFFECTIVENESS EVALUATION: PROCEDURES AND ELEMENTS ...... ‐ 216 ‐ 11.6 OTHER DETERMINANTS OF EFFECTIVE DISASTER HEALTH MANAGEMENT ...... ‐ 218 ‐ 11.7 ADDITIONAL SURVEY AND INTERVIEW RESULTS ...... ‐ 220 ‐ PART IV DISCUSSION ...... 3‐ ‐22

CHAPTER TWELVE: HEALTH CONSEQUENCES OF FLOODS AND PREVENTION MEASURES ... 3‐ ‐22

12.1 FRAMEWORK OF HEALTH CONSEQUENCES ...... ‐ 224 ‐ 12.2 INTERNATIONAL FRAMEWORKS AND STRATEGIES IN FLOOD DEATH AND INJURY PREVENTION ...... ‐ 229 ‐ 12.3 APPLICATION OF THE FRAMEWORK ...... ‐ 232 ‐ CHAPTER THIRTEEN: POLICY FRAMEWORK OF DISASTER HEALTH MANAGEMENT IN CHINA1‐ ‐24

13.1 KEY POLICY ISSUES ...... ‐ 241 ‐ 13.2 POLICY COMPONENTS (CONTENT) ...... ‐ 243 ‐ 13.3 POLICY PROCESS ...... ‐ 245 ‐ 13.3.1 Problem Identification and Policy Design ...... ‐ 6 ‐24 13.3.2 Policy Expression/ Implementation and Evaluation ...... 7‐ ‐24 13.4 FACTORS INFLUENCING POLICY (CONTEXT) ...... ‐ 248 ‐ 13.4.1 Political Factors ...... 8‐ ‐24 13.4.2 Socio‐cultural Factors ...... 9‐ ‐24 13.4.3 Economic Factors ...... 0‐ ‐25 13.4.4 Technological and Scientific Factors ...... 1‐ ‐25 13.5 ACTORS IN POLICY ...... ‐ 251 ‐ 13.6 POLICY IMPLICATIONS/ RECOMMENDATIONS ...... ‐ 253 ‐ 13.6.1 General Policy ...... ‐ 3 ‐25 13.6.2 Specific Disaster Management Policy ...... ‐ 4 ‐25 CHAPTER FOURTEEN: CONCLUSION, RECOMMENDATIONS, LIMITATIONS, SUGGESTIONS FOR FURTHER WORK AND UNIQUE CONTRIBUTIONS ...... 7‐ ‐25

14.1 CONCLUSION ...... ‐ 257 ‐ 14.2 RECOMMENDATIONS FOR FLOOD HEALTH MANAGEMENT IN CHINA ...... ‐ 258 ‐ 14.3 RECOMMENDATIONS FOR DISASTER HEALTH MANAGEMENT POLICY IN CHINA ...... ‐ 260 ‐ 14.4 LIMITATIONS ...... ‐ 262 ‐ 14.5 SUGGESTIONS FOR FURTHER WORK ...... ‐ 263 ‐ 14.6 UNIQUE CONTRIBUTIONS ...... ‐ 264 ‐ REFERENCES ...... 7‐ ‐26

APPENDICES ...... 1‐ ‐29

APPENDIX A: DISASTER RELATED TERMS ...... ‐ 291 ‐ APPENDIX B: DETAIL LIST OF ABC NEWS REFERENCE...... ‐ 301 ‐ APPENDIX C: QUESTIONNAIRE FOR HEALTH MANAGEMENT IN THE FLOODS ...... ‐ 303 ‐ APPENDIX D: QUESTIONNAIRE FOR DISASTER MANAGEMENT POLICY ...... ‐ 309 ‐ APPENDIX E: ETHICAL CLEARANCES ...... ‐ 313 ‐ APPENDIX F: PARTICIPANTS CONSENT FORM AND INFORMATION ...... ‐ 317 ‐ APPENDIX G: FLOOD FATALITIES IN CONTEMPORARY AUSTRALIA (1997‐2008) ...... ‐ 321 ‐ APPENDIX H: HEALTH IMPACTS OF FLOODS ...... ‐ 331 ‐

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APPENDIX I: CHARACTERISTICS OF DISASTER MANAGEMENT IN CHINA—A PRELIMINARY EVALUATION OF FLOOD MANAGEMENT IN JINAN, 2007 ...... ‐ 341 ‐ APPENDIX J: HEALTH CONSEQUENCES OF FLOODING IN CHINA AND AUSTRALIA ...... ‐ 343 ‐ APPENDIX K: PREVENTING FLOOD DEATH AND INJURY IN QUEENSLAND—ISSUE PAPER ...... ‐ 345 ‐

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List of Tables

Table 2‐1: Classification of Known Hazards in the Utstein Style ...... ‐ 17 ‐ Table 3‐1: Natural Disasters and Their Environmental and Human Health Impacts ...... ‐ 31 ‐ Table 3‐2: Causes of Floods ...... ‐ 36 ‐ Table 4‐1: Guidelines for Drug Donations ...... ‐ 58 ‐ Table 5‐1: Definition and Examples of Policy Types ...... ‐ 64 ‐ Table 5‐2: Explanations to Policies Failure ...... ‐ 73 ‐ Table 6‐1: Summarized Table of Natural Disasters in China from 1900 to 2010 ...... ‐ 83 ‐ Table 6‐2: Pre‐hospital Emergency Service Systems in China ...... ‐ 95 ‐ Table 6‐3: The development of China’s emergency management system ...... ‐ 97 ‐ Table 6‐4: Key laws and regulations concerning disaster management ...... ‐ 98 ‐ Table 7‐1: Brief Introduction of Jinan, Pan’an, and Lengshui ...... 8‐ ‐10 Table 7‐2: Brief Introduction of Charleville, Emerald, and Mackay ...... 0‐ ‐11 Table 8‐1: Manager Evaluation of Flood Management ...... 9‐ ‐13 Table 9‐1: Most Significant Floods in Australia in 2000‐2008 ...... 4‐ ‐15 Table 9‐2: Classification of Measures to Reduce Flood Losses ...... 7‐ ‐15 Table 10‐1: Comparison of Flood Case Scales and Health Impacts in China and Australia ...... 7‐ ‐17 Table 12‐1: Health Consequences of Floods ...... 5‐ ‐22 Table 12‐2 Frameworks and Strategies of Disaster Management in Different International Organizations ...... 0‐ ‐23 Table 12‐3: Best Practice in Flood Health and Injury Prevention ...... 2‐ ‐23 Table 12‐4: Key Elements of Successful Flood Health Management‐‐Prevention ...... 3‐ ‐23 Table 12‐5: Key Elements of Successful Flood Health Management‐‐Preparedness ...... 5‐ ‐23 Table 12‐6: Key Elements of Successful Flood Health Management‐‐Response ...... 6‐ ‐23 Table 12‐7: Key Elements of Successful Flood Health Management‐‐Recovery ...... 7‐ ‐23

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List of Figures

Figure 1‐1: reported (1900‐2008) ...... ‐ 3 ‐ Figure 1‐2: Number of people reported affected by natural disasters (1900‐2008) ...... ‐ 3 ‐ Figure 1‐3: The research plan ...... ‐ 9 ‐ Figure 1‐4: The research structure ...... ‐ 10 ‐ Figure 2‐1: The continuum between a single emergency and a catastrophe...... ‐ 14 ‐ Figure 2‐2: A Venn diagram of the interaction of natural hazards, industrial‐technologic hazards, and conflict hazards...... ‐ 15 ‐ Figure 2‐3: General phases of disaster life cycle ...... ‐ 19 ‐ Figure 2‐4: The perspective of disasters based on their specific characteristics ...... ‐ 20 ‐ Figure 2‐5: Natural disaster summary 1990‐2008 (linear‐interpolated smoothed lines) ...... ‐ 21 ‐ Figure 2‐6: Number of natural disasters by country: 1976‐2005 ...... ‐ 22 ‐ Figure 2‐7: Total number of deaths andpeople affected by 100,000 inhabitants (1974‐2003) .. ‐ 22 ‐ Figure 2‐8: Number of natural disasters reported 1900‐2008 ...... ‐ 23 ‐ Figure 2‐9: Number of people reported killed by natural disasters 1900‐2008 ...... ‐ 24 ‐ Figure 2‐10: Number of people reported affected by natural disasters 1990‐2008 (square rooted) . ‐ 24 ‐ Figure 2‐11: Average annual damage ($US billion) caused by reported natural disasters 1990‐ 2008 ...... ‐ 25 ‐ Figure 2‐12: Number of natural disasters in China from 1900 to 2009 ...... ‐ 26 ‐ Figure 2‐13: Number of disasters in Australia, 1970‐2008 ...... ‐ 27 ‐ Figure 2‐14: Total cost of disasters in Australia, 1970‐2008 ...... ‐ 28 ‐ Figure 3‐1: Injury pyramid for the 1994 Northridge Earthquake (persons or households with injuries)...... ‐ 34 ‐ Figure 4‐1: Impact of disasters on development ...... ‐ 49 ‐ Figure 4‐2: The disaster management cycle...... ‐ 52 ‐ Figure 4‐3: The spiral mode of disaster management cycle ...... ‐ 53 ‐ Figure 4‐4: Plan hierarchy ...... ‐ 54 ‐ Figure 5‐1: A systems model of politics and policy ...... ‐ 66 ‐ Figure 5‐2: Model for health policy analysis ...... ‐ 67 ‐ Figure 5‐3: The Australian policy cycle ...... ‐ 69 ‐ Figure 5‐4: Conventional policy process ...... ‐ 69 ‐ Figure 6‐1: Topographical map of China ...... ‐ 79 ‐

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Figure 6‐2: Political structure of China ...... ‐ 82 ‐ Figure 6‐3: China’s health care structure...... ‐ 86 ‐ Figure 6‐4: General disaster management structure in China ...... ‐ 90 ‐ Figure 7‐1: The research structure ...... 4‐ ‐10 Figure 7‐2 Convergence of evidence (single study) ...... ‐ 107 ‐ Figure 8‐1: Location of Jinan and the river systems...... 0‐ ‐12 Figure 8‐2: Rain recorded in different stations in Jinan on July 18th, 2007 ...... 1‐ ‐12 Figure 8‐3: Natural Water and Flood Flow in Jinan ...... 2‐ ‐12 Figure 8‐4: Yinzuo Shopping Centre being flooded...... 3‐ ‐12 Figure 8‐5: Location of Pan’an and routes ...... 0‐ ‐13 Figure 8‐6: River systems, Emergency Shelter Centres, and Reservoir in Lengshui ...... 4‐ ‐13 Figure 8‐7: Emergency Evacuation Centre in Lengshui ...... 6‐ ‐13 Figure 8‐8: Emergency rescue team conducting rescue in Lengshui ...... 7‐ ‐13 Figure 9‐1: Locations of Charleville, Emerald, and Mackay ...... 2‐ ‐14 Figure 9‐2: EMA organisational chart ...... 6‐ ‐14 Figure 9‐3: Titles of the peak State and Territory emergency management committees ...... 8‐ ‐14 Figure 9‐4: The Queensland Disaster Management System ...... 9‐ ‐14 Figure 9‐5: Organisational Structure of the Department of Community Safety ...... 1‐ ‐15 Figure 9‐6: Time‐line showing major Australian flood episodes as a function of the Southern Oscillation Index ...... ‐ 5 ‐15 Figure 9‐7: Flood management activities in Victoria ...... 6‐ ‐15 Figure 9‐8: Charleville hydrograph depicting flood/river heights during the 2008 flood ...... 9‐ ‐15 Figure 9‐9: Highest flood peaks in Warrego River at Charleville ...... 9‐ ‐15 Figure 9‐10: Locations of Roads and Rivers in Charleville...... 0‐ ‐16 Figure 9‐11: Fairbairn Dam Hydrograph depicting flood/river heights during the 2008 flood 5‐ ‐16 Figure 9‐12: Emerald Hydrograph depicting flood/river heights during the 2008 flood ...... 6‐ ‐16 Figure 9‐13: Mackay Hydrograph depicting flood/river heights during the 2008 flood (Hospital ) ...... ‐ 9 ‐16 Figure 9‐14: Mackay Hydrograph depicting flood/river heights at during the 2008 flood (Forgan Smith Bridge) ...... ‐ 0 ‐17 Figure 9‐15: Highest flood peaks in Pioneer River at Forgan Bridge, Mackay ...... 1‐ ‐17 Figure 10‐1: Emergency Shelter Centre in Quancheng Park, Jinan ...... 2‐ ‐18 Figure 10‐2: Stockpile of stones on the bank of the near Jinan City ...... 3‐ ‐19 Figure 11‐1: Framework of Disaster Management Policy ...... 4‐ ‐20

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Figure 11‐2: Detailed policy framework of disaster health management ...... 2‐ ‐22 Figure 12‐1: Relationship mind mapping of flood health consequences ...... 7‐ ‐22

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Abbreviations

ABC Australian Broadcasting Corporation AEP Annual Exceedance Probability AGDTRS Australian Government Department of Transportation and Regional Services AusAID Australian Agency for International Development AUSASSISTPLAN Australian Government Overseas Disaster Assistance Plan CCDTF Commonwealth Counter-Disaster Task Force (Australia) CDC Centres for Disease Control and Prevention CEA China Earthquake Administration CMA China Meteorological Administration COMRECEPLAN Australian Government Plan for the Reception of Australian Citizens and Approved Foreign Nationals Evacuated from Overseas CPC Communist Party of China CPPCC Chinese People’s Political Consultative Conference CRED Centre for Epidemiology of Disasters CSM Case Study Methodology DCPP Disease Control Priorities Project DHS Department of Homeland Security (US) DM Act Disaster Management Act 2003 (Queensland, Australia) ED Emergency Department EMA Emergency Management Australia EM-DAT Emergency Events Database EMO Emergency Management Office (State Council, PRC) EMS Emergency Medical Services EMSS Emergency Medical Services System FEMA Federal Emergency Management Agency (US) GNI Gross National Income HIV Human Immunodeficiency Virus HSD Homeland Security and Defence (US)

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ICU Intensive Care Unit IDNDR International Decade for Natural Disaster Reduction ISDR International Strategy for Disaster Reduction MCA Ministry of Civil Affairs (PRC) MOH Ministry of Health (PRC) MPS Ministry of Public Security (PRC) MWR Ministry of Water Resources (PRC) NCD National Civil Defence (Ministry of National Defence, PRC) NCDR National Committee for Disaster Reduction (MAC, PRC) NDRC National Disaster Reduction Centre (MCA, PRC) NEMC National Emergency Management Committee (Australia) NEMCC National Emergency Management Coordination Centre (Australia) NFID National Flood Information Database (Australia) NPC National People’s Congress (PRC) NRF National Response Framework (US) NWEMC National Workplace Emergency Management Centre (PRC) CRED Centre for Research on the Epidemiology of Disasters OFDA Office of U.S. Foreign Disaster Assistance OSFCDRH Office of State Flood Control and Relief Headquarters (PRC) PPRR Prevention; Preparedness; Response; Recovery PRC People’s Republic of China SARS Severe Acute Respiratory Syndrome SACMS State Administration of Coal Mine Safety (SAWC, PRC) SAWS State Administration of Work Safety (PRC) SES State Emergency Service SFA State Forest Administration SOI Southern Oscillation Index UN United Nations UNDP United Nations Development Programme WCDEM World Congress on Disaster and Emergency Medicine WHO World Health Organization

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XXVI

Part I Introduction

Chapter One: Overview

Disasters are an integral part of the history of the human species. Over the last decade almost 1 million people have been killed and 2.3 billion directly affected by disasters worldwide (EM-DAT, 2009b). The reported number of disasters (Figure 1-1) and the number of people affected by disasters (Figures 1-2) has been increasing. Possible reasons for the increase include improved reporting as well as increased impact of disasters resulting from increased population and density, cities in high risk areas, global warming, increased technologies, economic stress and armed conflicts (Etkin, 1999; Kirchsteiger, 1999). Although throughout history people have sought to understand, explain and manage the consequences of disasters, it was not until the latter part of the last century that highly organised efforts were made throughout the world to support disaster preparedness and response. These included the development of new theories, policies, legislation, systems and organisational structures. China has historically been particularly vulnerable to disasters due to the combination of a large population and exposure to significant hazards. In recent years the impact of major disasters in China such as the Severe Acute Respiratory Syndrome (SARS) epidemic, earthquakes and flooding have resulted in considerable public and government concern. This concern, along with preparation for the 2008 Olympic Games in , has resulted in the formulation of new policies and regulations which form the basis of China’s new disaster management system (Guo, Xiong, & Hu, 2008). In particular, lessons from the outbreak of SARS led to significant improvements in the nation’s capacity to manage health challenges through significant investment in the public health infrastructure and the upgrading of Centres for Disease Control and Prevention (CDC) (Wang, 2008a). The unresolved question is whether these new policies and infrastructure have improved the outcome for people suffering the impact of disasters, and whether the new

- 1 - policies and infrastructure align with the social, political and cultural environment in China. The aim of this study is to evaluate the effectiveness of China’s disaster health management system by examining the impact of floods on human health and wellbeing.

1.1 Background and Justification

1.1.1 An Overview of Disasters

Since the dawn of time, humans have suffered as a result of a broad range of disasters. Most prominent are the Black Death epidemic in the Middle Ages (Plague), the 1556 Earthquake in China, the 1918 Spanish Flu and the 1931 Central China Floods. More recently the 9/11 terrorist attacks, SARS, the 2004 Indian Ocean

Tsunami, Avian Flu, 2008 China Wenchuan Earthquake and the 2009 Influenza A (H1N1) have raised community awareness significantly. As disasters become more frequent and have more catastrophic impact, the community is becoming less tolerant of inadequacies in effective management (Dunlop, 2004). Figures 1-1 and 1-2 from the Centre for Epidemiology of Disasters (CRED) demonstrate an upward trend in both the number of reported disasters and the number of people affected by those disasters. Increased awareness and reporting undoubtedly contributes to these increases. However more people are being affected by disasters as a result of population growth, the development of large cities in high risk areas, changes to the natural environment by human habitation, global warming and technological development (Etkin, 1999; Kirchsteiger, 1999). In 2008 alone, disasters around the world caused 243,000 deaths, 398,000 injuries, and left 22 million affected. Moreover, it has been estimated that the economic cost of disasters in 2008 was approximately US$190 billion (EM-DAT, 2009b).

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Figure 1-1: Natural disaster reported (1900-2008) Source: EM-DAT: The OFDA/CRED International Disaster Database

Figure 1-2: Number of people reported affected by natural disasters (1900-2008) Source: EM-DAT: The OFDA/CRED International Disaster Database

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1.1.2 Disaster Management

The aim of disaster management is to minimize the impact of disasters by effective prevention, preparation, response and recovery management (Warfield, 2010). Disaster management involves a large number of public and private agencies which provide a vast range of services. Tasks range from maintenance of order and security (restrictive role) to search and rescue (proactive role), to provision of shelter, comfort, and rehabilitation (compassionate/ encouraging role) (Canton, 2007). The key to effective and efficient management is integration and coordination of these agencies and services. Reducing the health consequences of major emergencies and disasters requires concerted and well-planned medical services which are effectively integrated into all levels of emergency and disaster planning. Integration and coordination needs the support of sound systems, structures and processes, which in turn requires high level policy to be articulated where necessary through legislation and organisation design. Such disaster management policies and legislation have been evolving quickly in recent years. Principles of and approaches to disaster management have been established, including the Comprehensive Approach (Prevention, Preparedness, Response and Recovery (PPRR)), all Hazards Approach, and the all Agencies Approach (EMA, 2009c). Disaster management should be based on a prepared community, and the response should be based on normal arrangements and daily procedures to avoid confusion (EMA, 2009c). Disaster policies should not only identify the future direction and the principles which underpin that direction, but also spell out the system, structure and processes required to achieve the goals (Birkland, 2006). However, disasters occur at all scales and appear in all forms. Some are long-term processes of deterioration and others are rapid occurrences; some have their origins and roots in the past while others are created by chance and the risks posed by a particular environment; some are caused internally while others are created externally (Coppola, 2006). As disasters vary in different locations, disaster management policies need to be contextualised so that each country has in the end a policy tailored to its own individual needs.

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1.1.3 Disaster Profile and Disaster Health Policy Development in China

As a country vast in territory and complex in climatic and geographical conditions, China has been plagued by almost every kind of natural disasters, except for volcanic eruptions (Ting, 2004). Among all the hazards, drought, flood, wind storm, and earthquake are the most destructive (Ting, 2004). While there are remote regions with no or few inhabitants, the reality of China is that people and natural disasters are often connected. The eastern one-third of the country is where 48 percent of the disasters occur, and it is where more than two-thirds of the population resides. In addition, some settlements are located in river valleys that are subject to flooding, or are located within 100 miles of the coast, making them vulnerable to and the subsequent flooding and wind damage (Stoltman, Lidstone, & Dechano, 2004). Disasters vary with both region and season. Drought tends to occur in the Northwest Plateau and North China Plain in spring and autumn. Flood mainly occurs in the major river valleys in summer. Typhoon and storm surges usually strike the south-eastern coastal regions. Earthquakes are widely distributed, but occur commonly in south-western, north-western, and northern China. Forest and grassland occur mainly in the forest and pastoral areas of north-eastern, south-western, north-eastern, and northern China in the dry seasons of winter and spring (Ting, 2004). Disasters in China in the past 10 years (1999-2008) have caused a total of 113,279 deaths, with 1.17 billion persons affected, and a total economic cost of more than US$186 million (EM-DAT, 2009b). The 2008 Wenchuan Earthquake, causing more than 80,000 deaths (estimated), accounted for the majority of morbidity and mortality (EM-DAT, 2009b). Currently in China, the issues identified as most problematic in regard to disaster management include community infrastructure, government planning and the knowledge level of citizens (Ping, 2005). In the case of SARS, medical services were not provided sufficiently during the initial outbreak because of the government’s unwillingness to disclose information (World Health Organization, 2006). This inefficient integration and management of medical services in the initial response was extremely costly for the Chinese government in terms of reputation and economics (Wong & Zheng, 2004).

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Effective communication between political and medical channels as well as better management of China’s response would possibly have transformed the disaster into a more manageable situation.

1.1.4 Floods

“water, water, everywhere, nor any drop to drink” (Coleridge, 1798).

Flooding is a highly variable hazard taking many forms and affecting many people. Floods are the most common natural disaster accounting for 40% to 50% of all disasters and disaster-related deaths worldwide (Diaz, 2004; Malilay, 1997; Noji, 1991). According to the EM-DAT database (2009b), during the period of 2000-2009, floods (excluding ) accounted for 38.7% of the disaster events, 6.2% of deaths, and 43.0% of the population affected of all natural disasters in the world. This study focuses on floods as an example of disasters because they are most common and affect the most people. International experiences have demonstrated effective management of floods can reduce their impact on human health and wellbeing (Hajat et al., 2005). If the disaster policy response to floods works efficiently, then the policy framework should stand a good chance of enabling an appropriate response to any disaster. It is also expected that the accessibility of floods and its related data would be a reasonable approach to look into the details of disaster management.

1.2 Research Aim and Objectives

The aim of this research is to identify and evaluate the current policy framework of disaster health management in China, and to develop a new policy framework that would be most appropriate to the social, economic, and political environment, and reflect the capacity of the health system to respond to major incidents and disasters. The objectives of this research are listed as follows: 1. To describe the policy and systems of disaster health management in China; its evolution and the drivers that determined its current structure,

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2. To compare the policy structure between China and Australia, with Australia being an example of a relatively modern and mature disaster management system, 3. To evaluate the current policy framework and its implementation through detailed case studies of the health impact of floods in China in comparison with Australia, 4. To identify the key determinants of an effective disaster health management policy framework through literature review and survey of international experts. 5. To develop a new policy framework which will be appropriate to the social, economic, and political environment in China.

1.3 Research Questions

Management of the health consequences of major incidents and disasters requires well concerted and well-planned health services. The present capacity of China’s health system is stretched due to daily demands leaving it relatively unprepared to absorb the victims of major incidents and disasters. In addition, there appears to be a lack of coordination between agencies which would facilitate a more organised and effective response. Disasters have serious impacts on China; however disaster management is a new concept in the country. While there is significant achievement at the policy level, it is unclear as to how effective these policies are, and whether they are being applied effectively. The consequences are serious and many more lives may be saved if the disaster management is fully effective. By analysing the existing policy framework and making recommendations, it may be possible to reduce the future impact of disasters on health and wellbeing. A better organised response should be most relevant to the particular cultural and socio-economic circumstances of China. This response would require an in-depth knowledge and understanding of the peculiar risks and challenges of major incidents and disasters in China, the strengths and weaknesses of the current arrangements, and facilitators and impediments to organisational change. What is the current policy framework of emergency and disaster management in China? How should the policies be structured so that the roles of government, hospitals, other organizations and people in the health service are clear and their actions integrated

- 7 - during emergency and disaster situations to make the medical and disaster relief more efficient? The research questions that form the basis of this research include:

1. What is the current policy framework in China for disaster health management? 2. How did it develop to its current status and what are the factors which have influenced the design and development of that policy framework? 3. How effective is the current policy in regard to the management of actual events as evidenced by management of health consequences of floods? 4. How could the policy be improved to be more effective?

So far, it has been established that this research is based on testing the effectiveness of the current policy framework of disaster health management in China, and thus the key hypothesis for this research is either: • The current policy framework for disaster health management in China is fully effective and results in efficient management of the health consequences of disasters. (Null) or: • The current policy framework for disaster health management in China does not reach the highest possible levels of effective management and efficiency in dealing with the health consequences of disasters in China.

1.4 Research Scope and Methods

The scope of this research includes a detailed review of the literature in disaster health management; review of disaster health policy development in China; a comparative analysis of flood management drawing on three case studies from China and Australia respectively; and expert opinion, obtained through interviews, relating to disaster health management policy. As part of the analysis, this thesis proposes a conceptual framework for examining the health consequences of floods. This thesis also proposes a conceptual map which relates policies, policy expressions and their impact on disaster management in China.

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1.5 Thesis Structure

The conceptual plan for this study is outlined in the Figure 1-3. The information comes from three sources, including the literature (including publicly available sources such as government reports and websites), comprehensive case studies of floods in China and Australia, and the survey of expert opinion. The triangulation of the information will inform the identification of current policy structures and the issues associated with those policy structures, and produce a model for future policy arrangements which is validated and form the basis for recommendations for future action.

Figure 1-3: The research plan

This project uses a qualitative research approach involving several phases: Phase 1: An extensive review of the literature and identification of policies, legislation and implementation strategies. Phase 2: A comparative analysis using case studies of flooding in China and in Australia to identify the effectiveness of policy implementation Phase 3: Utilise a group of international experts from China and elsewhere to a. Evaluate the current policy framework against international benchmarks b. Evaluate the effectiveness of policy implementation in the management of floods c. Help develop and evaluate recommendations for policy improvements.

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Phase 4: Develop a policy framework for new policy arrangements which identifies the structural, system, research and educational needs. The model will be developed and validated utilising a modified Delphi technique with the panel of experts. Phase 5: Make recommendations in regard to the adoption and implementation of the model.

Figure 1-4 depicts the thesis structure: with experts’ opinion as a head, literature review and case studies as two hands, they form policy analysis in the body, and produce two seeds into the ground: flood health framework and policy framework.

Figure 1-4: The research structure This thesis is divided into four main parts which includes a total of 14 chapters: • Part I includes Chapter One only, and it is an introduction of the thesis; • Part II is the background and literature of this research, including Chapter Two to Six. The five elements of this thesis: “disaster, health, management, policy, China” was introduced in five chapters: starting with the introduction the basic disasters concepts and profiles; and then the health consequence of disasters; then disaster management

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and disaster management policies were discussed; and finally ends with the disaster health management in China. • Part III is the research methods and results, including Chapter Seven to Eleven. Part III covers research methods, presents the case studies of flood health management in China and Australia, undertakes a comparative case studies analysis, and examines experts survey results; • Part IV is the discussion, including the last three chapters that discuss the health consequence of floods, policy framework of disaster health management in China, and the conclusion. The following section, i.e. Part II, is a detailed examination of the literature and policies on depicting and profiling disasters, the health consequences of disasters, disaster management, policies and disaster management, and disaster health management in China.

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Part II Background and Literature

Chapter Two: Disaster Concepts and Profile

This chapter introduces the basic concepts of disasters and disaster profiles. It firstly explores the definitions, classification, cycle and impacts of disasters; and then depicts the profile of disasters with a particular focus on China. An understanding of what characterizes a disaster and how disasters are classified provides important background material to a policy study on disaster management. Similarly an examination of global trends in disasters enables flood disaster management in China to be contextualized as an important public health issue.

2.1 Disaster Concepts

Reports of disaster regularly consume the attention of the world. More than 3.4 million people lost their lives due to disasters over the past 25 years (EM-DAT, 2009b). Although many communities have organized efforts against disasters in the past, it was not until the latter part of the last century that policies and specialized organizations were established to organize .

2.1.1 Definition of Disasters

There is no agreed definition of a disaster. Some have tried to define disaster by the number of casualties (EM-DAT, 2009a).Others have used conceptual definitions which capture the impact of the event as a defining concept (EMA, 1999). Many different disciplines have an interest in disasters and each define “disaster”, using their own perspective. Usually, each definition reflects the focus and nature of the organization or individuals defining it. The term disaster is derived from the Latin roots dis- and astro, meaning “away from the stars” or, in other words, an event to be blamed on an unfortunate astrological configuration (Harper, 2001). In the daily use, people may say “It would be a disaster for

- 13 - me if I lost my job.” Cambridge Advanced Learner’s Dictionary (2003) defines disaster as “(an event which results in) great harm, damage or death, or serious difficulty”. As defined by the United Nations (UN), disaster is “a serious disruption of the functioning of society, causing widespread human, material, or environmental losses which exceed the ability of the affected society to cope using only its own resources” (United Nations, 2007). The World Health Organization (WHO) defines a disaster as “a sudden ecological phenomenon of sufficient magnitude to require external assistance”. The Australian government has a similar definition: “disaster is a serious disruption to community life which threatens or causes death or injury in that community, and damage to property which is beyond the day-to-day capacity of the prescribed statutory authorities and which requires special mobilization and organization of resources other than those normally available to those authorities” (EMA, 1999). However, in , a disaster is a crisis (危机), which is further defined as danger (危) and opportunity (机). This means that a disaster causes a crisis, but there is not only danger, but also an opportunity. This ancient concept in some respects is reflected in the modern concept underpinning the recovery and rehabilitation phases which emphasises growth and development (Berke, Kartez, & Wenger, 1993; Smith & Wenger, 2007). Disasters are not defined by a specific number of casualties but rather by the event itself and the venue in which it occurs (Antosia, 2006). In all definitions, disasters are something outside the normal experience of daily life that requires a change from daily management style and thinking. However there is no clear deemarcation between an individual emergency and a catastrophe. Indeed there is a continuum between the single event and a catastrophe; but the lines of demarcation are relative, and determined by the nature of the event, the resources available to respond, the organisational arrangements and the nature of the community impacted by the event (Figure 2-1). For example, a car with several casualties in a big city will probably not even be noticed by most people, while the same crash and casualties presenting to a rural community Emergency Department will require activation of the hospital disaster plan.

Figure 2-1: The continuum between a single emergency and a catastrophe.

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Disaster may not be associated with injuries. Some (e.g. an airplane crash) may result only in deaths. Others (e.g. some floods) may cause few or no injuries while causing great economic and social impact. While there is no uniform definition of what a disaster constitutes, a number of the definitions indicate that a disaster causes serious disruption to daily life, is associated with loss (such as loss of life, income, and environment), and requires mobilization of additional resources.

2.1.2 Disaster Classification

There are several ways to classify disasters; Hogan and Burstein (2007a) classified disasters into natural disaster, technological disaster, and conflict disasters as shown in Figure 2-2. This diagram demonstrates the interaction between various types of events and the overlaps reflect the fact that human activity interacts with technology and the environment in a way which produces complex events.

Figure not available due to copyright restrictions.

This Figure includes three circles, which forms a venn diagram, demonstrating the relationship between natural disasters, conflict disasters, and industrial-technologic disasters.

This Figure can be viewed in the print version of the thesis located in QUT Library.

Figure 2-2: A Venn diagram of the interaction of natural hazards, industrial-technologic hazards, and conflict hazards. Source:(Hogan & Burstein, 2007a)

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Natural disasters are caused by hazards that exist in the natural environment and pose a threat to human populations and communities. Examples of natural disasters include earthquake, volcanic eruption, , floods, storm, extreme temperature, and lightning. Industrial-technologic disasters result from the technological development of human society. Examples include plane crash, boat sinking, structural failure, and chemical explosion. Human conflict continues as a major source of tragedy. In recent years, terrorist attack has become of increasing concern to the world. It is important to note that each disaster type overlaps and interacts, resulting in a complex matrix of conditions (Hogan & Burstein, 2007a). Natural disasters can damage industrial facilities, resulting in release of hazardous materials. Development of dams may result in unintended flooding or drought in the neighbouring areas. Human development has often exacerbated natural hazards. Building communities in a flood plain increases the potential damage caused by flooding; building a hospital or factory on a known earthquake fault increases the potential that it will be destroyed by an earthquake. In the UTSTEIN Style, disasters are classified as natural disasters, man-made disasters, and mixed disasters as shown in Table 2-1 (Sundnes, Birnbaum, & Birnbaum, 2002). In this classification, natural disasters mainly include seismic and climatic disasters; man-made disasters include technological and conflict disasters; mixed disasters are caused by both nature and human, and includes such disasters as drought, desertification, floods, and .

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Table 2-1: Classification of Known Hazards in the Utstein Style

I. NATURAL I.1 Seismic I.1.1 Earthquake I.1.2 Volcanic eruption I.1.3 Tsunami I.1.4 Celestial collision I.2 Climatic: Meteorological I.2.1 High winds I.2.1.1 Gale I.2.1.2 Storm I.2.1.3 Tropical /Hurricane/Typhoon I.2.1.4 I.2.2 Precipitation I.2.2.1 Rain I.2.2.2 Snow I.2.2.3 Ice (, ) I.2.3 Lightning - fire I.2.4 Temperature extremes I.2.4.1 Heat I.2.4.2 Cold I.2.5 I.2.6 Drought I.2.7 Desertification I.2.8 Floods I.2.9 II.MIXED: NATURAL + HUMAN-CAUSED II.1 Drought II.2 Desertification II.3 Floods II.4 Erosion II.5 /mudslides II.6 Fire II.7 Health-related II.7.1 Epidemic of infectious disease II.7.2 Genetic II.7.3 Other III. MAN-MADE (HUMAN-CAUSED) III.1 Technological III.1.1 Release of substances III.1.1.1 Chemicals III.1.1.2 Biological III.1.1.3 Nuclear III.1.2 Transport III.1.3 Structural failure III.1.4 Explosions III.1.5 Fire III.1.6 Environmental interference III.1.7 Other III.2 Conflict (inter-human) III.2.1 Armed Conflict III.2.1.1 Conventional war (armed forces) III.2.1.2 Armed conflict/civil strife III.2.1.3 Complex human emergency III.2.1.4 Terrorism III.2.1.5 Other III.2.2 Unarmed Conflict III.2.2.1 Sanctions III.2.2.2 Embargo Source: (Sundnes, et al., 2002)

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2.1.3 Disaster Related Terms

Disaster management is a complex field with input from multiple disciplines including management, administration, public health, media, and police. Terms are often used loosely; so far clarity, a number of terms used throughout this thesis will now be defined. Agreed terminology is necessary to ensure a shared understanding by people who work in different fields and at all levels of government. A shared use of terminology will assist to ensure that the objectives, processes and practices in disaster management can be effective and carried out smoothly. Hence this study now explores some of the words commonly used in disaster health management; a detailed terminology list is attached in Appendix A: Disaster Related Terms. A hazard is “a source of danger that may or may not lead to an emergency or disaster”; risk is “susceptibility to death, injury, damage, destruction, disruption, stoppage, and so forth”. Impact is “the actual process of contact between an event and a society or a society’s immediate perimeter”. Damage is “harm or injury impairing the value or usefulness of something, or the health or normal functioning of persons”. The medical definition of disaster is “an event that results in casualties that overwhelm the health care system in which the event occurs”. Health disaster encompasses impaired public health and medical care to the individual victims. Disaster management is “the aggregate of all measures taken to reduce likelihood of damage that will occur related to hazards, and to minimize the damage once an event is occurring or has occurred, and to direct recovery from the damage” The cycle of disaster management includes concepts which capture the continuum of disaster management from prevention through preparedness to response and recovery as key aspects of the policy framework. Disaster medicine implies the clinical aspects of disaster management; however others consider this a relatively narrow perspective which fails to capture the multidisciplinary nature of disaster response. Disaster health management is used to reflect the broader nature of the response. Vulnerability is “the degree of possible/potential loss to a given element at risk resulting from a given hazard at a given intensity”. Resilience is the “pliability, flexibility, or elasticity of the population/environment to absorb an event”; resilience includes the

- 18 - absorbing capacity, the buffering capacity, and response to the event and recovery from the damage sustained. Thus, “Vulnerability=1-Resilience”. (Sundnes, et al., 2002)

2.1.4 Disaster Cycle and Impact

Over the long history of combating disasters, a set of repeating elements that make up the disaster process have been identified. The primary sets of problems consistently seen during disasters include communication, personnel, and supplies (Auf der Heide, 1996). A reasonable approach might be to start by understanding the behaviours more fully, and then the planning may take the form of channelling these behaviours into activities that are more constructive. Each disaster follows a general pattern in its development, often repeated throughout nature in quiescent phase, prodromal phase, impact phase, rescue phase, and recovery phase as demonstrated in Figure 2-3 (Hogan & Burstein, 2006).

Figure not available due to copyright restrictions.

This Figure shows the phases of disaster life cycle with a time line, including prodromal, impact, rescue, recovery, and quiescent.

This Figure can be viewed in the print version of the thesis located in QUT Library.

Figure 2-3: General phases of disaster life cycle Source: (Hogan & Burstein, 2007a). For different types of disasters, there are different perspectives based on their characteristics as shown in Figure 2-4. Disaster characterises such as the predictability, speed of onset, and lethality provide important information for making specific disaster plans. For example, an earthquake is a disaster with low predictability and high speed of

- 19 - onset, and results in a high morbidity and mortality rate, and thus the management of earthquakes focus more on the community education and preparedness.

Figure not available due to copyright restrictions.

This Figure shows the characteristics of different types of disasters in the predictability, lethality, geographical scope, and speed of onset.

This Figure can be viewed in the print version of the thesis located in QUT Library.

Figure 2-4: The perspective of disasters based on their specific characteristics Source: (Guha-Sapir & Lechat, 1986)

2.2 Recent Disaster Profile

As described in the opening chapter, the number of disasters reported and the number of people affected by disasters have been increasing in the past century as shown in Figure 1-1 and 1-2, and thus disasters have become of increasing concern to the world. The following section examines disaster from a global perspective and then concludes by profiling disasters in China and Australia respectively.

2.2.1 Global Disaster Profile

As shown in Figure 2-5, the number of natural disasters and the number of people affected by natural disasters has been increasing in the last century, especially after the

- 20 -

1960s; however the number of people killed by natural disasters has been continuously decreasing. It appears that more events were killing fewer people; presumably as a result of better disaster health management (Kahn, 2005).

Figure 2-5: Natural disaster summary 1990-2008 (linear-interpolated smoothed lines) Source: EM-DAT: The OFDA/CRED International Disaster Database

Figure 2-6 demonstrates the global perspective of disaster by demonstrating the relative frequency in different countries. It shows that America, Russia, China, , Australia, Indonesia and other countries in South East Asia have been hit by the largest number of natural disasters while west Asia, central Europe, and Africa are the least affected countries. As for the number of deaths and people affected by natural disasters, Figure 2-7 shows that China, India and some African countries were the most affected, largely corresponding to the population in these areas. However, more developed countries, such as , European countries, and Russia were less affected.

- 21 -

Figure 2-6: Number of natural disasters by country: 1976-2005 Source: EM-DAT: The OFDA/CRED International Disaster Database

Figure 2-7: Total number of deaths andpeople affected by 100,000 inhabitants (1974- 2003) Source: EM-DAT: The OFDA/CRED International Disaster Database Among natural disasters types, Figure 2-8 shows that floods followed by and epidemics have a higher occurrence, while each type of natural disasters showed an increasing frequency.

- 22 -

Figure 2-8: Number of natural disasters reported 1900-2008 Source: EM-DAT: The OFDA/CRED International Disaster Database Figure 2-9 shows the number of people killed by natural disasters. While the number of people killed by disasters such as earthquakes, storms, and volcanos is relatively stable, the number of people killed by epidemics has been decreasing, and the number killed by floods and other disasters have been increasing. Each type of disaster has irregular periods that killed a significantly higher number of people, probably due to several single events, such as the 1918 Spanish Flu, 1931 Central China floods, and 2004 India Ocean Tsunami. As for the number of people affected by natural disasters, Figure 2-10 shows that floods, , storms, and earthquake have affected the largest number of people. Interestingly, the number of people affected by climatic natural disasters such as floods, droughts, and storms has been increasing at a much higher speed than those affected by seismic natural disasters such as earthquakes and volcanos, especially after the 1970s. This is possibly due to the global warming (Kahn, 2005). However, recent events in Port- au-Prince (2010) and (2010) indicate that disaster profiling is far from being a static science, with one or two events impacting on potentially thousands of people.

- 23 -

Figure 2-9: Number of people reported killed by natural disasters 1900-2008 Source: EM-DAT: The OFDA/CRED International Disaster Database

Figure 2-10: Number of people reported affected by natural disasters 1990-2008 (square rooted) Source: EM-DAT: The OFDA/CRED International Disaster Database

- 24 -

In relation to the cost of disasters, Figure 2-11 shows Asia, America, and Europe are the three continents most affected by natural disasters. The most common disasters in Africa are earthquake, floods, and drought; America is mostly affected by storms; Asia is mostly affected by earthquake, flood, and storm; Europe is commonly affected by floods and storms; and Oceania is affected by storms, droughts, and floods.

Figure 2-11: Average annual damage ($US billion) caused by reported natural disasters 1990-2008 Source: EM-DAT: The OFDA/CRED International Disaster Database Prominent disasters examples in recent years include SARS, avian flu, 2004

tsunami, 2008 China Wenchuan earthquake, and 2009 Influenza H1N1 etc.

2.2.2 Disaster Profile in China

As a country vast in territory and complex in climatic and geographical conditions, China has been plagued by almost every kind of natural disasters, except for volcanic eruptions. Natural disasters occur frequently in China. It is estimated that during the period 1990 to 2009, disaster affected more than 26 million and killed about 115,000 per annum on average (EM-DAT, 2009b).

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While there are remote regions with no or few inhabitants, the reality of China’s situation is that people and natural disasters are often connected. The eastern one-third of the country is where 48 percent of the disasters occur, and it is where more than two- thirds of the population live. In addition, the population is often settled in river valleys that are subject to flooding, or they are located within 100 miles of the coast, which makes them vulnerable to typhoons and the subsequent flooding and wind damage (Stoltman, et al., 2004). Disasters vary with both region and season. Drought tends to occur mainly in the Northwest and North China Plain in spring and autumn. Flood and water logging mainly occur in the major river valleys in summer. Typhoon and storm surges strike mainly the south-eastern coastal regions. Earthquakes are widely distributed, but occur mainly in south-western, north-western, and northern China. Forest and grassland fires occur mainly in the forest and pastoral areas of north-eastern, south-western, north- eastern, and northern China in the dry seasons of winter and spring. Figure 2-12 shows the number of natural disasters in China from 1900 to 2009 according to EM-DAT: The OFDA/CRED International Disaster Database. Of the total 613 events recorded, floods, storm, and earthquake have significantly higher frequency than other types of disasters. Recent prominent disasters in China include the 2008 Ice

Storm, 2008 Wenchuan Earthquake, and Influenza H1N1.

Figure 2-12: Number of natural disasters in China from 1900 to 2009 Source: Generated using the EM-DAT: The OFDA/CRED International Disaster Database

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2.2.3 Disaster Profile in Australia

Australia has a large geographical area with a small population. Consequently, some of the world’s most severe natural hazards experienced in Australia rarely appear in the world . Australia experiences a range of natural disasters including bushfires, floods, severe storms, earthquakes and landslides. Reliable information on the frequency of disasters in Australia extends only from 1970s. Since 1980, the average number of disasters has been increasing as shown in Figure 2-13.

160

140

120

100 Disasters 80 of

60

Number 40

20

0

Year

Figure 2-13: Number of disasters in Australia, 1970-2008 Source: Generated using the Emergency Management Australia (EMA) Disaster Database (http://www.ema.gov.au/ema/emadisasters.nsf/).

Figure 2-14 shows the variable annual costs of disasters in Australia, which shows an upward trend. It is noted however, that the time frame of 30 years is a relatively short to discern trends.

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$3,500

$3,000

$2,500

AUD) $2,000

(Million $1,500

Cost $1,000

$500

$0 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 Year

Figure 2-14: Total cost of disasters in Australia, 1970-2008 Source: Generated using the Emergency Management Australia (EMA) Disaster Database (http://www.ema.gov.au/ema/emadisasters.nsf/). Across Australia, population and built environment continue to develop in hazard- prone areas, particularly in coastal and river valley locations (AGDTRS, 2004). Recent predominant disasters in Australia include the 2009 Victorian bushfire, floods in Queensland, Influenza H1N1 etc.

This chapter discussed definitions of disasters. It then examines the number and types of disasters across the world with a particular focus on China and Australia. While mortality and morbidity received more attention in this chapter, the following chapter explores in some detail the health consequences of disasters.

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Chapter Three: Health Consequences of Disasters

This chapter examines the health consequence of disasters in general and health impacts of floods in particular. This chapter is divided into two parts. The first part examines the concepts of direct and indirect health consequences; tangible and intangible health consequences; and immediate, midterm, and long term health consequences. The second part examines the causes and types of floods; factors affect the health outcome of floods; and the possible health consequences for the immediate, mid-term, and long term.

3.1 Health Impact of Disasters

In ancient and modern times, entire civilisations have been decimated by disasters in an instant. Epidemics and have resulted in sizeable reductions of the world’s population—as much as 30% to 50% across Europe during the 14th century bubonic plague (“Black Plague”) pandemic (Knox, 2010; University of Virginia, 1994) and up to 100 million during the 1918 Spanish Flu (Patterson & Pyle, 1991; Taubenberger & Morens, 2006) . Theorists have suggested that many of history’s great civilisations, including the Mayans, the Supe, the Norse, the Minoans, and the Old Egyptian Empire, were ultimately doomed by effects of floods, , earthquakes, tsunamis, El Niño events, and other widespread disasters (Fagan, 1999; Oliver-Smith & Hoffman, 1999; Zebrowski, 1997). The consequence of disasters is usually examined according to three factors (Coppola, 2006):

¾ Deaths/fatalities (human) ¾ Injuries (human) ¾ Damage (cost, reported in currency, generally US dollars for international comparison)

Disasters always have significant impacts on the human population, especially on health. Disaster often damages the fabric and infrastructure of society including roads, power supply, houses, and services. A disaster is generally considered a “low probability-

- 29 - high impact” event which is harmful, unexpected, and emergent (Ping, 2005). Human beings usually suffer a high morbidly and mortality. As shown in Figures 1-2, 2-9, and 2- 10, the number of people reported killed or affected by natural disasters has been increasing dramatically. Disaster may cause a number of health problems including (Noji, 1997a):

¾ deaths, injuries, or illness directly; ¾ destruction of local health infrastructure and other routine health services; ¾ adverse affects on the environment that cause risk for humans; ¾ adverse affects on the psychological and social behaviour of the stricken community; ¾ food scarcity and thus malnutrition; ¾ population movement and thus a higher morbidity and mortality.

Table 3-1 adapts and extends the work of Landesman (2005) and lists the most common natural disasters, and examples of their environmental effects, and their impacts on human health. Mass casualty requires organized medical treatment, and it is important to know the likely health impacts of specific type of disasters, so that triage, patients transfer and system management can be conducted in a more efficient way.

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Table 3-1: Natural Disasters and Their Environmental and Human Health Impacts Natural Environmental Effects Human Health Impacts Disasters / Cold , erosion, snow melt Hypothermia, drowning, trauma, wave/ Heavy (flooding), loss of plants and animals, starvation, disability, mental Snowfall river ice jams (flooding) health, death Cyclone Flooding, landslide, erosion, loss of plant Trauma, drowning, starvation, and animal life disability, mental health Drought Fire, depletion of water resources, Starvation, thirst, burning, deterioration of soil, loss of plant and disability, mental health, death animal life Earthquake Landslide, rock fall, avalanche, building Trauma, shock, limb ischemia, collapse disability, mental health, death Flood/ Heavy rainfall, fire, landslide, erosion, Drowning, trauma, disability, Thunder storm destruction of plant life mental health, death Heatwave Fire, loss of plants and animals, Starvation, thirst, heat stress, depletion of water resources, burning, drowning, disability, deterioration of soil, snow melt mental health, death (flooding) Lightning Fire Burning, disability, mental health, death Thunder Flooding, fire, landslide, erosion, Trauma, burning, drowning, storm/ Heavy destruction of plant life starvation, disability, mental Rainfall health, death Tornado Loss of plant and animal life, erosion, Trauma, disability, mental health, water disturbance death Tsunami Flooding, erosion, loss of plant and Trauma, drowning, starvation, animal life disability, mental health, death Volcanic Loss of plant and animal life, Trauma, burning, thirst, starvation Eruption deterioration of soil, air, and water disability, mental health, death pollution Destruction of ground cover, erosion, Bronchospasm, corneal abrasions, flooding, mud slides, long-term smog, trauma, burns, thirst, heat stress, and tainted soil. hunger, disability, mental health, death Source:(Landesman, 2005) and author

The health consequences of disasters can be categorised in several ways. The three most common distinctions are (1) direct and indirect consequences; (2) tangible and intangible consequences; and (3) immediate, mid-term, and long term consequences. These categorizations are important, so that each of the consequences can be addressed in the disaster’s management.

3.1.1 Direct and Indirect Health Consequences

The most obvious direct health consequences are injuries and deaths that can be attributed directly to the disaster (Shoaf & Rottman, 2000). The patterns of the injury and

- 31 - deaths may be different according to the type of disasters. In the case of flooding, the most obvious health consequences are drowning or injuries from flooding debris or structural collapse. The health care delivery system, including the physical infrastructure and personnel, may also be affected by the disasters directly. Indirect health consequences may result partly from the loss of routine health care and normal living conditions. This may be a result of the damage to the health care system or the overloading of the system with trauma-related care. Other indirect consequences of disasters may be the destruction of crops, leading to flood insufficiency, and contaminated water.

3.1.2 Tangible and Intangible Health Consequence

Tangible health consequences, to which a dollar value can be assigned, may include such effects as damage to hospitals and other health facilities, medical treatment needs, and loss of drugs (Coppola, 2006; Tobin & Montz, 1997). Tangible consequence in terms injuries and fatalities is commonly used to describe the impact of disasters. Intangible health consequences, on the other hand, are those that cannot be expressed in universally accepted financial terms, such as the value of a human life, stress, fear, anxiety, mental illness, sentimental attachment to places and things, and family and community relationships (Coppola, 2006; Tobin & Montz, 1997). The intangible cost, in terms of both individual pain and social suffering, can be of higher cost than the tangible cost of a disaster; however it is hard to estimate the intangible cost (Coppola, 2006).

3.1.3 Immediate, Mid-term, and Long-term Health Consequences

Immediate health consequences are those in the acute phase (approximately the first four weeks following the disaster) (Health Council of the , 2006). These include illness, disability, and death; loss in infrastructure; and loss of or disruption to health care delivery (Disease Control Priorities Project (DCPP), 2007). The burden of the immediate health consequences usually depends on the nature of the hazard. Mid-term health consequences occur four weeks to five years after the disaster (Health Council of the Netherlands, 2006). In this phase the direct health response that

- 32 - focused on trauma etc. may have stopped, but significant mental health consequences and infectious diseases still threaten the community. Thus it’s important to promote public health and sense of safety, connectedness, and hope during this period (Hobfoll et al., 2007). While the immediate health consequences of disasters normally gain efficient attention as they are so obvious, the long-term (five years and beyond) health consequences should not be neglected. Several studies have shown that both psychological and physical illnesses persist in the long-term (Berrios-Torres Si Fau - Greenko et al., 2003; Galea, 2007; Neria, Nandi, & Galea, 2008; Norris, Friedman, Watson, Byrne, & et al., 2002). The long-term health consequences include loss of medical care, interruptions in the control of communicable disease, loss of laboratory support and diagnostic capabilities of hospitals, loss of medical staff and expertise, and an increased incidence of mental depression. There are two issues that should be noted in the health consequences of disasters: Firstly, the numbers of death and hospital admissions are only the top of the pyramid, while other injuries can be depicted as being on the bottom of the pyramid and may account for most of the injuries. However, this still depends on the type of disaster. For example, a plane crash is likely to kill everyone on board; a flood may have more mild cases than deaths. Figure 3-1 shows the injury pyramid of the casualties resulting from the 1994 Northridge Earthquake which was studied by Seligson and Shoaf (2003).

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Figure not available due to copyright restrictions.

This Figure shows the injury pyramid with 27 DOA in the top, followed by 6 Die in Hospital, 9 Hospitalized/Trauma Cases, 129 Hospitalized/Non-Trauma, 8,200 HH Emergency Department Treat and Release, 16,400 HH Out of Hospital Treat and Release, and 221,400 HH Injured, No Treatment in the bottom.

This Figure can be viewed in the print version of the thesis located in QUT Library.

Figure 3-1: Injury pyramid for the 1994 Northridge Earthquake (persons or households with injuries). Source: (Seligson & Shoaf, 2003) The second but less discussed health consequence of disasters is that they may also provide potential health gains. These gains include the greater public recognition of hazard risk, decrease in future hazard risk by preventing rebuilding in hazard-prone areas; and new technologies used for health treatment.

3.2 Health Consequences of Floods

Floods are the most common natural disaster accounting for 40% to 50% of all disasters and disaster-related deaths worldwide (Diaz, 2004; Malilay, 1997; Noji, 1991). According to EM-DAT database, floods (excluding tsunamis) account for 38.7% of the events, 6.2% of deaths, and 43.0% of the population affected of all natural disasters in the world in the period of 2000 to 2009 (EM-DAT: The OFDA/CRED International Disaster Database, 2009). Flood may be defined as “the condition that occurs when water overflows the natural or artificial confines of a stream, river, or other body of water, or accumulates by drainage over low-lying areas” (, 2008). Floods are caused by rainfall, melting snow or ice or by structural failure of water containing structures

- 34 - including subterranean structures. The nature and extent of the flood is determined by the physical location, and topography, and by the built environment. Floods impact on the human community either directly through contact with the water or indirectly through the damage the water does to the natural and human-built environment. Even relatively small, localized floods may have a significant impact on people’s physical and mental health (Tapsell & Tunstall, 2008). The health consequences of floods vary depending on the nature of the flood, the geographical and demographic characteristics of the flooded area, and the policy arrangements for preparation and consequence management. Not only is the incidence of floods increasing, but rapid urbanization is resulting in the exposure of more people to floods. In addition, global warming and changes in land use is projected to have an impact on the frequency of floods worldwide (Haines & Patz, 2004; Wakuma Abaya, Mandere, & Ewald, 2009).

3.2.1 Causes and Types of Floods

The nature and consequences of floods vary according to the cause of the flood and the nature of the natural and human environment. Floods may be caused by a range of factors or combinations of those factors. Table 3-2 brings together knowledge from the extensive literature and provides a summary classification of the causes of floods. Different types of floods have different impacts on the human community and therefore different health effects.

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Table 3-2: Causes of Floods Causes Sub-category Comments and examples: Precipitation Rain Impact is dependent on the size and rapidity of the rain Snow Immediate impact from the snow and its impact and delayed impact from melting of snow and ice Rising water Sea water Sudden rises associate with tidal waves, Tsunami and level Long term rises due to global warming Fresh water Rising levels associated with planned or unplanned damming of waterways. For example the dams caused by landslides in the Sichuan Earthquake, China (2008) Rising subterranean water for example the mud flow in Indonesia (2007) Structural Failure of the dam Collapse of water retaining structures with sudden release failure of stored water Relocation of the For example a landslide into a reservoir displacing large stored water quantities of water Breaching of sea For example the breaching of dykes in . defences Reduced Prevention of For example development of wetlands, which reduces natural natural absorption absorption of rainfall drainage Blocked drainage As may occur through poor planning of water drainage infrastructure or through blocked drainage due to debris or trash.

3.2.1.1 Precipitation

Precipitation, including rain, snow, and hail, can have both immediate and longer term effects. Heavy rainfall can cause localized flash flooding or downstream (riverine) inundation (Costa, 1987; Pitlick, 1994). Snow fall causes immediate effects associated with hypothermia, ice associated injury and infrastructure or building failure while delayed floods may result from the melting of snow and ice (Dankers & Feyen, 2008). Hail can cause immediate injury to people and block drainage systems precipitating building inundation. Global warming increases the overall temperature of the oceans, which in turn increases torrential downpours, tropical storms, and hurricanes/ (Dankers & Feyen, 2008; Diaz, 2004).

3.2.1.2 Rising Water Levels

Rising water levels, both fresh water and sea water, may occur suddenly or gradually. Sudden rises of sea water are caused by tsunamis, tidal waves, storm surges or by breaches in sea defences. Longer term increases in sea levels are anticipated with

- 36 - global warming, melting of polar ice caps and thermal expansion of sea masses (Haines A & Patz JA, 2004). Rising fresh water may occur as a result of planned or unplanned damming of water drainage or by release of subterranean water sources to the surface. One extreme case of the latter was the mud volcano in East Java where steam, water, and mud erupted from underground resulting in inundation of land and villages. (Davies, Swarbrick, Evans, & Huuse, 2007)

3.2.1.3 Release of Stored Water

Floods may be caused by release of stored water associated with failure of retaining walls or structures or by the displacement of stored water as may occur with landslides into the water. For example the landslide in the in 1963, during which rocks, mud, earth and uprooted trees tumbled into the lake and made the dam overflow thus flooding the nearby villages (Favaro, Zaetta, Colombo, & Santonastaso, 2004).

3.2.1.4 Failure of Natural Drainage

Floods may also be caused or exacerbated by failure of natural drainage. Reduced absorption of water occurs when natural landscape is replaced with non- absorbent infrastructure, for example urban expansion or the replacement of wetlands and forests. Impaired drainage may also be associated with poorly planned or inadequate drainage systems in new constructions or drainage systems which become blocked with debris or trash (Poole & Hogan, 2007). The timing of the flood may also affect its impact. Heavy rain in coastal areas at high tide will have a greater impact because of the difficulty for the water to clear to sea.

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3.2.2 Factors that affect the health outcome of floods

Flood can affect human health in many ways. Apart from the quantity of water, there are many other factors that affect the severity and scale of floods, and thus their impact on human health.

3.2.2.1 Flood Type

The type of flood is directly relevant to the health consequences. The term ‘’ implies sudden onset and may be associated with tsunamis, sudden downpour, or breach of reservoirs. The sudden onset may entrap people resulting in drowning. In addition the forces associated with the hydrological pressure may carry debris along with the water and cause damage to buildings and other infrastructure such as . This debris can result in injuries to people. On the other hand, gradual inundation is more predictable and less likely to cause drowning and injury. Many floods are mixed in nature.

3.2.2.2 Geography

The geography of the area flooded has a significant impact on the nature of the flood and the health consequences. An area close to the sea is more likely to be affected by tidal waves and storm surge. Areas in a valley are more likely to suffer flash floods; often debris laden. Low lying areas are more likely to be affected by riverine flood and gradual inundation. There is a significant increase in mortality when flooding occurs within mountainous and narrow river valley areas (French, Ing, Von, & et al, 1983). However communities at greatest risk of flood are those in low-lying areas, near water, and located downstream from a dam (Coppola, 2006; Sylvia, 2006).

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3.2.2.3 Demography

The human health impact of floods is also dependent on the demographics of the population affected by the flood. This includes the size and density of the population as well as the level of awareness and education of the community and their capacity for escape. Several groups within the community are at particular risk and include older people, children, people with disabilities and illness, and people confined in the prisons. Children and older individuals are more likely to suffer adverse physical consequences during floods (Cherniack, 2008; Sommer & Mosley, 1972). Women are more affected psychologically than men (Choudhury, Quraishi, & Haque, 2006; Fothergill, 2001; Liu et al., 2006; Sommer & Mosley, 1972). Children and adolescents with chronic conditions are at increased risk of adverse outcomes (Rath et al., 2007). The poor are particularly vulnerable to floods, and isolation and lack of participation in decision-making intensifies their vulnerability (Zoleta-Nantes, 2000).

3.2.2.4 Community Infrastructure

The capacity of the community to respond and their attitude to disaster preparedness and prevention is related to the culture and education of the population. The extent of community infrastructure will affect the health and other consequences of the flood. Construction standards will affect the likelihood of building collapse. Well designed and maintained drainage systems limit the accumulation of water. Appropriate design of community infrastructure such as dams will limit the likelihood of failure. The availability of well constructed places of refuge and safety may limit or reduce death and injury. Appropriate design and safe location of health infrastructure is essential to the ongoing provision of health services in the event of a flood (Heide, 2007).

3.2.2.5 Disaster Management System

The effectiveness of the disaster management system may influence the health impacts of flood. A well-organized system is more likely to carry out flood preparation

- 39 - and respond more efficiently than others. Evacuation routes should be planned and practiced. The usual routes of access to and from the hospitals and health services may be flooded; therefore alternative routes should be planned in advance. Effective community communication is essential to limit the health risk and health consequences both in the short and long term.

3.2.3 Health Consequences of Floods

The health consequences of floods may be broadly categorized as direct or indirect. Direct consequences are those resulting from direct exposure to the water and the flooded environment and include drowning, injuries from debris, chemical contamination and hypothermia. Indirect consequences are those associated with risks associated with the damage done by the water to the natural and built environment and include infectious diseases, malnutrition, poverty related diseases and diseases associated with displaced populations (Ahern & Kovats, 2005; Du, FitzGerald, Clark, & Hou, 2010), The health consequences of flooding may also be described in terms of time as immediate, medium term and long term. There is no clear definition of these terms; indeed in many respects these period overlap. However the division is potentially useful to aid planning and management strategies.

3.2.3.1 Immediate health effects:

Immediate health effects of flood include the consequences that occur in the first four weeks of the flood. They include drowning, injury, burns and explosions, hypothermia, and those health effects caused by the disruption of health services. The leading cause of death in floods is drowning and most of these deaths are due to flash flooding rather than the slower riverine flooding (Noji E., 2001). Drowning often occurs as a result of individuals underestimating the power of the current or depth of the water during late evacuation, attempted salvage or inappropriate conduct. Many flood deaths can be attributed to motor vehicle use and are caused by driving on flooded roads or causeways or from the trauma associated with crashes occurring on wet roadways. More than 57% of all flood fatalities in the are associated with motor

- 40 - vehicles (French, et al., 1983; National Weather Service-Hydrologic Information Center, 2008). Drowning also occurs when people are swept away from their home or campsite, or while attempting to cross a bridge, or rafting or sailing in storm water drains or during evacuation or rescue. The number of such deaths is determined by the characteristics of the flood. Approximately 0.2% to 2% of flood survivors will require urgent medical care (Noji E., 1995). Flood-related injuries may occur as individuals attempt to escape from danger or as a result of the collapse of buildings or other structures. Orthopaedic injuries and lacerations may be caused by fast moving water containing debris (Noji E., 1995; Pan American Health Organization, 1981; Schnitzler, Benzler, Altmann, Mucke, & Krause, 2007). Injuries also occur when people return to their homes and businesses and begin to clean-up (e.g., from unstable buildings and electrical power cables). Falls from ladders, sprains and strains and wounds may occur as individuals repair homes or use chainsaws to clean up fallen trees and other debris (Brewer, Morris, & Cole, 1994). Electrical injuries may occur with flooding. Standing water anywhere close to electrical lines, circuits, or equipment represents a potential electrical hazard (Messner & Meyer, 2006). Additionally rescue boats may come into contact with overhead power lines; the power may be generated by solar power units in housing though the main electricity may be disconnected. Burns and explosions may be caused as floodwaters disrupt propane and natural gas lines, tanks, power lines and chemical storage tanks. Oil and other flammable, non- polar, low density liquids may allow fires to spread along the surface of floodwaters (Noji E., 2001). Hypothermia with or without submersion is seen in some floods and may occur in any season (James Poole & David E. Hogan, 2007). Ice dam breakage elevates the risk, but water does not have to be ice cold for hypothermia to occur. Most flood water is well below human core body temperature. Homeless individuals are at particular risk. Floods can have a significant impact on the provision of health services. Potential damage to health facilities from the flood may require displacement of patients and staff. Flooding may impair access to health resources or the ability of health personnel to provide their services. Flood can limit access to primary health care, and result in changes in the demand for services (as evidenced by the frequency and type of patient visits) (Axelrod, Killam, Gaston, & Stinson, 1994; Schatz, 2008). In ,

- 41 - the Department of Health and Hospitals was extensively damaged thus limiting the surveillance for illnesses, injuries, and toxic exposures (Centers for Disease Control and Prevention, 2005b). Flooding can also cause the loss of medical records, disrupt the provision of health resources, consumables and the infrastructure required to maintain services. Patients may also suffer from loss of medication or medical devices, and find difficulty accessing health services resulting in an exacerbation of health problems among families affected by the flood (Curry, Larsen, Mansfield, & Leonardo, 2001).

3.2.3.2 Secondary Health Effects:

The secondary health effects occur within the period of four weeks to five years after the flood, including health consequences caused by water contamination, chemical contamination, carbon monoxide poisoning, communicable disease, respiratory illness, and animal displacement. Contact with floodwaters without drowning does not, by itself, pose a serious health risk (Centers for Disease Control and Prevention, 1983). However, floodwaters may contaminate the local water and food supply and damage the sewage system resulting in contamination and potential for communicable diseases (Centers for Disease Control and Prevention, 2000; Noji, 1995). Contaminated water sources result in waterborne disease transmission, including Escherichia coli, Shigella, Salmonella, and hepatitis A virus. Faecal contamination of livestock and crops may also lead to the spread of infectious disease (Casteel, Sobsey, & Mueller, 2006). The flood or irrigation with contaminated water represents a risk to farm and other outdoor workers (Pianietti, Sabatini, Bruscolini, Chiaverini, & Cecchetti, 2004). Flood can cause nutrient runoff from agriculture and thus cause algal blooms, which alter the coastal ecosystems and threaten human health (Joyce, 2000). Flood waters may also result in the spread of chemicals. Industrial sites may become flooded, unleashing chemicals and other contaminants into the floodwaters. Flood can also lead to release of hazardous materials causing fires and/or explosions, toxic gas emissions, spills, damage to equipment, damage to pipes and connections, short circuits and/or power failures, punctured tanks and vessels, and structural damage to buildings and facilities in refineries etc. (Cruz, Steinberg, & Luna, 2001).

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Carbon monoxide poisoning is a relatively common risk during the event and recovery phases of floods (James Poole & David E. Hogan, 2007). Unventilated gas- powered electrical generators, gas-powered pressure washers, unventilated cooking tanks, and house fires started by candles are common culprits (Centers for Disease Control and Prevention, 2005a; Daley, Shireley, & Gilmore, 2001). In one study, fever accounted for 42.5% of health problems following a flood. (Kunii, Nakamura, Abdur, & Wakai, 2002). Communicable diseases are a concern during any disaster, though it is less commonly observed with flooding (Malilay, 1997; Western, 1982). Infectious diseases such as leptospirosis and melioidosis has been reported after some flood cases (Fau, Fau, Morales, Suarez-Villamil, & Souchet, 2003; Gaynor et al., 2007). However, it is a myth that communicable diseases are inevitable after every disaster. Infectious diseases that are not endemic nor brought into a region will not occur during disaster response (Richard & Josette, 1992; World Health Organization, 2010b). However, there are several reasons for increased risk of communicable diseases during flooding:

¾ Temporary shelters to house those displaced by flooding may result in crowded and unsanitary living conditions, increasing the incidence of infectious illnesses (Noji E., 1995). Flooding also leads to decreased basic hygiene if toilets become inaccessible and clean water is not available for washing. ¾ Lack of clean water, overcrowding, insufficient understanding of personal and domestic hygiene, nutritional deficiency and overall poor sanitation are the major contributing factors for the spread of diarrhoeal diseases (Sur, Dutta, Nair, & Bhattacharya, 2000). ¾ Vector-borne diseases may increase during periods of flooding. Stagnant water provides a breeding ground for many vectors such as mosquitoes resulting in diseases such as malaria and dengue.

Respiratory problems account for a significant proportion of morbidity associated with floods (Biswas, Pal, & Mukhopadhyay, 1999; Kunii, et al., 2002). Mould is a particular hazard for persons with impaired host defences or mould allergies. (Brandt et al., 2006). Microbial growth can cause potentially harmful inhalation exposures for

- 43 - persons entering or cleaning affected homes (2006; Riggs et al., 2008; Schwab et al., 2007). Animal displacement commonly occurs during periods of flooding. Displaced domesticated animals, rats, insects, snakes, and reptiles often result in an increased incidence of bites (Centers for Disease Control and Prevention, 2000; Ussher, 1973). Diseases transmitted by rodents may also increase during heavy rainfall and flooding because of altered patterns of contact (Diaz, 2007). Finally diseases amongst sick animals may spread to the human population.

3.2.3.3 Longer term health consequences:

Long-term health consequences of floods mainly include disability, mental health and chronic diseases as discussed below. In the longer term, disability from trauma incurred during the flood is a common cause of morbidity particularly if exacerbated by complications such as infection. Disability may also be associated with the exacerbation of chronic diseases such as asthma or ear, nose or throat conditions (Reacher et al., 2004). Mental health problems are common sequaelae of floods. Major life stressors such as natural disasters increase susceptibility not only to physical illness but also to poor mental health (Phifer, Kaniasty, & Norris, 1988) (Chae, Kim, Rhee, & Henderson, 2005; Norris, Murphy, Baker, & Perilla, 2004; Stimpson, 2004; Verger et al., 2003). People who have experienced a flood have been shown to have a fourfold risk of psychological distress than those not exposed to flood (Reacher, et al., 2004), and a suicide rate 13.8% higher than pre-disaster rates (Axelrod, et al., 1994). Mental health problems may derive from physical health problems or from personal losses, social disruption and economic hardship (Ahern & Kovats, 2005). Mental health consequences of exposure to disasters “have not been fully addressed by those in the field of disaster preparedness or service delivery” (Gerrity & Flynn, 1997). In developing communities young people and particularly girls have been shown to be particularly vulnerable (Bokszczanin, 2007; Rashid & Michaud, 2000). Disaster mental health teams should be sensitive to socio-economic status, local culture, tradition, language and local livelihood patterns (Choudhury, et al., 2006)

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Floods may be associated with extensive economic disruption which has significant health consequences. Antisocial/violent behaviour: assaults, gunshot wounds, and rapes have been reported following floods (Centers for Disease Control and Prevention, 2000). Destruction of health infrastructure including public health structures such as clean water and proper waste disposal contribute to social disruption. Access to medical services can be affected by both personal and community economic effect (Parker & Thompson, 2000; Wisner, Blaikie, Cannon, & Davis, 2004). Poor nutrition may follow floods due to crop destruction and the disruption of food supplies (Wakuma Abaya, et al., 2009). And the disruption of livelihood may also affect household incomes and their capacity to purchase food, especially in low-income countries (Parker, 2000a). In a study undertaken by del Ninno & Lundberg (2005) the nutritional status of children in households that were more severely exposed to the flood was seen to deteriorate, and children exposed to the flood were adversely affected.

This chapter has discussed the health consequences of disasters with a special focus on the health impacts of floods. It has also shown that there are considerable health consequences for populations affected by flood which stem from the direct and indirect consequences of flood as well as from the short and long terms impacts of the flood. For those seeking to manage the health consequences of flood, knowledge of the direct and indirect consequences and of the short and long-term sequealae of floods may enable a more comprehensive policy approach. The next chapter turns to examining how disasters are managed to minimize their impacts on humans.

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Chapter Four: Disaster Management

This chapter describes disaster management theories and practices in both developed and developing countries, with a particular focus on health. Firstly, the history of disaster management, basic concepts of disaster management, and the disaster management cycle are introduced. Then the management of the health aspects of disaster are discussed. Finally disaster management in developed and developing countries are compared so as to identify the characteristics of disaster health management in developing countries.

4.1 Introduction to Disaster Management

The human history is a history of fighting against all kinds of disasters. The western world is familiar with the biblical story of Noah who built the Ark to save humanity and the animals from the great flood. The Chinese has Nu Wa (女娲) who patches up the broken sky to stop the heavens’ water from entering the man’s world. While disaster management has developed since ancient times, it is only since the mid- 20th century that modern disaster management concepts emerged.

4.1.1 The Evolution of Disaster Management

The relationship between disasters and attempts to prevent their reoccurrence or reduce their impact is one that repeats itself throughout history (Canton, 2007). Evidence of risk management practices can be found as early as 3200 BC. In what is now modern- day Iraq lived a social group known as the Asipu, who acted as advisers on risky, uncertain and difficult decisions. When community members faced a difficult decision, especially one involving risk or danger, they could appeal to the Asipu for advice. The Asipu, using a process similar to modern-day hazards risk management, would first analyse the problem at hand, then propose several alternatives, and finally give possible outcomes for each alternative (Covello, 1985).

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The first “modern” is considered to be the Lisbon earthquake of 1755. The earthquake estimated to be of nearly 9.0 on Richter scale destroyed 85% of Lisbon’s buildings, and killed roughly one third of the city’s population. The Prime Minister took charge and applied many response measures, including ordering the army to surround the city and prevent workers from leaving, providing transportation for food delivery, mass burial at sea and controlling looting. This is considered a seminal event because it marked the beginning of a change of attitude toward the nature of disaster itself (Canton, 2007). However, modern disaster management, in terms of global standards and organized efforts to address preparedness, mitigation, and response activities for a wide range of disasters, did not begin to emerge until the mid-20th century (Coppola, 2006). On December 11, 1987, the United Nations General Assembly declared the 1990s as the “International Decade for Natural Disaster Reduction” (IDNDR) thus placing disasters and their management on the international policy agenda of UN member states and the public more broadly. In May 1994, UN member states met at the World Conference on Natural Disaster Reduction in Yokohama, , and developed the Yokohama Strategy and Plan of Action for a Safer World (El-Sabh, 1994). The nature of disasters is constantly changing; and there are several emerging trends in disaster and disaster management that are noteworthy. Firstly, disasters which produce mass casualties are increasing, in large part because of population increases and aging (Noji, 1994). Secondly, disasters are becoming less deadly and more costly. Thirdly, governments are becoming increasingly involved in emergency management (Canton, 2007). Fourthly, poorer countries are disproportionately affected by disaster consequence (Coppola, 2006). And lastly, health care capability is improved; and community expectation is rising in regard to disaster health management.

4.1.2 Disaster Management Concepts

Throughout history, disasters have had a significant impact on human development (Bankoff, Frerks, & Hilhorst, 2004). As shown in Figure 4-1, disaster caused a loss in the progress of human development. Effective disaster management and recovery efforts are able to reduce the impact of disaster on development. For example, Hurricane Mitch destroyed as much as 70% of the infrastructure in Honduras and Nicaragua (ISDR, 2004), and it is blamed for reversing the rates of development in those and other Central

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American countries by at least a decade (Oxfam, 1998). It has been noted that the 2004 Indian Ocean Tsunami washed away much of the economic and social progress in the Maldives and caused a 20-year setback in the development of this country (UNDP, 2005). Figure not available due to copyright restrictions.

This Figure shows the impact of disasters on development, with disaster cause a loss, disaster relief/Reconstruction speed up the re-development, though a development lag is constant.

This Figure can be viewed in the print version of the thesis located in QUT Library

Figure 4-1: Impact of disasters on development Source: (Asian Disaster Reduction Centre, 2005) However, disasters can both destroy development initiatives and create development opportunities, and those development schemes can both increase and decrease vulnerability (Stephenson & DuFrane, 2002). In a crisis (危机), it is very important to make use of this opportunity (机) after the disaster (危). The degree of the damage caused by disasters is affected by many factors, including the severity of the disaster, population density in the disaster-prone areas, local building codes and other mitigation efforts, community preparedness, the management of response and recovery (UNDP, 2004). Therefore, effective disaster management in all its forms is critical and it is important to establish standard principles and approaches of disaster management. Emergency Management Australia (EMA) (2009d) describes emergency management as a range of measures to manage risks to communities and environment, and described the measures as: comprehensive approach, all hazards approach, all agencies approach, and prepared community. Each of these approaches is guided by a set of concepts and principles.

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All agencies approach means all agencies work together through planning, response and recovery. It is important to clarify common rules and each agency’s role. In other words, this is a multidisciplinary approach as it brings together diverse agencies and people with varying roles and professional backgrounds. The context of emergency management for specific agencies varies and may include: ensuring the continuity of their business or service; protecting their own interests and personnel; protecting the community and environment from risks arising from the activities of the organisation; and protecting the community and environment from credible risks.

All hazards approach means a common approach to initial response regardless of the particular hazard. This concept is useful to the extent that a large range of risks can cause similar problems and measures such as warning, evacuation, medical services and community recovery will be required during and following emergencies. However, the response needs to be supported by hazard specific responses in due course.

Comprehensive approach focuses on the pre-event, event, and post-event continuum. It includes the four phases: prevention and mitigation; preparedness and planning; response and relief; recovery and rehabilitation (PPRR).

A prepared and resilient community is one that applies a comprehensive, all hazards and all agencies approach at the local level (typically at local government level), and one that includes mitigation and risk reduction, self-help, community resilience, and the strengthening of local agencies within this approach.

4.1.3 Disaster Management Cycle

Emergency management rests on three pillars: knowledge of history, an understanding of human nature expressed in the social sciences, and specialized technical expertise in response mechanisms (Canton, 2007). Comprehensive disaster management is based upon four distinct components, i.e. prevention, preparedness, response and recovery (PPRR). Effective disaster management utilises each component as following:

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¾ Prevention/Mitigation is a measure that aims to eliminate or reduce the incidence or severity of emergencies. Prevention seeks to deal with a hazard so that it impacts the society to a lesser degree. These measures can be physical or legal measures, such as clearing leaf litter from a household or Total Fire Ban days. Prevention includes capability development, which seeks to enhance national emergency management capabilities through the identification of gaps, and from this, the development and implementation of government initiatives to address these gaps. ¾ Preparedness/Planning equips people who may be impacted by a disaster or who may be able to help those impacted with the tools to increase their chance of survival and to minimize their financial and other losses. Aspects of preparedness include: plans and arrangements that are put in place before an emergency occurs; assessing risks which determines how likely an emergency event is to occur, as well as how severe it could be; business continuity which plans for the continued availability of essential business services; planning to mitigate the potential effects of an emergency. ¾ Response/Relief is to take actions and measures to reduce or eliminate the impact of disasters that have occurred or are currently occurring, in order to prevent further suffering, financial loss, or a combination of both. In the response, the eight “C” principles are identified in the standardisation of response arrangements: Command; Control; Coordination; Communication; Containment; Continuity; Capability and Clinical care. Communication in the disaster management is vital, including the message and the means. As for the message, the role of the modern mass media is crucial (Coppola, 2006). As for the means, the vulnerability of normal channels such as mobile phones should be considered, and new technologies for telecommunications should be deployed (Patricelli, Beakley, Carnevale, Tarabochia, & von Lubitz, 2009). Accessing and exchanging timely and accurate disaster relevant information can be difficult, which may inhibit the coordination and decision making (Celik & Corbacioglu, 2010; Yang, 2010). Different actors and stakeholders involved in disaster management, such as the local government and the NGOs, may have different perceptions and thus add to the difficulty in coordination (Bankoff & Hilhorst, 2009; Benini, Conley, Dittemore, & Waksman, 2009).

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¾ Recovery/Rehabilitation is returning victims’ lives back to a normal state following the impact of disaster consequences, including the reconstruction of the physical infrastructure and restoration of emotional, social, economic and physical wellbeing. The recovery incorporates consequence management, and generally begins after the immediate response has ended and can persist for months or years thereafter.

All disasters follow a cyclical pattern known as the disaster cycle as shown in Figure 4-2 (Alexander, 2002). However, as each disaster evokes better management, the cycle should be spiral as shown in Figure 4-3, which shows the development of the each management cycle. Figure not available due to copyright restrictions.

This Figure has three circles, with the internal circle inlcuding Quiescence, Pre-impact, Emergency, Restoration, Reconstruction; the middle circle covering Mitigation, Preparation, Response, Recovery; the outer circle covering Before the Event, Impact, After the Event.

This Figure can be viewed in the print version of the thesis located in QUT Library

Figure 4-2: The disaster management cycle. Source: (Alexander, 2002)

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Figure 4-3: The spiral mode of disaster management cycle Source: Author Canton (2007) argues that a plan at a certain level can’t be truly effective without the lower level plans in place to support it and provide a scaffolding effect. For example, poor mitigation plans means greater impact of disasters on the community, and thus increase the demand on personal and resources during emergency response; continuity plan failures may result in delayed recovery operations. Canton further identified a model of “plan hierarchy” as shown in Figure 4-4.

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Figure not available due to copyright restrictions.

This pyramid Figure has seven levels, including Risk Management Strategy at the bottom, followed by Strategic Plan, Mitigatioin Plan, Emergency Operations Plan, Continuity Plan, Recovery Plan, and Resilience on the Top.

This Figure can be viewed in the print version of the thesis located in QUT Library.

Figure 4-4: Plan hierarchy Source: (Canton, 2007)

4.2 Disaster Health Management

Disaster medical response has been around for thousands of years as the responsibility for the care of the injured from a disaster has always been borne by the Medical Emergency specialist (Ciottone, 2006). In the United States and many other countries, much of the disaster medical response has followed a military model, with lessons learned through battlefield scenarios during the last two centuries (Dara, Ashton, Farmer, & Carlton, 2005). However, military experience cannot always be directly translated directly into civilian practice. For instance, patients from the battlefield are mostly fit soldiers with trauma while patients in natural disaster include males and females across the life course with the ill and old disproportionately affected (Ciottone, 2006). With this realization, the creation of disaster medicine as an evolution from the military practice is necessary, and to develop or improve Emergency Medical Services Systems (EMSS) within societies with different resources is a common goal in the international health field (Dines, 1990).

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4.2.1 EMS in Disaster Health Management

The role of emergency medical service (EMS) in disaster is to provide effective pre-hospital casualty care, prevent further life-threatening or acute illness, and facilitate resolution of the medical component of the event (Hogan & Burstein, 2007b). However, there are many factors to consider: the resources supplies, medical caches, donations, immunization programs, and ethics. Thus, it’s important to set up principles for disaster health management (Landesman, 2005). The principles of clinical management are listed as following: • Triage should be continuous, and also at critical points; y Evaluation and diagnosis of the patients; y Essential care, which includes individual care based on normal practice; minimal care to ensure safety; priority for life and limb protection; y Clinical standards of care to avoid confusion; y Documentation of each event; y Protecting medical staffs’ families and keep their contacts; y Decontamination and isolation of patients with infectious diseases. Triage, evacuation, and definitive medical management are the three major phases of initial mass casualty and disaster care (Burkle, 1984). Triage was first formalized in Australasian Emergency Departments (EDs) following the seminal work of FitzGerald (1989) in Ipswich, Queensland, who developed and tested a five-point scale based on optimal time to medical intervention. During disasters, the goal of triage is to “do the greatest good for the greatest number” by sorting casualties into the highly injured who can wait for care without risk; the hopelessly injured who will not survive; and the seriously and critically injured who are prioritized for transportation and treatment based on their injury level and available resources (Hogan & Lairet, 2007). As the availability of resources may change, the triage should be a dynamic process of rapid evaluation and frequent reassessment. There are many ethical issues in triage and thus it must be based on sound medical criteria. Experience has shown that a good emergency medical service system (EMSS) can save lives and reduce suffering (MacFarlane & Benn, 2003). It has also been shown that when EMSS is badly managed, results will fall short of expectations, and patients will be ill-served (Ronald, 1986). So, the best way to model the EMSS is to make the best use of

- 55 - resources. It is important to identify the resources both available and needed in one country, and use these to develop further strategies to achieve attainable objectives.

4.2.2 Hospitals in Disaster Health Management

Hospitals play an essential role in both daily emergencies and disaster health management. Patients expect hospitals and the health system workers to be available to provide care in all circumstances. However disasters are not simply large emergencies and are both quantitatively and qualitatively different, and include such circumstances as large numbers of casualties, communication interruption, loss of staff, transportation, and damage to facilities (Heide, 2007). Disasters can be a special challenge to hospitals as its surge capacity is reduced and limited by ED overcrowding and ambulance diversions, thus endangering patients’ safety and increasing risk of in-hospital mortality, and hospital-related incidents (Khorram-Manesh, Hedelin, & Ortenwall, 2009). Nevertheless, it is important for hospitals to maintain essential health services during disasters, including the aspects of workforce protection, supply and equipment maintenance, access, and capacity creation (Barbera, Yeatts, & Macintyre, 2009; Bradt et al., 2009; Gamble, 2009). When the scale of disaster is unknown or may enlarge, it is necessary to preserve the health capacity at the early stage. The capacity perseveration may be divided into four levels as following: y Level 1 Concentrate expertise utilising existing infrastructure; y Level 2 Preserve infrastructure for the event by early discharge, limiting non- urgent activity; y Level 3 Expand health infrastructure through system-wide management, growing capacity and importing capacity; y Level 4 Ration access to health infrastructure through triage of patients.

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4.2.3 Personnel in Disaster Health Management

Health care personnel may not be willing to work in all disaster situations due to concerns about the safety of their family, as well as their own safety (Chaffee, 2009; Masterson, Steffen, Brin, Kordick, & Christos, 2009). Therefore, emphasis should be placed on the health of personnel both prior to and post the deployment of medical response teams (Aitken et al., 2009). Education and training, as well as enhanced financial remuneration and disability coverage may increase the response (Masterson, et al., 2009; Reilly & Markenson, 2009). Cell phone text messaging may be used to recall staff when necessary (Epstein, Ekbatani, Kaplan, Shechter, & Grunwald, 2010). Apart from doctors, nurses, and paramedics, there are other health workers that can contribute to the disaster health management. Pharmacists, as part of the disaster relief team, can play an important role in inventory management, formulary management, administration guidance, medication delivery, identification of a tablet, analysis of intoxicating substance, and therapeutic drug monitoring (Hogue, Hogue, Lander, Avent, & Fleenor, 2009; Takeda, 2010). Plastic surgeons are trained in acute trauma management, and also have expertise in the assessment and treatment of soft-tissue injuries, upper extremity trauma, facial fractures, and both operative and non-operative burns management (Thakar, Pepe, & Rohrich, 2009).

4.2.4 Pharmaceuticals in Disaster Health Management

Pharmaceutical supply and donation are critical elements in disaster medical response and relief. Disasters usually attract large pharmaceutical donations; while essential drugs assist the disaster relief, inappropriate pharmaceutical donation may create secondary problems for the recipients (Harrington, 2007). In order to prevent such problems for the recipients as massive quantities, improper labelling, expired drug, WHO(1999) identified a pharmaceutical donation guidelines as listed in Table 4-1.

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Table 4-1: Guidelines for Drug Donations

• Drugs should not be sent without prior consent by the recipient • Donated drugs should be approved for use in the recipient country and appear on the national list of essential drugs • Donated drugs should be obtained from a reliable source and comply with quality standards in both donor and recipient country • No drugs should be donated that have been issued to patients and then returned to a pharmacy or elsewhere • Donated drugs should have a remaining shelf-life of at least one year • Drugs should be labelled in appropriate language. And contain the generic name, strength, name of manufacturer, storage conditions and expiry date • Recipients should be informed of all drug donations that are being considered, prepared or actually under way Source: (World Health Organization, 1999) and author

On the other hand, request for certain products can be a challenge for the supply chain, such as the requests for influenza pandemic-specific products during the H1N1 pandemic influenza pandemic (Cusick, 2010) and the request of blood in Sri Lanka during 2004 India Ocean Tsunami (Kuruppu, 2010). In addition to the problems related to the identification and sorting of pharmaceuticals, the logistics of pharmaceuticals may become a problem for pharmaceutical donors. The logistics of pharmaceuticals may be restricted by the infrastructure, transportation, as well as pilfering of donations (Harrington, 2007).

4.2.5 Vulnerable population in Disaster Health Management

Vulnerable population groups in disasters include the frail older people, the children, the sick, and the disabled, the disadvantaged, and the least able. Thus, it is important for governments, relief agencies, and local partners to include and address these issues during their relief operations and policy planning (Chan, 2009; Chen, Wilkinson, Richardson, & Waruszynski, 2009; Gamble, Hanners, Lackey, & Beaudin, 2009; Powell, Plouffe, & Gorr, 2009). “People-focused” planning methodologies that plan with all segments of society, including the most vulnerable and marginalized groups,

- 58 - should be used; and people must be viewed not as a part of the problem to be solved or managed during an emergency, but rather a part of the solution to building more resilient and disaster-resistant societies (Hutton, 2009). The psychosocial effect on these groups, which may stem from socio-demographic status or ripple effects in the community, should also be considered (Lemyre, Gibson, Zlepnig, Meyer-Macleod, & Boutette, 2009). The survivors of disasters may become a vulnerable group; and their mental well-being is directly related to the level of exposure to a disaster and requires pre- and post-disaster intervention (Milligan & McGuinness, 2009).

4.2.6 Public Health in Disaster Health Management

Public health is concerned with two objectives in disaster management - the elimination of preventable consequences of the disaster itself and the prevention of loss due to disaster relief management (Foege, 1986). Rapid establishment of basic public health measures following a disaster have a substantial impact on the prevention of infectious disease outbreaks (Watson, Gayer, & Connolly, 2007). There have also been some myths around communicable disease in disasters, and it is important to know the reality in regarding to the management. Dead bodies may not pose a risk for outbreak, though it may heighten the concerns that outbreaks will occur (de Ville de Goyet, 2004; Pan American Health Organization, 2004). Infectious diseases that are not endemic to a region will not occur unless they are brought into the region during disaster response (Richard & Josette, 1992). The local population almost always covers immediate lifesaving needs, thus foreign medical volunteers may not be needed except those with skills that are not available in the affected country (World Health Organization, 2010b). Disasters are not random killers, rather they affect the most vulnerable group and the poor (Noji, 1997b; World Health Organization, 2010b). In the acute emergency phase of disasters, measles immunization is likely to be one of the most important preventative measures, especially for young children (Noji, 2005). Timely public health interventions include providing clean food, clean water, shelter; disease and nutrition monitoring; disease prevention; and basic medical care (Noji, 2007). It is important that the water and sanitation intervention is grounded in the local cultural and socioeconomic context (Jensen, Meyrowitsch, & Konradsen, 2010).

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4.3 Disaster Management in Developed and Developing Countries

Developing country is a term generally used to describe a nation with a low level of material well being. According to the World Bank (2009b), countries with gross national income (GNI) per capita below US$11,905 were considered developing in 2008. Developed countries are mostly located in North America, Europe, and Oceania. America is prone to many disasters including earthquakes, hurricanes, floods, tornadoes, forest fires. However, they were overshadowed by concerns about terrorist attacks since September 11, 2001 (Scanlon, 2004). In America, the Federal Emergency Management Agency (FEMA), which was established in 1979 and became part of the U.S. Department of Homeland Security (DHS) in 2003, is the main agency responsible for disaster mitigation and response (FEMA, 2009a). The National Response Framework (NRF), which replaced National Response Plan in March 2008, presents the guiding principles and establishes a comprehensive, national, all-hazards approach to domestic incident response (FEMA, 2009b). North America has relatively low rates of loss of life in disasters, partly from more effective forecasts and warning devices; partly from a more highly mobile population; and partly from more substantial structures having greater resistance to natural forces(Scanlon, 2004). Europe has variable geographical conditions, and regularly suffers from certain types of disaster, for example earthquakes, winter storms, flooding and pandemics, although the fatality rate is usually low. However, over a period of about 1000 years of relatively stable settlement, Europe has developed skills in avoidance, mitigation and management of the effects of natural disasters. For example, flood management measures include building higher dikes and embankments, early warning and evacuation, community education; avalanche management measures include planning their buildings, roads, and railways away from risks, building fences and planting forests (Houtsonen & Peltonen, 2004). Europe is often perceived as a region that suffers few natural disasters. Much of the vulnerability reduction in Europe is due to physical (engineering), governmental (planning), and social (education and experience) interventions, rather than to any lack of natural disasters threatening the human communities (Houtsonen & Peltonen, 2004).

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Japan is affected by disasters such as typhoon and earthquakes. Under the Disaster Countermeasures Basic Act, Japan formed the Central Disaster Management Council to ensure comprehensive disaster risk management. The council consists of the Prime Minister, Minister of State for Disaster Management, other ministers, heads of major public institutions and experts. (Asian Disaster Reduction Centre, 2009) Aware of locating in the “centre point” of natural disasters, Japan has worked to reduce its vulnerability by adjusting their building codes and introducing other hazard management policies, constructing new forms of protection and practicing safety and evacuation drills where appropriate (Sasaki & Yamakawa, 2004). In contrast to the USA, Europe and Japan, developing countries, such as China, Indonesia, and some other countries in Africa and Latin America are highly vulnerable to disasters. High fatality rates in these areas are not only due to geomorphology and population density, but also to lack of disaster mitigation policy, absence of risk assessment, weak institutional capacity, and community awareness (Alcántara-Ayala, 2002; Wakuma Abaya, et al., 2009). Poor building codes and/or poor implementation of building codes is also contributing to the vulnerability (Kreimer, Arnold, & Carlin, 2003). There is no doubt that “internationally accepted” disaster management concepts are also relevant in developing countries and disaster management planning within their economic constraints would greatly reduce the extra burden caused by disasters (Martin, Capra, Heide, Stoneham, & Lucas, 2001). However there are a number of reasons why the success of the developed countries has not been mirrored in developing countries: Firstly, the cost maybe is too prohibitive for developing countries to build dams, launch and monitor weather satellites, retrofit buildings and other infrastructure. Governments in developing countries would like to manage disasters as effectively as developed countries, but it’s unlikely that those governments can afford the funds. It’s simply too expensive to build power plants, gas storage facilities, and offshore drill sites to seismic and storm surge standards (Scanlon, 2004). Secondly, these activities may not stop future disasters which may be more serious. Hurricane Katrina in New Orleans in 2005, which caused 1,833 deaths, with 500,000 people affected, and had an economic damage of US$125 billion, demonstrated how a developed county can still be impacted greatly by disasters(EM-DAT, 2009c) . Thirdly, there is also evidence that some devices built to stop disasters threats may create or increase the chance of another disaster. Charles Perrow (1984) shows that

- 61 - reservoirs may lead to earthquakes, and the effects can be devastating when protective devices fail. Improved flood defence infrastructure may induce new development in the flood-prone zone, and thus putting more people and property at risk. Developing countries present a new environment in which to apply the unique expertise and knowledge of disaster management and disaster medicine. However, while international knowledge and experiences provide important reference points for developing countries, the collaboration of disaster management and disaster medicine development should be based on the understanding of the cultural, political and economic forces that affect the health care within that country (Sklar, 1988).

This chapter has discussed the general disaster management history, disaster management concepts, and the disaster management cycle. The chapter has also focused on disaster health management and compared disaster management in developed and developing countries. Having discussed disaster management approaches, this thesis now turns to examine the concept of policy. An understanding of policy theory and evaluation is central to the current research which is concerned with evaluating and comparing disaster management approaches in China and Australia and with formulating and validating a disaster policy framework.

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Chapter Five: Policy and Disaster Management

Previous chapters have focused on the nature and impact of disasters and the system that comprise disaster management. This chapter turns to examine policy concepts and theories. An understanding of policy concepts and theories will provide a foundation for examining and analysing disaster health management policy. The chapter firstly examines definitions of policy and identifies policy types. It then examines the top-down and bottom-up approaches to policy development and implementation. Lastly policy models are examined, including the policy elements of context, process, content, and actors.

5.1 Introduction

While the study of politics has a long history, public policy is a “new” area of study that is less than 100 years old (McCool, 1994). It is also a field that is multidisciplinary in approach, drawing from such fields as political science, economics, psychology and sociology. Public policy development is almost solely the domain of governments and public institutions. The fundamental objectives of most government policies address efficiency, equity, or security (Pearson, Gotsch, & Bahri, 2004). Policy analysis is “determining which of various alternative policies will most achieve a given set of goals in light of the relations between the policies and the goals” (Nagel, 1999). Policy analysis is methodologically diverse and can make use of both qualitative methods and quantitative methods, including case studies, survey research, statistical analysis, and model building. The analysis of disaster health management policy aims to improve disaster preparedness and management through various methods including needs assessment, identification of health care levels, and coordination (Bremer, 2003).

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5.2 Policies and Policy Types

A policy is “a statement by government of what it intends to do or not to do, such as law, regulation, ruling, decision, or order, or a combination of these” (Birkland, 2005). In the public policy process, it is important to gain an understanding of how various interests are organized and how various interests react to different kinds of policies. The intent of policy development is to drive reform or to improve a particular aspect of society. The earliest policy topologies generally separated policy into topical categories, such as education policy, health policy, and transportation policy. The modern era of policy topologies can be traced back to 1964 when Theodore Lowi divided policies into three categories: distributive, redistributive, and regulatory policy (Lowi, 1964). Ripley and Franklin then updated the topologies by dividing regulatory policy into protective regulatory and competitive regulatory (Ripley & Franklin, 1991). The Ripley and Franklin formulation is shown in Table 5-1.

Table 5-1: Definition and Examples of Policy Types Policy Type Definition Examples Distributive Policies that tend to distribute a good or Federal spending on local benefit to some segment of society, but infrastructure projects like dams whose costs are not deeply felt by another and flood control systems; farm group in the society. subsidies Protective Policy that regulates some activities for Air pollution regulations to Regulatory the protection of the public. protect the public health Competitive Policy that limits the provision of goods Policies intended to regulate Regulatory or the participation in a market to a trades or professions, such as selected group of people or organizations. law, medicine, plumbing, anti- monopoly legislation. Redistributive Policy that gives a benefit to one group by Welfare for social minorities, seeming to impose a discernable cost on aid to poor cities etc. another group. Source: (Birkland, 2005) and author. Particular policies may not fit into perfectly delineated boxes or cells; however, thinking about policies according to these different “types” assists in classifying policies and gaining insight into the features of particular policies. Disaster management policies are intended to protect people from disasters or distribute benefit to those affected by disasters. Thus disaster management policies generally fall into the categories of distributive policy and protective regulatory.

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5.3 Top-down and Bottom-up Policy Approaches

Policy operates in two distinct levels: the political/administrative level and the field level (Clark, 1994); thus there are two approaches to policy development and implementation: the top-down policy approach and the bottom-up approach. A top-down policy approach is one where policy-making elites comprising politicians and expert advisors at the state or national level take the lead in policy development and implementation. A bottom-up approach is one where policy arises from the efforts of the joint involvement of the field staff and consumers. The two approaches differ mainly with respect to where power ought to reside - either at the top, or at the bottom. A top-down policy approach can provide a consistent framework, establish objectives, guidelines, planning and funding processes, and information. Thus it can save time and resources, and achieve results efficiently and effectively (Nevill, 2004). A top- down approach is also likely to be transparent and accountable. However, it may underestimate the importance of local knowledge and commitment (Pereira, Carlos, Maravall, & Przeworski, 1993). A bottom-up approach has sound grass-roots support for the implementation of policies and strategies. Without the support of local people who will actually implement the policy, operational components of the policy will not be implemented in an efficient manner (Nevill, 2004). Thus the knowledge and experience of local people must not be underestimated in policy development and implementation. However, a bottom-up approach has been criticized as it can “waste resources on re-inventing wheels which could be supplied in an informed and cohesive way by a top-down structure” (Nevill, 2004). Top-down policies that are aimed at regulating field staff can “constrain but not construct” their practice (Clark, 1994). As local ideas and circumstances can vary, local leadership and commitment for change are critical to policy success. Therefore it is important to establish feedback channels so that the “map” supplied through the top-down structure can evolve in the light of bottom-up experience and knowledge. Top-down and bottom-up approaches can support each other and can be complimentary: the top-down model can often explain a policy’s formative development; where the bottom-up approach can explain the policy operational implementation (Clark, 1994).

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In relation to disaster management, a top-down approach can be used to model a generic framework of emergency management; while bottom-up can be used to identify and design specific functions required by emergency managers with predefined roles. It is recognized that while a top-down policy is needed, it is really the local-level bottom-up policy that provides the impetus for the implementation of a successful disaster management process (Pearce, 2003). The disaster management practices have evolved from largely a top-down relief and response approach to a bottom-up based risk management and vulnerability reduction approach (Yodmani, 2001).

5.4 Models of Policy and Policy Making

Different policy models have been developed by various policy experts to assist policy makers and researchers to better understand the process of policy making and reform. Easton (1965) and the systems modelers argued that we can think of the public policy process as the product of a system, influenced by and influencing the environment in which it operates. The system receives inputs and responds with outputs. The inputs can include issues, pressures, information and the like, to which the actors in the system react. The outputs are, in simplest terms, public policy decisions to do or not to do things. A simplified depiction of this system is shown in Figure 5-1. Figure not available due to copyright restrictions.

This Figure shows inputs (Election results, public opinion, communications to elected officials, media coverage of issues, personal experiences of decision makers), The Political System or "The Black Box", and the Outputs (Laws, Regulations, Decisions).

This Figure can be viewed in the print version of the thesis located in QUT Library.

Figure 5-1: A systems model of politics and policy Source: (Birkland, 2005)

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Three decades later, Walt and Gilson (1994) proposed a policy model which emphasises that policy analysis should not only include the content of policies, but also the actors involved, the processes needed to implement change and the context (social, political, cultural, economic, historical) in which the policy operates (See Figure 5-2). This highly simplified triangular framework enables both the novice and experienced analysts to explore the complex interrelationships of policy-making. However, it should be noted that while the concepts of context, process, content, and actors are listed separately, they are influenced by each other. For example, the policy making process is affected by the actors, their power, values, expectations; the content is a reflection of the context and the actors’ power and expectation (Walt & Gilson, 1994).

Figure 5-2: Model for health policy analysis Source: (Walt & Gilson, 1994)

5.5 Policy Elements

Walt and Gilson’s model provide a framework for analyzing policy. It was specifically developed for furthering the understanding of policy development and implementation in developing countries and thus will be used in this thesis to analyse the disaster health management policies in China. The four policy elements under this framework, i.e. the policy context, policy process, policy content, and actors involved, are examined in this section.

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5.5.1 Context of Policy

Policy is developed based on the current environment or context. The context of the policy may include the structural, social, cultural, economic, and technologic environment of the society. Policies may need to be adjusted when the context changes. The government’s role and the “public interest” form the structural context of the policy. There is an ongoing debate about whether the government exercises power in favor of the dominant classes or represents the majority views (Walt & Gilson, 1994). Social-cultural context of policy includes the social beliefs, religions, values, ways of perceiving and understanding the world, and community expectations. The social- cultural context is a very important factor in disaster management policies in terms of risk management and psychosocial recovery (e.g. management of dead bodies) (Gilbert, 2007; Jasanoff, 1986). The economic context determines the resources available for disaster management, and thus limits the policy options. Disasters in turn may have a significant impact on the economy. As a developing country, China has to construct disaster management policies in such a way as to efficiently utilise the existing resources. Chapters two, three and four of this thesis provided a general context for disaster management policies. As the number of disasters and the number of people affected by disasters are rising, effective disaster management policies are more in demand. However, the context of the disaster management policies in different countries varies greatly; and context-specific disaster health management policies are needed in China.

5.5.2 Process of Policy

Policy process can be represented in many ways. Althaus, Bridgman and Davis (2007) developed an eight step policy cycle in The Australian Policy Handbook, including issue identification, policy analysis, policy instrument development, consultation (which permeates the entire process), coordination, decision, implementation and evaluation as shown in Figure 5-3. However these steps are not necessarily sequential and can be overlapping; they may also need to be repeated several times through the

- 68 - development of policy. It is described as a cycle due to the need to continually review and refine policy based on the outcomes of implementation, or changes in the environment.

Figure 5-3: The Australian policy cycle Source: (Althaus, et al., 2007) Many other policy process models have been developed to describe the political- policy-administrative process involved in developing and implementing policies. However, the most basic model identifies four phases or stages associated with policy process (Anderson, Brady, & Bullock, 1978; Barkenbus, 1998) as shown in Figure 5-4. Once a problem has been identified and the decision makers place the issue on the agenda for active consideration, there are three aspects of the policy process: policy formulation, policy implementation, and policy evaluation.

Figure 5-4: Conventional policy process Source: (Barkenbus, 1998)

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Agenda setting is the process by which problems and alternative solutions gain or lose public and elite attention, and thus government interest. Parties, interest groups, departments and private companies all compete to draw attention to their key issues through parliament, the media, public events, and private lobbying. Cobb and Elder (1972) suggested issues have the best prospect of attracting the attention of politicians when a topic has mass appeal. E.E. Schattschneider (1975) developed the theory that issues are more likely to be elevated to agenda status if the scope of conflict is broadened. There are two key ways that disadvantaged groups can expand the scope of conflict: groups go public with a problem by using symbols and images to induce greater media and public sympathy for their cause; groups appeal to a higher decision-making level. There are an infinite number of disaster management issues that could reach the agenda of decision makers. Greater disaster losses, as well as predictions about the more hazardous natural environment in the future, may elevate disaster management as higher priority for the decision makers. When a disaster occurs, disaster management approaches are tested and can be found wanting, thus leading to change. For example, the September 11 Attack expanded the “terrorism” agenda in the U. S.; 2003 SARS changed the government agenda in China. The relationship between flood disasters and the demand by the public for a policy response is well known (Tobin & Montz, 1997). However, it usually takes a severe and damaging flood, such as the flood after Hurricane Katrina, to place flooding and disasters on the political agenda, at a time when the public and media response is such that a failure to act is politically unacceptable (Miller & Rivera, 2006; Parker, 2000b).

The policy formulation or policy development is the development of policy alternatives for dealing with problems on the agenda. While policy agenda determines the “major direction” of policy change; the policy formulation is centered on the “means” of policy. Actually, the formal policy formulation concerns itself with “details of implementation: who gets the political credit, what agencies get control of the program, and exactly how much money will be spent” (Dye, 1998). Policy formulation occurs in government bureaucracies, interest group offices, legislative committee rooms, meetings of special commissions, and policy-planning

- 70 - organizations (“think tanks”) (Dye, 1998). The formulation is made through technical analysis, consultation, and political process to develop new policies. The assessment and consultative processes are essential to define and formulate policies as the policy formulation group gathers information and understanding. Though it is not possible to assess all possible impacts of a given policy in the complex societies and governments, attempts should be made to assess as many areas as possible. The assessment and consultation processes not only lessen the chances of getting unexpected or unintended consequences, but also indirectly gains public support to implement the policy. The legitimization or the approval of the policy is the final phase of policy making. It is a process of bargaining, competition, persuasion and compromise among interests groups and government officials; and conflict between them may delay or alter the final policy (Dye, 1998; Holzinger, 2001).

Policies themselves are not self-executing, and the difficulty of achieving policy implementation can be substantial as implementation means a change to normal practice (Ingram & Mann, 1980b). Implementation brings together many actors and forces that cooperate and clash with each other the attempt to achieve policy goals. The policy implementation can be affected not only by contextual matters such as social, political, and economic conditions, but also by the nature of the problem, diversity of problems being tackled, the size of the target group, and the extent of behavioral change required (Howlett & Ramesh, 1995). To ensure policy success, it is essential to maintain the interest and support of relevant stakeholders: the overseeing of implementation by politicians can be necessary, and the concept of mandate may be used by governments to support policy delivery on the ground (Althaus, et al., 2007). Additionally, a vast literature suggests the following key lessons for successful policy implementation (Althaus, et al., 2007; Ingram, 1990):

¾ All policies are built on implicit theories about the world and how it operates; ¾ Policies should include as few steps as possible between formulation and implementation; ¾ The responsibility should not be shared among too many players; ¾ There must be a clear chain of accountability;

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¾ Those who deliver a program should be involved in policy design; ¾ Continuous evaluation is essential to ensure policy evolves and becomes more effective;

This research will look into the detail of how these lessons can be applied to disaster health management in China. This will be discussed in the third and fourth parts of this thesis. Policy evaluation is the most easily “neglected” phase in the policy cycle due to the potential embarrassment it could bring to those who were responsible for the policy formulation and implementation (Barkenbus, 1998). However, policy evaluation is an essential part that can provide feedback to all the other phases of the policy cycle, and it forms part of the transparency and accountability of governments. This is especially true for disaster management: new policies, laws and programs created in the wake of a disaster but lacking the requirement for performance and evaluation may result in reduced or limited effect when the next disaster strikes. Policy evaluation is a process that aims to establish whether the policy addresses the problem that it was meant to, and whether it has achieved the desired outcome. It is also aimed at identifying what didn’t work, why it didn’t work, and what unintended consequence occurred. Policy evaluation involves a close examination of policies and their accompanying techniques of application, and may take the form of a monitoring activity (is the policy working?) and a retrospective evaluation (did the policy work?). Where policy has not produced the outcome intended, it is important to examine the process of implementation and adoption of the policy to identify barriers - structural, cultural or scarcity of resources - that may have prevented appropriate implementation. Many citizens believe that policies fail because of poor design or incompetent administration. This may be true in some cases, but policies may also fail because of unanticipated circumstances, resistance to the policy during implementation but after enactment, and the vagaries of the political process (Birkland, 2005). Helen Ingram and Dean Mann (1980a)provide us with a list of reasons for policy failure as shown in Table 5-2.

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Table 5-2: Explanations to Policies Failure

Table not available due to copyright restrictions.

This Table lists the possible reasons for policies failure, such as changing circumstance, political boundaries etc.

This table can be viewed in the print version of the thesis located in QUT Library.

Source: (Ingram & Mann, 1980a) Disaster management policy failures may result from the impact of changing environment, relationships with other policies, boundary issues, excessive policy demand, lack of sound bases, or failure of political institutions. The case studies and survey of experts are used in this research to explore the policy failures and their reasons based on disaster health management in China.

5.5.3 Content of Policy

Policies are typically promulgated through official written documents. Thus, policies, including disaster management policies, usually have standard formats that are particular to the organization issuing the policy. The content of policy may typically include title, effective date, contact, introduction, policy statement, and resources. The policy title is usually required to be brief, descriptive, and clear. The official effective date must be stated as it may be different than the date the policy was adopted. The contact details are for consultations regarding the policy. The introduction may include the policy background, purpose, and the authoritative basis of the policy, the

- 73 - applicability and scope, and the responsibility. The policy statement is the policy itself; it includes statements of rules or standards, and usually a glossary as well. The resources are usually links to related information. There are two faces of power: compel people to do things and keep people from doing things (Bachrach & Morton, 1962). Policy takes the form of strategies and actions within a set timeframe. Policy tools or policy instruments are “elements in policy design that cause agents or targets to do something they would not do otherwise or with the intention of modifying behavior to solve public problems or attain policy goals” (Schneider & Ingram, 1997). Policy tools include explanation, direct service provision, transfers grants, tax, regulations, loans, insurance, contracts, licensing, informal procedures, capacity building, inducements, sanctions and hortatory techniques. Policy designers must consider a number of elements when selecting a policy tool, including political feasibility, resources available to implement policy, behavioral assumptions about the target populations. Policy tools and implementation are inextricably linked to each other. The choice of policy tools both influences implementation and is influenced by implementation. Learning from real or purported policy failure is an important part of the policy adjustment (Birkland, 2005). Therefore, policy should have an objective that can be analysed and assessed. Evaluation process - a description of the way in which the impact of the policy will be assessed and a timeline for this - should be part of the policy.

5.5.4 Actors in Policy

Public policy can impact on the way we live, our ability to earn income, our level of freedom, the equity and fairness with which we are treated by government. Therefore, many groups are interested in influencing public policy to achieve advantage for themselves or their community. Group competition to set the policy agenda is fierce because no society, political system, official actor, unofficial actor, or individual person has the capacity to address all possible alternatives to all possible problems that arise at any one time. (Hilgartner & Bosk, 1988) The concept ‘interest group’ itself can be misleading as it refers to individuals, organizations or institutions that are associated in a body that aims at influencing public policy. In most advanced capitalist democracies, the number of interest groups is very

- 74 - large indicating that their political mobilization capacity is considerable. As an important implication, interest group systems are loosely inter-connected and segmented into quite a few sub-systems. Policy players can be mainly divided into official actors and unofficial actors (Birkland, 2005). Official actors are given responsibilities in laws and have the power to make and enforce policies; they include legislative, executive, and judicial branches. Unofficial actors include those who play a role in the policy process without any explicit legal authority (or duty) to participate; they are involved in the politics because they have the right to be, and have important interests to protect and promote. For disaster mitigation, response, and recovery policies, the government plays an essential role. While the central government plays the major role in formulating the disaster management policies the local governments are usually more important in implementing them. The media plays an important role in disaster management policies in two ways: media advocacy to put disaster management in the policy agenda; and media monitoring enhances policy implementation. Experts can (and usually do) play an important role in each phase of the disaster management policy making. Though “scientific research results do not play an important role in the agenda setting process”, experts do drive issues to the agenda through legitimizing issues (Dearing & Rogers, 1996). Experts can serve both instrumental and enlightenment functions in policy formulation. In the implementation, experts can provide specificity to vaguely worded legislative mandates. The evaluation is recognized as a professional activities in which experts are actively involved (Barkenbus, 1998).

Additionally, outsiders such as donors may also play a role in shaping the disaster management policy decisions.

This chapter outlined the relationship between policy and disaster management and identified policy types, policy approaches, and policy models. The policy context, policy process, policy content, and interest groups under the Walt and Gilson model were examined in detail. The following chapter turns the focus to the disaster health management China.

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Chapter Six: Disaster Health Management in China

“Think of Danger in Times of Safety”---- Zuo Zhuan (Written approximately in 403BC-386BC).

Having discussed policy theories and approaches this chapter briefly examines the geography, demography, economy and political structure of China. This background information is important in providing a platform for discussing policy development and disaster management in China, as policy studies indicate that political institutions, economics, geography, demographics and history all play a part in each countries policy responses. China has a long history of disaster management with the above philosophical saying from the famous book Zuo Zhuan (左传) as a symbol of Chinese ideology of getting prepared for any danger in times of safety. In a certain sense, the history of Chinese civilisation is a history of combating natural hazards and disasters. In the course of history, China has created ambitious disaster mitigation projects of long standing, such as the Dujiangyan Water Diversion and Irrigation Project in Sichuan Province (completed in 256BC); the Sea Dike along the coast of Hangzhou Bay in Zhejiang Province (originally completed around 1047AD); and the ancient seawall on the Changjiang River (Yangtze River) Delta coast (originally completed around 780AD). Such projects have resulted in a rich experience in hazard and disaster reduction (Stoltman, et al., 2004).

6.1 Background information of China

6.1.1 Geography and Demography

The People's Republic of China (PRC), commonly known as China, has jurisdiction over 22 provinces, five autonomous regions (Xinjiang, Inner Mongolia, Tibet, Ningxia, and Guangxi), four municipalities (Beijing, Tianjin, , and Chongqing), and two highly autonomous special administrative regions (Hong Kong and Macau). The PRC's capital is Beijing (The Central People's Government of PRC, 2009a).

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Located in East Asia and at approximately 9.6 million square kilometres, China’s territory has a diverse range of geographical conditions, including forest steppes and deserts in the dry north and subtropical forests in the wet south. The terrain in the west is rugged and high altitude; in contrast, mainland China's eastern seaboard is low-lying and has a 14,500-kilometre long coastline bounded on the southeast by the . Drought tends to occur mainly in the Northwest Plateau and North China Plain in spring and autumn while typhoon and storm surges mostly strike the south eastern coastal regions (Ting, 2004). Figure 6-1 shows how China’s terrain descends in three steps from the west to east: the red colour representing Tibetan plateau averaging more than 4,000 meters above sea level; yellow colour representing Inner Mongolia, Loess and Yunnan-Guizhou plateaus, and the Tarim, Junggar and Sichuan basins averaging between 1,000 m and 2,000 m; and green colour representing plains in the east averaging 500 to 1,000 m. Most of China's population lives in the relatively flat and fertile south-eastern third of the country. Because of the terrain, China’s three main river systems: Yangtze River, Yellow River and the Pearl River as shown in Figure 6-1, all flow from the west to the east. While these rivers are the main economic areas in China, they are also where the floods occur (Ting, 2004). And in recent years, more severe rainfall have been observed in these areas, possibly due to global warming (Gong & Wang, 2000; Shi, Gao, Wang, & Giorgi, 2009). In terms of plate tectonics, China is part of the Eurasian plate, but the margins of the Indian and the Philippine Sea plates are involved in the Himalayas and in the Coastal Range of Taiwan respectively (Zhang, Liou, & Coleman, 1984). Thus, more than 70% earthquakes with a magnitude greater than 4.0 are in Qinghai-Tibet Plateau and Taiwan stress district, of which the 2008 Wenchuan Earthquake is a good example (B.C. Burchfiel et al., 2008; Xie, Cui, Zhagn, & Wang, 2006). The coastal area of China is also vulnerable to potential tsunamis associated with earthquakes in the South China Sea (Liu et al., 2007).

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Figure 6-1: Topographical map of China Source: (China Internet Information Center, 2009)

China has a population of about 1.33 billion (estimated 2009), with 46.6% being urban population (National Bureau of Statistics of China, 2010a). Life expectancy at birth is 73 years at 2007 (The World Bank, 2009a). Family planning policy in China started in early 1980s. Since then, population growth rates have slowed and life expectancy has risen. However, the “one child” policy has brought about some important changes: rising gender ratio that may have social impact (119.5 males to 100 females at birth); ageing population (8.5% of the population are at the age of 65 or above) that shift health care towards chronic diseases and disabilities; and the challenge on the tradition of providing long-term care at home for elderly parents and grandparents (World Health Organization, 2009). The population distribution can have significant impacts on the nature of emergency management. For example, about 60% of the total population live in rural

- 79 - areas which are poorer, and they are distributed at less than 10 persons per square kilometre in Western China. China’s combination of a large population and high geographical risks has a great impact on disaster occurrence and thus the health of the population.

6.1.2 Economy

Since initiating market reforms in 1978, China's economy has changed from a centrally planned system that was largely closed to international trade to a more market- oriented economy that has a rapidly growing private sector and is a major player in the global economy. China in 2008 was the third-largest economy in the world after the US and Japan, although in per capita terms the country is still lower middle-income (The World Bank, 2009c). GDP in 2009 is about US$4,910 billion, and the growth rate is 8.7%, which means GDP per capita is US$3,692 in 2009 (National Bureau of Statistics of China, 2010a). About 2.8% of the population, or 36.0 million people, live below the poverty line (annual net income below US$175) (National Bureau of Statistics of China, 2010a). Inequity has increased and gaps exist in socioeconomic indicators between geographic regions, rich and poor households, urban and rural residents, and migrant and resident populations within cities. For example, economic development has been more rapid in coastal provinces than in the interior, and the urban population has expanded from 173 million to 594 million in the period of 1978 to 2007 largely due to the relocation of rural labourers and their dependents to the urban areas to find work (Fang, 2009; State Statistics Bureau of China, 2008; Zhang & Song, 2003). Up to 30% of poor people state that health is the single most important cause of their poverty. Ill-health can lead to poverty through reduced earning capacity and high out-of-pocket medical expenses that can be financially catastrophic. And the poor may be disproportionately affected by disasters compounding the effects on both health and poverty. (Asian Development Bank, 2004).

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6.1.3 Political System

The Constitution of the People's Republic of China is the highest law within the People's Republic of China. Under the Constitution, the political system in China is organized as shown in Figure 6-2. In China, people exercise state power through National People’s Congress (NPC) and the local people’s congresses. NPC is the highest authority of state power and the only legislative house in the PRC ("Constitution of the People's Republic of China ", 2004). Under the NPC, there are government organs including the President of China, Supreme People’s Court, Supreme People’s Procuratorate, and State Council. Lead by the Premier, the State Council is the central government of China. Under the State Council, there are 27 Ministries and Commissions and many other organizations ("The State Council," 2008). Beside NPC, National Congress of the Communist Party of China (National Congress of CPC, which is held once every five years), and Chinese People’s Political Consultative Conference (CPPCC) also holds high political power. CPC Central Military Commission is the highest military leading organ of the China. Apart from the Communist Party of China (CPC) that is in power, China has eight non-Communist parties, who hold the CPPCC ("Constitution of the People's Republic of China ", 2004).

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CENTRAL COMMITTEE OF THE NATIONAL PEOPLE’S CONGRESS CHINESE PEOPLE’S POLITICAL CHINESE COMMUNIST PARTY CONSULTATIVE CONFERENCE Standing Committee General Central Military Chair: Wu Bangguo Chair Secretary Commission Chair 13 Vice Chairs Jia Qinglin Hu Jintao Hu Jintao Secretary General: Li Jianguo 9 Politburo Standing Committee Members NPC Committee Director s

•Agriculture and Rural Affairs •Education, Science, Culture, and Public Health •Environmental and Resource Protection Supreme People’s Court •Financial and Economic Affairs President: Hu Jintao President: Wang Shengjun • Foreign Affairs Supreme People’s Procuratorate Vice President: Xi Jinping • Internal and Judicial Affairs • Legal Affairs President: Cao Jianming • Ethnic Affairs • Overseas Chinese Affairs

State Council Premier 5 Vice Premiers 5 State Councilors Secretary General Offices of the State Council* Wen Jiabao Ma Kai Legislative Affairs Office: Cao Kangtai Research Office: Wei Liqun

The 27 Ministries and Commissions Other Key Organizations under the State Council*

• Ministry of Agriculture •Ministry of Human Resources and •Ministry of Transportation •China Banking Regulatory commission Supervision, Inspection, and Affairs Social Security •Ministry of Water Resources •China Insurance Regulatory Quarantine •State Administration of Taxation •Ministry of Civil Affairs • • • • •Ministry of Commerce Ministry of Industry and Information National Audit Office Commission General Administration of Sports State Electricity Regulatory Technology •National Development and Reform •China Securities Regulatory •National Bureau of Statistics Commission •Ministry of Culture • • • •Ministry of Education Ministry of Justice Commission Commission China National Tourism State Forestry Administration •Ministry of Land and Resources •Ministry of Population and Family •Development Research Center of the Administration •State Intellectual Property Office •Ministry of Environmental Protection •Ministry of National Defense Planning Commission State Council •State Administration for Industry and •State Asset Supervision and •Ministry of Finance •Ministry of Public Security •People's Bank of China •General Administration of Customs Commerce Administration Commission •Ministry of Foreign Affairs •Ministry of Railways •State Ethnic Affairs Commission •General Administration of Press and •State Administration of Radio, Film, •Xinhua News Agency •Ministry of Health • •Ministry of Housing and Urban‐rural Ministry of Science and Technology Publications and Television •Ministry of State Security •General Administration of Quality •State Administration for Religious Development •Ministry of Supervision

* Not Comprehensive

Figure 6-2: Political structure of China Source: (The US-China Business Council, 2008), www.gov.cn and Author

After 1978, Mao's successor Deng Xiaoping and other leaders focused on market- oriented economic development and by 2000 output had quadrupled. For much of the population, living standards have improved dramatically and the room for personal choice has expanded, yet political controls remain tight. China's 11th Five Year Plan (2006-2010) forms the basis of the Government's current economic and social development efforts. Realizing its challenges in balancing the economy to further strengthen sustainable economic and social development, China’s

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11th Plan aims to sustain the rapid and steady development of China's ‘socialist market economy’ while, in addition, aiming to achieve the ‘five balances’: balance between urban and rural development; balance in regional development; balance in social and economic development; balance between human beings and nature; balance between domestic and international development (World Health Organization, 2009).

6.2 Disasters in China

Natural disasters occur frequently in China, affecting more than 200 million people every year. They have become an important restricting factor for economic and social development. China experiences a great range of natural disasters. Among all the hazards, drought, flood, typhoon, storm surge, and earthquake are the most destructive (Yang, 2004). Table 6-1 lists the number of disasters, the number of people killed and total number of people affected in China recorded by EM-DAT: The OFDA/CRED International Disaster Database.

Table 6-1: Summarized Table of Natural Disasters in China from 1900 to 2010

Number of Total Type of Disasters Events Killed Affected Drought 29 3503534 386414000 Seismic activity (earthquake and tsunami) 118 872366 68855668 Epidemic 10 1561498 9829 Extreme temperature 10 337 77135880 Flood (flash flood, general flood, coastal flood) 195 6595072 1654593149 Insect infestation 1 ‐ ‐ Mass movement dry (landslide) 6 454 5473 Mass movement wet (avalanche and landslide) 42 2879 83878 Storm (local and tropical) 198 173290 416304517 5 243 56613 Source: (EM-DAT, 2009b) Technological disasters are also common in China. There were countless fire incidents, and more recently, mine safety incidents (The Central People's Government of

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PRC, 2010a). Food safety issues can also create a major incident, e.g. the Chinese milk scandal in 2008 caused by melamine. SARS, avian flu, and other pandemics add to the threat to public safety and security. Even though most of its citizens rate China as the most peaceful nation in the world, China faces terrorist attacks and other criminal threats. The East Turkestan Islamic Movement is one of the most active terrorist organizations in China (Lu, 2003). They have perpetrated several bombings and other attacks in Xinjiang and other cities in North China since the 1990s. China has also experienced riots carried out by the Tibetan Independence organization (March 14, 2008 in Lhasa) and Xinjiang Independence organization (July 5, 2009 in Urumqi).

6.3 Floods in China

Because of its geography and location in the world, China is particularly vulnerable to flooding. In China, as in many other countries, settlements tend to be built along rivers, which are subject to flooding. About 350 million people live along the banks of the Yangtze and a further 100 million along the Yellow River, and these two rivers are affected by floods almost every year, with increasing severity (Miller & United Nations Department of Humanitarian, 1997). The population growth has meant that more land has been developed for housing, which in turn increases runoff and flooding. Estimated deaths in the 1931 China floods were 3,700,000, and ranked it the deadliest flood of all times as well as the deadliest natural disaster of all times (EM-DAT, 2009b). The 1887 Yellow River flood claimed between 0.9 million to 2 million lives, and ranked second in death toll in both flooding and natural disasters (Gunn, 2007). The 1938 Yellow River flood was third, with about 840,000 deaths (Lary, 2001). In terms of frequency, rainstorms and floods occur most often in the south-eastern coastal areas, the Yangtze and Huaihe River valleys, and the Dongting and Boyang Lake areas (Yang, 2004). Over the past 50 years, natural disasters have on average reduced China's harvests by approximately 1% annually. This has particularly contributed to the construction of the world's largest flood-control and hydroelectric project - the Three Gorges Dam on the Chang Jiang (Yangtze River) above Yichang (China Three Gorges Corporation, n.d.).

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6.4 Health Care System in China

In order to understand disaster health management in China, it is firstly necessary to understand the health care system. China has a very centralized and relatively restrictive political structure. Health care is directed from the central government and focused more on primary health care (Frederick, Xiaoping, Walter, & Edward, 1994). The health care model has been adapted to the underdeveloped economic base and to large demand of the population. Figure 6-3 shows the structure of the health care system in China. There are six levels of administration in line with the political system in China. The Ministry of Health, which is under the State Council, is in charge of key medical universities, China CDC, and some other academic organizations; the health bureaus in each level are in charge of the hospitals and CDCs in the same level; the village clinics are in the bottom of the structure, and provide the basic health care. Health facilities are highly centralized in China nowadays, most health facilities are located in urban areas, while less than 8.9% are in rural areas where 56% of the population lives (Huang, 2008; Zhang, 2007). Central funding is supporting the re-introduction of a New Cooperative Medical System in rural areas and a parallel programme for the uninsured in urban areas that plans to achieve universal coverage by 2020 (Dong & Phillips, 2008).

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Figure 6-3: China’s health care structure Source: (Hesketh & Zhu, 1997) and author

6.4.1 Ministry of Health and Health Bureaus

The Ministry of Health (MOH) of China is a member of the State Council with a mandate in health. It plays the role of providing information, raising health awareness and education, ensuring the accessibility of health services, and monitoring the quality of health services provided to citizens and visitors in China. The MOH is also involved in the control of illness and disease, coordinating the utilisation of resources and expertise where necessary. There are 16 components within the MOH, including the Office of Health Emergency, the Department of Health Policy and Regulation, the Department of Disease Control etc. In addition, there are many institutions affiliated with the Ministry of Health, including the Chinese Centre for Disease Control and Prevention (China CDC), the National Centre of Health Inspection and Supervision, the China Medical Association, the

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Training Centre for Health Officials, the Logistics Centre for the Ministry of Health, and some other hospitals and publishers (The Central People's Government of PRC, 2009b). Local health bureaus of provincial governments, city governments and county governments are the local health administration organization, and report the conditions of health reform and development to local People’s Congress. The main function of the health bureaus are administration management, implementation and supervision.

6.4.2 Centre for Disease Control and Prevention (CDC)

As mentioned above, China CDC is an agency affiliated with the PRC Ministry of Health. China CDC is a non-profit institution working in the fields of disease control and prevention, public health management and service provision. The CDC in China can be traced back to early 1950s, when the former Soviet Union model of epidemic prevention was introduced and the Hygiene and Anti-Epidemic Stations were established nationwide (Lee, 2004). In order to ensure China’s system is compatible with international standards, the Hygiene and Anti-Epidemic Stations were gradually reorganized into CDCs at the end of the 1990s; the Chinese Centre for Disease Control and Prevention (China CDC) was officially established based on the original Chinese Academy of Preventive Medicine in January 2002 (Claeson, Wang, & Hu, 2004; Lee, 2004). The weaknesses of the public health system in China such as limited information sharing and insufficient financing were revealed by the SARS epidemic; and this has led to an increased allocation of resources to public health institutions (Cao, 2003; Gong, 2003; Koplan, Liu, Lei, & Dusenbury, 2005). However it has been noted that a considerable proportion of these funds went to capital improvements and equipment acquisition, rather than salary, benefits support, training and skill building of the workforce (Koplan, et al., 2005).

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6.4.3 Hospitals

The Ministry of Health classified hospitals into three levels according to their size ("Statute of hospital classification and management (in Chinese)," 1989):

• Level Three Hospital - general or comprehensive hospital at national, provincial or city level (more than 500 beds) • Level Two Hospital - hospitals at medium size city, county or district level (more than 100 beds but less than 500 beds) • Level One Hospital - township hospitals (less than 100 beds)

The hospital classification is not simply based on the number of hospital beds, but rather according to the hospital’s function, technology, infrastructure and service quality; and the level is evaluated by specially organized committees in the provincial or local level. Such classification is to ensure efficient resource allocation and hospital management though measures such as patients transfer and special drug limitations according to classification level. According to their ownerships, there are five types of hospitals in China as listed below (ChinaVista.com, 2008):

• Hospitals of public health system, including the hospitals under the leadership of Ministry of Health or Health Bureaus of local governments at provincial or county level. • Military hospitals, including the hospitals belonging directly to Health Department of General Logistics Department of PLA (People’s Liberation Army), the hospitals belonging to military areas, and the hospitals belonging to Armed Police. • Hospitals funded by Ministries, including hospitals founded and managed by Ministries or State Bureaus of metallurgy, electricity, machinery, aviation, post and telecommunication, nuclear industry, coal and civil affairs. • Private, share holdings and Sino-foreign joint venture hospitals • Hospitals affiliated to medical education and research institutes Different ownership of these hospitals means they each have different focus and provide special care for different organizations or groups, and form some level of

- 88 - competition. However, such diversity in ownership and function provides a challenge to coordination in disaster preparedness and response.

6.5 Disaster Health Management Structure in China

Disaster health management is framed to underpin the national disaster management structure and the daily emergency medical service system (EMSS). This section therefore examines the disaster management and EMSS structure in China.

6.5.1 General Disaster Management Structure

China does not have national level emergency management departments like EMA in Australia or Department of Homeland Security and FEMA in the United States. Instead, many departments share their responsibility for emergency management through different focus and approach. Several of the leading organizations are listed in Figure 6-4 and explained below:

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Figure 6-4: General disaster management structure in China Source: (Information Office of the State Council, 2009; The Central People's Government of PRC, 2010b)and author There are two key agencies that provide integrated emergency management in China: Emergency Management Office (EMO) and National Civil Defence (NCD). The EMO, a sub-office of the Office of the State Council, was established in December 2005; the EMO establishment was considered as a milestone of the modern emergency management system in China as EMO is a national level organization that coordinates key national emergency management agencies, including those relating to Civil Affairs, Work Safety, Public Security and Health (Office of the State Council, 2006). EMO’s role covers emergency planning, natural disasters, technological , public sanitation issues, social security concerns, and recovery and reconstruction activities. The NCD, an

- 90 - organization under the Ministry of National Defence, covers aerial defence, chemical, biological, radiological, and nuclear (CBRN) and other common accidents in cities. The NCD has its own resources and personnel for emergency response. The Ministry of Civil Affairs (MCA) generally leads natural disaster relief, with support from other relevant departments. It is responsible for social and administrative affairs. MCA is in charge of registration and administration of associations, non- government organizations (NGOs) and foundations. MCA also takes care of the aged, children, orphans, disabled people and retired army personnel. The National Disaster Reduction Centre (NDRC) of MCA is a specialized agency which provides information and supporting decision making on various natural disasters. It provides reference material for disaster management departments in their decision- making in addition to technical support for China's disaster-reduction undertakings by way of collecting and analysing disaster information, assessing disasters and emergency relief, and analysing and studying disasters using such advanced technology as satellite remote sensing (MCA, 2010). The office of National Committee for Disaster Reduction (NCDR), which is headed by a Vice Premier of the State Council, is also located in Ministry of Civil Affairs. The NCDR comprises 34 ministries and departments, including relevant military agencies and social groups. It functions as an inter-agency coordination body under the State Council, and it is responsible for studying and formulating principles, policies and plans for disaster reduction, coordinating major disaster activities, giving guidance to local governments in their disaster reduction work, and promoting international exchanges and cooperation. The Ministry of Public Security (MPS) is the principal police authority and domestic security agency on the mainland China and responsible for most of the day-to- day law enforcement in mainland China. It controls and administers the People's Armed Police, and is the leading body in China pertaining to antiterrorist, criminal prevention and other security related crisis responses. The phone number “110” is designated for normal police and “122” for traffic accidents. In general, the MPS does not undertake paramilitary functions, nor does it conduct domestic intelligence which is the responsibility of the Ministry of State Security. (MPS, 2009) Another important role of the MPS is fire fighting. Unlike fire-fighting organizations in other countries, the Fire Bureau is directly under MPS in China. The

- 91 - phone number “119” is designated for fire emergencies throughout China. However, the State Forest Fire Prevention Headquarters has its office in the Forest Public Security Bureau, which is under the guidance of both the MPS and the State Forestry Administration (SFA). The Ministry of Water Resources (MWR) is responsible for water administration, including developing water resources development strategies, plans and policies; undertaking integrated water resources management and supervision; providing guidance to hydrological work; and providing guidance to the management and protection of water infrastructures. The Office of State Flood Control and Drought Relief Headquarters (OSFCDRH), which is a departmental office in the MWR, organizes, coordinates, directs and supervises nationwide activities of flood control and drought relief. (MWR, 2008) The State Administration of Work Safety (SAWS), reporting to the State Council as a non-ministerial agency, is responsible for the regulation of risks to occupational safety and health in China. The National Workplace Emergency Management Centre (NWEMC) and State Administration of Coal Mine Safety (SACMS) are the two main organizations under the SAWS, and they are mostly in charge of technology disasters. They are responsible for several emergencies ranging from Hazardous Materials, traffic incidents, mine safety and others. (SAWS, 2010) China Meteorological Administration (CMA), a public service agency under the State Council, is responsible for organizational and operational management of the national meteorological services as a whole. CMA's meteorological service consists of weather forecasting, climate prediction, weather modification, drought and flood monitoring and forecasting, and lightning prevention, agro-meteorology and eco-meteorology, climate resource exploitation, etc. (CMA, 2009) China Earthquake Administration (CEA) enforces the earthquake administration in China under the administration of the State Council. Similar to other organizations under the State Council, CEA formulates and implements strategies, guidelines and policies, laws, regulations and standards regarding and disaster mitigation; prepares earthquake zoning map; supervises and inspects relevant earthquake preparedness work; and serves as the Earthquake Disaster Relief Commanding Headquarter of the State Council.(CEA, 2009) Additionally, the army plays an important role in disaster management in China. The Ministry of National Defense, which is a ministry under the State Council, does not

- 92 - exercise command authority over the People’s Liberation Army, rather it exercise its disaster management role through the National Civil Defence (NCD) (PRC, 2010). The Central Military Commission exercises command and control of the People's Liberation Army; however their role in disaster management is not straightforward, though the army is legally responsible for disaster response and is actively involved in large scale disasters such as the (Li, Huang, & Sun, 2009). Under the central government, all local governments follow the same structure to establish a province or city level Emergency Management Office. Thus the local level EMO has authority to coordinate the same level officers of Civil Affairs, Work Safety, Public Security, and Health and other related agencies in emergency responding, disaster relief and recovery. By the national law, the details of each emergency that occurs must be passed up the chain of command until they reach the level most qualified to take command of the situation. For example, SAWS issued the Regulation of Coal Mine Production Safety Incident Reporting and Investigation, which classifies emergencies into four levels. This is typical of the way in which the Chinese emergency management system works to improve the effectiveness (Bai, 2008; State Administration of Work Safety, 2008). These four levels are listed below:

• Level 1 Incident: extremely serious incident, over 30 fatalities (or over 100 serious injuries, or direct economic loss of over 100 million Yuan (US$14.6million)). Action: Escalate to the state council • Level 2 Incident: serious incident, between 10~30 fatalities (or 50~100 serious injuries, or direct economic loss of 50~100 million Yuan (US$7.3~14.6 million)). Action: escalate to province level • Level 3 Incident: major incident, 3~10 fatalities (or 10~50 serious injuries, or direct economic loss of 10~50 million Yuan (US$1.5~7.3 million)). Action: escalate to city level • Level 4

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Incident: normal incident, less than 3 fatalities (or less than 10 serious injuries, or direct economic loss of less than 10 million Yuan (US$1.5 million)). Action: escalate to local level.

The current disaster management structure has experienced both success and failure as evidenced by disaster management cases such as the response to the 2008 Wenchuan earthquake and the 2008 snow storm (Hui, 2009; Liu, 2009). Transparency and volunteerism were incorporated in the management to facilitate a fast and efficient response in both cases. However, problematic issues include lack of integrated cooperation and communication; the lack of social initiatives; imperfect policies and regulations (Li, 2009). For example, flooding, earthquakes and epidemics are managed by MWR, CEA and MoH respectively. However disasters may involve many fields and thus it could be argued that there is a need of a special authority to integrate the efforts (Li, 2009).

6.5.2 Emergency Medical Services System (EMSS)

The concept of Emergency Medical Services System (EMSS), now widely shared throughout China, was imported and introduced by Chinese medical professionals studying outside China (Burkle, Zhang, Partick, Kalinowski, & Li, 1994). Thus the Chinese EMSS was implemented by adapting elements of both North American and European models (Robbie, 2001). China’s EMSS framework comprises three sectors: the pre-hospital emergency service, the emergency department (ED) and the intensive care unit (ICU), and forms a survival chain of emergency stabilization, rapid transportation, in-hospital resuscitation and definitive treatment (Guo, 2003; Hung, Cheung, Rainer, & Graham, 2009) There are five principal pre-hospital emergency service systems in China as shown in Table 6-2.

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Table 6-2: Pre-hospital Emergency Service Systems in China EMS Model Typical locations Explanation Purely pre- Shanghai, Tianjin, The pre-hospital emergency service has no hospital care Nanjing, and inpatient beds. Hangzhou Independent Beijing and Shenyang Emergency service centres are independent of emergency hospital emergency departments with similar service centre capabilities. They are equipped with their own emergency department and intensive care unit. Pre-hospital care Chongqing, , There are no separate emergency service supported by Qingdao and Haikou centres. Pre-hospital emergency services are general hospitals provided by the nearby hospitals. The ambulances are staffed by medical workers from the hospital. Unified and There are no emergency service centres for communication Shenzhen ambulance dispatch, but there is a unified command centre communication command centre for handling ‘120’ calls in the city. The call would then be forwarded to the closest appropriate hospital for ambulance dispatch. Integrated Suzhou Pre-hospital emergency service is incorporated within fire and into the fire and police departments. Patients are police stabilized and transported to nearby hospitals. departments

In China, the pre-hospital service is reached by dialling “120”, the fire and rescue service on “119” and police on “110”. The “120” calls in different cities are managed by different institutions, but requests are then forwarded to the appropriate centres for ambulance dispatch. There is not a recognized “paramedic” profession in China. Staff working in emergency service centres includes medical doctors, registered nurses and drivers. The standards of care can be variable as most doctors working in the field only have a basic medical degree, rather than specialized pre-hospital care training (Lv, Zhou, Zhang, Yu, & Meng, 2002). The road ambulances remain the main vehicle, and use of aero-medical transport is very rare for public use. Usually there are two types of ambulance vehicles: advanced care (monitoring) ambulance and general ambulance. Some of the larger emergency medical centres are equipped with mobile intensive care units and minor operating suites. Two-way radios with a set frequency are often used on board ambulances. In big cities such as Beijing and Shanghai, global positioning systems are used to hasten response times (Zhang, Tao, & Gui, 2004). From the patient’s prospective, it is a “fee for service” system, though about 25% of the population in the urban areas have obtained medical insurance (Ali, 2001). Due to

- 95 - the cost of the ambulance, calls are made only for conditions perceived to be emergencies, such as strokes and head injuries, trauma, and cardiovascular diseases. In 2001, the “999” ambulance system, i.e. the Emergency Centre of Red Cross Society of China Beijing Branch, was introduced in Beijing. However, the co-existence of the two ambulance systems in Beijing has been controversial and a source of confusion (Wang, 2008c). The role of hospital emergency departments and emergency service centres overlaps in some Chinese cities. This is especially true with independent emergency service centres as in Beijing and Shenyang (Hung, et al., 2009).

6.6 Disaster System and Policy Development in China

Due to the culture of China and the lack of relevant policies and structures in the history, one characteristic of the history of crisis management in China is the necessity of ‘hero style’ people to manage it (Zeng, 2004). Since the founding of People’s Republic of China (PRC) in 1949, the Chinese government and people have worked to develop procedures for disaster mitigation and preparedness, including the establishment of the Central Commission on Natural Disaster Relief (1950) to take direct charge of the management of natural disaster relief and mitigation. The government then further set up the Central Meteorological Bureau (1950), State Oceanic Administration (1964), and State Seismological Bureau (1952). Since the economic reform that started in late 1970s, China has come a long way in disaster management. The National Natural Disaster Reduction Plan of the People's Republic of China (1998 -2010)(replaced by the National 11th Five-year Plan on Comprehensive Disaster Reduction in 2007), which is the first national disaster reduction plan of the Chinese Government, was promulgated in April 1998. The Chinese government also established the China National Commission for the International Decade on Natural Disaster Reduction in 1989, which was renamed as China Commission for International Disaster Reduction in 2000 and further renamed as China National Committee for Disaster Reduction (NCDR) in 2005. After the SARS outbreak in early 2003 and in preparation for the Olympic Games in 2008, the Chinese central government proposed to speed up the development of a

- 96 - public health management system. The Regulation for Coping with Public Health Outbreak was issued after the SARS outbreak in May, 2003, and it was followed by many other policies and regulations that form the new system. Table 6-3 provides a chronology of events which describes the key process and formulation of China’s emergency and disaster management system.

Table 6-3: The development of China’s emergency management system Time Key Events Importance 1998 China National Commission for the It later become the China International Decade on Natural Disaster National Committee for Reduction was established Disaster Reduction (NCDR) May, An emergency management system was It was the first city 2002 formally established in Nanning city, emergency management Guangxi Zhuang Autonomous Region. system in China. October, The Shanghai Disaster and Emergency It was the first Disaster and 2003 Management Overall Plan was issued. Emergency Management Plan in the provincial level. July 22- The State Council organized the first Emergency management in 23, 2005 national emergency management working China became regular, meeting. institutional, and legal December Emergency Management Office (EMO) A disaster management 2005 was established in the General Office of working office in the national the State Council level January 8, The State Council issued Master State Disaster emergency response 2006 Plan for Rapid Response to Public system is established in Emergencies (Master Plan). Related China departments in the State Council have worked out national special incident plan and department plan. Each province, autonomous region, and municipal city has completed their provincial public emergencies response plan. November Emergency Response Law of the People’s An important legal basis for 1st, 2007 Republic of China was promulgated and the disaster management in effective. China Source: www.newssc.org, www.gov.cn, author

China has also been developing international links with respect to disaster management, especially in recent years. For example, China is a member of the various international organisations such as the United Nations and Asian Disaster Reduction Center (ADRC). The Red Cross Society of China is a member of the International Federation of Red Cross and Red Crescent Societies (International Federation of Red Cross and Red Crescent Societies, 2010). Additionally, China has a National Focal Point

- 97 - for organizations such as the International Strategy for Disaster Reduction (ISDR) and the United Nations Platform for Space-based Information for Disaster Management and Emergency Response (UN-SPIDER) (ISDR, 2010). From a legislative perspective, the state has promulgated more than 30 laws and regulations concerning disaster prevention and reduction since the early 1980s. Table 3-5 listed some of the most important laws and regulations. As can be seen in Table 6-4, half of these laws and regulations were issued after 2003, i.e. post SARS. The mass epidemic of SARS in 2003 was a seminal event and revealed flaws in the Chinese public health policies and guidelines, and led to reconstruction of the national public health system and the disaster management system. The policy literature reveals that a “crisis” situation is often a stimulus for the development and/or re-development of policy and this was the case in China post SARS. Table 6-4: Key laws and regulations concerning disaster management Focus Name of the Laws or Regulations Year Issued or Reviewed General Emergency Response Law of the People's Republic of 2007 Emergency China Response Weather Drought Control Regulations of the People's Republic of 2009 Related, Esp. China Flood Hydrology Regulations of the People's Republic of China 2007 Flood Control Regulations of the People's Republic of 2005 China Water Law of the People's Republic of China 2002 Grassland Law of the People's Republic of China 2002 Law of the People's Republic of China on Desertification 2002 Prevention and Transformation Regulations on the Administration of Weather Modification 2002 Meteorology Law of the People's Republic of China 1999 Flood Control Law of the People's Re-public of China 1998 Forestry Law of the People's Republic of China 1998 Regulations on the Administration of Security of Reservoirs 1991 and Dams Law of the People's Republic of China on Water and Soil 1991 Conservation Earthquake Law of the People's Republic of China on Protection 2009 Against and Mitigation of Earthquake Disasters Regulations on the Prevention and Control of Geological 2004 Disasters Regulations on the Handling of Destructive Earthquake 1995 Emergencies Fire Control Fire Control Law of the People's Re-public of China 2009 Forest Fire Control Regulations of the People's Republic of 2009 China Grassland Fire Control Regulations of the People's Republic 2009 of China Work Safety Regulations of Coal Mine Safety Supervision 2000

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Law of the People's Republic of China on Safety in Mines 1993 Regulations on Emergency Measures for Nuclear Accidents 1993 at Nuclear Power Plants Environmenta Law of the People's Republic of China on the Prevention 2008 l Disaster and Control of Water Pollution Law of the People's Republic of China on the Prevention 2005 and Control of Environmental Pollution from Solid Waste Law of the People’s Republic of China on Prevention and 2003 Control of Radioactive Pollution Marine Environment Protection Law of the People's 2000 Republic of China Law of the People's Republic of China on the Prevention 1996 and Control of Pollution from Environmental Noise Disease Food Safety Law of the People’s Republic of China 2009 Prevention Animal Epidemic Prevention Law of the People's Republic 2007 of China. Regulations on Handling Major Animal Epidemic 2005 Emergencies Law of the Peoples Republic of China on the Prevention 2004 and Treatment of Infectious Diseases Regulation on the Urgent Handling of Public Health 2003 Emergencies Regulations on the Prevention and Control of Forest Plant 1989 Diseases and Insect Pests Source: (Information Office of the State Council, 2009) and Author

China has also adopted a disaster emergency response system featuring central leadership, departmental responsibility, and disaster administration at different levels with major responsibility on local authorities. Accordingly, the emergency plans are formed at levels as: state overall emergency response plan, state specialized emergency response plans, departmental emergency response plans, and local emergency response plans. As mentioned in Table 7, Master State Plan for Rapid Response to Public Emergencies (Master Plan) is the foundational emergency plan; meanwhile 51 other national level emergency plans were developed by 2009, as well as many provincial, and local, and corporation emergency plans. The Master Plan specified the system of forecasting, information report, emergency response, emergency treatment, mitigation, and evaluation etc. Under the Master Plan, public incidents were divided into natural disaster, accident disaster, public health incidents, and social security incidents. And public incidents were also divided into four levels: Level Ⅰ (extremely serious, Red), Level Ⅱ (serious, Orange), Level Ⅲ

(major, Yellow), Level Ⅳ (normal, Blue). Additional to these policy development, disaster research and education has been developing in China as well. A large number of journals related to disaster management

- 99 - have developed in recent years. The Journal of Natural Disasters, Natural Disaster Reduction in China, Fire Safety Science, Overview of Disaster Prevention, Journal of Disaster Prevention and Mitigation Engineering, City and Disaster Reduction, Occupational Health and Emergency Rescue, and China Public Security are good examples of recent disaster management journals. Some of the most famous ones are organized by central government such as China Earthquake Bureau and Ministry of Civil Affairs etc., while some others are organized by provincial governments, universities, and academic associations etc. Most of these journals were initially issued around 2000. The official website for China’s central government, www.gov.cn, has also provided educational materials and reports of current emergencies. While there have been marked achievements in China in recent years in relation to disaster policies, there are still problems with the current disaster system and policies. Firstly, administrative barriers still exist between agencies and represent a major problem in China. For example, each administration area was trying to protect only itself during the initial period of SARS and some government officials denied the problem and restricted news report. This caused migrant-workers and students to return home to an environment of panic and chaos; it also lead to residents feeling insecure, and to rumors circulating (Lai, 2004). Although uniformity of leadership structures and a requirement for each level to take responsibility are the principles of emergency management in the Master Plan, in reality it is difficult to make different departments work collaboratively. Each department under the State Council and the local governments may work with a different emphasis according to their own plans and interests. Secondly, the current laws and regulations may lack consistency. Though the Master Plan is specifically designed for the emergency management at the national level with local plans to support it, many laws and regulations are limited in scope and unable to become one systematic program. Thirdly, the Master Plan does not include media and public in the information flow. Media can be a useful tool for aiding communication. Media can also act as a monitoring system of the local governments. Rumours always start in the public when they were not provided with sufficient information. Therefore media should be actively involved in disaster management to provide public with updated information. Additionally, there are issues such as lack of specific laws or regulation relating to the army’s involvement in distaste response. Other defects within the overall system, such

- 100 - as the fact that the Fire Department of the Forest Public Security Bureau falls under the control of two senior departments - the Ministry of Public Security and the State Forest Administration – need to be fixed by regulation that clarifies the role and responsibilities of each office.

Part II of the thesis is the background and literature of this study. As can be seen in the introduction, disasters occur quite often in China and pose a significant risk of impact on the health of the people; and the disaster management systems and policies are newly formed in China. Therefore, it is necessary and timely to evaluate the current disaster health management policies. The following Part III will evaluate the management of flood as an example of the disaster health management in China. It will then compare these cases in China with those in Australia, and finally it will propose and validate a policy framework for disaster health management in China with experts’ survey and interviews. The following part will include five chapters that address the research methodology, three case studies in China and Australia respectively, a comparative case study synthesis, and the policy analysis of disaster heath management.

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Part III Research Methods and Results

Chapter Seven: Research Methods

This chapter sets out the research methods for this study in detail. In keeping with many policy studies, this study uses a case study methodology (CSM) and survey of experts. Within the CSM, it uses primary source document analysis, primary source examination of policies in two countries, media reports, and face-to-face interviews. The survey of experts includes face-to-face interviews and questionnaire survey of experts through the internet. Nvivo software was used to assist the data analysis.

7.1 Methodology Overview

Detailed analysis of the literature has raised the following questions that have been formed into the research questions for this research which has been introduced in Chapter One:

1. What is the current policy framework in China for disaster health management? 2. How did it develop to its current status and what are the factors that have influenced the design and development of that policy framework? 3. How effective is the current policy in regard to the management of actual events as evidenced by management of health consequences of floods? 4. How could the policy be improved?

The aim of this research is to identify and evaluate the current policy framework of disaster health management in China, and to develop a new policy framework that would be most appropriate to the social, economic, and political environment, and reflect the capacity of the health system to respond to major incidents and disasters. The objectives of this research are listed as follows:

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1. To describe the policy and systems of disaster health management in China; its evolution and the drivers that determined its current structure, 2. To compare the policy structure between China and Australia, with Australia being an example of a relatively modern and mature disaster management system, 3. To evaluate the current policy framework and its implementation through detailed case studies of the health impact of floods in China in comparison with Australia, 4. To identify the key determinants of an effective disaster health management policy framework through literature review and survey of international experts. 5. To develop a new policy framework which will be appropriate to the social, economic, and political environment in China.

In order to achieve the above aims and objectives, information will be sourced using a number of approaches, allowing the triangulation of data as shown in Figure 7-1. These approaches include the literature review, case studies, and survey of experts. While the literature review depicted in Figure 7-1 has been examined in detail in Part II, Part III will examine the case studies and survey of experts as detailed below.

Figure 7-1: The research structure

Case studies are used to explore the research questions. In order to limit the research to a manageable scale, six locations that are vulnerable to floods were chosen, with three locations in Australia and China respectively. The locations were chosen based on available resources and logistical issues in terms of accessing flood locations and

- 104 - relevant experts. These case studies are then used to compare flood health management in the two countries and propose recommendations for a disaster health management policy framework in China. The survey of experts was used to validate the analytical process and to propose a policy framework and inform recommendations. This research involved 10 interviews in person, and 22 surveys through email. Both interviews and surveys are based on the same questionnaire which is attached in Appendix D. The experts, both domestic and international, were selected based on their expertise and availability.

7.2 Research Ethics Review

This research involved human subjects. The research interviewed people and asked people to fill out questionnaires. In accordance with the Queensland University of Technology Human Ethic Committee, ethical clearance was sought. The present research has been approved by the Mackay Health Service District Human Research Ethics Committee (representing Queensland Health) with protocol number: 01/08, and Queensland University of Technology with approval number: 0800000484. The ethics clearances are attached in Appendix E. Eligible participants for the interviews and surveys were provided with the Participants’ Information and Consent Form as attached in Appendix F. The participants were informed of the study purpose, the voluntary nature of participation, any possible risks, confidentiality issues, and their freedom to withdraw from the study at any time. The Participants’ Information Package also contained the contact details of the principal investigator, research supervisor, and QUT human ethics committee. The written consent forms were copied and filed in a locked cabinet, and the participants’ identity has been kept confidential.

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7.3 Case Study Methodology

7.3.1 Case Study Methodology Overview

Historically, Case Study Methodology (CSM) has been used by many researchers and applied to various research areas, such as psychology, sociology, political science, social work (Gilgun, 1994), business (Ghauri & Gronhaug, 2003), industry, and health services. This methodology has also been applied frequently to studies related to disasters (Chen, Liu, & Chan, 2006; Masozera, Bailey, & Kerchner, 2007; Prizzia, 2006). CSM has long been stereotyped as a weak social science method that has insufficient precision and objectivity, and limitation for generalization from case study results. However, Yin (2003a, 2003b) argues that it is appropriate not only for exploratory purposes but also for descriptive and explanatory purposes, and he provides persuasive examples of case studies that are exploratory, descriptive, and explanatory. He further points out that all methods have limitations. The essence of a case study is that it tries to illuminate a set of decisions: why they were taken, how they were implemented, and with what result. According to Yin (2003b), CMS is the most appropriate to answer “how” and “why” questions. This is particularly the case when the researchers need to focus on a contemporary phenomenon within some real-life context where they have little or no control over the event under study. Flooding is such a phenomenon where the researcher has no control over the event. Therefore CMS is seen as an appropriate methodology for the current research. One of the principal and unique advantages of case study methodology is that it has the ability to deal with various sources of evidence, and no single source has an absolute strength over all the others. Sources of evidence can complement one another (Stake, 1995; Yin, 1999, 2003b). The use of multiple sources of evidence is one of the tactics to increase the construct validity when conducting case studies (Yin, 2003b). Six or seven major sources of evidence are most commonly used in case studies, these being: (1) documentation, (2) interviews, (3) archival records, (4) direct observation, (5) participation, (6) participant observation, and (7) physical artefacts (Yin, 2003b). Herriot and Firestone (1983) and Yin (2003b) argue that the evidence from multiple cases is often considered more compelling, and thus the overall study is regarded

- 106 - as being more robust. In the current study, three case studies were conducted in each of two countries, and the six cases complement one another in terms of flood types and management approaches. Triangulation is an effort to see if the information collected from different sources is consistent. If they have the same meaning, conclusions can be stated confidently and if they are different or contrary, more effort toward conformation is needed (Stake, 1995). Yin (2003b) (p. 98) emphasized that “… the most important advantage presented by using multiple sources of evidence is the development of converging lines of inquiry, a process of triangulation… Thus any finding or conclusion in a case study is likely to be much more convincing and accurate if it is based on several different sources of information…” Data triangulation is illustrated in Figure 7-1.

Figure not available due to copyright restrictions.

This Figure shows various sources which forms inputs to Fact, including Archival Records, Open-ended Interviews, Focus Interviews, Structure Interviews and Survey, Observations and Documents.

This Figure can be viewed in the print version of the thesis located in QUT Library.

Figure 7-2 Convergence of evidence (single study)

Source: COSMOS Corporation 1983 cited in Yin (2003b).

Investigators triangulation means another research team or investigator observe the same event to see if the observation yields similar results and if interpretations are the same. Triangulation in investigations occurs when a body of evidence and/or information is collected, reviewed and assessed by two independent researchers or research teams. Similar interpretations produce very strong findings. However, it is likely to be rare to have more than one research team undertaking the same research at the same time. A

- 107 - valuable alternative is for the primary researcher to present collected data to a panel of researchers or experts who then discuss alternative interpretations and to get additional data from the case study (Stake, 1995). This approach will also be applied in the current study to increase the validity of information and credence for the interpretation of the cases.

7.3.2 Case Study Location Selection

The case studies from locations in China were chosen to depict diversity in population size, geographical location, and the type of flooding experienced. Despite financial constraints, three locations were selected: Jinan City in Shandong Province, Pan’an County in Zhejiang Province, and Lengshui Town in Zhejiang Province. A brief overview of the three locations is shown in Table 7-1 and a map of China which includes these locations can be found in Figure 6-1.

Table 7-1: Brief Introduction of Jinan, Pan’an, and Lengshui Places Jinan Pan’an Lengshui Population 6,000,000 200,000 10,000 Location River bank The Origin of the River The Origin of the River with a reservoir downstream Related Yellow River, Qiantang River Oujiang River River Xiaoqing River Raining Mainly from June to Mainly from June to Mainly from June to season August August August Manner of Flash flood in the City Typhoon and flash flood, Typhoon, flood. An anti- being with additional cases of typhoon drill was flooded landslide and bursting of employed in preparation river banks

Jinan was an example of a large sized city which has been devastated by flash flooding. This famous “spring city” on the bank of the Yellow River and near the Mountain Tai was flooded on July 18th, 2007 by three hours of rain, which left 39 people dead. This city was also chosen for convenience as the Shandong Provincial Centre for Disaster Control and Prevention (Shandong CDC) cooperates closely in partnership with the Queensland University of Technology. Pan’an is a county town in the middle of Zhejiang Province. This is a typical small city in south east China where the city is surrounded by hills and typhoons are common

- 108 - during the summer seasons. A typical typhoon called Wipha passed through Zhejiang Province in September 2007, causing torrential rainfall. Excessive run-off from the surrounding mountains flooded the city. The local CDC issued an invitation to the author of the current research to visit the Centre, and was very cooperative in terms of the data collection and access to experts. Lengshui is a small town in the middle of Zhejiang Province with a population of approximately 10,000 people, situated at the point where three rivers merge to form one large river. This town will provide an example of how the infrastructure development of recent years has contributed to flood mitigation. In Lengshui, the new disaster management policies in China are an example of organizational arrangements, which can be examined at the local level.

The flood cases in Australia have been chosen in order to examine flood management models in a developed country, and allow a comparison with cases and flood management models in China. The three locations in the State of Queensland, Australia are Charleville, Emerald, and Mackay. All of the three locations were flooded in early 2008. As with the case studies in China, the Queensland locations were chosen to represent diversity in population size, geographical location, and the nature of the flooding they experienced. They were also selected due to their relative proximity to the Queensland University of Technology which is based in Queensland, Australia and timeliness due to these flood events occurring during the study period. An overview of the characteristics of these locations is provided in Table 7-2 and a map of Queensland which includes these locations can be found in Figure 9-1.

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Table 7-2: Brief Introduction of Charleville, Emerald, and Mackay Places Mackay Emerald Charleville Population 91,000 15,000 3,500 Location On the river bank and 18 km downstream of a On the river bank near the sea big reservoir Related Pioneer River Nogoa River Bradley Gully, Warrego River River Time of Feb 15th, 2008 Jan 19th to Jan 24th, 2008 Jan 17th to Jan 21st, 2008 Flooding Manner of Localized flash flood Flood from upstream Flash flood and flood being with a dam from upstream flooded Brief Heavy rain in a short Overflow from the Firstly, the Bradley Description period of time caused Fairbairn Dam, which is Gully flooded some the inundation of the upstream on the Nogoa houses near its banks. whole city as Mackay River, threatened to Then, the Warrego is a low area, and the flood low lying suburbs River’s un-completed tidal action slowed the of the town. levee bank became a escape of the water as threat to the town as it flowed to the sea. water from the upstream flowed towards it.

Mackay is a city located on the east coast of Australia on the Pioneer River. Flooding poses a considerable threat to Mackay with 17 of the total 29 suburbs being susceptible to inundation from the Pioneer River while flash flooding may occur as well. Typical flood mitigation measures including levees and warning systems are in place in Mackay. The case highlights how flood is managed in a coastal city location. Emerald is on the Nogoa River where a large dam, the Fairbairn Dam, is upstream. This dam has significant impact on flood mitigation. The case highlights how flooding is managed in a middle-sized town in Australia with the dam upstream. Charleville is typical of a small town in western Queensland which is flooded regularly by the flood waters from upstream. Although in 2008, this town was affected by a flash flood, the bigger threat came from upstream floodwater which usually takes several days to travel downstream and impact on Charleville. This case demonstrates how disaster response resources can be quickly mobilized at different government levels to produce a fast national emergency response that, with cooperation, can enable a town to construct temporary levees before the flood’s arrival.

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7.3.3 Data Collection

A wide variety of data related to the flood events was collected from different sources. The background information and the case information were collected from news reports, governmental reports and academic databases (e.g. Medline, CNKI, Wangfang). As the study had a major focus on disaster health management in China, interviews were conducted with experts in the field in China. A semi-structured one-to-one in person interview was conducted with a total of 15 middle-level managers in China. These middle-level managers were predominantly from the field of public health, and to a lesser extent from the flood management and seismological sectors. Five middle-level managers were interviewed in each location in China. The number was chosen to allow for a sufficient number of different opinions to emerge from the interviews, while also considering the resources and time available. Interviewee selection was largely purposive. In detail, the selection criteria for purposive recruitment of interviewees are as follows:

• They have played an important role in the flood health management; • Their roles in the flood health management are different from each other; • They are key officers in the related flood management departments; • They are expected to have some understanding of current policies regarding flood health management; • They are accessible through official or personal channels.

The initial contact with the potential interviewees was made by contacting the CDC which plays a major role in the management of emergency health services in China as well as contacting other departments at the local level. And once in the department, people were contacted directly by the research team. For the convenience of the research, some personal contacts were used in selecting the potential interviewees. Each interview was carried out face-to-face. The interviewee was asked a series of questions regarding policy implementation in the preparedness, response, and recovery phases of the flooding event, and the evaluation of the policy and policy implementation. All the questions were prepared in a Questionnaire on Health Management of Floods (See

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Appendix C) and were informed by the literature and discussion with study supervisors as well as two emergency care physicians from a large tertiary teaching hospital. The questionnaire was piloted on the supervisors and an experienced research assistant. Minor modification was made to enhance the readability and sequence of the questions. The interviews in the three locations in China were conducted in Mandarin Chinese. The questionnaire was translated into Chinese by two qualified translators and then back- translated into English by two different qualified translators. The difference in any translations was solved by a group discussion among the professional translators. The interview results were translated into English and double checked by qualified translators to confirm the understanding of the language. The interviews were audio recorded and kept together with the questionnaire. For the purpose of confidentiality, all the materials related to the interview, including paper copy, computer files and voice record on flash disk, were physically stored in a locked cabinet. The information will be stored for five years in accordance to National Health and Medical Research Council (NHMRC) guidelines.

7.3.4 Data Analysis

Yin (2003b) proposed three analytic strategies: relying on theoretical propositions, thinking about rival explanations, and developing a case description. Yin also developed five analytic techniques: pattern matching, explanation building, time-series analysis, logic model, and cross-case synthesis. The principles of triangulation were applied in the entire process of data collection and analysis as triangulation has been considered as a strategy to increase the construct validity of the case study (Denzin, 1989; Yin, 2003b). A theme identification method was applied in analysing the open-ended questions. Several of the questions asked the respondents to rate their answer on a scale from 1-10, and for these questions mean and range scores were reported. The analysis includes several steps. Firstly, the issues/ problems were defined, including the physical and health impact of the flood. Secondly, the data were analysed as to why or how the flood caused such impact, including the resources, people, and processes; as well as to what are the constraints and opportunities demonstrated in the cases. Thirdly, alternatives to the ways the problems can be solved were generated by

- 112 - comparing different cases and comparing the management in China and Australia; the “doing nothing”, which means not changing the current strategy, is considered as a viable alternative. Fourthly, these alternatives were analysed and evaluated based on the criteria of their efficiency, consistency with the current framework, implement-ability, as well as the fitness of them to the social, economical, and cultural background. And finally, the preferred alternative is presented and used to develop recommendations.

7.3.5 Validity and Reliability Issues

International comparative research makes an important contribution to the recognition of the social and human sciences as legitimate scientific disciplines (Hantrais, 2009). Though comparative approaches may come close to the experimental method, often validity, reliability, replicability and plausibility are difficult to demonstrate. Multidisciplinary and multi-strategy approaches are useful devices to achieve greater validity and reliability (Hantrais, 2009; Yin, 2003b). The current study seeks to address advice from Hantrais and Yin by undertaking a comparative analysis which is multi- disciplinary and uses a multi-strategy approach. Having presented the methodology for examining the ‘bottom-up’ perspective of experts at the field level, who work on a ‘day-to-day’ basis in prevention, preparedness, response and recovery (PPRR), the study now turns to examine the methodology used for gaining a macro or ‘top-down’ perspective. The methodology for the ‘top-down’ perspective uses face-to-face interviews and electronic surveys to formulate and validate the policy framework of disaster health management in China.

7.4 Survey of Experts

A survey of experts was used to identify key factors of a model for future disaster health management policy arrangements. In this research, 10 international experts were interviewed face-to-face with a pre-designed and piloted questionnaire; another 22 international experts were surveyed through email with the same questionnaire. The experts were selected based on the person’s background and expertise in disaster health management and policy analysis.

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7.4.1 Selection of Experts

The study required that survey participants were to be experts in emergency and disaster health management. Such experts would have the experience and seniority to provide strategic suggestions and critique of the disaster health management policy framework. It was recognized that experts in such an arcane policy domain would be difficult to locate. The research team identified that the best possible and feasible way to recruit such experts would be to conduct interviews during an international congress in emergency and disaster health management. The research team identified the 16th World Congress on Disaster and Emergency Medicine, which was held in Victoria, Canada in May 2009 as the congress to be used. This congress occurs every two years, and its timing aligned with the progress of the current research. While every effort was made to ensure the experts have essential knowledge and understanding of disaster health management policy, this study also seeks to ensure a variety of the backgrounds of these experts. All the experts interviewed and surveyed in this research are actively involved in disaster health management, including the World Association for Disaster and Emergency Medicine (WADEM) Board members; Emergency Department managers, emergency physicians, nurses, anaesthesiologists, paramedics; disaster health management researchers and professors. Interviewees came from universities and governmental organizations with experience in disaster health management and policy. Most of these experts attended the 16th world Congress on Disaster and Emergency Medicine, which was held in Victoria, Canada in May 2009. These experts came from different countries, including the United States, Canada, Australia, , , Belgium, Netherlands, Japan, Taiwan (China); as well as developing countries, including China, India, Indonesia, Nepal, and the Maldives.

7.4.2 Data Collection

This study conducted the recruitment throughout the 16th world Congress on Disaster and Emergency Medicine (WCDEM), which was held in Victoria, Canada in

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May 2009. The researcher, in consultation with his supervisors, contacted three experts prior to the conference to arrange interviews during the time of the conference; five interviews were conducted during the conference. Additionally, the researcher made new contacts for interviews or surveys during and after the conference using snowball sampling via a “friend of a friend”. Difficulties were encountered in accessing the experts at the WCDEM because they had commitments to the conference program and they were busy in making use of the opportunities posed for networking with their colleagues. A total of 10 face-to-face interviews were conducted between May 2009 and December 2009 in Victoria Canada, Brisbane Australia, and Beijing and Tianjin in China. Each interview was voice recorded for in-depth analysis. The researcher transcribed the spoken words into a written text to study and analyse, so as to work reliably with the exact words of the participants. Additional data was obtained from email surveys conducted after the conference. A total of 27 emails were sent to the contacts made during the conference. A reminder email was sent to each participant one week after the initial email. A total of 22 experts replied with completed questionnaires by December 2009 and the other five did not reply or replied with little usable information. These email surveys were conducted to expand the knowledge base, additional to the in-depth interview. Participation was entirely voluntary. The participants were informed of the study purpose, voluntary participation, possible risk, confidentiality, and freedom to withdraw from the study at any time. Eligible participants for the interviews and surveys were provided with the Participants’ Information and Consent Form as attached in Appendix 4. The Participants’ Information Package contains the details of the principal investigator, research supervisor, and QUT ethics committees in case there were any queries. Written consent was obtained from each participant. The written consent forms were photo- copied and filed in a locked cabinet, and the participants’ identity was kept anonymous. The voice record was electronically labelled and stored.

7.4.3 Data Analysis

The interview audio records were transcribed into a written text, to allow for thematic analysis. These texts were combined with the email survey results, and used for

- 115 - the analysis. All the files that were developed in the course of working with the transcripts of interviews have been retained in a retrievable format. Thematic analysis using a grounded theory approach was applied to the data. Thematic analysis focuses on identifiable themes and patterns (Aronson, 1994; Tuckett, 2005). Firstly, the themes and patterns are derived from direct quotes or paraphrasing common ideas. Then all the data that relate to the already classified patterns were identified. After that, related patterns were combined and catalogued into sub- themes, which form a comprehensive view of experts’ opinion on disaster health management policies. The grounded theory method, which emphasizes developing theory from data, was applied in the coding system (Charmaz, 2006; Thomas & James, 2006). The initial codes were both detailed and numerous. Fine grained codes were later connected into broader categories through theoretical coding. Nvivo 8 (QSR International, 2008), which is a qualitative data analysis computer software package, was used to assist the data presentation and analysis.

7.4.4 Validity and Reliability Issues

It is recognized that data collection and analysis can be affected by the researcher’s values (Babbie, 1990; De Vaus, 2002; Yin, 2003b). These authors indicate that research values can cause shortfalls to full and thorough analysis. Thus, it is advised that researchers should look at all the data collected, rather than that which suits our purposes (Yin, 2003b). It is also recommended that researchers should test their scales and measures, and evaluate the validity and reliability of the variables. De Vaus (2002) cautions that researchers should look for ‘negative’ results and do all that is possible to report inconvenient results. In order to address these issues, the researcher attempted to recruit experts with varying backgrounds and experiences and from different countries, so as to gather a broader range of views. Such an approach should assist in gathering data from people from different cultures and disaster management systems to facilitate the validity and reliability of the findings.

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This chapter introduced the methodology for the case studies of floods in China and Australia as well as the methodology for the validating a policy framework for disaster health management in China. In effect, the case studies in China and Australia took a bottom-up approach (Fischer, Miller, & Sidney, 2007; Goggin, Bowman, Lester, & O'Toole, 1990; Sabatier, 1986) in that interviews were conducted with local managers who have to apply the policies at the field level during a disaster event. Conversely, the interviews with international experts took a top-down approach (Fischer, et al., 2007; Sabatier, 1986) in that the interviewees were all senior people who work at the macro level with disaster health management policies. The following chapter will examine the case studies of flood heath management in China, while Chapter Ten will take a comparative analysis of flood health management in China and in Australia.

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Chapter Eight: Case Studies of Flood Health Management in China

This chapter examines the three cases of flood health management in China, including an evaluation of the management of the cases utilizing the PPRR framework as an evaluation of the effectiveness of policy expression. As mentioned in the case study methodology, the three case studies in China examined flood health management at Jinan, Pan’an, and Lengshui in 2007 and 2008.

8.1 Introduction

To better understand the characteristics of disaster health management in China and evaluate the policy effectiveness and implementation at the local level, this research involves an evaluation of flood health management at these selected locations and contrasts this with the management of flood in Australia. This research uses three flood management cases in different governmental levels in China so as to have an overall view of China’s disaster management system and to compare the effectiveness of management at these levels of government.

8.2 Case Studies—Jinan

8.2.1 The Context: Jinan

Jinan is the capital city of Shandong Province, China, and has a population of 6 million. The GDP in the city in 2009 was 335.14 billion Yuan (US$49 billion); and the urban residents’ annual per capita disposable income was 22,722 Yuan (US$3,326) in 2009 compared with 17,175 Yuan (US$2,515) in China as a whole (Jinan Statistics Bureau, 2010; National Bureau of Statistics of China, 2010b) The annual rain fall in Jinan is approximately 450-650 millimetres (Jinan Statistics Bureau, 2007). Jinan’s neighbours include Mount Tai to the south and the Yellow River

- 119 - in the north. Thus, the terrain of Jinan slopes down from south to north. It is only about 10 kilometres from the mountain in the south to the Xiaoqing River in the north, but the height difference is 95-135 meters. There are two major water systems in Jinan - the Yellow River and the Xiaoqing River as shown in Figure 8-1. The Yellow River, which is the second longest river in China, goes through the north of the city. However, as the Yellow River is above the city ground level due to silt deposition, and “the bottom of Yellow River is as high as the top of the Jinan Train station tower”, thus the water from Jinan is unable to drain into it. The Xiaoqing River, which starts in Jinan and drains into the sea, is 237km long and drains an area of 10336 square kilometres; it is the only drainage river for Jinan.

Figure 8-1: Location of Jinan and the river systems Source: Google Maps Daming Lake and Baiyun Lake are major lakes in the city. Jinan is glorified as the “Spring City” for its numerous natural springs. However, in recent years, many springs have stopped running, and the local government closes the gate to the ring river around Jinan to keep the water and to maintain the water levels in the lake, and thus to preserve its scenic appearance (See Figure 8-3).

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8.2.2 Case Description

On 18 July 2007, a flash flood in Jinan city caused 39 deaths, 171 injured and 333,000 affected, with economic loss of 1.32 billion Yuan (US$194 million) (Yang, Yi, & Zhuo, 2007; Ye, 2007). This flood is considered as a once-in-a-hundred-year flood. From 8am, July 18th to 8 am, July 19th, an average of 142.2mm of rain fell on Jinan city. Most of the rain fell between 5pm and 8pm, July 18th; and the highest regional record was 151mm in 1 hour and 180mm in 3 hours. Out of the total 21 automatic rainfall stations in Jinan city, 19 recorded a rainfall of more than 100mm; 11 recorded more than 140mm; 4 recorded more than 160mm (see Figure 8-2). Figure not available due to copyright restrictions.

This Figure shows the rain record in Jinan on July 18th, 2007, in the three levels of more than 150mm, 100~150mm, and 50~100mm.

This Figure can be viewed in the print version of the thesis located in QUT Library.

Figure 8-2: Rain recorded in different stations in Jinan on July 18th, 2007 Source: (Yang, et al., 2007)

The rain started just at the rush hour when 1 million people were on their way home (Guo, 2007), causing flash flood in the mountains on the south side of Jinan, which then flowed into the city. The streets were flooded, and the water depth ranged from tens of centimetres to more than 1 meter. The Xiaoqing River soon over-flowed, and its branches were unable to drain, thus flooding the surrounding areas. The Xiaoqing River

- 121 - exceeded the alert water level 1.04 meters. The deepest ponding in the city exceeded 4 meters. The total area that drains into Jinan city is 415 square kilometres, and during the day the total rain in this area was 60 million cubic meters. 110 square kilometres drained into the city. The water passed through Yingxiongshan Road, Shungeng Road, and Second Ring East Road as the drainage channels over-flowed (See Figure 8-3). The highest speed of water during the flood was approximately 4 meters per second (14.4 km/h) (Guo, 2007; Xu, Sun, & Ma, 2009b).

Figure 8-3: Natural Water and Flood Flow in Jinan Source: (Jinan Urban Planning Bureau, 2007), Google Map and Author Yinzuo Shopping Centre, which is an underground shopping centre covering an area of more than 30,000 square meters in the middle of the Spring City Square (the very middle of the city), was flooded with more than 1 meter of water due to the back flow of water from the ring river (See Figure 8-4). The economic loss in the Yinzuo Shopping Centre alone was about 50 million Yuan (US$7.35 million)

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Figure 8-4: Yinzuo Shopping Centre being flooded.

8.2.3 The Impact of the Flood

This flood disaster is one of the worst in Jinan history, and has significant impact on the health and economy of Jinan. A total of 39 people died due to the flood, most of them were young to middle aged people who were on their way home from work: • 26 were drowned (including 4 drowning that were car related). Most of them were knocked over on the road by the fast running water, and were swept into the drainage channel (Guo, 2007). Three people drowned together in a car as it was swept away into the drainage channel. Another four people drowned together while they were walking through a railway bridge opening, and the nearby underground drainage channel was pushed opened by the high pressure of water. There was also a person drowned in his car because he couldn’t open the door due to water pressure. (Ye, 2007) • 5 were killed by collapsing walls. Four students at 10 years of age were killed when passing a stone wall of 20 meters long and the wall fell on them in the

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school campus. Another person was killed while working in a factory, because the factory building collapsed. (Ye, 2007) • 6 were killed by electric shock. Two of them died on the streets due to the street lamp electricity leakage. A mother and daughter died in front of their house when the mother slipped and tried to grasp the grounding line in a hurry. (Ye, 2007) • The other 2 cases remain unknown.

A total of 330,000 (5% of the population) were directly affected by the flood; 171 were injured according to Jinan Meteorologic Bureau (Yang, et al., 2007). The total economic loss as a result of the flooding is estimated to be 1.32 billion Yuan (US$194 million). 1805 houses collapsed and 802 vehicles were damaged by the rainfall. 14,000 square meters of road were damaged; more than 500 sewage covers were washed away. 26 power lines were cut off. 21,500 mu (14.34 square kilometres) of farm fields were flooded (Yang, et al., 2007). More than 140 factories and companies were flooded, including Yinzuo Shopping Centre as described above.

8.2.4 The Health Management--Prevention

There are several factors in the disaster prevention phase that contributed to the flood damage in Jinan. Firstly, the drainage system was not able to cope with such a heavy rain, thus water was kept in the city area. This flood in Jinan is considered as a once-in-a-hundred-year flood; however the drainage system in Jinan city was only able to cope with once-in- twenty-year flood. Jinan’s flood drainage system mainly relies on flood drain pipelines. There were more than 60 small channels that were used as flood drain channels; however they were designed for 5% to 2% Annual Exceedance Probability (AEP) and thus were only capable of draining as this flood is considered to be the water level kept rising during the rain (Jia, Li, Cao, & Zuo, 2009). Additionally, the sewer was old and it was blocked by trash and leaves (Guo, 2007).

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Secondly, Xiaoqing River is the only drainage river for Jinan city, and it reached 23.59 meters during this flood at Huangtai Bridge Gauge Stattion, which was 1.05 meters higher than the alert level (Xu, Sun, & Ma, 2009a; Zhang, Zhang, Zhang, & Zhang, 2009). In such a situation, the water from the city was not able to drain into the river; on the contrary, there was a risk that water from the Xiaoqing River might flow back into the city. Thirdly, many old houses still exist in the middle of the city. They were not constructed to modern standard, and thus contributed to the degree of damage (Guo, 2007). After the “7.18 flood”, the Jinan city redesigned its drainage system. A “hold back water in the south, divide water in the middle, drain water in the north” drainage system was designed. Jinan city also plans to expand the width of Xiaoqing River to 70 meters from its current 50 meters, so as to enable it reach the 1% AEP flood standard (Xu, et al., 2009a). The city has also re-designed its flood emergency response system, as the former system was designed for 5% AEP floods (Xu, et al., 2009a). The new system emphasizes how to inform the citizens of emergencies and what to do during the flood, and utilises a wide range of media channels. For example the Jinan government established a system to use SMS (cell phone short message) to send out emergency warnings.

8.2.5 The Health Management--Preparedness

At 3pm, 18th July, the Shandong Provincial Meteorologic Bureau forecast Yellow warning, which is a level 3 warning in the 4 level scale (level 1 being the most urgent). The Meteorologic Bureau, together with the Land and Resources Bureau of Shandong Province, issued a geology disaster warning two hours later. However, many citizens didn’t get this information (Qiu, Chen, & Wen, 2009). They even didn’t know the meaning of the Yellow warning. At 4pm, Jinan Radio and TV stations started to broadcast news of the heavy rain. However, the city government didn’t expect the rain to be so heavy. The Yellow warning means the rain will exceed 50 millimetres within 6 hours; however the heaviest rain was 180 millimetres from 5:30pm to 8:30pm on July 18th.

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In the Yinzuo Shopping Centre, they received the weather warning at about 4pm. They prepared about 4,000 sandbags to prevent water leaking into the shopping centre in accordance with past practice; they also assigned people to watch the water level in the Ring River, which is beside the shopping centre (Guo, 2007) (See Figure 8-3). They bought pumps as well. But the 4,000 sandbags proved to be inadequate, and the pumps failed to function as the water in the shopping centre had cut the power off.

8.2.6 The Health Management--Response

It started raining at 5.15 pm, and the water started to flow onto the roads at 5.30 pm. At 6.10 pm, the ring river over-flowed, and the Yinzuo Shopping Centre was flooded. At 6.30 pm, the city was inundated, and the traffic stopped. They government did try to provide what services they could. There were more than 1,000 traffic police on the roads during the rain. However, some of them lost communication with headquarters as their radios stopped working from being wet (Guo, 2007). And they couldn’t assist the traffic much as many cars were flooded and couldn’t drive at all. The Water Resources Bureau did manage to drain water from a reservoir in the west and close the two reservoirs in the south, so as to provide clean water (Guo, 2007). All the emergency telephone systems, including hotline 110 (police), 120 (Ambulance), and 119 (Fire) were totally overwhelmed. The 110 phone line received more than 3,800 calls within several hours on July 18th, overloading the phone system to the extent that not even a baseline level of response could be maintained. “She called 110 and 119 in the car, but it’s either the line was busy or there were no more police available.” Xiao Yue remembered. (Ye, 2007) Staff from the Jinan Civil Affairs Bureau, with the help of the citizens, totally evacuated 112,000 flood victims (Li & Dong, 2007). However, they were mostly transferred to higher levels in the same building or their relatives, rather than pre- prepared shelter centres. In the Yinzuo Shopping Centre, they used 4000 sandbags to build a temporary levee of 1.2 to 1.3 meters high. But the sandbags were swept into the shopping centre as the water surged higher. The centre had continued business operations so there were still many people there when the levee was swept into the shopping centre at 6.10pm (Guo,

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2007). The shopping centre was able to begin emergency procedures, using the emergency power. People managed to escape, but most of the things inside were flooded, including 76 cars. The gate of the Ring River was closed, and this is one of the reasons the Ring River over-flowed. “They should have started to drain the water into the Daming Lake and the Xiaoqing River early, the cost wouldn’t have been so high if they did it earlier” a citizen said (Guo, 2007).

8.2.7 The Health Management--Recovery

In the recovery, the Jinan government used pumps and movable pumps to pump water in the evening of July 18th. More than 30 pumps were used to drain off water in the Yinzuo Shopping Centre. As for the financial assistance to the flood victims, 10 million Yuan (US$1.5 million) and 5,000 blankets were provided by Shandong Provincial government; 15 million Yuan (US$2.2 million) were provided by Jinan City government; 8.68 million Yuan (US$1.3 million ) were provided by local district governments; 2.95 million Yuan (US$) were donated by the citizens and companies in the city (Li & Dong, 2007). The insurance industry in total paid 126 million Yuan (US$18.4 million) for 20 deaths and injuries and 10,544 cases of property damage, approximately 9.5% of the total estimated cost which is 1.32 billion Yuan (US$194 million) (Wang & Huang, 2007; Yang, et al., 2007). A pension of 20,000 Yuan (US$2,928) was provided to the family for each death. In the public health sector, the Shandong Provincial Centre for Disease Control and Prevention (CDC) and Jinan CDC both participated in the sterilization, vector control, and infection control. They used pharmaceutical products such as 10% Beta cypermethrin, PPA, and chlorine disinfectant. They were also educating the citizens how to protect their health after the flood and distributing education materials. No infectious disease was detected after the flood, though some skin diseases were reported. However, they didn’t have education materials ready before the flood. Some emergency plans were considered as no more than a piece of paper for the purpose of higher level inspection. There were not enough equipment and drugs in store for the emergency response. Some managers in the interview also admitted that the situation and

- 127 - the leadership were chaotic. Some other managers stated that the government should focus not only on making emergency plans, but also on how to implement them. The army came to help quickly. More than 3500 person-times from the army, as well as 960 person-times from the militia reserve forces, came to assist transferring goods and clean-up with their super-powered pump within the first four days after the flood (Li & Dong, 2007). Some companies donated drugs. The media were on the scene to report all the cases possible, not only the government reports, but also the moving stories of what actually happened during the flood, such as the community leaders trying to help the citizens. But one manager pointed out that some media members were trying to “sell their stories and fool people”. The city resumed its normal function quickly, and most people started their normal life on the second or third day. At the time of the interview, about one year after the flood, nothing significant can be noticed except some marks on the walls and people’s memories.

As can been seen in this case, problematic issues of the disaster health management exist in infrastructure standards, disaster monitoring and warning, stockpiling of disaster response equipment, inter-organizational cooperation arrangements, and disaster relief procedures. These issues form the policy leanings from this case study, and they will be further discussed in Chapter Ten: Comparative Case Study Findings and Synthesis.

8.3 Case Studies—Pan’an

8.3.1 The Context: Pan’an

Pan’an is a small county located in the middle of Zhejiang Province with a population of approximately 200,000. The rural per capita net income in 2009 was 5,518 Yuan (US$807.9) while the urban residents’ annual per capita disposable income was 16,154 Yuan (US$2,365.2) (Zhou, 2010). They are compared with figures of 5153 Yuan (US$754.5) and 17,175 Yuan (US$2514.6) respectively in China as a whole (National Bureau of Statistics of China, 2010b).

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There are approximately 5,200 mountains within this county, and thus it was named as the “country of mountains and the origin of all rivers”. The mountainous nature of Pan’an makes it vulnerable to mountain floods, which are quick and dangerous. Pan’an is subjected to typhoons regularly (3-5 typhoons passing through Pan’an each year) during summer and autumn, especially in July and August. The typhoon not only brings the wind, but also a large amount of rain.

8.3.2 Case Description

“Wipha” typhoon reached Zhejiang province in early 19th Sep, 2007 (See Figure 8- 5 for the typhoon route). The central wind speed was about 162 km/h (level 14). The typhoon lasted 14 hours in Zhejiang Province. It started raining on 19th Sep, 2007. Through the whole typhoon process, the average rainfall in Pan’an was 215mm. The rain caused a burst in the levee in Huangyutian Village, Lengchuan Town, and a landslide in Yushan Town in Pan’an County. A total of 5,160 people were evacuated in the county, and the 51 people were rescued by the Military Emergency Rescue Team (Zhang, Yang, & Yu, 2007).

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Figure 8-5: Location of Pan’an and typhoon routes Source: (Office of Zhejiang Provincial Flood Control and Drought Relief Headquarter, 2009) and author

8.3.3 The Impact of Flood

Throughout Zhejiang Province, a total of 7, 600, 300 people from 55 counties were affected in the “Wipha” typhoon; 5 people died and 3 remain missing. It caused a total economic loss of 5.62 billion Yuan (US$826 million) (Zhejiang Meteorological Bureau, 2007). In Pan’an County, 157,500 people (about 75% of the population) from 20 towns were affected by the typhoon, and one person was killed in the typhoon. A total of more than 800 houses were destroyed; and the levee was breached in 120 locations. The total economic loss is about 120 million Yuan (US$17.6 million).

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The burst levee in Huangyutian Village caused two houses to fall while another house seriously damaged (Chen, 2007b). The landslide in Yushan Town forced the evacuation of 400 students and some residents living nearby (Wang, 2007). Additionally, 5400,000 square meters of farmland was affected; 450 domestic animals were killed. A total of 115 roads were damaged, and the direct economic loss of road destruction is 6.32 million Yuan (US$0.93 million) (Pan'an Traffic Bureau, 2007). The flood and typhoon also caused electrical power shortages and telecommunication disruption (Zhang, et al., 2007).

8.3.4 The Health Management--Prevention

Typhoons affect Pan’an regularly, and people get used to them. However, each typhoon still causes loss of life and great damage. A typhoon and the wind and rain that it brings are unpreventable. It is in the area of forecasting, and therefore of community preparedness that improvements might be made. Some of the houses and buildings are very old, and thus are not safe in the Typhoon and the rain. People then who live in the older sections of the city are thus at greater risk of death or injury; and this added danger is a known risk. With improvements to forecasting, preparation of safe shelters and good communications, such risks can be reduced. Pan’an Flood Control and Drought Relief Headquarter is the organization that guides and coordinates the emergency response in flood and drought. This Headquarters includes personnel from around 20 organizations including the Water Resources Bureau, Meteorological Bureau, Transportation Bureau, Construction Bureau, Land Resources Bureau, Civil Affairs Bureau, Health Bureau, Police Bureau etc. However, in each section, such as the Health Bureau, the number of staff might be so small that specific people cannot always be assigned for each corresponding responsibility. Sterilization and vaccination drugs are available in the county CDC. But the problem is that the drugs such as bleaching powder can easily exceed their expiry date, which will result in waste, thus depleting the already limited funds that are available.

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8.3.5 The Health Management--Preparedness

Before the typhoon arrived, the provincial government and the county government issued warnings in regarding to the typhoon, and the media released the information to the public. The warning of typhoon can usually be issued one week before the typhoon arrives. Additionally, each organization has its own warning system, which means the headquarters of each organization will issue warnings to their branches. However, the provincial warning system can’t cover smaller and local cases such as cyclones and lightning. And the local governments are in need of more equipment. One example is that a town within the Pan’an County was hit by a severe cyclone, but the Flood Control and Drought Relief Headquarter didn’t know this until the local people reported it (Chen, 2007a).

8.3.6 The Health Management--Response

Because the typhoon was forecast about one week in advance, all the staff in the relevant government departments were ordered to stay alert and work in the front line during the typhoon. Response speed and the level that information reaches are the two main issues. As Pan’an is in a mountainous region, some areas are not covered by cell phone signals, and the telephone may be interrupted during floods, therefore, information release may be a problem during the response phase. During the flood, all the leaders in various departments of the county government were divided into several groups and sent to different flooded areas to guide the rescue (Zhang, et al., 2007).

8.3.7 The Health Management--Recovery

Charity Federation, Disabled Person Federation, and Red Cross were the main agencies providing assistance after the flood. Usually, rice, medicine, blankets etc. are provided to the victims.

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Various organizations, such as the Pan’an Tobacco Monopoly Bureau, carried out donation activities for the flood victims (Lu, 2008). Volunteers groups went to villages to help the flood recovery, including house services teams, medical teams, and environmental protection teams. They provided services such as household facilities maintenance, disease prevention, and environment rehabilitation (Pan'an League Committee, 2007). Farmers’ houses and farming were insured. In the whole province, 2364 houses fell down, and 1800 houses were partly damaged, and the total insurance for damaged houses were 25.4 million Yuan (US$3.72 million) (Zhejiang Rural Houses Insurance Working Group Office, 2007). This case differs from the Jinan case in a number of ways: the flood caused by typhoon allows sufficient warning; the area was hit by a combination of riverine flood and flash flood; the affected population is more used to flooding; the case is studied in the county management level. Key issues arising from this case study include a need for more detailed and precise warning; potential waste in the drug stockpiling; lack of an inter- organizational platform to conduct the response and recovery. These issues and their policy implications will be dealt further in the comparative analysis in Chapter Ten.

8.4 Case Studies—Lengshui

8.4.1 The Context: Lengshui

Lengshui is a town located in the south of Pan’an County. The total population is about 10, 000. The residents’ rural per capita net income was 5,009 Yuan (US$733.4) in 2008, while it was 9258 Yuan (US$1355.5) in Zhejiang Province and 4761 Yuan (US$697.1) in China (Hu, 2009; National Bureau of Statistics of China, 2009; Zhejiang Statistical Bureau, 2009). Most of the people in the town reside along the river bank of the Haoxi River, which is the origin of Ou Jiang River (The second longest river in Zhejiang Province). Three small branches of the Haoxi River combine into one in this town. (See figure 8-6). Typhoons visit this town very often, and usually cause a great flood in the Haoxi River.

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Figure 8-6: River systems, Emergency Shelter Centres, and Reservoir in Lengshui

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8.4.2 Case Description

Kalmaegi Typhoon arrived at Lengshui on July 19th, 2008 (See Figure 8-5 for the typhoon route). The central wind speed was 72 km/h (level 4). Though the Kalmaegi Typhoon was not a typical big one, a local anti-typhoon and flood drill was carried out during this typhoon, and it demonstrated the typical flood rescue response at the local government level. A total of 600 people, including leaders from the Pan’an County government, staff from the local government, police, citizens from the town, participated in this anti-typhoon and flood drill. The drill included information monitoring and forecasting, river bank rescue, evacuation of staff and residents.

8.4.3 The Impact of Flood

The Zhejiang Provincial Government raised the disaster emergency response system to level-II on July 17th, and evacuated 232,533 people and 27,032 boats to safer places (Chen, 2008). The typhoon didn’t follow the predicted direction and abated when passing Zhejiang Province, thus it only caused minor damage. However, this case was selected as it demonstrated the process typical flood rescue in the local government.

8.4.4 The Health Management--Prevention

The river in Lengshui is called “Hao Xi”, which means “Good River”. But it used to be named as “E Xi” which means “Bad River”, because flood was normal in this river and had caused great damage to the local people (Chen, 1997). In order to mitigate the flood damage, the Lengshui government adopted two main measures: riverbank reinforcement and small river basin management. For example, in Yantan village, the river banks used to be very old and vulnerable to the floods. In the past five years, all the river banks around the village were reinforced, and the village is safe from “once every 60 years” floods. As for the small river basin management, the local government is building small reservoirs (See Figure 8-6).

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Additionally, three emergency shelter centres has been established in the town in 2008 (See Figure 8-6 and 8-7). As demonstrated in the Anti-typhoon drill, food and medical services are provided in the shelter centres during disasters.

Figure 8-7: Emergency Evacuation Centre in Lengshui

8.4.5 The Health Management--Preparedness

The typhoon warning was issued, and the rescue drill was carried out when the typhoon was passing through the town. Each village has an emergency rescue team, with 6 people in one group, and they were under the leadership of the rescue team in the town. The town had 5,000 sandbags, 20 shovels, and 40 life jackets. They also have an emergency light system for the whole town. Drugs and medical team were also part of the drill.

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8.4.6 The Health Management--Response

During the drill, the people in Lengshui carried out an active rescue action. Each village will have at least one person who monitors the flood situation. If the flood exceeds the alert level, the monitoring person will warm people by beating a drum. They think electrical equipment is not reliable during floods. Sand bags were used to patch up one location where the river bank was breached (see Figure 8-8) If anyone is injured during the disaster or the disaster rescue, the town government will pay for the medical expenses. The clear division of work leads to quick response. All sorts of people, including the emergency rescue teams, the monitoring person, the local leaders, as well as the citizens and victims know what to do during disasters, and thus speed up the response. Additionally, the wide involvement increases people’s sense of responsibility and increases the local response capacity.

Figure 8-8: Emergency rescue team conducting rescue in Lengshui

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8.4.7 The Health Management--Recovery

Bleaching powder is usually applied to the flooded area, and the CDC usually guides the cleaning and bleaching. The CDC also provides pesticide for rodents, mosquitoes, cockroach and flies. The local government initiated Cooperative Medical Services, and 95% of the farmers are attending this service. In this Service, each citizen is given a free physical check-up each year, which includes blood pressure and type-B ultrasonic. The leaders will usually visit the victims of the floods, and provide them some financial and material assistance. The money and the flood relief goods are usually from the provincial government or donation.

Compared to the previous two cases, this case is managed in the local township level with much more effort in preparedness. With limited damage and an apparent more rational management, key issues can still be observed as policy implications from this case including: higher building standards, a more transparent disaster relief funds, and more advanced warning technology. Together with the previous two cases, the key issues and their policy implications from this case will be examined against the case studies in Australia in Chapter Ten.

8.5 Analysis and Conclusion

The managers in these three locations appreciated the content of government policies in disaster management and were pleased with the outcome of this flood case management. On a scale of 1-10, the managers gave 7.87 (5 to 10) for the content of government policies in disaster preparedness, 7.93 (5 to 10) for the disaster response, 8.47 (6 to 10) for disaster recovery, and 7.87 (3 to 10) for disaster policies implementation (see Table 8-1).

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Table 8-1: Manager Evaluation of Flood Management

Policy and Preparedness 7 5 8 5 10 10 9 10 9 9 7 8 8 5 8 Disaster response 7 5 8 5 10 10 8 10 9 9 5 8 8 8 9 Disaster recovery 8 6 10 7 10 10 9 10 10 9 8 6 8 7 9 Policy implementation 8 7 9 6 10 10 8 10 10 9 7 7 6 3 8

Advantages in flood management include: strong political leadership in command and control; swift mobilisation of army personnel; effective field public health management; and management of casualties. Challenges in flood management include: timely and accurate flood warning; disseminating the warnings to the public; limited power in command for public health sectors; absorbing capacity in infrastructure and buffering capacity in resources such as medical sterilisation materials.

8.5.1 Policy Execution in the Local Level

Emergency plans and regulations are all in place, but at the very local level, it’s more in a form for higher level government inspection than for actual implementation. “Policy preparation in the provincial level is very sufficient, but not at the local level” a local manager says. “Earlier this year, we have a ‘Hand, Foot and Mouth Disease’, and we started the level 2 emergency. But it’s mainly on the form, and it’s not realistic for us to be very serious about it yet.” Another local manager pointed out. At the provincial and state level, a Disaster Management Commission is a requirement, but in the county level, there is only such a small number of administration staff that they can’t meet the requirements and those policies become a show rather than a reality. There is another aspect of policy implementation. The local managers indicated that implementing the policies is simply not realistic because the local farmers couldn’t understand our policies. The farmers are usually not well educated; therefore some laws to support enforced evacuation maybe necessary. “The farmers may even try to stay in their dangerous house and protect it during evacuation.” A local manager said.

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8.5.2 Construction as Mitigation

River banks construction and small river basin management has been developing quickly as the major means of flood mitigation. However during the construction process, finance is a constant problem, especially in the rural areas. China is a developing country and many government leaders focus on the economic development which would be part of their political achievement; and thus disaster prevention has been neglected. The other issue during the flood levee construction is the difficulty of getting a consensus of land use planning. All the land is owned by the government in China; however, each piece is contracted out to private people on the long term (30 years). Farmers are not willing to sacrifice their land for the levee construction as many of them still depend on it. Additionally, the quality of levee structures has become a concern as there is a lack of construction quality monitoring system.

8.5.3 Media Dilemma

Public communication is essential to disaster management; managers need to deal with the media. However, managers may don’t know how to deal with the media or lack the skills to deal with the media. These middle level managers, especially those from the county or town level, have difficulties in dealing with the media as evidenced in the interviews as well as in the literature (Ma, 2005; Zhu, 2008). While most of the managers admitted that local media helped to release warning information, they also expressed their concern in regard to a lack of regulation of the media. Some managers have some adversarial views of the media: they believe that the media interfere in the disaster management and can cause a second disaster.

Having examined the three cases and their management in China, the following chapter examines the three cases in Australia, so as to provide a comparison of the flood health management in China with a more experienced disaster management system in Australia.

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Chapter Nine: Case Studies of Flood Health Management in Australia

This chapter outlines the context by describing disaster management arrangements in Australia, analyse their effectiveness through three case studies. This analysis examined Australia’s approach to prevention, preparedness, response, and recovery (PPRR), so as to provide a consistent basis for comparison with the management of floods in China.

9.1 Introduction

“Drought declared one day, flooded the next!” This was the situation faced by many communities in Queensland in early 2008. The La Nina event brought flooding to Queensland, which had experienced El Nino and drought for several years (Sian Fullerton, 2008). It is a situation experienced commonly in Australia where often dry and semi-arid rural areas may be suddenly affected by severe tropical storms (including cyclones) and by the monsoonal trough pushing south into central areas of the country. The ‘weathered’ geography of Australia limits the rapid flash flooding that occurs in more geologically new landscapes. Tropical coastal areas may be confronted with torrential downpours of hundreds of millimetres of rain in very short periods of time while the flat expansive central areas may be broadly inundated by relatively small amounts of rainfall. Flooding is often viewed in a good way by people in rural areas in Australia as it brings relief from the perennial challenge of a dry continent and when passed, brings promise of crop and fodder growth. The threats to human health, while nowhere near as dangerous as in other locations, remain considerable and require careful planning, preparation and response management. The aim of this chapter is to review the policy, planning, preparedness and response to floods with a view to determining the effectiveness of current arrangements, and providing a comparison with case studies in China. This chapter begins with a review of policies and plans and then examines three floods in rural areas as a means of determining the effectiveness of the expression of those arrangements in managing and

- 141 - preventing health consequences of flooding. The cases are floods which occurred in early 2008 at Charleville, Emerald, and Mackay in Queensland as shown in Figure 9-1. These three locations were chosen for their diversity in geography and population, as well as the variety of flood types and management.

Figure 9-1: Locations of Charleville, Emerald, and Mackay

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9.2 Disaster Management in Australia: Policy Framework and Structure

Disaster management in Australia is structured in accordance with relevant legislative instruments. Figure 9-4 identifies the responsibilities of each tier of Australia’s disaster management system as outlined in the Disaster Management Act (Queensland) 2003. This Act establishes Disaster Management Groups at State, District, and Local levels, and forms a disaster management system (Department of Emergency Services, 2004). State Planning Policy 1/03: Mitigating the Adverse Impacts of Flood, Bushfire and Landslide aims to influence land use planning and development decisions to create settlement patterns that reduce the community’s vulnerability to flood, bushfire and landslide events (Department of Emergency Services & Department of Local Government and Planning, 2003). Health is a key domain within disaster management. Disaster response arrangements are aimed particularly at protecting the health and welfare of people. However health services have a particular responsibility to maintain health services to the public while also protecting the health and wellbeing of their staff, patients and the community, and the health infrastructure. Thus health services are engaged at each level of the disaster management framework. As discussed previously, floods are the commonest cause of disaster throughout the world resulting in the deaths of thousands of people annually and the displacement of millions (Diaz, 2004; Noji, 1991). In Australia, the threat of floods to property damage and human injuries is often exceeded by the perceived benefits from restoration of water supplies and the subsequent growth of crops and fodder in a generally parched landscape. The health consequences of floods have been categorised in terms of immediate, medium term and long-term. They may also be categorized as those related to direct contact with flood water (e.g. drowning and injury) or those due to the secondary consequences of the damage done by the flood (e.g. destroyed food supplies, and displaced people). The geography and environment in Australia are different to many other countries. Floods are more likely to come with a warning and thus are less likely to result in direct drowning and injury. Indeed studies into deaths from floods in Australia have shown that the most common causes of deaths since European settlement occurred through attempts

- 143 - to cross creeks, bridges or roads in times of flood (Coates, 1999). More recently it is likely that the most common causes of deaths from floods are misadventure from driving of motor vehicles onto flooded roadways or from inappropriate behaviour such as surfing in flooded drains (FitzGerald, Du, Jamal, Clark, & Hou, 2010). However despite this relatively benign view of floods, considerable health risks associated with flooding remain in Australia.

9.2.1 National Level

9.2.1.1 National Legislation

The role of the Commonwealth Government in emergency management is essentially to assist States in developing their emergency management capabilities. In 1995 the Commonwealth Government released 1995 Commonwealth Government Emergency Management Policy Statement, which stated the States and Territories have the predominant constitutional responsibility while the Commonwealth Government will provide support and assistance (EMA, 2009a). Emergency Management Australia (EMA) is the Commonwealth agency responsible for reducing the impact of natural disasters and those caused by human activity on the Australian community. To provide a framework for its operations, EMA maintains and uses four Commonwealth Government emergency response plans, which guide the response to disasters and emergencies in Australia and overseas, and are designed to cover most major natural, human-caused and technological emergencies and disasters. The Plans are as follows (EMA, 2000):

• Australian Government Disaster Response Plan (COMDISPLAN) for the provision of Commonwealth Government assistance following a disaster within Australia including the offshore territories. • Australian Government Overseas Disaster Assistance Plan (AUSASSISTPLAN) for the provision of Australian assistance to overseas disasters. • Australian Government Plan for the Reception of Australian Citizens and Approved Foreign Nationals Evacuated from Overseas (COMRECEPLAN) for the

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reception of persons evacuated to Australia following an overseas disaster or civil emergency. • Australian Government Contingency Plan for Space Re-Entry Debris (AUSCONPLAN SPRED) for the response to the re-entry of radioactive space debris. A number of specialized national hazard-related plans are maintained by appropriate Commonwealth Government agencies on behalf of the Commonwealth Government and States and Territories. These plans cover national search and rescue arrangements (Australian Maritime Safety Authority), pollution of the sea by oil (Australian Maritime Safety Authority), management of communicable diseases in Australia (Department of Health and Aged Care), and major outbreaks of exotic animal, crop and aquaculture diseases (Department of Agriculture, Fisheries and Forestry- Australia) (EMA, 2000). Thus these plans and agencies provide the preparedness for responding to a range of potential disaster types.

9.2.1.2 National Structure

The basis of the national system for managing major emergencies and combating disasters is a partnership between Commonwealth, State or Territory and local governments, and the community. At the national level, emergency management policy coordination, as distinct from operational coordination, is provided by the National Emergency Management Committee (NEMC). The committee is chaired by the Director General, Emergency Management Australia, and consists of the Chairpersons and Executive Officers of the peak State emergency management committees or equivalents (Emergency Management Australia, 2000). The Commonwealth Counter-Disaster Task Force (CCDTF) is a senior interdepartmental committee, chaired by the Department of the Prime Minister and Cabinet, comprised of representatives of Commonwealth Government departments and agencies with a significant role to play in the provision of disaster relief or rehabilitation assistance. It is responsible to the Minister for Defence. On the advice of the Director General EMA, the Chair may activate the CCDTF during the response and recovery phase of a disaster in support of EMA activities.

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Emergency Management Australia (EMA) is a Division within the National Security and Criminal Justice Group in the Attorney-General’s Department. EMA is responsible for the day-to-day management of the Commonwealth function in emergency management. The organizational structure of EMA, as shown in Figure 9-2, includes mainly three departments which are community and sector development, capability and operational coordination, and emergency management policy and liaison.

Figure 9-2: EMA organisational chart Source: (Emergency Management Australia, 2009b) and author EMA operations and coordination tasks are conducted from the National Emergency Management Coordination Centre (NEMCC) in . The NEMCC also coordinates Australian assistance to overseas countries on behalf of the Australian Agency for International Development (AusAID) (Emergency Management Australia, 2000). A range of Commonwealth agencies contribute to emergency management, such as the Bureau of Meteorology and the Australian Geological Survey Organization. The

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Department of Finance and Administration administers the National Disaster Relief Arrangements, a scheme where the Commonwealth reimburses State expenditure on disasters according to predetermined thresholds and formulae (Emergency Management Australia, 2000).

9.2.2 State Level (Queensland as an example)

9.2.2.1 State Legislation

The Constitutional responsibility for the protection of lives and property of Australian citizens lies predominantly with the States and Territories. To meet this responsibility, States have established emergency management arrangements which are supported by legislation in all States. States also provide emergency response agencies such as police, fire, ambulance, health and emergency services (EMA, 2000). Each of the States and Territories has its own emergency management system. Although government administrative arrangements differ between States and Territories and emergency management systems, and titles and procedures vary to reflect those differences, the roles of these systems are very similar. Figure 9-3 shows the titles of the peak State and Territory emergency management committees. The state of Queensland is used here as an example of the counter-disaster legislation and arrangements and the location of the flood case studies.

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Figure not available due to copyright restrictions.

This Figure shows different emergency management committees in Australia, including QLD State Disaster Management Group, NSW State Emergency Management Committee, ACT Emergency Management Committee, VIC Emergency Management Council, SA State Disaster Committee, WA State Emergency Management Advisory Committee, NT Counter-Disaster Council, TAS State Disaster Committee, Christmas Island Counter-Disaster Committee, Cocos (Keeling) Islands Counter-Disaster committee, Norfolk Island Emergency Management Committee, Jervis Bay Territory Emergency Management Committee.

This Figure can be viewed in the print version of the thesis located in QUT Library.

Figure 9-3: Titles of the peak State and Territory emergency management committees Source: (Emergency Management Australia, 2000) In Queensland, the Disaster Management Act 2003 (DM Act) provides the legislative basis for the establishment of Disaster Management groups for State, disaster districts and local government areas, as well as for their powers, authorities, functions and duties and matters incidental to and consequent upon their establishment. The DM Act is administrated by the Minister for Emergency Services. Additionally, DM Act establishes the detail planning requirements at each level and provides for the conferring of extra-ordinary powers on selected individuals and groups. The roles and operations of the two volunteer disaster management groups in Queensland, i.e. the State Emergency Service (SES) and Emergency Service Unit (ES) are also maintained by the DM Act. The State Disaster Management Plan (SDMP) is prepared under the provisions of DM ACT. SDMP ensures a common understanding of State disaster planning arrangements, and outlines concepts, roles, responsibilities, processes and finances to stakeholders. It also provides the basis for the development of planning guidelines for Local and District Disaster Management Group plans.

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9.2.2.2 State Structures

Each State has a peak emergency management or counter disaster committee or council, comprising senior members of relevant Government agencies and other organizations, which considers emergency and disaster management matters; they are responsible for ensuring that plans and arrangements are in place for dealing with emergencies and disasters (Emergency Management Australia, 2000) Each State has an operational authority responsible, usually one of the emergency services, to lead the development and activation of appropriate disaster plans. There is also a State Emergency Operation Centre (or equivalent) capable of coordination of all resources required to deal with disasters at the State level. Queensland Disaster Management System comprises three tiers: Local, District, State. Additionally, Queensland may require Commonwealth support on times of disaster, and thus Commonwealth government forms the fourth level (See Figure 9-4). In the State level, key components of the disaster management system include Major Incidents Group (MIG), State Disaster Management Group (SDMG), and State Disaster Coordination Centre (SDMG, 2005). Figure not available due to copyright restrictions.

This Figure shows different levels in the Queensland Disaster Management System, including Commonwealth Government, State Government, Disaster District, Local Government.

This Figure can be viewed in the print version of the thesis located in QUT Library.

Figure 9-4: The Queensland Disaster Management System Source: (Queensland's Disaster Management Services, 2008)

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MIG provide high level Ministerial guidance and support in event of a significant incident or disasters. The membership of MIG is conceptually determined on an event-by event basis, including but not limited to: Premier (Chair), Attorney-General, Minister for Police, Minister for Emergency Services, and Minister for Health. However, MIG is not a legislated group (SDMG, 2005). SDMG is the peak policy and planning group for disaster management in Queensland. It is established under the DM Act, and comprises the chief executive of the Department of Community Safety (Director General), chief executives of other departments, and appropriately qualified officer of the department. The working body of SDMG is the State Disaster Coordination Group (SDCG). The SDMG is also supported by an operational coordination group (State Disaster Coordination Group), a mitigation policy and planning committee (State Disaster Mitigation Committee) and a committee that provides strategic direction of the whole-of Government chemical, biological, and radiological (CBR) response capability (CBR Steering Committee) (State Disaster Management Group (SDMG), 2005). The Department of Community Safety In Queensland provides services covering all phases of emergency and disaster management. This Department includes Queensland Ambulance Service, Queensland Fire and Rescue Service, Queensland Corrective Services and Emergency Management Queensland as demonstrated in Figure 9-5. Additionally, this Department also has Corporate Support Division and Strategic Policy Division which provide strategic and business support to the operational services and volunteers. SES and ES volunteers are under the leadership of Emergency Management Queensland (Department of Community Safety, 2009).

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Figure 9-5: Organisational Structure of the Department of Community Safety Source: (Department of Community Safety, 2009) and author

9.2.3 District and Local Governments (Queensland as an Example)

Local governments are a major partner in the emergency management system in Australia that provide a variety of services such as public works and environmental health systems on a daily basis, and particularly when the community is affected by emergencies and disasters. In Queensland, the DM Act established Disaster Management Groups at three levels: State, District, and Local (for individual or combined Local Governments and Community Councils). For disaster management purposes, Queensland is divided geographically into 23 Disaster Districts. Each District has a District Disaster Management Group and a District Disaster Management Coordination Centre. Queensland State is further divided into 125 Local Government areas and 34 Aboriginal

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& Torres Strait Islander Councils, one or more of which make up a Disaster District. Each Local Government area establishes a Local Disaster Management Group and Local Disaster Coordination Centre. The Disaster Management Groups and Coordination Centres at the District and Local Levels are responsible for preparing a District or local counter-disaster plan, establishing and maintaining a local emergency service and making resources available for counter-disaster purposes. Local level operations are coordinated through Local Government disaster management arrangements, and depending on the scale of the event, at Disaster District and State levels. If local governments require additional resources to manage an event, they can request support through their District Disaster Coordinator. A “state of disaster” may be declared when the magnitude or threatened magnitude of a disaster or impending disaster is, or is likely to be, so great in extent or severity, that the counter-disaster measures necessary or desirable are either beyond the capacity of the District’s statutory services, or are beyond the resources of a Disaster District Coordinator. District can request for assistance to State via State Disaster Coordination Centre. State requests for Commonwealth assistance can only be made by the designated senior State emergency management officer who is authorized to request assistance in the event that State or commercial resources cannot meet requirements. After gaining the approval of the Minister for Defence as the Minister responsible for emergency management matters, the NEMCC can call on Commonwealth resources and seek any commercial assistance considered necessary (Emergency Management Australia, 2000). In recent years, the Australian Defence Force has provided most of the Commonwealth material assistance.

9.3 Floods in Australia

Flooding is, overall, Australia’s costliest form of natural disaster, with an estimated losses of over AU$314 million a year (BTE, 2001). On the positive side, floods have some beneficial aspects, such as cleansing excess salt from the soil and recharging underground aquifers (Bureau of Meteorology, 2009a).

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9.3.1 Characteristics of flood in Australia

Australia suffers from a highly variable climate. Because of this, flooding in Australia’s river systems occurs sporadically, unlike the regular flooding in river systems elsewhere. In Australia, years or even decades can elapse before a severe flood occurs in a river system of interest. A in Australia in the period of 2000 to 2008 is listed in Table 9-1.

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Table 9-1: Most Significant Floods in Australia in 2000-2008 Dates Location Subtype Killed Affected Damage (USD Million) 20/11/2008 Queensland General Flood 4 1200 03/01/2008 Brisbane, Yarrahappini General Flood 1 3000 90 08/06/2007 Central Coast, Hunter Flash flood 9 5000 1300 05/04/2006 Katherine, Beswick General flood 1100 30/06/2005 Lismore, Byron Bay General flood 3 3000 58 08/12/2004 Narrabri, Orange, Moree General flood 3 120 15 19/10/2004 Bellingen, Coffs Harbour General flood 100 5.5 14/01/2004 Queensland, General flood 3400 32 02/12/2003 Melbourne region Flash flood 50 75 13/05/2003 Sydney region, New South Wales Flash flood 300 24/02/2003 Northern New South Wales Flash flood 100 12/02/2003 Stanwell, Wowan, Mt Morgan General flood 1 20 2 15/03/2001 Yamba, Coffs Harbour, Bal General flood 3 3001 200 23/02/2001 Pigeon Hole, Kalkarindji Storm surge/coastal flood 670 13 01/02/2001 Grafton, Maclean General flood 00/01/2001 Granville, Merrylands 1 330 12 02/12/2000 Berrigan, Corowa, Deniliquin General flood 600 265 Source: (Centre for Research on the Epidemiology of Disasters, 2009), Created on: Mar-23-2009.

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In northern Australia, most of the big floods occur in summer or early autumn in association with tropical cyclones or intense monsoonal depressions. Outside the tropics, coastal areas of eastern Australia mostly receive their flood rains from so-called “east coast lows” that develop over the Tasman Sea. In the southern states, flooding is mostly a winter-spring phenomenon, associated with unusually frequent low pressure systems and fronts. However some major events have occurred in the summer half-year as systems of tropical origin extend or move south. Some inland floods, notably those of Lake Eyre, may be initiated by rain falling many hundreds of kilometres away. Over much of Australia, flooding is more likely than usual during La Niña years and less likely in El Niño years. Extended periods of high SOI in 1916/17, the mid-1950s, and the early to mid-1970s, were periods of widespread, frequent flooding (See Figure 9-6).

Figure 9-6: Time-line showing major Australian flood episodes as a function of the Southern Oscillation Index Source: (Bureau of Meteorology, 2009a)

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9.3.2 Government cooperation in flood management

Commonwealth, State, regional and local authorities, as well as local communities and individuals all have a vital role to play in flood management. The scope of flood management is described within the context of three overlapping activity clusters: prevention, response, and recovery. Activities required to manage a flood event, and the relationships between them, are outlined in Figure 9-7.

Figure 9-7: Flood management activities in Victoria Source: (Melbourne Water, 2006).

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9.3.3 Flood risk management and insurance

Management of flood risk to reduce the devastating impacts on the community has evolved significantly since the 1950s when the main focus was on reducing risk through mitigation works where they were cost effective. Today an effective flood risk reduction strategy requires consideration of existing and future communities and a combination of reducing the exposure of the community to flood risk and reducing the vulnerability of people and property to flood risk (The National Flood Risk Advisory Group, 2008). There are some studies that have examined the general benefits of flood mitigation measures. Table 6-2 shows the classification of measures to reduce flood losses (Bureau of Transport and Regional Economics, 2002).

Table 9-2: Classification of Measures to Reduce Flood Losses Table not available due to copyright restrictions.

This Table lists the various measures to reduce flood losses, mainly in the categories of flood modification, property modification and response modification.

This table can be viewed in the print version of the thesis located in QUT Library.

Source: (Bureau of Transport and Regional Economics, 2002)

In the insurance aspect, the key for consumers today, is to ensure that they are informed of the current flood risks to their home and to take feasible and available mitigation steps. The Insurance Council estimates that there are approximately 170,000 homes in the community where a high flooding risk may lead to high localized premiums or a simple lack of availability where insurers cannot accept the risk level. The general insurance industry is working on developing a national flood information database (NFID) (Insurance Council of Australia, 2008)

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9.4 Case Studies--Charleville

9.4.1 Brief Introduction of Charleville

Charleville is the largest town in the southwest of Queensland, Australia. It is located some 750 kilometres west of Brisbane (the Queensland capital), and has a population of about 3,500 (Australian Bureau of Statistics, 2008a). Charleville is on the banks of the Warrego River, and the Bradley Gully runs through the town (Refer to Figure 9-9). The average rainfall of the area is nearly 400mm a year (BOM, 2008c).

9.4.2 Charleville Flood Description

On the 17th and 18th January, 2008, the Charleville district recorded a total of 190 millimetres of rain (Bureau of Meteorology, 2008b). Initial flooding in the Bradley Gully (as shown in Figure 9-9), forced the evacuation of a dozen homes, six businesses and a caravan park. By Jan 18th, water had inundated a total of 40 homes and businesses. However, the more significant threat to the town arose from flooding in the Warrego River, which reached 6.02 meters on Jan 21st (Bureau of Meteorology, 2008f) (For comparison, the Warrego River reached a historical high of 8.5 meters in 1990 when the whole town was forced to evacuate. See Figure 9-8 and 9-9). Besides inundating buildings, flooding forced many road closures. All main roads connecting Charleville were closed, including the road to Quilpie and to Adavale in the west; and the Mitchell Highway and Warrego Highway to the south (Figure 9-10).

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Figure 9-8: Charleville hydrograph depicting flood/river heights during the 2008 flood Source: (Bureau of Meteorology, 2008a)

Figure 9-9: Highest flood peaks in Warrego River at Charleville Source: (Bureau of Meteorology, 2008f)

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Figure 9-10: Locations of Roads and Rivers in Charleville. Source: (Google Maps, 2008)

9.4.3 Prevention/ Mitigation

Flood is mostly not preventable. However, we can mitigate the effects of floods through identifying the flood risks and reducing the community vulnerability. While Charleville is mostly dry in central Australia, floods are not uncommon as the monsoonal depressions often move south into western Queensland with major floods occurring every 10 years (See Figure 9-9). Thus flood mitigation procedures are in place including river bank and levee construction. Warrego River flood warning systems are operated by the Commonwealth Bureau of Meteorology, and the Bureau’s Flood Warning Centre issues Flood Warnings and River Height Bulletins for the Warrego River during flood events (Bureau of Meteorology, 2008f). Local views vary in regard to the effectiveness of flood mitigation: “I’ve been here over 50 years, and I’ve seen the Gully and the River come up a number of times and it’s a

- 160 - shame to think that the Gully is still coming up and will do so after the levee bank is completed.” Mr. George Balsillie, a retired local and the president of the Charleville Historical Society said (Harris & Lyons, 2008). Other residents have blamed a new levee in town for flooding homes and businesses along the Bradley Gully. “The natural water course where the gully went into the river was blocked-off by the levee bank—the little pipe there can’t handle the pressure”, Mr. Balsillie explained(ABC News, 2008).

9.4.4 Preparedness

Preparedness is the process of developing a formal program of response, including training and staff development; identification and classification of resources; development of standard operating procedures; emergency response plans, and communications plans; pre-placement of key supplies and protective equipment. As for the standard operating procedures and response program, there were local disaster arrangements in place. The State Counter Disaster Plans, including Communications Functional Plan, Emergency Supply Functional Plan, Health Functional Plan, and Transport Functional Plan etc. are also important preparedness plans. There are also threat specific Plans, Queensland Flood Coordination Committee etc., all of which together form the emergency response plan and response programs. On the educational level, Emergency Management Australia has carried out a series of educational programs, including providing educational materials such as booklets etc (Emergency Management Australia, 2008). Queensland Health, Department of Community Safety, and some universities also have educational programs, short term training courses, and some special training programs (QUT, 2010; SES, 2009). Special equipment supply locations are around Queensland. On the health perspective, Emergency Departments of hospitals have disaster health resources available, so that doctors can access these right away when they need to go to the site for treating patients. In accordance with legislative requirements, local disaster arrangements were in place. The local Government disaster management committee met regularly to prepare for possible events including flooding. Local health officials were active participants in the planning and preparedness. The committee had an established disaster management plan. There were three flood boats located in Charleville for use by local State Emergency

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Service (SES) group and there was also a stockpile of 4,500 sandbags ready before the flood (Emergency Management Queensland, 2008).

9.4.5 Response

Local disaster arrangements were activated in Charleville on Jan 17th, and evacuation procedures were initiated. Four SES crew members were on standby for almost the whole evening of Jan 16th to check on properties along the Warrego River (ABC News, 2008), and warned residents of rising water from Bradley Gully (ABC News, 2008). A dozen homes, six businesses and a caravan park were evacuated on Jan 17th. Some people were moved to the emergency accommodation in the town’s show grounds that day. Tea, coffee, sandwiches were provided at the emergency accommodation (ABC News, 2008). On Jan 18th, the local SES sandbagged the town hall and the Catholic Church. A stockpile of 4,500 sandbags were in place, and another 1,000 sandbags were ordered with extra pumps and lighting, all of which arrive in the evening of Jan 18th (ABC News, 2008). As part of the Commonwealth’s Disaster Response Plan, A Defense Force Hercules from New South Wales sent 500 meters of temporary flood barriers (metal frames and waterproof membranes) to fix two big gaps in a levee protecting the town from floodwaters on Jan 18th (ABC News, 2008). A team of specialist engineers and flood response experts from New Zealand arrived and two makeshift levee banks were then constructed overnight on Jan 18th. A rescue helicopter was sent to tour flood-affected regions on Jan 19th to conduct food and medicine drops to isolated properties (ABC News, 2008). In terms of health perspectives, however, Queensland Health was not expecting the hospital at Charleville to be affected by rising floodwaters, the South West Health Service transferred 9 patients by air to Roma and Toowoomba with more transfers planned for the Jan 18th (ABC News, 2008). Patients from the nursing home were moved to the second story of the hospital on Jan 18th (ABC News, 2008). And 16 aged care patients from Charleville Hospital boarded a plane bound for Brisbane on the morning of Jan 19th as a precaution (ABC News, 2008).

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The Prime Minister Kevin Rudd, Federal Opposition Leader Brendan Nelson, and Queensland Premier Anna Bligh all visited Charleville to support the rescue and paid tribute to everyone helping to deal with the floodwater (ABC News, 2008).

9.4.6 Recovery

With recovery plans in place as guidance, the recovery process was set in place. On Jan 21st, once the flood in Warrego River started to recede many businesses in town started returning goods to their original location, and bringing back equipment that had been moved to higher ground (ABC News, 2008). The Neighbourhood centre worked in conjunction with Ergon Energy (the supplier of electricity) to check houses inundated by the flood waters to ensure they were safe before the owners returned. Working teams of low-security prisoners also assisted with the clean-up and rebuilding in flooded communities (Wetering, 2008). On Jan 24th, part of a temporary levee bank to protect the town was pulled down to free up traffic. The Department of Main Roads sent out teams with local knowledge to assess flood damage to roads and repair potholes. The federal government’s national disaster relief funding was also available to fund repairs. A phone number to report road damage was also published in the media. Australian Government disaster relief payment has a set amount of $1000 per adult and $400 per child for people who are eligible. Eligibility criteria and application guidelines were released for federal government grants of up to $25,000 to help flood affected primary producers and businesses. There were also low interest loans of up to $100,000 available with an initial interest rate of four per cent (Wetering, 2008). The Charleville Neighbourhood Centre was transformed into a one-stop-shop for people needing flood recovery assistance. The Red Cross, the Queensland rural adjustment Authority and Centrelink were also operating out of the Centre.

9.4.7 Results

With all the emergency systems and plans in place, Charleville appeared to have avoided a major flood crisis, with the swollen Warrego River still contained by the

- 163 - temporary levee, though the water from Bradley Gully had forced many evacuations. The flood monitoring system had been useful. The emergency siren warned people early in the morning, and ensured all necessary evacuations could be carried out early. The temporary levee was constructed quickly and worked well, with a significant contribution made from outside agencies including the Air Force Hercules and the flood technical experts from New Zealand. On the health side, precautionary health strategies were successful. Some hospital patients who were old or had complex care needs were transferred to other hospitals early as a precaution. Similarly, the nursing home also took some precaution measures by relocating residents to “higher grounds”. However, the newly built levee was criticised for blocking off water from flowing through its natural courses.

9.5 Case Studies--Emerald

9.5.1 Brief Introduction of Emerald

Emerald is a town located in the Central Highlands district of Queensland, Australia. The town lies almost 300 kilometres from the coast, and the Tropic of Capricorn runs through the town. Emerald has a population of about 11,000(Australian Bureau of Statistics, 2007a). Emerald lies on the Nogoa River, a tributary of the Fitzroy River. The Fairbairn Dam, a short drive to the south of Emerald, was opened in 1972, and holds back the waters of Lake Maraboon. The lake covers an area of up to 150 km², and can hold 1.3 million mega litres of water in its full capacity. The average annual rainfall in Emerald is about 521 mm (Bureau of Meteorology, 2008e).

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9.5.2 Emerald Flood Description

As shown in Figure 9-11 and 9-12, rains of high intensity from Jan 16th to Jan 19th pushed the flood height in the Fairbairn Dam slowly; and the height in the Nogoa River in Emerald quickly increased as the dam began to overflow. On Jan 19th, the Fairbairn Dam, which is only about 18 kilometres away from Emerald, was filled to capacity and water started flowing over the wall for the first time in 17 years. About 1000 people turned out to watch water flowing over the damn wall that day (ABC News, 2008). On the evening of Jan 19th, SES asked 50 residents living along the Nogoa River to leave their homes. They had also dropped a second written notice to up to 200 to 300 households advising there might be a need to move those people the next morning (ABC News, 2008). On Jan 20th, the spill over at the dam wall reached two meters. The government started monitoring the situation hourly. Additionally an evacuation plan was being prepared for the town. On Jan 21st, the Queensland Government issued a disaster declaration for the state’s central highlands. More than 1,300 people left their homes and hundreds more were asked to prepare for possible evacuation. The overflowing river also cut off access to the Capricorn Highway, and more than 60 homes were inundated with water (ABC News, 2008).

Figure 9-11: Fairbairn Dam Hydrograph depicting flood/river heights during the 2008 flood Source: (Bureau of Meteorology, 2008a)

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Figure 9-12: Emerald Hydrograph depicting flood/river heights during the 2008 flood Source: (Bureau of Meteorology, 2008a)

On Jan 22nd, Nogoa River, which cuts through the middle of Emerald, broke its banks and floodwaters spread slowly across the town. A thousand homes were evacuated; and scores of businesses had water across their shop floors (ABC News, 2008). Sandbagging started to protect those businesses and homes which were not yet inundated. The main evacuation centre in Emerald reached capacity, and people were taken by train (the bridge was flooded) to a second evacuation centre on the other side of the river. By the end of that day, 2,500 people had been registered at the town hall and agricultural college where evacuations centres were set up(ABC News, 2008). On that evening, Premier Anna Bligh arrived in Emerald and stayed there to support the community for the night. On Jan 23rd, water flowed into the town with Nogoa River at 15.3 meters high. After that, floodwaters steadied. A total number of more than 2,700 people had left their homes (ABC News, 2008). On Jan 24th, 240 homes were found to be swamped by water, another 80 homes suffered minimal water damage and numerous businesses were under water. Bogantungun, situated about 130 km west of the city of Emerald, recorded total of nearly 700mm rainfall within 4 days. Many houses in and around the city of Emerald were evacuated due to floodwaters. On Jan 27th, the Vince Lester Bridge, which had been closed for more than a week, was reopened.

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9.5.3 Prevention/ Mitigation

Most of the mitigation measures in Emerald were similar to those of Charleville, as both of them are in the state of Queensland. However, one thing is very special in Emerald: Queensland’s second biggest reservoir, the Fairbairn Dam and Lake Maraboon, are located about 18 kilometres upstream of the city. Completed in 1971, with a water volume of 1,301,134ml (Department of the Environment), the Fairbairn Dam has a large social and economic impact on Emerald. It not only reduces the risk of flood and drought, but also changed the lifestyle and economics in Emerald. The population and economics in this area have grown markedly since the completion of the dam (Queensland Government, 2000). In early 2008, the Fairbairn dam played an important role in mitigating the impact of flood.

9.5.4 Preparedness

The preparedness in Emerald is similar to the case in Charleville. As with Charleville, Emerald had in place emergency response plans, resources, and SES personnel that are required to formulate disaster management.

9.5.5 Response

Evacuation was the main response measure during the flood in Emerald. As the flood became more threatening, more and more people were evacuated, which ensured their health and safety. Flood predication and monitoring provided an essential base for the flood evacuation and other precautions. The flood situation was monitored hourly before Emerald was actually hit by the flood. From a health perspective, Environmental Health Services carried out mosquito control measures after the flood (Emerald Shire Council, 2008) and provided a series of advices to the residents, relating to cleanup, drinking water, food safety, mosquito diseases, floodwater etc. (Queensland Health, 2008). From an animal health perspective, Queensland AgForce president Peter Kenny also worked with the Queensland

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Government to drop more than 6,000 bales of hay to cattle stranded in the Nogoa basin and along the Belyando River (ABC News, 2008).

9.5.6 Recovery

During the recovery phase, people from many different backgrounds and sectors were motivated into action. The Queensland Government extended special powers to police in Emerald. At least two dozen electricians were placed on stand-by in case they were needed in Emerald. And a task-force was set up in Emerald to assess the flood damage. Two Army Black Hawks dropped fodder to cattle stranded in flood waters around Emerald. Authorities assessed control options of mosquitoes and sand flies. Volunteers were sent to central Queensland. Over 80 staff and local volunteers from the Red Cross were working on the ground. On the financial side, the Queensland and Federal governments announced more financial help for Queensland families and business directly affected by floods (up to $25,000 for small businesses, including farmers; one-off payments of $1,000 for adults and $400 for children for eligible people; the state has also set-up a disaster relief appeal, with a $100,000 initial contribution (Queensland Government, 2008). The total insured cost for this flood was AU$70 million (US$63 million) (Insurance Council of Australia, 2010).

9.5.7 Results

The impact of Emerald flood in early 2008 was largely mitigated by the Fairbairn dam. Without it, the flood would have been much more serious. However, despite the dam, the town was flooded. Evacuation was used as the main measure in the response phase. Many people and agencies were very active in the flood response and recovery phase. With the leadership of Central Highlands emergency service groups, the flood response had been a successful one.

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9.6 Case Studies--Mackay

9.6.1 Brief Introduction of Mackay

Mackay is a city on the eastern coast of Queensland, Australia, about 970 km north of Brisbane, on the Pioneer River. Mackay is nicknamed the sugar capital of Australia because its region produces more than a third of Australia’s cane sugar. Mackay has a population of about 92,183(Australian Bureau of Statistics, 2007b). Mackay’s average annual rainfall is 1585mm, and a large proportion falls in the months December through to March (Bureau of Meteorology, 2008d)

9.6.2 Mackay Flood Description

The Mackay flood of Feb 2008 is very different with those previously examined: the rain and flood is much more intense; the affected population is larger, and the local geography is low on the beach. As shown in Figure 9-13 and 9-14, rains in the Mackay region pushed the water up in the Pioneer River from Feb 13th to Feb 15th.

Figure 9-13: Mackay Hydrograph depicting flood/river heights during the 2008 flood (Hospital Bridge) Source: (Bureau of Meteorology, 2008g)

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Figure 9-14: Mackay Hydrograph depicting flood/river heights at during the 2008 flood (Forgan Smith Bridge) Source: (Bureau of Meteorology, 2008g)

On 15th February, 2008, 600 millimetres of rain fell from 3:00 am to 9:00 am, and waist-deep water inundated Mackay (Watson & Hall, 2008). In total, 1000 millimetres of rain fell on Thursday night (Feb 14th) and Friday morning (Feb. 15th). The Pioneer River, which runs through Mackay city, was measured at 9.9 meters high at Hospital Bridge, 7 meters at Forgan Bridge. This was not so high compared with the highest flood of 1958 (Figure 9-15), which peaked at a height of 9.14 metres on the gauge at the Forgan Bridge. Many locals woke to find water rushing through their homes, roads cut and telecommunication systems down (Colvin & Butler, 2008). Hundreds of homes to the North, South, East, and West of Mackay city were flooded with up to 1.5 meters of water. “Mackay is such a low area and any amount of rain like this is just going to cause widespread flooding.” a local ABC news staff reported (Watson & Hall, 2008). Moreover, the Pioneer River was at high tide, reducing the ability of the water to escape to sea. On the morning of Feb. 15th, the Mackay Disaster Coordination Centre spent most of the morning operating without landlines and sometimes without mobile phones. However, still the Mackay SES switch had 52 call outs (ABC News, 2008). SES had been using boats to rescue stranded residents because of the flooding of the roads. Around 1000 people left homes and eight evacuation centres were established. After the heavy raining in the early morning, schools and businesses were closed, and the area was declared a disaster (ABC News, 2008).

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By Feb. 16th, around 2,000 homes were evacuated. On 18 Feb, the floodwater receded from Mackay region. The flood damaged approximately 4000 homes and one 17- year-old person died when he disappeared into the Pioneer River.

Figure 9-15: Highest flood peaks in Pioneer River at Forgan Bridge, Mackay Source: (Bureau of Meteorology, 2009b)

9.6.3 Prevention/ Mitigation

Mackay’s location on the coast alternated the mitigation strategies as the city is usually safe from riverine flooding. However, it is still susceptible to flash flooding and local inundation, particularly at high tide when the water can’t escape to the sea. Mackay has similar mitigation measures with Charleville and Emerald. However, as Mackay is located close to the sea, it doesn’t need to worry that the water from the river will inundate the city. But this doesn’t mean Mackay is immune to floods, a flash flood like the one in early 2008 can still be a big disaster for the city. The weather forecasting and the water monitoring systems were criticised as the Weather Bureau had only forecast 110 to 200 millimetres of rain, not 600 millimetres of rain (Colvin & Butler, 2008).

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9.6.4 Preparedness

Mackay has similar preparedness measures with Charleville and Emerald as well. However, some locals have blamed the scale of the damage on poor planning in terms of both planning for the new suburbs and population growth and planning for emergency management. But, authorities said nothing could have been prepared the city for the “freak” event.

9.6.5 Response

The 2008 flood hit Mackay suddenly in the early hours of the morning, and thus response to it was difficult. The two major difficulties were that: the telecommunications system went down; and the roads were flooded. Boat became the only means of transport. From a health perspective, the address of magnitude of the flood was problematic. District Manager Mackay Health Service Kerry McGovern said: “Mackay Base Hospital is only dealing with emergencies” (ABC News, 2008). As all roads were flooded, it was difficult to get staff in to work, and hard to transfer patients. Additional Fire and Rescue, Ambulance, Emergency Management Queensland and SES personnel were sent to Mackay from Rockhampton and Brisbane. However, the problem was that all roads were cut, even the airport was flooded, and no one from outside was able to get in. Premier Anna Bligh, Emergency Services Minister Neil Roberts, and Federal Minister for Human Services Senator Joe Ludwig visited Mackay on Feb. 16th.

9.6.6 Recovery

The flood hit Mackay suddenly, but fortunately, because Mackay is so close to the sea, the water ran out to the sea quickly. On Feb 16th, residents started cleaning the mud and debris from their inundated homes and businesses, and starting to count the financial cost. More than 100 businesses in the north Queensland town were forced to close after floodwaters damaged stock and internal fittings. On Feb. 22nd, the city’s waste facilities

- 172 - were open including the rural transfer stations, and Green Waste at Bayersville, Bucasia and Walkerston. However, the Mackay Local Disaster Coordination Centre continued to operate. The Department of Communities was open (9:30am to 4:30pm daily) community recovery centres at the Church of Christ Hall on Beaconsfield Road, Magpies Sporting Club at Glenella, and at the old Victoria Park Preschool on Shakespeare Street to help residents with support and information (ABC News, 2008). On the financial side, people affected by the floods could apply for Emergency Assistance Payments of up to $160 per person and $740 per family for essential items such as food, clothing, medication, and emergency accommodation. A one-off Centrelink payment of up to $1000 per adult was also available (ABC News, 2008). The total insured cost for this case was AU$410 million (US$369 million) (Insurance Council of Australia, 2010).

9.6.7 Results

Due to the suddenness and scale of the flood, Mackay was hit badly. The whole city was inundated, and the loss was considerable. Inaccurate forecasting has been attributed as a major reason behind the impact of this flood. However, not just one factor lead to the extent of the flood. The monitoring system didn’t function well; at the time of the day (heavy rain started at 3:00 am), even radio could not warn people as many people were sleeping; and the volume of rain was too exceptional to be accurately predicted.

9.7 Case Study Discussion

With all the emergency systems and plans in place, Charleville responded to the flood with evacuation, transfer of patients, and the temporary levee construction, and avoided a major flood crisis. The impact of Emerald flood was largely mitigated by the Fairbairn dam and Lake Maraboon (water volume: 1,301,134ml) that located about 18 kilometres upstream of the city; however evacuation and movement of goods to higher grounds also mitigated the impact.

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Due to the suddenness, the time of day and scale of the flood, Mackay was hit badly. The monitoring system and warning system didn’t function well enough to respond to such an emergency. Access to this city was problematic during the initial period. The disaster management is carried out through the four levels as listed in Figure 9- 4. In the three floods in early 2008, all four levels of government were involved. Assistance from the State and Commonwealth government are valuable during the preparation, response, and recovery phases. The policies and plans in place ensured the successful cooperation between different government levels, and made the external assistance arrive quickly. However, as shown in these three cases, emergency systems and plans worked out well for flood from upstream, but not well enough for flash flood in Queensland. Flood management by the state and commonwealth level assisted Charleville to avoid a major flood crisis; but the flood in Mackay was too sudden for the external assistance to arrive. It is necessary to increase the disaster management capability in the local level, especially for potential disasters that are more likely to be unpredictable. Through external aid and local cooperation, there is little loss of life and people recovered from the flood well and quickly.

Having examined the three case studies in China and Australia respectively, the following chapter turns to the comparative case study analysis and synthesis.

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Chapter Ten: Comparative Case-Study Findings and Synthesis

This chapter aims to compare flood case studies in China and Australia, in order to identify areas that inform China’s disaster health management system. Australia has a mature disaster health management system which dates back to the 1960s (Smith, 2006) while China’s system is relatively new and largely emerged out of the SARS epidemic in 2003 (Guo, et al., 2008). This chapter begins by examining the scale of the disasters in each of the case studies, and then compares the disaster health management procedures in detail. The chapter concludes by presenting key policy lessons that emerged from the case studies in terms of policy successes and failures and leads directly to a detailed analysis of these lessons in subsequent chapters.

10.1 Introduction

Studying multiple cases makes it possible to build a logical chain of evidence as outlined by Miles (1994) and Huberman and Yin (2003b). Here, the case studies in China and Australia are compared with and contrasted to one another, so as to find out how disaster health management operates at the field level in China, and to identify the strengths and weaknesses learned from each case. This Chapter in effect draws together a ‘bottom-up’ perspective in examining detailed operational aspects as they play out at the field level in China and Australia. This bottom up analysis is complemented by a top down policy analysis in subsequent chapters which seeks to convert the observations of case management into policy proposals.

10.2 Flood Scales and Consequences in Case Studies

The scale of the floods in each location is summarised in Table 10-1. The number of people affected in Australia was not reported; so for the purpose of comparison, we

- 175 - estimated the number of people by multiplying the number of homes by 2.5, which in 2006 was the average household size (Australian Bureau of Statistics, 2008b). As shown in the table, the rainfall in Australia is more intense than that in China. However, as the total population in China is much larger, more people were affected by the floods. Jinan and Mackay both experienced flash flooding. The rainfall in Mackay was almost twice the intensity and length of that in Jinan; and the percentage of people affected was twice that of Jinan. However, the floods in Jinan caused 39 deaths and 171 injured, while there was only one death in Mackay and no reported injury. Pan’an and Emerald are both relatively small cities and experienced floods that allowed for a period of warning: typhoon can be predicated a few days before its arrival while the dam level upstream from Emerald is a strong predictor of likely flood. However, the percentage of people affected in Pan’an (78.7%) was much higher than that of Emerald (5.3%). Lengshui and Charleville are both small towns and were not severely affected by floods. Their management procedures represent possible “best practice” in terms of disaster health management arrangements in the local government level in China and Australia respectively.

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Table 10-1: Comparison of Flood Case Scales and Health Impacts in China and Australia China Australia Jinan Pan’an Lengshui Mackay Emerald Charleville Government Province Capital County Town Town Large City Small City Town Level Total Population 6,000,000 200,000 10,000 91,000 15,000 3,500 Time of Flood July 18th to 19th, Sep 19th to 20th, July 19th to 20th, 2008 Feb 15th to 18th, 2008 Jan 19th to 24th, 2008 Jan 17th to 21st, 2008 2007 2007 Flood Type Flash Flood Flood Associated Flood Associated with Flash Flood Flood from upstream Flash flood and flood with Typhoon Typhoon from upstream Rain Intensity 142 mm within 1 215 mm throughout 28.9mm throughout 600 mm from 3 am to 700 mm within 4 days 190 mm within 2 day, mostly within the typhoon the typhoon 9 am days 3 hours Number of 333,000 157,500 600 10,000 2,700 100 People Affected (4000 homes) (320 homes) (40 homes) Percentage of 5.6% 78.7% 6.0% 11.0% 5.3% 2.9% People affected Number of 39 1 0 1 0 0 Deaths Prevention Old drainage Some houses are Some houses are too Land use planning Fairbairn Dam The new levee bank system too old and old; new riverbank, project was not vulnerable to floods levees, small reservoirs completed yet and typhoon under construction Preparedness Limited stockpile of Divided roles of Multi-sectoral training National arrangements Inter-organizational Local and national sandbags; lack of different leaders; in progress; equipped to access resources; cooperation, SES cooperation training reasonable with reasonable flood boats, SES training arrangements; rescue resources stockpile facilities and resources training boats available; SES training

Warning Several hours’ One week warning, One week warning, and Insufficient warning Hourly monitoring and Insufficient warning warning, with with situation planned drill early warning for the local flash insufficient alert updated each day flood; early warning level for the riverine flood

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Response The government Local leaders pay Planned response; Use boats to rescue Evacuation; Evacuation; tried to keep visit to the affected assigned people to stranded residents Sandbagging; Sandbagging; providing the basic area and guide the monitor the situation services; medical rescue Send flood barriers to and police hotlines fix two big gaps in a couldn’t meet the levee protecting the demand town Recovery Pump water Donation; insurance Hand out donation, free Early re-opening of mosquito control Prisoners help the immediately; payment; free drugs medical check, free waste facilities; measures; clean-up; sterilization of the for cockroach and drugs for cockroach government disaster health advice to Government disaster flooded area; rodent control and rodent control; relief payment residents; relief payment compensation to the local leaders pay visit Electricians on standby; dead persons’ to the victims Government disaster families; control of relief payment rumours

Source: Data derived from detailed case analysis performed in this thesis

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10.3 Disaster Health Management Procedures Comparison in Australia and China

The management of all the cases are analysed to highlight how disaster policies worked in response to flood events. Aspects of prevention, preparedness, response, and recovery (PPRR) are discussed in greater detail in the following sections.

10.3.1 Prevention

Flood prevention is a critical component of disaster health management policy. Flood prevention measures can include structural flood defence measures, emergency shelters, building construction standards, land use planning, multi-sectoral platform, flood insurance programs, and flood risk reduction through environmental management. Each of these approaches is used in Australia and developing in China, and are discussed in further detail below.

Structural Flood Defence

Structural flood defence is one of the most important modern mitigation procedures (Kundzewicz & Menzel, 2003). Flood may be prevented or contained by such structural flood defence including flood detention basins, reservoirs, river training, river bank construction, bridges, and diversion channels. Mackay’s closeness to the sea and the river bank infrastructure prevents it from being flooded by the river. However, as the rain was so intense, the drainage system in the city failed, and flood water entered many properties and flooded roads. However, the rain in Mackay occurred mostly in the early hours of the morning (starting at 3:00 am) before people went to work, and thus prevented danger to many people. In Emerald, the Dam upstream significantly reduced the scale of the flood. In Charleville, river bank and levee construction has been adopted as its location placed it in danger of riverine flooding. However, during this flood in 2008, a new levee that was yet

- 179 - to be completed was blamed for blocking the natural water course, and was seen as a contributor to the flood event. In Jinan, the drainage system, including the rivers and underground drainage, could not cope with the once in a hundred years flash floodwater and as a result the streets and many properties, including the shopping centre in the middle of the city, were inundated. Flowing water in the street became a major threat to the people on their way home; flood water in properties became a direct threat to many people and they could not escape. After this flood in 2007, the Jinan government invested 8.6 billion Yuan (US$1400 million) to increase the Xiaoqing Riverbank system from 5% Annual Exceedance Probability (AEP) to 1% AEP (Wang, 2008b). Both Pan’an and Lengshui are hit frequently by typhoons, which are usually followed by flood. Thus, river bank construction has been a constant focus of the local government, including building an “ecological river bank” that combines plants and riverbank. However, some sections of the river bank and some bridges are still at risk due to financial constraints. Pan’an, as a county town, was able to concentrate more resources and thus has a relatively old riverbank system; Lengshui, as a small rural town, has to focus on small projects, including reservoirs that only have limited capacity. As can be seen above, structural flood defence can prevent or limit flood risks, especially during a riverine flood. However, the drainage in the city area may require more attention. Flood defence may need further development in both Australia and China; and it is noticed that the construction of flood defence and drainage systems in China is largely constrained by financial limitations.

Structural Building Measures

Poor building standards can lead to structural failure during a flood, which can be a potential risk to those in the building and the public. Structural building measures for preventing flood risks include stricter building codes, and enhanced standards for critical public facilities and infrastructure. In Australia, strict building codes are established and executed to ensure that buildings meet certain standards (Australian Building Codes Board, 2010). No death or injury occurred due to structural failure in the Australian case studies.

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However, in China it is still common to see people build their own properties without any professional guidance, even though building codes are available. In the Jinan case, five people were killed by collapsed walls during the flood. Another six were killed by electric shock. These deaths could have been prevented if the houses and power lines were built to a higher standard. Additionally, 1,805 and 800 houses collapsed or were damaged in Jinan and Pan’an respectively. Therefore, it is important for China to ensure that building standards are properly implemented whilst also ensuring old buildings and infrastructure are properly maintained.

Emergency Shelters

Emergency shelters provide an important safe evacuation location during times of flooding and other disasters. Shelters can provide food, water, and shelter, and reduce exposure to hazards. Thus, emergency shelters are very important public health intervention. In the three case study locations in Australia, emergency shelters were available and used in each location, and food, water, and makeshift medical clinics were provided in these shelters. It is also noted that non-government organizations such as the Red- Cross and Salvation Army have an established role in providing food, clothing, and emotional support within these shelters. Their services are extended to victims and emergency support staff. Jinan city now has 11 emergency shelter centres which were established in 2008 (after the flood). Quancheng Square is capable of providing temporary shelter for 60,000 people and longer-term shelter for 20,000 people. Quancheng Park has similar arrangements with a capacity of 40,000 people and 10,000 people respectively (as shown in Figure 10-1). However, no one was evacuated to any emergency shelters during this flood event. In Pan’an, the local government is responsible for providing emergency shelters. In Lengshui, three emergency shelter centres (local schools and village hall) are newly established. In all the three locations in China, emergency shelters or evacuation centres have been set up after the flood in 2008, and their effectiveness is yet to be tested.

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While the idea of emergency shelters is simple and clear, and accepted by the governments in China, the standards and services available in these shelters are yet to be tested. Additionally, community awareness of these shelters may need to be increased.

Figure 10-1: Emergency Shelter Centre in Quancheng Park, Jinan

Land Use Planning

Land use planning is the systematic assessment of physical, social and economic factors to encourage and assist sustainable development. In terms of disaster management, land use planning is aimed at guiding new development away from disaster risks. It also assists to keep health infrastructure in a safe place so that medical services can be maintained during disasters. Both Australia and China engage in land use planning. In Queensland, the Department of Infrastructure and Planning, together with local governments, is responsible for integrated and sustainable planning of infrastructure and buildings. In both Jinan City and Pan’an County, Urban Planning Bureaus have been established. However, the benefits of land use planning regarding disaster management are yet to be fully realized. Convenient but hazardous location for a development requires a

- 182 - comprehensive cost-benefit analysis. In the policy perspective, a disaster risk statement is recommended to be included in land development plans.

Multi-sectoral Platforms

Multi-sectoral platforms aim to enhance the coordination between different disciplines and different government levels. They provide a mechanism for improving and disaster advocacy, coordination, advice, and resources. In Australia, multi-sectoral platforms are in place and are of great importance during flood management. The platform is not only planned on the paper, but also works in the field. In Mackay, the Weather Bureau, Fire and Rescue, Ambulance, Emergency Management Queensland, Department of Communities, Mackay Local Disaster Coordination Centre, Centrelink, and Green Waste all work together in all aspects of prevention, preparedness, response and recovery (PPRR). Additionally, the Church of Christ Hall, Magpies Sporting Club, and Victoria Park Preschool were used as community recovery centres after the flood. In Emerald, patients with complex care needs were transferred by ambulance, trains, and planes to Rockhampton Hospitals (275 kilometres east of Emerald); Environmental Health Services adopted mosquito control measures; Queensland AgForce (a non-government organization for graziers and farmers) worked with Queensland Government to drop hay to cattle; volunteers were sent to central Queensland for 30 days; low security risk prisoners were sent to assist the clean-up and rebuilding in the flooded communities after the flood. In Charleville, flood barriers were transported by the Air Force from New South Wales; specialist engineers from New Zealand were sent to help install barriers; extra flood boats were sent from other Queensland communities such as Clifton and Goondiwindi on the first day of the flood; patients with complex care needs were sent to Roma, Toowoomba, and Brisbane; government and non-government organizations including Charleville Neighbourhood Centre, Red Cross, Queensland Rural Adjustment Authority, Centrelink, and Ergon Energy all played an important role based on the multi- sectoral platform.

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Thus it can be seen that multiple governmental agencies at Commonwealth, State, and local levels of government cooperated in the management of the floods, as well as non-governmental agencies such as Queensland AgForce, churches, sporting, charitable and humanitarian agencies. International assistance from New Zealand was also used. In China, multi-sectoral platforms were newly established after the SARS epidemic in 2003 as discussed in Chapter Six. The case studies in China found that these organizations did collaborate in some ways; however some limitations in the extent of cooperation were noted. In Jinan, both Shandong Provincial Meteorologic Bureau and Shandong Provincial Land and Resources Bureau issued warnings; Water Resources Bureau managed to provide clean water; the traffic police kept working on the roads during the flood; Shandong CDC and Jinan CDC cooperated in sterilization, vector control and infection control after the flood; the army came to assist the clean-up. However, six deaths were due to electric shock, and it was noted that ambulances were not able to respond quickly (Ye, 2007). There is a need to involve more organizations and respond collaboratively. In Pan’an, the Flood Control and Drought Relief Headquarters includes personnel from around 20 organizations including Water Resources Bureau, Meteorological Bureau, Transportation Bureau, Construction Bureau, Land Resources Bureau, Civil Affairs Bureau, Health Bureau, and the Police Bureau. During this flood event, provincial government and the county government issued warnings of typhoon; each organization also issued warnings for their system. The Charity Federation, Disabled Person Federation and Red Cross provided assistance to the victims after the flood. In Lengshui, the local government demonstrated an ability to coordinate departments. Different departments, including leaders from the county level government and medical assistance teams, were involved in the drill. They divided the leading organization into Chief Commander, Information Monitoring Group, Emergency Transfer Group, Logistic Group, Emergency Rescue Group, Backup Group, and Medical Group. This does integrate each department; however flood management is a long-term process and will need cooperation in prevention, preparedness and response as well as recovery phase. In short, both Australia and China have some degree of existing multi-sectoral cooperation. Flood management in Australia can be quickly escalated into a higher level when necessary to make use of resources that are not available at the local level, such as

- 184 - the temporary levees and flood boats. However, this is less effective in China: the Ring River gate was not opened in the Jinan case; the Shandong provincial declaration of a state of disaster was only issued the day after the Jinan flood; no equipment or resources assistance were sought from higher governmental level in the two cases in Zhejiang. Thus some policy failures were identified in the three case studies in China. It may be necessary to enhance more frequent training and drills across different government agencies and levels in China.

Flood Insurance Programs

Flood insurance is a necessary part of flood mitigation and recovery as it increases public awareness and compensates some of the cost that flood victims incur. However, the problem associated with flood insurance is that a high flood risk may lead to high premiums or a simple lack of availability when insurers cannot and will not accept the risk level. In Australia, flood insurance programs are being further developed. The Insurance Council of Australia is examining mechanisms to increase the availability of affordable flood insurance for the community. It is also examining the formation of a National Flood Information Database (NFID) that was first released in November 2008 (Insurance Council of Australia, 2009). NFID is used by insurers to determine the flood risk to individual properties, and thus inform premium calculations as well as where flood cover will be offered. In the case of the floods in Emerald and Mackay, the total insured cost was AU$70 million (US$63 million) and AU$410 million (US$369 million) respectively (Insurance Council of Australia, 2010). Property insurance has only been developed in China in recent years. For example, in 2006, the Zhejiang Provincial Government introduced a three year (2007-2009) trial of ‘Policy Insurance for Rural Houses’. This trial was continued further in 2010. In this scheme, the whole province was divided into two areas according to the risk level (15 Yuan (US$2.2) premiums for Level 1 area and 10 Yuan (US$1.5) premiums for Level 2 area); the premium was a co-payment by the provincial government, local government, and the residents. The People’s Insurance Company of China (PICC) is the sole company in this scheme, and residents were covered for 18,000 Yuan (US$2,635) per family or 3,600 Yuan (US$527) for each room of houses destroyed during any disasters, including

- 185 - floods (Zhejiang Provincial Government, 2006). In the whole province, farmers’ participation rate in this scheme reached more than 95%, and this rate increased to 98.6% in 2009 (Zhejiang Provincial Development and Reform Commission, 2009). In the case of the Wipha Typhoon in Zhejiang Province (where the Pan’an Country is located), the total insurance for the destroyed or damaged houses during the typhoon and flood were 25.4 million Yuan (US$3.7 million) for 2,364 houses. In Jinan, the insurance coverage is mainly on cars and the uptake for insurance is mostly by companies wishing to cover property and staff. In this studied case in Jinan, the insurance industry paid a total 126 million Yuan (US$18.4 million) for 20 deaths and injuries and for 10,544 cases of property damage, representing approximately 9.5% of the total estimated cost which was 1.32 billion Yuan (US$194 million) (Wang & Huang, 2007; Yang, et al., 2007). Australia has an extensive flood insurance program based on private sector markets with wide-spread coverage. Conversely, in China the government is seeking to expand flood insurance programs directly, but these efforts remain in the early stages. Therefore, enhanced insurance programs with more industry involvement are necessary in China.

Ecological Flood Risk Reduction

Floodplain preservation, restoration, and enlargement can mitigate flood through ensuring greater absorption of water, and thus reduce run-off. In recent years, global warming, which is likely due to greenhouse-gas emissions, has been blamed for more frequent and intense flooding (Doornkamp, 1998; Feyen, Barredo, & Dankers, 2009; Monirul Qader Mirza, 2002). In both Australia and China, “ecological and sustainable development” is a popular idea; and both countries have national parks and forests which have been preserved (Howell, Wilson, Davey, & Eddington, 2008; Zhu, 2007). With a much smaller population, the pressure on the ecosystem in Australia is much smaller than that in China. In Lengshui, “ecological riverbanks” have been developed, and may provide an example that could benefit flood prevention in China. However, as a non-structural measure, its importance and social acceptance is yet to be realized and increased in both Australia and China. A larger public and policy realization of the importance of ecological and sustainable development is necessary; and

- 186 - ecological development by land owners and developers should be encouraged or mandated.

By comparing China with Australia, it was found that China could better improve prevention aspects of structural flood defence, structural building measures, emergency shelters, building construction standards, land use planning, multi-sectoral platform, flood insurance programs, and flood risk reduction through environmental management.

10.3.2 Preparedness

Flood preparedness measures include a range of strategies such as building community resilience, increasing coordination among departments and agencies, training and drills, and equipment and resource accumulation and storage. These preparedness measures in China and Australia will be compared in the following section.

Community Resilience

Community resilience is the capacity of linked social-ecological systems to absorb recurrent disturbances such as floods or hurricanes, so as to retain essential structures, processes, and feedbacks (Walker, Holling, Carpenter, & Kinzig, 2004). Sophisticated disaster management arrangements, as well as the public education and awareness programs in Australia contribute to a sense of resilience. In addition, the overall national wealth, insurance arrangements, building codes and organizational structures provide an enhanced capacity to recover. China, as a developing country, has less national and individual capacity to rebound from major challenges. The overall community resilience in China may be increased by enhancing public education and awareness programs, building a culture of disaster resilience and preparedness, and improving the community involvement.

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Command and Control

Command and control during disasters can ensure the success of coordination and the multi-sectoral platform. Disaster management structures, systems and arrangements form the basis of command and control. In Australia, a clear command and control structure and system is established and practised as shown discussed in Chapter Nine. Coordination centres were established in the Commonwealth, State, and District level to ensure clear command, control, and coordination. China, as discussed in Chapter Eight, has strong political leadership in command and control, though the public health sectors have limited powers of command. The case study in Jinan revealed that command and control structures were wanting and that escalation to the next level could have occurred in a timelier manner. This emphasises that those agencies that are part of the coordination and multi-sectoral platform need to address command and control and have clear guidelines of when and how to escalate a disaster to the next level. It would appear that command and control from the ‘top’ political level is strong, however command and control at the field level (bottom) requires improvement. Therefore, a stronger command role for the health sector should be enabled. The implementation of organising standardised operation procedures should be enhanced. Standardised command and control arrangements will also help to reduce errors or wrong decisions that were made by the leaders when under pressure.

Training and Drills (Exercises)

Trainings and drills are important aspects of preparedness and are designed to test and develop coordination arrangements. They provide a mechanism for practice in the event that something serious happens. In Australia, training and drills are conducted regularly either through coordinated inter-departmental drills, or evacuation drills within a single organization. On occasions, training and drills can include mock scenarios such as a plane crash or communicable disease outbreaks which require a response from multiple organizations. The State Emergency Services (SES) in Queensland, as described in Chapter Nine, is a community

- 188 - based volunteer organisation that provides adequate and appropriate training to its members to ensure safe and effective response during disasters. In China, many of the drill and training opportunities are still conducted for show as the scenario is revealed to the people before-hand. For example, the Lengshui case demonstrates the best possible reaction to disasters in the local town. However, this drill was based on a script, and everyone was informed of the time, location, and what to do before the drill. Thus the drill does not mimic ‘real life’ and may limit genuine learning. For flood health management, regular trainings and drills for decision making, warning, sandbagging, evacuation, rescue and personal safety are necessary to ensure the effectiveness of the response. Thus they should form part of the policy requirements. The training should ideally be conducted for emergency management staff, hospitals, local volunteers, the army and militia.

Resources Storage

The stockpiling of emergency resources and equipment is an important disaster preparedness measure. Both Australia and China have policies regarding resource stockpiles. However, whether the resources are sufficient is largely dependent on the scale of the flood. Levees, sandbags, boats, food, drug, and fresh water are all emergency resources that will help to limit the health impacts of flood. In Australia, stockpiles in each location include sandbags and purpose-designed equipment such as boats and radios, and they are managed through the State Emergency Services. Resupply from centrally located stockpiles, including fodder for cattle, can also be made quickly. For example, Charleville had a stockpile of 4,500 sandbags ready for the event of a flood, and levees were transported quickly in this studied case. However in China, stockpiling is limited as there is a lack of coordination and resources. In Jinan, the Yinzuo Shopping Centre prepared 4,000 sandbags to prevent water from leaking into the shopping centre. This turned out to be insufficient. In the Pan’an Centre for Disease Control and Prevention (Pan’an CDC), sterilization and vaccination drugs were stored; however the local managers complained there was a lack of systems to ensure the use of expiring drugs and replacement of drugs that have exceeded their use-by date. In Lengshui, 5,000 sandbags, 20 shovels, 40 life jackets, and

- 189 - an emergency power system were prepared for the flood, but these would be insufficient during a very large flood. Stockpiling more equipment and drugs may not be realistic in China due to limited resources. However, more coordination arrangements can be made to ensure the sharing of resources and quick resupply. For example, instead of the government buying boats, arrangements may be made with the private sector to employ their boats for emergency rescue purposes. By comparing China with Australia, it was found that China could better improve preparedness aspects of community resilience, command and control, training and drills, and resources storage.

10.3.3 Response

Flood response measures include flood warning and forecasting, road control, evacuation, emergency levees, resupply, and avoidance of contamination. The response measures in China and Australia are compared in the following section.

Flood Forecasting and Warning

Compared to other types of disasters, floods are relatively predictable. Flood forecasting and warning are most important in preventing the health impacts of floods. In Charleville, four SES crew members were on standby to check on properties along the Warrego River during the first day of the flood. An emergency siren was used at 4.30 a.m. to warm the residents of flooding in the Bradley Gully. In Mackay, the Bureau of Meteorology expected 110 to 200 millimetres of rain, but the actual rainfall was approximately 600 millimetres within six hours. In Jinan, a flood warning was issued, however, as in Mackay, it underestimated the scale of the flood. However, not many people understood the warning level. After the flood, flood warning was enhanced, including using SMS (Cellphone short messages) to send out warnings. In Zhejiang, typhoon warnings are usually issued a week in advance with close monitoring and update. However, this is usually at the provincial or national level. At the local level, the traditional way of monitoring the flood situation is still

- 190 - prevalent. The traditional method makes use of feedback and monitoring by people at the local level. In Lengshui, at least one person was assigned to monitor the flood situation in each village, and the flood warning was sent out through drumbeats. As can be seen above, flood and rain forecasting can be technically difficult, especially for flash flooding. The key to preventing health consequences from floods is to get timely warnings to the people; thus flood warning should be enhanced in both Australia and China. Such timely warning should include both the message of impending flood as well as other relevant advice. In Australia, radio is commonly available in vehicles and in homes. In China, public communication is mostly via television or newspaper, and therefore is not as readily available or timely. Recent deployment of cell phone messages to send out warning may be a good strategy for warning population. However regular test of the system is required to ensure the effectiveness of the warning; and test of the content of the message is necessary to ensure public acceptance.

Road Control

Road control and closure prevents people from entering the flood water, and thus is critical to preventing death and injury. More than half of flood fatalities in Australia are vehicle related (FitzGerald, et al., 2010). In Charleville, the main roads to the west of Charleville were closed on the first day of flooding, including the roads to Quilpie and Adavale. The Mitchell Highway was also cut-off, though most roads were more likely to be cut-off by the floodwater than by active closure such as by police or SES. It is noteworthy that in the Jinan case, most of the deaths also occurred on the roads, when people were on their way home. Although more than 1,000 traffic police were on the roads to control the traffic, as they usually do during the rush hour, their performance was hampered by the flood as many cars were inundated with water and couldn’t move. Many police lost communication with headquarters as their radios were damaged by constant exposure to moisture. The risk of entering flood water is often underestimated. Potential risks of flood water include the depth and speed of flood water (10-20 cm of water above the chassis can float a typical car while people may fall over in flood water deeper than one’s ankles), as well as the roadway status under the flood water (FitzGerald, et al., 2010; The National

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Centre for Atmospheric Research, 2008). Thus, it is important to enhance road closure during flood events, as well as to use public education to stop people and cars from entering the flood water.

Evacuation

When flood is of a scale that cannot be contained, early evacuation is the best way to protect people’s health. Special consideration needs to be paid to vulnerable groups such as the frail elderly and those with complex medical needs. Early evacuation to other towns or cities of patients who require intensive care can ensure their safety while also increasing the local health service capacity during floods. In Charleville, a dozen homes, six businesses and a caravan park were evacuated in the first day of the flood; nine patients were flown out, and patients from the nursing home were moved to the second floor of the hospital; 16 patients from the aged care facility were sent to Brisbane as a precaution before the second wave of flooding was expected. In Emerald, evacuation plans were prepared when the dam overflowed; the number of evacuations increased from 50 to 2,700 people; and two evacuation points were opened; a number of patients were transferred to Rockhampton Hospitals. In Mackay, many local residents woke up to find their homes flooded. About 2,000 homes (approximately 5,000 people) were evacuated. However, in China evacuation is a less developed and more challenging process. Even if the government ordered evacuation, people might not be willing to move due to concerns about protecting their own property. In the Jinan case, a total of 112,000 victims were evacuated to various locations. Unlike the Australian case studies, the evacuation tended to be mainly to nearby safe locations such as the home of their neighbours or relatives, rather than to a ‘shelter’ (Li & Dong, 2007). Proper regulation of enforced evacuation, as well as public education and evacuation drills may enhance the safety and efficiency of evacuation including the compliance of the public to obey evacuation orders. Emergency shelters, as previously discussed, should be efficiently identified and used in evacuations.

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Emergency Levees

Emergency levees are useful for riverine flooding and may prevent the whole area or building from being inundated. However, this is only effective when the flood is not too large and there are sufficient levees. In Charleville, a temporary levee was sent by the Air Force to fix two large gaps in the levee, and ultimately helped Charleville to avoid being inundated by the Warrego River. In Emerald, sandbagging was used to protect businesses and homes. In Mackay, there was neither time nor personnel for sandbagging due to the timing of the flood, and more than 100 businesses were flooded. In Jinan, the 4,000 sandbags for the shopping centre proved to be insufficient. As the flash flood occurred inside the city, sandbags in Jinan were intended to protect a single location, rather than a large area or precinct. In preparing for the flood of the Yellow River, Jinan city prepared stockpiles of stones for temporary levee construction. Figure 10-2 illustrates the stockpiling of stones and the yellow river can be noted in the background. In Lengshui, sandbagging was used to patch-up the breached river bank (see Figure 8-8).

Figure 10-2: Stockpile of stones on the bank of the Yellow River near Jinan City As can been seen from the case studies, temporary levees were prepared and used as an important strategy for flood response in both Australia and China. However, while all possible effort should be made to protect the whole city or town with a levee, it may also be necessary to prepare sufficient levees or sandbags for key infrastructures such as hospitals in order to continue to provide vital health services. Highly populated facilities

- 193 - such as underground shopping centres may also be a priority for sandbagging. Additionally, expertise in sandbagging and levee building should be included in the training of emergency management staff and volunteers.

Emergency Rescue

When a flood cannot be contained and evacuation cannot be or is not carried out, and emergency rescue will have to be conducted to rescue people in danger. In Mackay, the flood was so severe that the communication system was mostly down, though Mackay SES had quite some call-outs in the morning of flooding. In Charleville and Emerald, SES crew members were on standby early and responded quickly. Their response included temporary levee construction in Charleville and food and medicine drops to isolated properties by helicopters. In the Jinan case, all the hotlines, including 110 (police), 120 (ambulance), and 119 (fire) were overwhelmed. There were cases where lived could have been saved had the ambulance and rescue team being able to arrive in time. However, both communication and access failures affected the rescue. In Pan’an, the county government leaders were divided into groups to guide the local rescue in different locations. In Lengshui, an emergency rescue team comprised of six people was established in each village. The emergency rescues in Australia were conducted in a professional manner and were efficient as evidenced by the use of specialised equipment, coordination between agencies and a timely response. In China emergency rescue teams were established in different government levels, however there was a noted lack of efficiency and capacity as seen in the Jinan case. Specialized training and drills of local emergency management staff and volunteers may be necessary to ensure efficient emergency rescue.

Resupply

When the flood lasts for a prolonged period of time, resupply becomes necessary. With a pre-organized system and modern transportation equipment, resupply becomes relatively easy. In the six case studies, most of the flood events only lasted a short period of time, and thus resupply was not of significant importance.

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Avoidance of Contamination

Avoidance of contamination during flooding can prevent health problems through ensuring clean water and a clean environment, especially during local flash flooding. However, this is usually of lower importance when the emergency rescue is in process. In the case studies, no clear strategy for avoiding contamination was observed, though efforts were made after the flood event. Lack of efforts in avoiding contamination partly resulted in clean-up difficulties. For example, in Australia, Mackay city’s waste facilities re-opened several days after the flood. In China, efforts were made to successfully provide clean water to the residents of Jinan. Possible contamination during a flood can result in negative health consequences. Contamination can include excreta, waste, and other dangerous goods such as chemical spill. Thus, policy strategies should include identifying possible contamination sites, enhancing the security of the infrastructure in these locations, and transfer dangerous goods to higher grounds or safe place when flood is forecast.

By comparing China with Australia, it was found that China could better improve response aspects of flood forecasting and warning, road control, evacuation, emergency levees, emergency rescue, resupply and avoidance of contamination.

10.3.4 Recovery

Flood recovery includes prompt restoration of services, prompt cleanup, provision of social welfare, provision of health care services, community education, disease surveillance, and disease control. The recovery measures in China and Australia are compared in the following section.

Restoration of Services

Prompt restoration of services, including maintaining or restoring normal services and security (particularly health services), should be the first priority after a flood to enable normal life to return for the citizens. This will keep people physically away from

- 195 - potential danger (e.g. power lines and contaminated water), but also psychologically influence people’s feeling to assist them to recover quickly. In Charleville, the Department of Main Roads started assessing flood damage on the third day after the flood. The Neighbourhood Centre and the Ergon Energy worked together to check houses inundated during the flood, to make sure homes and businesses were safe before the owners and workers returned. In Emerald, the police were granted extra powers during the floods and at least four persons were arrested for looting. In Mackay, waste facilities re-opened several days after the flood. In Jinan, the Water Resources Bureau managed to provide clean water after the flood. The police arrested a person who disseminated a rumour through the internet that many people were killed in the Yinzuo Shopping Centre. As can been seen above, the maintenance and restoration of essential social services and order were attached with high importance in both Australia and China. Areas given priority include essential social services, health services, clean water provision, sewerage security, power supply, telecommunication and social security. While each government sector and industry is responsible for their own service provision, arrangements may be made so that additional material and personnel support can be obtained from other sectors or higher government levels.

Clean-up

The clean-up should be conducted quickly, so as to prevent mosquitoes, rats, cockroaches and mould from reproducing and spreading diseases, as well as allowing people to return home early. However, extra caution should be taken during the clean-up as the flooded site might be unstable or chemically contaminated. Official guidance and advice should be given to the residents during clean-up. In Mackay, residents started cleaning once the flood receded. In Emerald, 30 volunteers were sent to assist the clean-up, and more than 20 electricians were on stand- by in case they were needed. Clean-up started in Charleville the day after the flood. In Jinan, the army was deployed to assist the clean-up. However in China, no clear guidance and advice for clean-up was evident from the case studies. On the policy level, sufficient personal and equipment should be allocated for quick and safe clean-up. Additionally, appropriate education and supervision should be

- 196 - provided to staff and citizens, particularly regarding electricity safety, chemical safety, carbon monoxide poisoning and other hazardous materials.

Social Welfare

People affected by a flood usually require material and financial assistance to recover. Social welfare after a flood is essential to assist the community in recovering from the flood. In Australia, social welfare is provided quickly after a flood. In Charleville, federal government grants of up to $25,000 were available to help the flood affected primary producers and businesses. Low interest loans of up to $100,000 were available as well. In Emerald, the Queensland and Federal governments arranged financial help for residents: $25,000 for small businesses and farmers, $1,000 per adults and $400 per children was available for eligible people. In Mackay, payments for essential items such as food, clothing, medication, and emergency accommodation were available: up to $160 per person and $740 per family. More importantly, the Department of Communities opened three recovery centres in Mackay to help residents with information and to access social benefits. In China, social welfare is being enhanced. In Jinan, the local government sent a pension of 20,000 Yuan (US$2928) to the family for each person who died in the flood. A total of 10 million Yuan (US$1.5 million) and 5,000 blankets were provided by Shandong Provincial government; 15 million Yuan (US$2.2 million) were provided by Jinan City government; 8.68 million Yuan (US$1.3 million) were provided by local district governments; 2.95 million Yuan (US$432 thousand) were donated by the citizens and companies in the city (Li & Dong, 2007). In Pan’an, the Charity Federation, the Disabled Person Federation, and the Red Cross provided assistance after the flood. In Lengshui, local government leaders usually visit the victims after a disaster, rather than people applying for financial help. This may be partly due to farmers’ illiteracy; however it also reflects that the system could be more transparent. A nation’s capacity to provide emergency relief is dependent on its economy. China does have the Ministry of Civil Affairs and its sub-organizations Civil Affairs Bureau in different government levels which are responsible managing disaster relief

- 197 - resources as described in Chapter Six. However, a more transparent approach could be established to assist the victims’ recovery.

Health Care Services

Heath care services are of critical importance but can be difficult to maintain after a flood. Besides the normal daily pressure, people who get injured during the flood may place additional demand on the health services; exacerbation of chronic diseases may put more burdens on the healthcare system; and some infectious diseases may occur after a flood. The staff of hospitals and their families may be victims of the flood as well and thus unable to provide care. In Australia, some patients in Charleville and Emerald were sent to other places before the flood, so as to ensure their safety and increase the local health service capacity. In Mackay, extra medical personnel were sent to help after the flood, though Mackay Base Hospital was only able to deal with emergencies during the time of flooding. In Jinan, health care services were mostly maintained after the flood. There was also social support to the health services, including drug donations in Jinan to assist the recovery. In Lengshui, the local government conducted advance payment for potential flood victims. As discussed in the disaster health management section in Chapter Four, health service capacity may be preserved and managed in four levels. The studied cases did not result in high demand for health services; however the health services in Australia followed their strategy such as flying out patients before the event in Emerald and Charleville and rationing access during the event in Mackay. Such approaches were not noted in the China case studies and the Australian response can provide valuable policy ideas for China. There is a need to build and enhance disaster health services capacity management strategies in China. Additionally, regulations regarding health service capacity management during disasters, such as the provision of additional health care workers during disasters and the encouragement and handling of necessary drug donations, should be established.

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Community Education

Community education on health and safety is an important strategy to promote health in the community after a disaster. In both Australia and China, post disaster health education was conducted at some level. Health education information was disseminated through booklets, websites, newspapers, radios, and TV in both Australia and China. However, in Jinan, the health education booklets were prepared urgently by staff in the CDC after the flood. Community education enables people to make informed decisions about health and safety related activities. While event-specific education is quite effective and popular after a disaster, community education is a long-lasting process that not only can prevent health problems but also can increase social capital.

Disease surveillance and control

There was no evidence in any of the case studies of an outbreak of any diseases after the flood. However, disease surveillance and control are necessary to ensure the ongoing safety of the people. In Australia, the Environmental Health Services started mosquito control measures in Emerald even before the flood was over. In China, the Provincial CDC and the city CDC in Jinan conducted sterilization, vector control, and infection control. In Pan’an, medical teams were sent to villages to carry out disease prevention. There were also disease control activities within organizations, such as cockroach control within the financial institutions. Disease surveillance and control is mainly the domain of the health sector; however, other sectors should also be involved to carry out certain measures: for example, the Education Department should take on the task of providing hygiene education to staff and students. If potential communicable diseases are monitored, immunization and vector (mosquito, cockroaches and rats) control as well as disease specific measures should be conducted. Additionally, routine disease control practices that may have been interrupted by the flood should be resumed.

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By comparing China with Australia, it was found that China could better improve recovery aspects of services restoration, clean-up, social welfare, health care services, community education and disease surveillance and control.

10.4 Comparative Case Findings

In order to protect people and their property, attention has been put on higher dams and embankments. However, this may lead to even greater pressure to develop marginal land that subsequently puts more people and property at risk. Despite higher embankments and more complex response plans, a larger scale flood may occur and result in damage to the community. While structural measures may continue to be an important flood defence method in China, it is but one approach to the disaster health management of floods. Non- structural measures are also important approaches. For example, integrated flood management, land use planning and ecological flood management are becoming important strategies for preventing flood in the long run. Flood insurance is also being introduced; however this method should be used in a more proactive way: the insurer and the insured should work together to make the best effort possible to prevent floods, rather than using a simple risk-sharing method. Multi-sectoral platforms are important for bringing all the stakeholders together to ensure coordinated cooperation, not only in planning and practise drills for prevention and preparedness, but more importantly for response and recovery. Communication is a key to inter-organizational cooperation. International cooperation and arrangements should also be made as part of the platform. Community resilience implies building the capacity of the community to absorb the disturbance and retain essential structures. It focuses on improving the community’s ability in dealing with disasters. Training and drills, community education, and resources storage are important preparedness measures to ensure that organizations and the community can collaboratively respond to disasters with sufficient equipment and drugs.

Flood forecasting and early warning is essential to prevent flood death and injury. Flood forecasting techniques should be improved as much as possible; flood warning

- 200 - should be made through multiple channels; flood warnings should also include guidance on how to protect life and property. During the flood, emergency levees and sandbagging can be important measures to contain flood water. When flood water cannot be contained, evacuation and road control should be deployed. During evacuation, the power of flood water should not be underestimated as it can easily sweep away people or cars, and cause serious injury or death. Emergency rescue and medical services should be conducted as efficiently as possible during the flood. The affected people are likely to have a high level of need during the flood when the services are interrupted. This was the rationale for evacuating people with high care needs such as frail elderly to other towns so that the existing services would not be overwhelmed. The challenge for the emergency rescue services includes transportation during floods, personnel to work and respond in the hazardous environment, and the communication system that may be non-operational during the flood.

When possible, the affected community should try to prevent contamination of the water and start clean-up quickly. These actions may reduce the risk of infectious diseases and further contamination. Disease surveillance and control should be conducted together with health education after the flood. This is so that diseases possibly exacerbated by the flood can be identified early and controlled, thus lessening communicable disease impact on the community. Re-supply will be necessary for prolonged flooding. Additionally social welfare after the flooding will likely be required, including maintaining or restoring critical services as quickly as possible. This is to help affected people recover from the secondary impacts of flooding and resume their normal life. Psychological care should also be provided to the affected community.

This chapter has detailed the lessons learnt through comparative analysis of the management of floods in Australia compared with China. The Australian case studies highlighted the advantages of a mature emergency management system (EMS) which is well tested through training and disaster events. A number of areas for improvement were identified for China. In both countries sudden flooding is a bigger challenge to EMS

- 201 - compared to flooding with a slower onset. These observations form the basis of subsequent analysis of the policy implications of these findings The next chapter examines the international experts’ interviews and survey results in regard to disaster health management.

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Chapter Eleven: Findings of Interviews and Surveys with International Experts

This chapter analyses a policy framework for disaster health management. The aim of this analysis is to identify the key factors of a ‘good’ policy framework for disaster heath management. As discussed in the methods section (Chapter Seven), the findings of interviews and survey with international experts are informed by a ‘top-down’ perspective to the policy process. The research findings are discussed and examined in detail in six sections, including the characteristics of a conceptual policy framework of disaster health management, elements of policy development, elements of policy implementation, policy effectiveness evaluation elements and procedures, other determinants of effective disaster health management, and additional survey results. At last, all the results are summarized into the new conceptual policy framework.

11.1 Introduction

Experts’ opinions of disaster health management policies are a key component of this research. The results of the interviews and surveys of international experts are used to propose a policy framework for disaster health management, which then may inform recommendations for policy development and implementation. The interviews and surveys of experts were based on a rationale of disaster management policy development as outlined in Figure 11-1. This framework was used as a basis for guiding the interviews and surveys, and the elements of this framework correspond with chapter headings. Effective disaster health management that aims at minimizing the human health impact of disasters is based on many determinants, including the extent, location and timing of the event, the political structure of the country, and the policy framework for disaster health management. The policy framework not only deals with policy development, but also policy implementation and evaluation. The policy analysis which was undertaken used a grounded theory approach to derive themes from the results of interviews and email surveys of the experts. The interview and survey questionnaire can be found in Attachment D.

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Figure 11-1: Framework of Disaster Management Policy

11.2 Characteristics of a Conceptual Policy Framework of Disaster Health Management

A policy framework aims to identify principles that guide the development and implementation of policy and initiatives to achieve the government’s priorities. In consulting with the experts, a number of key characteristics of a disaster health management policy framework were identified. These key characteristics are discussed below; however, it is not possible to determine a rank order of priority.

1. Risk Assessment and Recognition A recurring theme identified by the experts was the importance of recognising and undertaking risk assessment. Comments to this include: “The most important is the recognition of risks in the community.” “You should be able to assess and understand these risks.” “Look at the statistics to see if the situation is real.”

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Disaster management policy should allow for risk assessments and recognition. The respondents indicated that if you do not know what risks exist within the community, you cannot predict which will lead to disasters, and thus can’t frame policies related to disaster management. Therefore, one of the key elements of the policy framework is the recognition of risks in the community and the knowledge and ability to assess and understand these risks.

2. Strategic View Another dominant theme identified by the interviews and surveys was the need for a strategic or macro approach that can encompass multiple disaster types— not just lessons learned from last disaster which may not suit the next one. “It’s vital to have an understanding that policy should address disasters of type and scope that have not yet been experienced.” The respondents stated that policy is actually a strategic plan, and the policy writer has to understand strategic planning.

3. Community Resilience Another theme which emerged centred around prioritizing community resilience building, rather than focusing solely on the relief phase. In the words of one respondent: “A real effort should be made to build the absorbing and buffering capacity of communities based on risk assessment and NOT solely focused on disaster response.”

4. Inclusive and Accountable A number of respondents identified a theme around continuous improvement and accountability. “The framework should be accountable, i.e. with a system to improve itself.” It was stated by several participants that the framework should be comprehensive and include the ability to continuously improve the prevention, preparedness, response, and recovery, which form the dynamics of disaster management. Participants also suggested that the framework should support on-going policy development and formulation, so that policies can be modified for the future. It was stated that the framework should include reviewing of the policies and policy implementation,

- 205 - especially after a disaster. The review can be done through collecting data on outcomes and assessing the effectiveness of the response.

5. Well-ordered Structure with Designated Roles Most of the respondents described the importance of a well-ordered structure with designated roles. All organizations need to be coordinated and follow the same framework. Two of the respondents summed up this theme as follows: “Clear list of authority and delegated authorities of who is in charge of what is important for disaster management.” should be made available. “Local organizations’ plans should be linked together.” The framework should consider how health fits into the broader disaster management system. Emergency services, community services, agriculture and other industries will have their own emergency systems, and these systems should be integrated with the health response plan. It is important to embed health needs into the prevention, preparedness, response, and recovery arrangements. These essential needs for health care include provision of clean water, arrangements to provide or maintain sewage, provision of food with reasonable quality, monitoring for infectious diseases, chronic disease and illness related to mental health, as well as monitoring of environmental health.

6. Fault Tolerant A small number of respondents (n=3) identified a ‘fault tolerant’ system as being important in disaster health management policy. To this regard, it was stated that the decisions of a lower level during disasters should be reported to the higher level immediately; so that the higher level has a chance to monitor the situation and change the decision if necessary. In the words of one respondent: “The decisions need to be reported, and if it’s a bad decision, it needs to be changed.”

7. Communication Structure and Information Technology Most respondents acknowledged that the disaster health management policy framework needs the support of the best possible communication structure and information technology. The managers need to know what’s happening through video, internet, telephone etc.

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8. Rigidity and Flexibility From different points of view, more than half of the respondents suggested that the policy framework should have some rigidity and some flexibility. As putted by one respondent: “Framework has to be flexible enough to lead and assist.” It is advised by the respondents that the policy framework should be simple and easy to understand. The generic framework should be an all-hazards approach and be able to be adapted to most situations and tailored for an individual circumstance. Additionally, the disaster management framework should integrate with other plans, such as road control, security, fire fighting and ambulance.

9. Education and Awareness One common theme identified by the respondents is the necessity of education and training at all levels to increase people’s awareness. As suggested by one respondent: “Awareness through education would be very desirable.” The respondents suggested that people always believe that disasters will not happen unless you are living in high risk area. However, it’s just a matter of time until a disaster will occur and we need to be aware of it in our daily living. It is desirable to keep people aware of the possibility of a disaster occurring.

10. Engagement of Community Engagement of the community is another theme identified by several respondents. Though partially overlapping with the theme ‘rigidity and flexibly’, this focuses on the “mutual understanding between the community and policy makers”. The respondents pointed out that the situation where only policy-makers know about risks and the community is not informed will ultimately lead to tragedies. Of course, policy-makers cannot control everything, but they can indicate the possibility of risk and can promote disaster preparedness within communities. This theme is emphasized by the words of one respondent: “Mutual understanding between community and policy makers is important; policy makers should know the community.”

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11. Funding The last key theme identified by a few respondents is the funding of disaster health management policies. In the words of a respondent: “There should be effective funding of health disaster management at all levels.”

11.3 Elements of Policy Development

In developing policies, there are many elements to consider. The experts identified 10 key themes as essential elements of effective policy development. These are discussed below; however, a priority ranking of order cannot be determined.

1. Adequate Leadership A dominant theme raised by most participants was the importance of leadership in policy development. The agencies that are responsible for policy development should be well-defined and well-funded, and given the authority to produce the policy. This is a top- down approach that can effectively and efficiently provide a consistent framework and guidelines. In the words of a respondent: “Make sure the people are empowered and paid to do policy development.” It’s important to ensure the existence of specific government departments that will take responsibility for the policy development, such as the FEMA and Homeland Security and Defence (HSD) in the USA and EMA in Australia. The resources and personnel should be identified in the policy. The people responsible for policy development should be empowered, and the grouping of these people should be kept as consistent as possible. Continuity of staff and leadership was seen as important.

2. Expertise Advice and Research Evidence More than half of the respondents indicated that policy should be developed by a group of experts, rather than one person dictating all decisions. Respondents suggested that: “A good policy should be based on valid knowledge.” “Scientists that provide the evidence basis should be involved.” “Question all assumptions—such as the availability of life lines.”

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“We should use research; and policy should be driven by what works.” In detail, the respondents pointed out that in developing policies, experts in the field of disaster management should be organized to meet together and discuss ways of managing disasters. The policy should also be research-driven and evidence-based (e.g. policy should be based on epidemiological evidence). The policy should also move beyond the special interests of discipline groups or colleges, and be developed in consultation with industry and government.

3. Clear Goal and Terms A common theme identified by more than half of the respondents is that the goals of the policy should be clearly stated, and the terms in the policy should be well defined. “Clear stated goals and well defined terms are important.” Additionally, the respondents suggested that the time-frame for these policies to take effect should be specified.

4. Easy to Access, Practical and Realistic, Specific, and Easy to Implement Another theme identified by many respondents is that the policy should be easy to access, practical and realistic, specific, and easy to implement. “The policy should have identified resources and personnel.” “The policy should be simple and straight forward.” The respondents further pointed out that the main body of the policy should be simple, straight forward and no more than several pages. If the policy is too long and too complicated, it will lie on the shelf and have no practical value.

5. Locally Developed, Owned, and Accepted Most respondents stated that the policy should be “developed, owned, and accepted by the community or region” based on geographical zoning. This is a bottom-up approach which should be used to ensure sound grass-roots support for the policies. This is complementary to the above mentioned top-down approach. The respondents further stated that policies should be made from within the area, rather than made for the area. Only if the policies are developed by the people within the community can they be implemented properly. The policy should be the local people’s idea, rather than some directive from an external organization. It’s important to analyse

- 209 - the international standards, and learn from the policies and experiences of other countries and areas. However, it’s more important to apply this learning to local circumstances, and to ensure the policy relates to local conditions.

6. Standards and Flexibility Another key theme identified by the participants is that policies should have standards while also allowing certain flexibility. The national framework must be flexible enough to lead to and to assist local policy development and implementation. The national framework should be very generic while the local ones should be reasonably specific. For example, the national policy should instruct a standard incident command system while the local policy may have to adjust it to account for regional limitations (e.g. of trained personnel or resources). In the words of a participant: “Policy should be able to be adapted to most situations but tailored for each individual situation.”

7. Clear Linkages with Other Policies Several participants identified a theme of “clear policy linkages between disaster management policies and other policies”. In particular, the disaster management policies should fit into the health framework, and the health framework should fit into the national policy framework. One participant pointed out that it is important to ask: “How does health management fit into the broader disaster management system?”

8. Contemporary and Updated Another dominant theme identified by the participants is that policies should be contemporary and updated every few years. In the words of some respondents: “There should be on-going policy development and formulation, so that policies can be modified for the future” “It should be contemporary. Every few years it should be updated.” Some respondents pointed out that it is important to learn from the experiences of disasters and to improve the local policies and systems through these experiences. In China, there are always awards and praises after a disaster response, but people are reluctant to publicly identify problems. However, these are valuable opportunities to learn from policy successes and failures and thus improve disaster policy development.

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9. Involve all the key stakeholders A large number of respondents agree that policy development should involve all the key stakeholders and ensure that each organization knows what others are doing. It should also ensure that all individuals and organizations involved follow the same framework. In the words of respondents: “Identify who are the stakeholders.” “Knowing who are the stakeholders and their attitude in case of disaster situation.” “The policy should be acknowledged and accepted by all agencies involved in the disaster management.” “Consult with industry and government.” The respondents stated that it is important to ensure all personnel are committed to active participation in disaster management, and that all the relevant organizations understand that they share responsibilities and must operate as a team. The involvement of all the key stakeholders requires them to coordinate with each other, particularly the police, fire, and medical staff. Several respondents pointed out this. This is particularly so in China as currently many local governments do not follow the national policy framework. There is, it appears, a reluctance on the part of members of organisations at the local level, and even of individual departments within those organisations to give up even a part of their autonomy and thus of their power. Sometimes the Government’s emergency plans serve no purpose other than to be readily available for show or in case of inspection by higher authorities. The respondents stated that the involvement of the stakeholders in policy development will increase their awareness, which will assist with policy implementation. The departments’ coordination in a hospital during a disaster is a good example: in a disaster, patients might be transferred to the hospital by all sorts of vehicles, including personal cars, ambulances, taxies etc.. The media’s vehicles will put further pressure on traffic flow. Therefore, it is important for the support department of the hospital to control incoming vehicles so that the doctors are available to assess and treat patients. The patients should be treated in a relatively quiet environment, rather than one disturbed by the presence of families and the media.

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10. Inclusion of Regular Drills and Practices The last key policy development theme indentified by the respondents is that regular drills and practices should be built into the policy. In the words of some respondents: “Adequate training at all levels should be part of the policy.” “Each year, there can be different drills, so that the whole community is aware we have the disaster plans.”

Additionally, there were issues raised that were of value but of lesser priority. These included the need to base new or developing policies where at all possible on existing policies; and the suggestion that in policy development all assumptions (such as the availability of life lines), should be questioned.

11.4 Elements of Policy Implementation

An analysis of the interviews and surveys revealed 10 aspects that were considered by the experts as important elements for effective policy implementation. These are described in the following section, however their priority ranking are not determined.

1. Well Defined Structures and Agencies Most respondents agreed that policy implementation requires “well defined structures and agencies”. And it is necessary to make sure the stakeholders have an interest in the policy implementation and that the structure is clear. In the words of some respondents: “Each organization within the tiers has its own area of power. Generally such organizations do not want interference from outside.” “Standardized incident command is necessary.”

2. Specific Disaster Health Management Governmental Organizations A dominant policy implementation theme identified in the interviews and surveys is the importance to maintain the existence of specific governmental organizations whose

- 212 - sole responsibility is disaster management, disaster policy development, implementation and evaluation. In the words of some respondents: “It’s important to have specific government/departments that are responsible directly and only for disaster management policy development and implementation.” “Many emergency response teams are headed by local government leaders; but the leaders may not have the expertise.” Additionally, the respondents also stated that professional groups should be involved in every possible aspect of policy implementation. However, political intervention should be minimised. The “paper plan syndrome”, which means written disaster plans may be only an illusion of preparedness unless accompanied by other requirements such as training, should be eliminated.

3. Delegate the Power A large number of respondents agreed that power should be delegated to the appropriate people for effective policy implementation, and the coordination between groups should be ensured. In additional, all the stakeholders should be identified and empowered to maintain their authority and responsibility. In the words of one respondent, there is a need for a “Clear responsibility statement to empower the stakeholders.” The respondents further explained that it is necessary to ensure control and command at the political level and the agency level work together. The cooperation between different agencies and different departments in the same agency is very important.

4. Maintain Stakeholders’ Interest Additional to delegation of power, many respondents also identified a theme of ensuring the stakeholders’ interest. The respondents stated that “It is important to involve them as part of both the policy development and the implementation.” The respondents further explained that the policy should be acknowledged and accepted by all agencies involved in disaster health management. Local cooperation is very important, thus implementation should make sure that local people understand the policy and their role, and realize that disaster management is everyone’s business.

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5. Communication A dominant theme identified by most respondents is communication in policy implementation, such as who is involved, what they are doing. In the words of some respondents: “Managers need to know what is happening.” “A very good information and communication system is important.” Some respondents suggested that the leading organizations, usually the police, must be able to talk to the fire, health, and communicable disease prevention people, at any time. Good communication involves not only the pathways of communication, but also clarity in regard to the message and the means (e.g. radio communication technology). For example, VHF radio sets that are battery powered will be very useful during disasters, while mobile phones may become overwhelmed.

6. Recognition and Understanding of Disaster Risks A large number of respondents agreed that “recognition and understanding of disaster risks” will assist policy implementation. In the words of one respondent: “If people lack understanding of disasters and think it will never happen, they will not be interested, and will put the plan on the shelf and never read it.” On the other hand, if people don’t understand its importance (consider it as a waste of time and money) and don’t care, disaster management policy will be far less likely to be implemented. “Limited experience and exposure to disasters may inhibit the policy implementation.” Some respondents further explained that “who takes the responsibility for the damage, i.e. who should have taken preventative measures?” always becomes an issue when a disaster occurs, and thus the community as well as policy makers need to think about how to minimize the damage in terms of human health impact and economical loss beforehand.

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7. Maintain Policy Familiarity Familiarity with the policy is considered to be necessary by many respondents: people should know what the policy is, and the correct authorities should know the plan. One of the respondents stated: “Awareness and familiarity by the staff of the policy is very important.” Additionally, some respondents suggested that summary cards should be available as well as major disaster plan documents. All agencies involved should know the disaster plan and their own role in it.

8. Full Participant of Health Elements Several respondents stated that full participant of health elements should be in evidence throughout the whole of the disaster management framework. The respondents further explained that we need to see health working in the system, including the agencies for disease control, hospitals, public health, public-private health, medical facilities of universities and other medical research institutions.

9. Financial Support Financial support is also indentified as an important theme in the interviews and surveys. Finance was considered critical to the implementation of a plan by some respondents: “The overload of the current daily health system will inhibit policy implementation.” “Full financial support is the best.”

10. Specific Measurement of the Consequence The last theme identified in the interviews and surveys is that it is important to have specific measurement of the consequence of policy implementation, so that the policy development and implementation can be evaluated and improved in due course.

Some other factors affecting disaster management policy implementation were also identified, but only by a small number of respondents. It was stated that limited experience and exposure to disasters may affect the disaster management and policy

- 215 - implementation in a negative way. Conversely it was indicated that a recent disaster experience would assist implementation.

11.5 Policy Effectiveness Evaluation: Procedures and Elements

To ensure effective disaster management, it is important to have specific evaluation procedures to measure policy effectiveness. The evaluation can cover many aspects, and the procedure and method for policy analysis depends on the evaluation purpose. In consultation with the experts, seven evaluation procedures and elements were identified for disaster health management policy:

1. Advisory Committee Most respondents stated that one of the key measures or elements of policy effective evaluation is to form an advisory committee. Quotations of respondents in this respect include: “It is important to organize an advisory committee to carry out any evaluations.” “Independent evaluation of the policies is necessary.”

2. Analysis of Real Event More than half of the respondents acknowledged that the most important way to analyse or evaluate a disaster management policy is through the analysis of what works and what does not after a major disaster. “We need to analyse actual events.” “Validated outcome studies are the best way.” The respondents further explained that analysis of real events should have a particular focus on communication and whether the right people were in charge. In the heath aspect, it is important to examine the clinical outcomes as well.

3. Analysis of Policy Operations in Exercise, Trainings, Drills, and Scenarios Another important process of policy effectiveness evaluation acknowledged by most respondents is through examining how the policy operates in exercise, trainings,

- 216 - drills, and scenarios. The respondents stated that we can use different modelling exercises to see if the system works, such as table-top drills, structured scenario based exercise (e.g. Emergo Train System (KMC, 2007)), and other mimicking models. In the words of some respondents: “Use different modelling exercises to see if the system actually works.” “Run well-simulated disasters involving all related organizations.” “Measurement should be based on the element analysis of disasters.” The respondents further explained that a government may spend a lot of money on disaster prevention, yet the damage is still far more than expected. The reason may be that while they have a very good infrastructure, the people in charge of emergency response and the people in the community don’t know how to react. Thus, it is important to run drills and exercises. Several respondents emphasized that the evaluation of disaster management and policy implementation may be conducted through testing of people’s knowledge of the existing policies. Drills and exercises should be treated seriously, and this is yet to be so in some developing countries. In the words of one respondent: “Many of the drills are just for show and they may only be intended to provide material for a video for propaganda or a documentary”.

4. Involvement of Key Players Another criterion in the disaster management policy evaluation identified by several respondents is whether the framework allows all the key players to be involved, and whether there is evidence of people’s actual contribution. In the words of a respondent: “Find evidence of people actually contributing as part of the framework.”

5. Operating Procedures Respondents also identified the need to evaluate operating procedures, so as to ensure they are well-established. In the words of one respondent this requires “Evaluation of whether the operating procedures are well-established”

6. Assessments by Experts

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Some respondents also identified the need for assessments to be conducted by relevant experts. The respondents explained that it is important to accept and consider assessments made by experts, who assess the policy and implementation by looking into such aspects as: “Does policy translate into practices? Is there a demonstrated connection between practice and the procedural changes in institutions/organizations and the policy framework?”

7. Scientific Evidence The final evaluation theme identified in the interviews and surveys of experts is that where available, scientific evidence should be used in the evaluation of policies and the practical applications that follow them.

Many respondents also emphasized that the disaster health management policy relate to other policies, and thus the evaluation results may not solely depend on the disaster health management policy effectiveness and implementation. For example, communicable diseases or violent crime may increase in a poor neighbourhood, which in turn increases the incidence of HIV, TB or injury and may cause a public health disaster. Public health surveillance and law enforcement surveillance may improve the neighbourhood and decrease disaster risks.

11.6 Other Determinants of Effective Disaster Health Management

Effective disaster health management can depend on many factors. Six key factors were identified as having potential to influence the effectiveness of disaster health management, including the nature of the event; the social, political, culture, and economic environment of the community; surge capacity; education, training and research. Firstly the nature of the event, including the predictability, type, scale, location and timing, largely determines how effectively the disaster management can be carried out. The nature of the event should also determine which organization is in charge of the disaster response. The scale of the disaster determines whether the response is managed at

- 218 - local, regional, national, or international levels. Floods are mostly predicable while earthquake can hit a community without warning. The geographical location of the disaster affects disaster management: remote areas are less likely to get emergency supplies in the immediate instance. Secondly, the political and social environment is very relevant. Social stability provides the foundation for a long-lasting, positive attitude toward disaster management. Freely allowed public criticism of the government, politicians and management can ensure that disaster management is openly discussed and thus prioritized. On the other hand, tight political control can centralize resources and enable rapid mobilization. Thirdly the culture of the affected community, which largely determines public expectation and attitudes toward services during disaster management, plays an important role in disaster management. There should always be enthusiastic people to drive the system; and community expectation is one of the driving elements. The community’s tolerance to disasters may be related to the culture. For example in Australia a single death would be considered calamitous, but in China it would not cause such concern. Fourthly, the economic situation of the country affects the funding available for disaster management. The funding then determines the available resources and equipment such as vehicles, communication facilities, and other special equipment. On a broader point of view, the funding also determines disaster management research capacity, education and training levels which prepare the community. Related to the economic situation is the surge capacity of the existing health infrastructure to respond during disasters. If the existing critical infrastructure, including public health infrastructure, is already over-loaded, then surge capacity would be very limited. Resources allocation, including health, fire, law enforcement, food, water, economics etc, and mutual aid arrangements are important for building surge capacity. The surge capacity of hospitals includes medical and staff resources, such as lists of medical or nursing staff available for emergency work, and stockpiles of emergency rescue drugs. The staff lists and equipment and drug stockpiles should be systematically updated. Building surge capacity is dependent on communication and transportation tools, such as adequate helicopters, boats, and ambulances. One important aspect of surge capacity is to have arrangements in place to ensure people are safe to respond. People who should respond during disasters may not do so immediately. Therefore, adequate personal protective supplies are necessary. For example,

- 219 - life jackets should be provided to flood response team members; and vaccine programs should be prioritized for responding staff during pandemics. Additionally, education, training, and research are always important. Education and training should be conducted for all specialties and fields with frequent training cycle. Education includes school curriculum education at the lower level, staff disaster management training in each industry, and professional disaster management training and research for experts. Education within the community can increase community disaster awareness and knowledge; and response knowledge such as first aid skills may save many lives during emergency situations. For hospital managers, doctors and nurses, it is essential to provide some level of disaster health knowledge and an understanding of the roles they may be required to play. It is important to ensure that all of these determinants are integrated into disaster health management policies. Logical planning and organization can be achieved through policy. Independent disaster management evaluation can improve the policy.

11.7 Additional Survey and Interview Results

In addition to comments on the disaster health management policy framework, policy development, and policy implementation, the experts also provided the following general key suggestions for disaster health management. Firstly, each player needs to be checked for evidence of their understanding of their roles and work. Evidence can be found through asking: have all the stakeholders worked as part of the disaster management? How did they work? How well did they work? Secondly, government should be engaged to apply comprehensive disaster management and improve each stage of disaster management, namely the prevention, preparedness, response, and recovery (PPRR); and to build policy into this management cycle. In the disaster management cycle, the importance of prevention should be emphasised. Disaster management measures should be used to avoid major disasters as much as possible, including mitigation strategies such as strict building codes and standards, chemical handling procedures, requirement for the reinforcing of defence structures, and more accurate disaster prediction.

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Thirdly, policy development and policy implementation are not parallel; rather they are a cycle and a continuous process. It is worth noticing that the elements and parts in the disaster health management policy framework are related to each other, and they are separated only for the purpose of research. In summary, the experts’ survey results are captured in Figure 11-2, which forms a policy framework for disaster heath management.

Part III introduced the primary research elements of this thesis, including the methodology, case studies, and experts’ interview results of policy analysis. Part IV discusses the relevance of this information, and leads to recommendations for policy development. The discussion includes three chapters addressing the issues of flood health management, disaster management policies in China, and a final conclusion and recommendation.

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Figure 11-2: Detailed policy framework of disaster health management

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Part IV Discussion

Chapter Twelve: Health Consequences of Floods and Prevention Measures

While drowning is an obvious health consequence of floods, the full health impact is more extensive and less clear. For example, one study found a four-fold increase in illness among people whose homes had been flooded compared with those whose homes were not flooded (Waring, Reynolds, D'Souza, & Arafat, 2002). The speed of flood onset is the main factor determining the number of drowning. However, floods are often long- term events that may last days to weeks or longer (US Department of Commerce, National Oceanic and Atmospheric Administration, & National Weather Service, 2002). Management of the health impact of floods is dependent on an extensive knowledge and understanding of the health risks and on the capacity of the community and the health system to mitigate or manage those risks. All floods are unique in that the regions affected have different social, demographic, economic, and population health characteristics. But, many similarities exist, and knowledge of the causes of death and types of injuries and illnesses from floods is essential to ensure that health and emergency medical relief is well-managed (Noji, 2000). This chapter consists of three sections. Firstly, in order to aid the development of prevention, mitigation and response strategies, the health consequences of floods are identified and categorised. A conceptual framework is constructed to assist health disaster managers with planning, preparation and response by directing their efforts at the causes of those consequences. Secondly, international best practice and policies in disaster management are summarized and reflected into flood health management, to provide guidance to the future policy development. Finally, the flood health impact framework and international best practice have been employed to propose some key elements of future successful flood health management in China.

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The issues indentified in Chapter 10 are incorporated into the development of the conceptual framework as well as the key elements of successful flood health management in China. Further policy issues are then discussed in Chapter 13.

12.1 Framework of Health Consequences

Adverse health outcomes associated with floods have been identified from the literature, case studies, and the thematic analysis of experts views has been summarised as “direct and indirect” and “immediate, medium and long term”. Table 12-1 shows how the health consequences fit within this conceptual map as a basis for informing prevention and mitigation, planning, response and recovery strategies. Table 12-1 also depicts how primary, secondary and tertiary prevention and mitigation strategies may address these risks. The immediate direct health consequences of floods include drowning, injury and hypothermia; the more indirect immediate health consequences are health risks associated with displacement of people or loss of medication are less obvious. The mid-term direct health consequences include the complications of injury, infection and poisoning due to chemical contamination; while mid-term indirect health consequences are starvation, injury, and communicable diseases caused by factors such as animal displacement and contamination of water. The long-term direct health consequences are largely mental health and the exacerbation of chronic diseases; while the long-term indirect health consequences are malnutrition and mental health caused by affected or destroyed economies and livelihood.

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Table 12-1: Health Consequences of Floods

Immediate (first 4 weeks) Mid-term (4weeks to 5 years) Long-term (5 years and after)

Health Impacts Strategies Health Impacts Strategies Health Impacts Strategies

Direct Drowning Public Complications of injury Early medical care Mental illness -- from Support and awareness loss and grief counselling Rescue Insurance Structural flood defence Levees Early forecast and warning Injury Building codes Infection-- skin and eye Early medical care Chronic diseases Effective health • Trauma Injury--debris Evacuation infections, faecal-oral care collapsed building, car Public infections crash etc. awareness • Electrical Injury Road Control • Burns and Explosions Early forecast Injury and warning Hypothermia Rescue Poisoning—Chemical Risk management Disability Early Awareness contamination Decontamination intervention Rehabilitation Animal Bites Rescue Mental health--shock Support and counselling

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Indirect Health risks associated Rescue Communicable diseases— Clean food and Malnutrition—poverty, Economic with the displacement of Shelter • overcrowding, water damage of property recovery patients, disabled persons, Safe health • vector, Safe waste disposal Aid and senior people, children services • exposure to infectious Refugee care assistance etc. (e.g., heart attack, disease Immunisation programs illness deterioration) • Animal displacement and programs disease Clean-up • Contamination of water Community education Loss of health workers and Awareness Poor health outcome— Rebuilding health Mental illness— Economic essential drugs Rescue and health services disruption services a priority livelihood, income, recovery assistance homes destroyed strategies Mental health—anxiety Mental first Starvation— Food supplies Trauma—civil Restore local and shock from the flood aid: Defusing, • Failure of distribution Recovery of the disturbance economy and losses debriefing and system, local economy Address health support • Damage to crops Rebuilding of needs • Damage to water and public health Security sanitation infrastructure infrastructure Injury—from repairing Awareness and aid houses etc. Exposure to thermal stress, Awareness and aid e.g. sunburn—damage of homes

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Figure 12-1: Relationship mind mapping of flood health consequences

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However the relationship between causes and health consequences is complex. Therefore, the relationship between the flood and the health consequences can be illustrated in the way of mind mapping as shown in Figure 12-1. The green ripples present the health outcomes in the immediate term, mid-term, and long-term. The relationships between floods and health consequences are only partly evidence-based; however this hypothetical model distils out the relationships that are intuitive and rational. This model seeks to describe the relationship between flood impacts and health consequences in terms of “immediate, mid-term, and long-term health consequences” and also “the direct and indirect health consequences” in a way that interventions can be attached to each of those areas. The limitation is that diagrammatic representations cannot capture complex interrelationships, and become too simplistic as the research inquiry deepens. Thus a more sophisticated discussion may be required to provide the basis for future development of the policy. For example, in the case that a whole village or town is destroyed, the relocation of the people may put an extra burden on the new community, and thus cause psychosocial problems. This relationship is indirect and management of the health consequences are often focussed on the intermediary elements. The conceptual map depicted in Figure 12-1 may assist health planners and emergency managers to ensure a comprehensive and rational approach in planning for and responding to the health consequences of floods. Floods vary greatly in their characteristics, their impact and the vulnerability of the populations they affect. Areas at greatest risk are low-lying, near water, and located downstream from a dam. The health impacts of floods depend upon various factors, including the characteristics of the flood hazard, patterns of exposure and underlying vulnerability of the population. The health impacts of a particular flood event are context specific, and are also very different between developed and developing countries. The current review may be biased towards developed countries as the US and Western countries have published more than other countries and experts from these countries predominate internationally. Variations in populations, density, resources and building codes between developed and developing countries will alter the health impact. Disruptions to food supply are more likely to occur in developing countries while motor vehicle related injuries are more predominant in developed countries.

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The range of risks to health and well-being, both physical and mental, is understood, though there remains uncertainty about the strength of the association and the public health burden for specific health effects. Overall, it is difficult to assess the duration of symptoms and disease, and the attribution of cause, and there is a relatively weak scientific evidence base to assess the health impacts of flooding. Most flood-related morbidity and mortality are preventable through education, good floodplain management, and prediction-warning systems. The health consequences of flood depend upon the vulnerability of the environment and the local population. Improved disaster management including mitigation and preparation has contributed to a reduction in flood related deaths. The provision of clean food and water as well as the safe disposal of waste has reduced the incidence of communicable disease outbreaks following floods (World Health Organization, 2010a). Improved risk management of chemicals and other contaminants is also reducing the risks associated with disruption of these during major floods. Long term mental health problems have been identified more clearly as a problem and responses need to be more coordinated. The destruction of health service infrastructure can be avoided by improved design, location and construction to appropriate standards. International collaboration often ensures a rapid replacement of damaged health infrastructure in both the short and longer term.

12.2 International Frameworks and Strategies in Flood Death and Injury Prevention

The management of flooding is just one type of disaster management, therefore it is important to draw upon international best practice and policies in disaster management in general and reflect them into flood death and injury prevention. Though derived from different views and expressed in different ways, all the frameworks of different international organizations share similar ideas and strategies as shown in Table 12-2.

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Table 12-2 Frameworks and Strategies of Disaster Management in Different International Organizations Organizations Frameworks Key Strategies Common Strategies International Hyogo Framework for 1. Ensure disaster risk reduction as a priority with 1. All-hazard disaster risk reduction through Strategy for Disaster Action 2005-2015 institutional basis for implementation institutional frameworks Reduction (ISDR) 2. Monitor disaster risks and enhance early 2. Monitor the risks and provide early warning warning 3. Improve resilience 3. Support community risk reduction and 4. Reduce the underlying risk factors increase community resilience 5. Strengthen disaster preparedness for effective 4. Strengthen emergency preparedness for response effective response World Health Risk Reduction and 1. Assessing and monitoring baseline information Organization Emergency Preparedness on the status of risk reduction and emergency (WHO) preparedness 2. Institutionalizing risk reduction and emergency preparedness programmes and establishing an ISDR & UNDP & WMO effective all-hazard/whole-health programme 3. Encouraging and supporting community-based Reducing underlying risk factors, including risk reduction and emergency preparedness social and environmental conditions, land use programmes etc. 4. Improving knowledge and skills in risk reduction and emergency preparedness and response United Nations Reducing Disaster Risk: A 1. Appropriate governance Development Challenge for Development 2. Factoring risk into disaster recovery and WHO & UNDP Programme (UNDP) reconstruction Improve knowledge and skills of risk 3. Integrated climate risk management reduction 4. Managing the multifaceted nature of risk. 5. Compensatory risk management. 6. Addressing gaps in knowledge for disaster risk assessment.

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World Bank Preventable Losses--Saving 1. First pillar: assessing risk World Bank Lives and Property through 2. Second pillar: emergency preparedness Disaster risk financing Hazard Risk Management 3. Third pillar: investments in risk mitigation 4. Fourth pillar: institutional capacity building 5. Fifth pillar: catastrophe risk financing World Integrated Flood 1. Ensure a Participatory Approach Meteorological Management (IFM) 2. Integrate Land and Water Management Organization Concept 3. Manage the Water Cycle as a Whole (WMO) 4. Adopt a Best-Mix of Strategies 5. Adopt Integrated Hazard Management Approaches Source: Derived from (ISDR, 2005; Pusch, 2004; UNDP, 2004; WHO, 2007; World Meteorological Organization, 2009)

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Therefore, in terms of flood health and injury prevention, the international strategies can be summarized as in Table 12-3.

Table 12-3: Best Practice in Flood Health and Injury Prevention

1. Create and strengthen national integrated flood reduction mechanisms through multi- sectoral national platforms. 2. Identify, assess, and monitor the flood risks and develop early warning systems. 3. Inform the community of flood risks, vulnerability and prevention measures; motivate the community towards resilience through education and training. 4. Strengthen flood disaster preparedness for effective response during floods. 5. Reduce the flood risk by reducing a broader range of underlying risks. Strategies include environmental protection, natural resources management and land use planning. 6. Improve our knowledge of and skills in analysing flood risks through understanding of flood behaviour, and flood modelling. 7. Provide flood insurance programs.

12.3 Application of the Framework

The key elements of successful flood management which reduce deaths and injuries are listed in Table 12-4. These are based on comprehensive disaster health management theories outlined in this thesis and a conceptual map of health consequences derived from the research. These elements are listed in sections as Prevention, Preparedness, Response, and Recovery (PPRR). In each section, the elements are listed according to their importance and urgency based on whether they are effective, cost- saving, aiming multiple targets, and feasibility. They have also been developed with consideration of the interdisciplinary and intersectional partnerships between different organizations and the possible effects of climate change.

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Table 12-4: Key Elements of Successful Flood Health Management--Prevention No. Strategies Explanation Consequence Risks 1 Strengthen integrated • Strengthen the multi sectoral national platforms of flood risk • Multi-sectoral Different organizations have flood risk reduction reduction, with designated responsibilities at all levels to facilitate national platforms for different understanding of mechanisms through coordination across sectors. flood risk reduction. their role and responsibility, multi-sectoral • Integrate flood risk reduction into development policies and • Integrated flood and may limit coordination. national platforms planning at all levels of government. reduction • Adopt and modify legislation to promote flood risk reduction mechanisms. incentives. • Decentralize responsibilities and resources for local flood risk patterns and trends. • Review and update flood management plans and policies with a particular focus on the most vulnerable areas and groups. • Promote community participation. 2 Land Use Planning • Systematic assessment of physical, social and economic factors in New buildings and • Local governments lose such a way as to encourage and assist land users in selecting facilities are likely to revenue from the flood plain options that increase their productivity, are sustainable and meet the be in “safe-zones” and and thus do not want to follow needs of society. thus prevent death and the planning. • Incorporation of flood risk assessments into planning and injury of people. • More expensive for the new management of flood-prone settlements, particularly highly development. populated areas, rapidly urbanizing settlements, mountain and • Inconvenience of the coastal flood plain areas. location • Mainstream flood risk considerations into planning procedures for • Hard to define the acceptable major infrastructure projects, including the criteria for design, risks (e.g. 1% APE or 0.2% approval, and implementation. AEP). • Development and upgrading of the guidelines and monitoring tools for flood risk reduction in context of land-use policy and planning, and practical steps to encourage their use. • Encouragement of the revision or development of building codes and standards to make them more applicable in the local context.

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3 Structural flood • Building structures to block flood entering the populated areas, People are protected • Expensive expenditure for defence measures including such measures as: from the effects of the limited resources. • Raised bridges and approaches flooding. • River bank levees and sea walls • Investments in the area • River training increase after each structure • Diversion channels are completed, causing a • Flood detention basins further need to prevent • Reservoirs upstream flooding. 4 Structural Building • Strengthen critical public facilities and infrastructure, particularly Stronger structures to Can only withstand small scale Measures schools, hospitals, water and power plants, communications and withstand the flood; floods and thus only suitable transport lifelines, disaster warning and management centres. prevent the structures for low flood risk areas. • Raise building standards, flood proofing buildings. from the • Raise houses above the flood level. contamination of flood waters. 5 Flood insurance and • Provide flood insurance programs to enable property owners to • Financial risk- • Only those exposed to high reinsurance programs purchase flood insurance as protection against flood losses. sharing among the risk want to get flood • Participating communities agree to adopt and enforce ordinances public. insurance. to reduce the risk of flooding. • Flood insurance • Private insurance doesn’t premiums which can want to get involved as they reflect the risk of can’t make profit. flooding, and thus deter unsuitable development and increase people’s awareness. 6 Integrated flood risk • Encourage sustainable use and management of ecosystems, Protect the This is a long-term process and reduction into including control of erosion, promotion of forestation, repopulate environment, and thus may contradictory to economic environmental and wildlife, and educate the public on environmental issues. reduce the flood scale development in the short term. natural resources • Integrate flood risk reduction with existing climate variability and and on-set speed. management future climate change in new strategies.

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Table 12-5: Key Elements of Successful Flood Health Management--Preparedness No. Strategies Explanation Consequence Risks 1 Build a culture of • Collect, compile, and disseminate relevant • The more people are aware Large amount of resources flood safety and knowledge and information on flood hazards, of the flood risk, the more required for the programs. resilience vulnerabilities and capacities. flood reduction measures will • Promote the inclusion of flood risk reduction be implemented in all sectors knowledge in relevant sections of school curricula at of society, and thus reduce all levels as well as other channels. flood risks. • Promote the engagement of media to stimulate a • Help people make rational culture of flood resilience and strong community decisions in dealing with involvement. flood. 2 Promote • Support exchange of information and coordination A holistic approach toward Some agencies may be reluctant coordination between different agencies at all levels. flood risk reduction and to cooperate due to their internal between different • Develop regional approaches for cases that may management. issues. agencies at all exceed national coping capacities. levels 3 Promote regular • Staff should be trained with skills in observation, • Rapid and effective flood Staffs trained to carry out staff training and data analysis, decision making, sandbagging, flood management and rescue. management and rescue may not flood preparedness warning, evacuation, rescue, resupply, etc. • Timely access to essential be available during floods due to exercises • Flood response and evacuation drills should be food, drug, and equipment for their own expose to floods. practiced. local needs. 4 Promote • Promote the engagement of relevant stakeholders in Timely response to the flood in Community organizations community the community base on the spirit of volunteerism. the local community. without appropriate guidance preparedness • Link the community response with the national can’t work effectively. disaster response mechanisms. 5 Ensuring the • Promote establishment of emergency funds. Sufficient fund, equipment, The unused drugs may be a provision and • Ensure sufficient storage of emergency equipment food and drugs during floods. waste. reliability of flood and food. response resources • Promote household advance purchase of medicine.

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Table 12-6: Key Elements of Successful Flood Health Management--Response No. Strategies Explanation Consequence Risks 1 Flood • Use hydrological models to forecast future floods to give • The affected people and Early warning has little relevance if forecasting population time to take precautions. community have more people do not have the ability to and early • Include Tidal, fluvial, surface water flood modelling. time to prepare for the respond to warnings in terms of warning • Monitor the performance of flood forecasting systems. flood. taking decisions on preventive • Disseminate flood information, including what effects • Critical resources are actions and evacuation. occur at a particular level of flooding (road closures, concentrated in critical inundation level) and what to do to protect personal health, areas as the forecasts through radio, television, phone, internet, newspaper, loud- indicate when and where hailer, or doorknocking by emergency staff. the flood is likely to occur. 2 Road Control • Prevent people from entering flooded risk areas by • Keeps people in the safe Extra personnel burden on the police. controlling the road. zone. • Exemption from tolls for quick travel. • Smooth travel for quick response. 3 Evacuation Relocate people temporarily from areas at risk of the Keep people in a pre- People may be exposed to more consequences of flooding to places of safety. planned safe zone. hazardous environments as a consequence of their evacuation. 4 Levees Use sand bags or levees to prevent flood from entering the Protect the flood water They may fail or be overtopped in an river banks or specific buildings and facilities. from entering the area. uncontrolled fashion. 5 Resupply Develop arrangements to provide supplies of essential items Affected people get • Geographic dispersal of those who to properties and/or communities when they are isolated by enough supplies during are cut off by flooding from normal flood. the flood. means of supply. • Flood may last a long period. 6 Avoidance of Avoid water being contaminated by excreta, waste, and Water and food safety for • Difficulty to locate the contamination other dangerous goods. the affected population. contamination site. • Limited resources during the flood response period.

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Table 12-7: Key Elements of Successful Flood Health Management--Recovery No. Strategies Explanation Consequence Risks 1 Prompt Restoration Promptly restores essential services, including Essential services are quickly • Restoring electricity may of Services hospitals, electricity supply, water supply, sewerage, restored and available to the cause fire etc. telephones and police stations etc. public to maintain order and • Water might still be provide health services. contaminated by flood water. 2 Prompt clean-up • Wash away contaminated mud. • Prevent mosquitoes and mould Clean-up workers may • Clean and disinfect every surface. etc. from growing. encounter potential dangers • Check electronic system and other appliances. • Prevent water-borne diseases. including musculoskeletal • Remove moisture from the house and vacuum • Psychological benefit for the hazards, heat or cold mould or mildew. affected population as they can stress, motor vehicle-related return home early. dangers, fire, drowning, and exposure to hazardous materials. 3 Provide social • Provide emergency shelters for the affected. • Social welfare keeps the Not sufficient resources welfare • Employ volunteers, such as St Vincent de Paul and affected in a safe condition and available. the Salvation Army to provide food and clothes etc. maintains their health. • Provide financial assistance to the affected. • Reduces exposure and limit the outbreak of disease. 4 Provide health care Public health and social care authorities organize and Convenient access for people • Staff shortage owing to services coordinate response to the needs of injured and and sick and injured. deaths, injuries, disease etc. displaced people and to changing disease patterns, • Physical damage and including “normal” health care and additional disruption of health services for the chronically ill, mentally or infrastructure. emotionally disturbed, and those sustaining injury. • Access to and from the health facilities may be disrupted. 5 Community Communication of information that enables people to Increases social capital and Different groups have different education on make informed decisions about health-related avoids different hazards receptivity of message, and health, safety, activities. different ability to take action. hygiene etc. 6 Disease Systematic collection and analysis of data on Timely data collection and Ongoing public health

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surveillance communicable diseases, injuries, and vector in the analysis provides the foundation surveillance system provides a population after a flood. for effective disaster response. baseline data while specific disaster-related programs are established following a flood. 7 Disease control • Preventative measures to protect susceptible Control measures can • Routine disease control population, such as immunization and hygiene specifically tackle diseases practices may be interrupted by education. associated with floods. the floods. • Response measures to combat disease organism • Immunization can absorb and its vectors, for example, water treatment or critical resources, and give mosquito control. people a false sense of security in terms of hygiene and health behaviour.

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This chapter proposed a framework of health consequences of floods, and then utilised international frameworks and strategies to reflect on the management of health consequences, and finally presented the key elements of successful flood health management. The following chapter will examine the policy framework of disaster health management in China so as to take into consideration of these international frameworks and strategies and to lead to commendations for improvement.

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Chapter Thirteen: Policy Framework of Disaster Health Management in China

Based on the case study results and the results of interviews with experts, this chapter proposes a policy framework for disaster health management in China which comprises four parts: the key policy issues, factors influencing policy, components of policy, and policy recommendations. The policy model of Walt and Gilson (1994) is used to guide the analysis. As discussed in detail in Chapter Five, this policy analysis model emphasizes not only the content of policies, but also the actors involved, the processes needed to implement change and the context or processes (social, political, cultural, economic, historical) which may explain why policy outcomes were not achieved (See Figure 5-2). The content, process and context of disaster health management in China will be discussed in three sections.

13.1 Key Policy Issues

The research outcomes clearly identified that the most significant improvements are to be derived from improvements in the generic management of disasters, rather than the health aspects alone. Based on the literature review, case studies and experts’ interview, the key policy issues of current emergency and disaster management in China have been identified as the following. ¾ Organizational Structure Many departments and organizations are involved in disaster management in China, which may cause confusion and a lack of command, control, and coordination. There is a need for a centralised organization to integrate and coordinate all the relevant departments involved in disaster management. This organization would not only be in charge of disaster policy and guideline development, but also deal with public education, training, and research at different levels. ¾ Coordination Policies are required to ensure a clear command and coordination structure, which involves all the key stakeholders, including military representatives. This will

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facilitate a better understanding of the roles and responsibilities of the various stakeholders and policy actors. ¾ Communication Communication includes information sharing between disaster management organizations and institutions, as well as the information flow between the disaster response agencies and the public. Communication not only involves the way of sending out the message, but also needs to ensure the message sent is well-understood and that those at the other end have the capacity to receive and process the message. ¾ Funding and Insurance Specialized funding is necessary for disaster management development. Insurance schemes are required to ensure compensation is available for disaster victims. It is important that the disaster relief funding and materials are available to the victims as early as possible, when they are most needed. ¾ Engagement of Experts In order to ensure the disaster management policy is executable, it should be tested by a committee of disaster management experts, using a variety of case scenarios at different governmental levels. The ‘expert’ committee should consist of senior experts from different sectors, including the health sector, to provide different views and ensure the comprehensiveness of the policy. Additionally, international experts should be included if possible, as a person from ‘outside’ may have a broader view. ¾ Local Volunteer Groups Local people have the best knowledge of the local risks, and they are usually the first to respond. However, there is currently a lack of organization and training for the local volunteer disaster management groups and a lack of authority for them to respond. The local Communist Party Committee or religious groups should be encouraged to form emergency response volunteer groups; and these groups should be provided with training and basic equipment. ¾ Rigidity and Flexibility Policies should be embedded with both rigidity and flexibility, i.e. the policy framework and the guiding principles should be established at the central government level to ensure common understanding while the policy should also have enough flexibility to allow the local government to apply local interpretations to the disaster

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management policy. Only when local people accept the disaster management policies will they execute the policy effectively. ¾ Fault Tolerant Disaster management is usually conducted with urgency and thus with high pressure, however currently in China a single person may have too much responsibility, which adds to the fragility of the system. The policy should be designed in such a way that the failure of a single person (or of several people) cannot cause the complete failure of the whole disaster management system. ¾ Risk Assessment Local risk assessment and management should be addressed in the disaster management policy, which aims to build a more resilient local community. In addition, a local approach to risk assessment may inform local mitigation strategies. ¾ Emergency Medical Services System (EMSS) The EMSS forms the basis of emergency health response to major incidents and disasters. The capacity of an EMS system determines the degree to which disaster health services can be provided. China could make improvements in this area, by enhancing consistent standards and evaluation systems, by facilitating information release to the public, by developing programs to educate lay persons, as well as by providing more advanced facilities for patients’ transportation and care. However, ultimately any system will be overwhelmed in catastrophic disasters (e.g. earthquakes). As a result, systems and structures will be necessary to expand and complement emergency response capability. These should include volunteer groups appropriately trained, including in first aid, as well as assistance from national and international organizations.

13.2 Policy Components (Content)

As shown in the case studies in China, policy frameworks are made at the national level. However, the local government may not necessarily want to or be able to follow the framework; rather they would establish policies as required and leave these local policies on the shelf for their superiors’ inspection. This follows the Chinese common saying “the inferior will have measures that can counter any policy from the superior” (Ding & Ding,

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2004). Therefore national policy should be designed in such a way as it can be cascaded to local and institutional policy to ensure successful policy implementation at the local level. Without the acceptance and recognition of the local government, disaster management policies will not be implemented properly and successfully. Meanwhile, local jurisdictions do learn from history, that is, they learn from previous experience of risk and this process is expedited under specific conditions (Brody, Zahran, Highfield, Bernhardt, & Vedlitz, 2009). Implementation monitoring and policy feedback systems should be embedded in the disaster management policy. Thus disaster health management policy content can be described by both “top-down” and “bottom-up” policy approaches; a national framework requires cooperation and engagement of local jurisdictions and actors. An integrated planning approach should be taken to ensure different departments have clear roles and responsibilities during disasters and they are aware of what other departments are doing. There is no doubt that many departments should be involved in a large scale disaster, however only an integrated approach will make the best use of the available resources. To achieve this, a specialized disaster health management organization equivalent to the FEMA in the US or EMA in Australia may be formed or transformed from an existing organization, to guide and coordinate the disaster management effort. Additionally, this specialized disaster management organization may carry out education and training programs for specialized groups or the general public. The establishment of the Center for Disease Control and Prevention (CDC) has resulted in significant progress in pandemic prevention and control, as evidenced by the reasonable success of controlling the Influenza H1N1. This is an example of how the creation of a centralized dedicated infrastructure leads to appropriate direction, leadership, training and improved coordination across the system. Therefore, it would be most successful if there is a dedicated emergency management agency like the concept of CDC. Education and training should be considered as part of the disaster management policy. Disaster health education occurs at different levels, from community information and health worker awareness to college and university programs in the form of undergraduate and postgraduate degrees. While education at suitable levels is being conducted in different areas in China, a national framework is needed to guide the education. Disaster health training and drills should be conducted in a timely manner to

- 244 - ensure people’s awareness and clarity of their roles in disaster health response and recovery. The importance of the storage of disaster management resources should be emphasized, especially emergency medical supplies. When storage is not possible, contract arrangements may be made to ensure private resources can be employed for disaster management purposes. For drugs and medicine that have a limited shelf life, stored supplies must be regularly checked and replaced before expiry (Drugs at that time unexpired may be donated for prompt use in hospitals). Disaster relief funding and insurance programs should be part of the disaster recovery efforts to ensure critical resources are available to the victims during the emergency period. Disaster prevention is a cost-effective way of disaster management, thus the local disaster risks should be assessed and properly managed before the disaster actually occurs. Disaster forecasting and warnings should also be enhanced to ensure the timeliness and accuracy of the warning. Meanwhile, efforts should be made to ensure the warning is well received and understood by the public. If possible, action guides should be sent with the warning as well. Additionally, efforts should be made to increase community resilience, including local people’s self-reliance and participation. A local disaster response volunteer group may be organized in a professional manner to increase the community resilience.

13.3 Policy Process

The policy process, or the policy cycle, includes eight steps as identified in Chapter Five, including issue identification, policy analysis, policy instrument development, consultation (which permeates the entire process), coordination, decision making, implementation and evaluation. For the convenience of the analysis, this section summarizes the process under two headings.

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13.3.1 Problem Identification and Policy Design

Disasters can raise public awareness and thus put the issue to the top of the policy agenda. Due to the number of disasters and their scale that China has experienced in recent years, the government is aware of the problem and attaches high priority to disaster health management. The policy in China usually has a clear direction. However, a higher level of debate, consultation with experts, and public participation during the policy design process is desirable. The policy consultation and debate itself can be a process of increasing public awareness and of gaining opinions from different perspectives. Additionally, the policy design process should also engage international knowledge and experiences as much as possible, and apply the international expertise to the situation in China. For better understanding and coordination between departments, the articulation of the policy should be as clear as possible. The role and responsibility of each department should be clarified; and the power and responsibility of the leaders should be assisted by clear procedures and supporting committees. The policy should be easily accessed and implemented. The policy has to be executable, so testing by table top or community emergencies may be necessary before the policy was finally issued. Alternatively the policy can permit enough flexibility to allow the local government and people to apply to their situation; so that the policy is locally accepted and owned. Regular drills can be made as part of the policy to enhance the policy execution and implementation. As it is a developing country, many policies in China are not integrated or updated; partly due to limited resources in the government. However, it is important to ensure close linkage of the disaster management policies with other polices and keep them updated. For example, the land use planning policy may well assist disaster prevention; and the disaster management policy alone may not be executable without supporting policies such as international cooperation policies.

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13.3.2 Policy Expression/ Implementation and Evaluation

China’s ability for rapid policy implementation can be seen in the 2003 SARS epidemic. The Chinese government was able to control SARS quickly. Strong governmental control enabled the mobilization of personnel and resources, which contributed to pandemic control. However, more financial and material support may be needed for relatively poor rural areas. Policy implementation requires an understanding and acceptance of the local community, as well as their interest. Therefore, the policy must allow local people to apply their situation and experience; and the local government should be delegated sufficient power in disaster management. Due to the fact that disaster management policies involve multiple organizations, the agency in charge of implementation may rely on others who may not necessarily have the same interests to carry it out. Therefore the leading agency should be permitted higher authority to ensure policy implementation while responsibilities should be assigned to relevant organizations to maintain their interests and involvement. Additionally, education and training are needed to promote better understanding and implementation of the policy, as well as recognition of disaster risks. As China is continuing to focus on economic development, many officers and local leaders may need to understand the importance of disaster management. Policies, when initially implemented, may not be perfect and may result in unforeseen consequences. Thus, evaluation should be built into all stages of the policy process. The effectiveness of the policy requires ongoing assessment; and steps must be taken to ensure the disaster management policies are successfully maintained with sufficient resources. Timely evaluation and policy maintenance may be challenging as disasters may not occur for a long period of time and may for this reason be given lower priority. Evaluation should be conducted with agreed indicators of success. The evaluation may be based on paper or drills. However, real disasters provide the best opportunity for emergency management evaluation, thus data should be collected and records kept during disasters for assessment and evaluation.

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13.4 Factors Influencing Policy (Context)

The context of the policy includes many factors such as the social, political, cultural, economic, and historical factors. This section examines factors that influence the disaster health management policies in China.

13.4.1 Political Factors

China’s quick mobilization of both personnel and material resources in the SARS in 2003 and the Wenchuan Earthquake in 2008 has demonstrated the efficiency of the Chinese government. Success in implementing a new disaster health policy program may depend on the government's skill in generating extensive support. Different sectors in the government, such as the Ministry of Civil Affairs and the Ministry of Health, may need to play important roles in disaster management, and therefore coordination is essential. Therefore, there is a necessity to better integrate the government departments and organizations involved in disaster management. As can be seen in the literature review of the disaster management structure in China in Chapter Six, many organizations and departments have been involved in disaster management. It is important to integrate these organizations and ensure clear leadership in disaster management, which will ultimately make the emergency management more efficient and effective. The literature suggests that the more agencies and dependency relationships involved in a policy implementation, the more likely that a policy will fail (Laurence J. O'Toole, 1986; Slack, 2009). Thus a clear mandate for leadership in disaster management as evidenced in organizations such as EMA or FEMA, as previously outlined, appears warranted. The cooperation between the local government and the army is of vital importance as the army has the material and personnel resources. Local government wouldn’t have the authority to mobilize the army, therefore it may be sensible to enhance or clarify the arrangements to ensure the provincial government or the central government can be contacted quickly in disasters to authorize the army’s involvement. At the local level, the capacities and commitment of the local actors impact on the disaster management policy implementation. Local knowledge of the risks and local

- 248 - experience can greatly assist the disaster management and response. Therefore, local actors’ voices and involvement should be encouraged as much as possible. Additionally, volunteer groups are usually an important part of the disaster management. Rather than establishing new disaster management volunteer groups, the Communist Party, which has about 76 million members and 3.7 million local committees (The Organization Department of the CPC Central Committee, 2009), should be encouraged to form a local disaster response volunteer group similar to the SES in Australia. However, proper disaster management training and education should be conducted for any volunteer group; and their roles should be clarified to avoid confusion during a disaster.

13.4.2 Socio-cultural Factors

Social capital, which is defined as a function of trust, social norms, participation, and network, can play an important role in disaster management, especially in recovery (Adler & Kwon, 2002; Nakagawa & Shaw, 2004). Similarly cultural mores can impact on how people prepare, respond and recover from a disaster. Chinese culture is traditionally influenced by the three blended religions of Confucianism, Buddhism and Daoism. More recently, Muslim, Christianity and Marxism-Maoism have influenced the Chinese culture. While Deng Xiaoping’s “Socialism with Chinese characteristics” policy allowed reform and opening up, the other religions keep shaping the Chinese culture and assist the establishment of many volunteer groups that do provide help during disasters. These philosophical and religious principles have an important impact on disaster management: such as the principles that human beings should keep in a harmonious relationship with nature and that they should practice good personal behavior and should give and accept aid during disaster response and recovery. Media outlets are playing a critical role in refashioning culture, societal goals, and material aspirations inside China. With almost universal access to television and an estimated 404 million current internet users (30% of the population) (Ministry of Industry and Information Technology of the PRC, 2010), the community expectation for emergency services during disasters is rising, especially for emergency health services.

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Education is another factor that shapes the culture and forms the policy context. As the general education continues to improve, there is more awareness of disaster management and higher level of policy participation. Improved education levels will also improve individuals’ preparedness and response during disasters, and may improve social capital.

13.4.3 Economic Factors

The economics of a country directly determines the available resources, and thus its capacity in disaster preparedness, response and relief. China is rapidly developing economically, though a large number of people are still not affluent. The poorer people may be disproportionately affected by disasters, and thus require more consideration in the disaster management policies. Though disaster insurance schemes are available in China, they are of limited protection as the general public cannot afford high premiums. It is sensible to encourage insurance companies to develop a variety of disaster insurance schemes to suit different people. Additionally, a national pool of disaster relief funding may be set up through cooperation between the government and industries to ensure that immediate disaster relief funding is available to the victims. China may not be able to provide all required emergency management facilities, such as the flood boats that are available in Western Queensland. However, arrangements can be made to use the resources that are available during disasters. For example, contracts can be made with private boat owners to use their boats for emergency response. China used to place high value on economic self-sufficiency, however as the economy is expanding, China is engaging more deeply with the global economy. This change impacts on China’s foreign policy choices, and in a degree heightens China’s involvement in disaster management internationally. This has provided an invaluable opportunity for China to learn from international experiences, as well as to enhance cooperation arrangements for disaster response and relief domestically.

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13.4.4 Technological and Scientific Factors

China was lagging behind in technology. However, China has been developing or importing technology through research and international cooperation. Weather forecasting systems, flood and earthquake monitoring systems are rapidly available in China. However, there is still a necessity to improve technology and promote the use of new technologies at different levels of government. While policy implementation can be restricted by lack of technology, policy can also encourage technological development. Taking the case in Lengshui as an example, drums are still used for flood warning. While it may make sense in the traditional environment, the drums don’t send a clear message during floods. Waterproof phones and radios should be developed and employed in disasters to ensure clear communication. There is also a need to promote evidence-based decisions derived from data acquisition. Options for strengthening evidence-based activities include rigorously adhering to evidenced-based interventions, using evidence-based tools to identify new approaches to problems of concern, studying model programs as well as failed ones to identify approaches that deserve replication, and improving standards for evidence of effectiveness in disaster science and services (Bradt, 2009).

13.5 Actors in Policy

A range of actors are involved in disaster health management in China. Official actors, including the People’s Congress and governments at different levels, have power and play an essential role in developing, implementing, and evaluating disaster health management policies. The central government’s role is not only to establish policies, guidelines and standards, but also to implement these policies and manage response at the national level. The local government usually plays a more important role in implementing policies; they should apply the policy to their local disaster risks and management environment. Throughout the process of policy development, experts in disaster health management should be actively engaged to provide professional advices and suggestions. These experts may include senior researchers, officers, hospital managers, doctors, nurses,

- 251 - emergency management services staff who are actively involved and experienced in disaster health management. Additionally, international experts may be invited to provide an international perspective. Ambulance, hospital emergency departments and ICUs form the chain of emergency medical services during disasters. Their surge capacity determines the level of health services that can be provided to the victims during disasters. Thus measures should be adopted in the policy to build their surge capacity, including high standards for infrastructure to withstand the impact of the disaster, patient transfer agreements between different hospitals, equipment and drug storage, and training and drills for the staff. During peace time, it is reasonable to get the army actively involved in disaster response and recovery as they have the available personnel and resources. However, proper training and education should be conducted for the army to carry out actions such as rescue and clean-up. The media plays an essential role in disaster management. It is not only a means of informing the public, but also a monitoring system feeding back relevant information to the disaster managers. Freedom for the media regarding what to report and from what angle should be permitted as much as possible; however, regulations, such as the code of conduct of the media should be strictly established. Donors, including charity organizations, pharmaceutical and medical equipment companies, as well as other organizations and individuals are an important aspect of disaster recovery. China is very successful in attracting civil donations as can be seen in the flood case studies and the 2008 Wenchuan Earthquake (Zheng, 2009). However, proper guidance should be made by the government as to what is needed by the victims. Donations should be made through transparent donation systems. As discussed early in the comparative case study analysis in Chapter Ten, insurance is developing quickly in China. Insurers also have an important role in disaster prevention and recovery, and thus the development of disaster insurance should be encouraged and assisted through policy arrangements. Finally, and most importantly, the local community is the first one affected by disasters and first to react. The Community’s abilities in disaster prevention, preparedness, response, and recovery should be improved through various channels such as education, self-reliance building, mutual help and local volunteer groups. Rather than establishing a new nation-wide volunteer emergency management group, existing social and political

- 252 - groups such as the Communist Party may be used as a base to establish this volunteer group. However, as with the army, proper disaster response and emergency rescue training should be available for the volunteers.

13.6 Policy Implications/ Recommendations

Based on the background of China’s political system, economic development, and culture, together with the current emergency and disaster management systems, structures, and regulations, this research has identified policy recommendations in terms of both general policy as well as specific disaster management policy.

13.6.1 General Policy

General policies are those that relate to the society as a whole. General policies include both strategic policy and specific policy. Strategic policies are policies that have a significant impact on the country, and thus impact indirectly on disaster management, for example economic policy and foreign affairs policy. Focused policies are policies that focus on specific implementation, such as urban development policy. Strategic policies determine the macro-environment of the country, and thus affect disaster management. For example, harmonious foreign affairs policies will bring more international support during time of disasters, while adverse foreign relations may cause wars and other disasters. Focused policies focus on a certain aspect of the society, and impact on the disasters indirectly. For example, high building standards may be more costly in the economic sense, but are good disaster prevention measures which withstand flood or earthquake. The EMS systems and the hospitals form the foundation of disaster health management, and thus policies for these areas have a particularly important effect on disaster health management. Therefore it is suggested that all the general policies should address the affect of the policy on disaster preparedness. These should include a ‘Disaster Management Impact Statement’, which ensures that the disaster management implications of all policy developments are considered.

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13.6.2 Specific Disaster Management Policy

Although the broad policy appears of international standard, the policy could be further improved. The areas of weakness of disaster management policies in China include coordination, disaster management infrastructure, resources, disaster forecasting and warning, social welfare, and community education. Specific disaster management recommendations include the following: 1. Establish a new system and structure which will enhance the disaster health management policy in China. China should transform existing organizations to establish a central organisation similar to the Federal Emergency Management Agency (FEMA) in the USA or the Emergency Management Australia (EMA) in Australia. This agency should have provincial and local agencies similar to the structure of CDC. This organization (possibly named as Emergency Management China) would be responsible for leading nationwide preparedness through planning, policy advice, standards development, education and incident evaluation. It would also provide operational support to the national and local government bodies in the event of a major incident. This organization should actively involve experts in different policy areas throughout all phases of disaster management. 2. Review national and local plans to reflect consistency in planning, and to emphasize the advantages of the planning process. Integrated plans should emphasize clear policy expression and articulation, and integrate existing disaster management organizations and ensure role clarity. 3. Enhance community resilience through community education and the development of a local volunteer organization. China should develop a national strategy which sets direction and standards in regard to education and training, and requires system testing through exercises. There is also a necessity to enhance public education for disaster health management, including first aid skills training and general disaster response awareness. Other initiatives may include the development of a local volunteer capability with appropriate training to assist professional response agencies such as police and fire services in a major incident. An existing organisation such as the Communist Party may be an appropriate structure to provide this response in a cost effective manner.

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4. Continue development of professional emergency services, particularly ambulance, to ensure an effective infrastructure is in place to support the emergency response in disasters. 5. Develop and improve financial arrangements to restore security. These include funding for development of plans, educational programs and research. A national disaster relief fund, which provides an immediate source of funds for relief following a major event, should be established and enhanced. Funding for disaster health management should be enhanced, not only from government, but also from other sources such as donations and insurance. It is necessary to provide a more transparent mechanism to ensure the funding is dispersed according to the needs of the people affected. Insurance should be used as a means of risk identification and awareness-raising, rather than simple risk sharing. 6. Rather than focusing on the disaster response and disaster relief, emphasis should be placed on prevention and preparedness. Effective early disaster warnings should be enhanced to ensure sufficient time for preparedness, especially for typhoon, flood, storms, tsunami, drought and earthquake. Efforts should also be made to ensure real time early warning alerts are well-received and understood by both the cooperating agencies and the public. For natural disasters such as flood and drought, an ecological disaster prevention approach should be used. This could be achieved by requiring a disaster management risk analysis and disaster management impact statement for specifically development proposals. 7. China should develop local disaster health management infrastructure utilising existing resources wherever possible. Strategies for enhancing local infrastructure could include the identification of local resources (including military resources) which could be made available to support disaster responses. It should develop operational procedures to access those resources. The disaster health management policy should include both rigidity and flexibility. While national or provincial policies set the strategic guidelines and standards; the local government should adapt them to the local situation and risks. The system should also allow for fast escalation of the management to higher levels, so as to reduce the risk of failure at the local level.

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With the introduction of the framework of flood health consequences and management strategies in the last chapter, and the policy framework of disaster health management in China in this chapter, this study now comes to its conclusion. The next chapter, which is the final chapter of this study, will summarize the study’s findings, recommendations and limitations. It will also make suggestions for further research and identify the unique contributions of this study.

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Chapter Fourteen: Conclusion, Recommendations, Limitations, Suggestions for Further Work and Unique Contributions

This is the final chapter of the thesis. It summarises the research findings and leads to conclusions, and recommendations in regard to flood health management and future policy development of disaster health management in China. Finally this chapter evaluates research limitations and makes suggestions for further research, and positions the research in light of its original contribution to the corps of knowledge around disaster health management in China.

14.1 Conclusion

The aim of this PhD study was to identify and evaluate the current policy framework of disaster health management in China, and to develop a new policy framework that would be most appropriate to the social, economic, and political environment, and reflect the capacity of the health system to respond to major incidents and disasters. The objectives, in summary, were to examine the current policies and systems of disaster health management in China; compare the policy structure with that in Australia; and evaluate the policy and its implementation through detailed case studies; identify the key determinants of an effective disaster health management policy framework through literature review and a survey of international experts; and develop a new framework which would be appropriate to the social, economic, and political environment in China. The key research questions were: What is the current policy framework for disaster health management in China? How did it develop into its current status? How effective is it? How can the policy be improved? These research questions were answered through a literature review, case studies in China and Australia, and a survey of international disaster health management experts as summarized below. Firstly, an extensive literature review was conducted which analysed literature in the areas of disaster concepts and profiles, health consequence of disasters (floods),

- 257 - disaster management, disaster management policy and disaster health management in China. Policy documents and secondary data sources such as flood statistics and newspaper reports were also analysed and contributed to the literature review. Secondly, three case studies of flood health management in China, and another three case studies of flood management in Australia were conducted as a basis for comparison. The case studies were analysed according to the four stages of disaster management: prevention, preparedness, response, and recovery. These cases studies examined in detail the flood health management at different governmental levels, and distilled the strengths and weaknesses of the current policy and systems of disaster health management in China. The literature review and analysis of the case studies informed the development of a framework of flood health impacts. Thirdly, a survey of disaster health management experts was conducted, including 10 face-to-face interviews and 22 online email surveys. The interviews and the online surveys were based on the same questionnaire. The survey results were utilised to identify the key elements of disaster policy and to propose a new policy framework for China. The literature review, analysis of the case studies and survey of experts informed recommendations for improving disaster health management. The key outcomes of this study are a conceptual framework of health consequences of floods and a policy framework to guide disaster health management in China detailed in the following sections.

14.2 Recommendations for Flood Health Management in China

Based on the literature review, policy analysis of international guidelines, analysis of the case studies, and interviews with experts, key suggestions are proposed for a policy framework for disaster health management in China. The health consequences of flooding can be classified as direct and indirect. Floods can also have immediate, mid-term, and long-term health consequences. The health consequences that occur according to whether they have direct or indirect consequences or have immediate, mid-term, or long-term health consequences will require different management strategies and policies. The prevention and management of the health

- 258 - consequences of flood can be achieved through efforts in the areas of prevention, preparedness, response, and recovery. In the prevention phase, integrated flood management platforms should be organized so that they can involve multiple organizations, as well as national and international cooperation arrangements. Flood risk assessment and land-use planning are essential flood prevention measures for keeping human dwellings away from flood hazardous areas. Structural flood defence and building measures such as codes and standards can protect human health when the scale of the flood does not surpass the structural standards; therefore the structural standards should be raised when possible. Flood insurance programs should be developed, not only to share risks within the community, but also to increase the public awareness. And finally, ecological approaches should be adopted to reduce the effects of flood and other extreme climate conditions. In the preparedness phase, a culture of flood safety and resilience should be built as much as possible in alignment with the resources available. The coordination between different agencies and different levels, as well as community preparedness, should be promoted; this can be partially achieved through training and exercises. Additionally, flood response resources should be prepared, including funds, materials, medicine, and personnel. In the response phase, flood forecasting and warning are the most important strategies as to allow time for evacuation and preparedness. Flood warning should be conducted through various means (radio, television, inner-organizational etc.), and the message sent should be clear and easily understandable by the public. Other response measures include road control and evacuation that prevent people from entering flood water during the emergency period. Additionally, levees may be used to protect an area of a certain infrastructure. When the floods lasts a prolonged period of time, resupplies should be arranged to ensure people have clean food, water and shelter. Lastly, contamination of water by waste and other dangerous goods should be avoided when possible. In the recovery phase, prompt restoration of services and clean up should be conducted to prevent health consequences. Social welfare and health care services should be provided as soon as possible. Disease surveillance and disease control should be strictly conducted after a flood to prevent or control infectious diseases.

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14.3 Recommendations for Disaster Health Management Policy in China

Based on the literature review, and analysis of the case studies and the expert interviews, key suggestions are proposed for disaster health management policies in China. The research outcomes clearly identified that the most significant improvements are to be derived from improvements in the generic management of disasters, rather than the health aspects alone. Policy includes the three aspects of content, context, and process, all of which involve actors as individuals or groups. For the content of disaster management policy, firstly it should be executable at the local level: it should ensure local governments’ interest in the policy and have a monitoring and feedback system to ensure the effective implementation. Integrated organizational structures should be formed to ensure the coordination between different stakeholders. A specialized disaster management organization may be formed or transformed from an existing organization to lead disaster management, in order to conduct education and training. Sufficient disaster management resources, especially emergency medical supplies, should be stored for quick response and rescue. Disaster relief funding and insurance programs should be established, and it is essential that they are available to the disaster victims as soon as possible. High importance should be attached to disaster risk assessment and management as a cost-effective measure of disaster management. Disaster forecasting and warnings should be enhanced to ensure the warning is accurate and is received and understood by the public. Local volunteer groups should be formed and trained for quick and effective disaster response, which forms part of a resilient community. In keeping with the new public health paradigm, more general public policies may have an impact on disaster management and health outcomes, such as building construction codes and land use planning regulations. Therefore, it is advisable that all the general policies should include a ‘Disaster Management Impact Statement’. Disaster management policy processes include agenda setting, policy development, policy implementation and policy evaluation. For policy development, it is necessary to ensure the policy is embedded with both rigidity and flexibility, so that disaster management will have national standards, but also allow for application by the local community. The policy should also involve extensive consultation to ensure

- 260 - comprehensiveness as well as a means of raising public awareness. Clear articulation of the policy should be made to ensure each key stakeholder understands their respective roles and responsibilities. Additionally, the policy should be kept updated and have a smooth linkage with other policies. Policy implementation is relatively straight forward in China with high level of command and control. However, financial and material support may be necessary for relatively poorer areas. Structurally, the local government should be delegated authority to apply the policy to local situations; the leading organization should be permitted to coordinate all the key stakeholders. Education and training should be conducted to ensure the success of the disaster management policy implementation. And lastly, evaluation should be carried out to ensure successful policy maintenance. Within the disaster management policy context, political, socio-cultural, economic, and technological factors are relevant. Politically, the one party system enables China a clear policy direction and rapid resource mobilization. However, integration of departmental disaster management efforts, including the army, is needed; and the local voice should be encouraged. Political party members may be organized into disaster response teams which can play a similar role as the emergency response volunteer groups in some other countries. China is a country with long cultural history of being harmonious with nature and of people helping one other. This assists disaster prevention, response and recovery. Modern religious and cultural exchange may assist disaster management through volunteer work and donations. The media and the internet are reshaping the culture and thus raising community expectations to some degree. While the media is important to disseminate emergency alerts, regulations may be needed to allow them to report freely in a way that does not impede the disaster management effort. Education is an important factor in building the social capital. It is also important for disaster recovery and community resilience. Economically China may need to establish insurance and national disaster relief funding for disaster victims, especially for financially impoverished people. Due to limited resources, appropriate arrangements should be made with the private sector to use their resources for disaster management purposes. Economic development may also provide an opportunity for international cooperation in disaster management. New technologies should be developed and employed in areas such as disaster forecasting,

- 261 - warning and communication. An evidence-based approach to decision making during disasters is important. Additionally the capacity of an Emergency Medical Services System (EMSS), which is the foundation of emergency health response, should be enhanced.

14.4 Limitations

Due to the nature of policy analysis and disaster management research, qualitative research methods are adopted in this study. Thus, the limitations associated with qualitative research methods are inevitable. However, the net effect of these limitations is unlikely to impact on the outcomes of this research because of the use of multiple sources of information and the broad diversity of inputs. The observation and analysis of case studies requires a considerable amount of experience and skills to observe and record the events accurately and completely. Due to the researcher’s personal experiences, knowledge, attitudes and beliefs, the analysis and interpretation in the study may be biased. Efforts to reduce bias were made through structured approaches to interview and analysis, training and close supervision by the supervisors. The case study reports were made, whereas possible, in consistency with the Guidelines for Reports on Health Crises and Critical Health Events (Per Kulling, Marvin Birnbaum, Virginia Murray, & Gerald Rockenschaub, 2010). Due to limited time and resources, only three case studies were conducted in China and three case studies in Australia. While every effort was made to ensure the representativeness of the case studies, the nature of disaster cases is opportunistic, and thus their findings may not be readily extended to wider populations with certainty. However, the triangulation of information sources (literature, case studies, and experts opinion) lessens the relative weakness of any particular data source. Flooding is one of the most common types of disaster, and thus is best suited for the study into the disaster management system in China. However different disasters have different characteristics including different management strategies, and thus floods may not represent the management of other disasters. Both China and Australia are very big countries geographically. However, their management strategies are very different due to the differences in population size,

- 262 - political institutions, and the natural and social environment. For example, evacuation may be the best way to protect life and health in Australia while this is simply not realistic in China due to the population size. As floods in China are usually associated with typhoon, they often cause disastrous situations. However in Australia, the flood sometimes may mean relief from drought, which helps the agricultural sector. The experts in the study were selected for their expertise and availability, thus it is not a random sample. The selection may be biased toward the people who can afford to attend the conference and the volunteering spirit of the experts.

14.5 Suggestions for Further Work

This study focused on the general disaster health management policy framework and flood health management in China. However, China is such a big country, and each region is different. Therefore, more research should be conducted into disaster health policy development and implementation at the local level to ensure local cultural relevance. As a developing country, limited resources are available for disaster health management in China. Besides learning from the experiences of other developed and developing countries, it is necessary for China to develop disaster health management policies that are cost effective and suitable for the current social, political, and economic environment in China. Thus future research is necessary to examine whether the current disaster management policies can motivate the stakeholders to utilise their resources and work under a coordinated planning framework. For example, the role of the army in disaster management needs to be further clarified, and the arrangements should be formalized to ensure an efficient response. Further research should be conducted into the economic impact of disasters and to quantify the potential or actual loss. The economic analysis may further justify and support investment in mitigation (such as new infrastructure and more strict land use planning), preparedness, education, and research. Disaster education and training are conducted in different areas in China. However, there is a lack of a consistent framework and guidelines for education and training.

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Research is necessary to determine the needs for disaster health education and training standards and models of education appropriate to the community in China. Currently much research regarding disaster management is undertaken by various organizations. However, there is a lack of clear direction. A national framework that identifies research direction and research requirements may be necessary. This can be done through research funding schemes. China is developing quickly in both economics and society, thus the situation in China, as well as the disaster health management policy appropriateness, may be changing quickly. Therefore, additional research should be conducted into how the disaster health management policies can be adapted and updated to meet the changing nature of disaster health management in China. Community resilience and response capacity building should also be the focus of future research.

14.6 Unique Contributions

This research is a policy analysis of disaster health management in China concentrating on the management of floods. Disaster health management is a relatively new policy domain in China and this doctoral research highlighted areas where disaster response can be strengthened. Policy studies in health are rare, especially in developing countries such as China. Comparative health policy analysis is also rare, especially analysis that involves cases from two different countries with very different characteristics of each case such as in this research. This study enabled the identification of factors that worked well as well as those that could be improved in relation to how disaster health management policy operates at the field level. This research proposes significant improvements in the management of disaster health in China that would be culturally and socioeconomically appropriate. The research developed and validated a policy framework for disaster health management in China, and identified areas of improvement based on a thorough examination of three case studies in China and also an understanding of the policy issues in both China and Australia.

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The research has also identified a framework for understanding the health consequences of floods. This is a unique contribution to the examination of the health consequences of floods and extends existing work in this area. Although China has a relatively centralized system of government, the research found that both a top-down and a bottom-up approach are required for an optimal policy response. Additionally Walt and Gilson (1994)’s policy model provided an appropriate framework for analysing disaster health management in China and in furthering the understanding of the respective contribution of content, context, process and actors. Lastly, this research also provides a model for others seeking to undertake health policy analysis. And the importance of the research in this innovative aspect should not be underestimated.

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Appendices

Appendix A: Disaster Related Terms

This is an extensive list of definitions of disaster related terms used in this thesis. It is not intended to be all-inclusive nor comprehensive. Definitions used here are adapted from publications or governmental and organizational documents, and focus on their common usage and understanding in all of the disciplines involved in disaster health management.

Absorbing capacity: the ability of a society to dissipate the effects of an event. It is part of the overall society resilience.

Affected: people who requires immediate assistance and basic survival needs during a period of emergency, such as food, water, shelter, sanitation and immediate medical assistance.

Aid: the free material or financial assistance or other support given to an organization, community or country.

Alarm Procedure: alerting every party concerned precedes repressive disaster management. Various optical and acoustical means of alarm are possible: flags, lights, sirens, radio and telephone.

Building code: a set of ordinances or regulations and associated standards intended to control aspects of the design, construction, materials, alteration and occupancy of structures that are necessary to ensure human safety and welfare, including resistance to collapse and damage.

Capacity: the maximum amount that can be contained or produced.

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Casualty: any person suffering physical and/or psychological damage by outside violence leading to death, injuries, or material losses.

Command and control: maintenance of authority with somewhat more distributed decision making

Communication: all forms used for interchange of information, including newspapers, television, telephone, facsimile, internet, satellite and other facilities that can be used in time of disaster. Community profile: characteristics of the local environment prone to a chemical or nuclear accident: population density, age distribution, roads, railways, waterways, types of dwellings and buildings, and the relief agencies locally available

Contingency plan: an anticipatory emergency plan to be followed in an expected or eventual disaster, based on risk assessment, availability of human and material resources, community preparedness, local and international response capability, etc..

Classification: disasters can be classified utilizing various parameters; man-made versus God-made, the radius of the disaster site, the number of dead, the number of wounded, the average severity of the injuries sustained, the impact time, and the rescue time.

Cost: a loss or sacrifice; an expenditure of resources.

Damage: the negative result from the impact of an event.

Decision maker: person who have the ability, resources, and authority to make decisions or judgements and to act on them.

Disaster: the occurrence of widespread, severe damage, injury, or loss of life or property, with which the community cannot cope, and during which the affected society undergoes severe disruption. From a medical point of view, a disaster needs only two criteria: victims and a discrepancy between the number and treatment capacity.

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Disaster health management: systematic process of using administrative decisions, organization, operational skills and capacities to meet the challenge of mitigating from, planning for, responding to, and recovering from health consequences of disasters.

Disaster management: the body of policy and administrative decisions and operational activities which pertain to the various stages of a disaster at all levels.

Disaster medicine: the study and collaborative application of various health disciplines-- e.g., paediatrics, epidemiology, communicable diseases, nutrition, public health, emergency surgery, social medicine, community care, and international health--to the prevention, immediate response and rehabilitation of the health problems arising from disaster, in cooperation with other disciplines involved in comprehensive disaster management.

Disaster site: an area where the immediate impact of the disaster take place.

Early warning: some timely form of an impending event; advance notification of a problem in time for appropriate possible actions

El Niño: Anomalous warming of ocean water resulting from the oscillation of current in the South Pacific, usually accompanied by heavy rainfall in the coastal region of and Chile, and reduction of rainfall in equatorial Africa and Australia.

Emergency: a sudden and usually unforeseen event or situation that must be countered immediately to minimize the consequences.

Emergency management: the organization and management of resources and responsibilities for addressing all aspects of emergencies, in particular preparedness, response and initial recovery steps.

Emergency medical services: the aggregate of various resources and personnel necessary to deliver medical care to those with an unpredicted immediate need outside a hospital and continued care once in an established emergency facility.

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Epidemic: either an unusual increase in the number of cases of an infectious disease, which already exists in the region or population concerned; or the appearance of an infection previously absent from a region.

Epidemiology of disaster: scientifically measure and describe the health effects of disasters and the factors contributing to these effects. Epidemiologic research of disaster is only feasible when a uniform and standard definition, classification and scoring system for (the medical aspects of) disasters is established.

Evacuation: moving persons and supplies from an unsafe to safe area.

Event: event occurs when the hazard is realized or becomes manifest.

Flash flood: rapid inland floods due to intense rainfall. A flash flood describes sudden flooding with short duration. In sloped terrain the water flows rapidly with a high destruction potential. In flat terrain the rainwater cannot infiltrate into the ground or run off (due to small slope) as quickly as it falls.

Flood: overflows of areas not normally submerged with water

Forecast: definite statement or statistical estimate of the likely occurrence of a future event or conditions for a specific area.

Hazard: anything that may pose a danger. In disaster management, it refers to a natural or human-made phenomenon that has the potential to adversely affect human health, property, activity, and/or the environment.

Impact: the actual process of contact between an event and a society or a society’s immediate perimeter.

Injured: people suffering from physical injuries, trauma or an illness requiring medical treatment as a direct result of a disaster.

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Killed: Persons confirmed as dead and persons missing and presumed dead.

Land-use planning: the process undertaken by public authorities to identify, evaluate and decide on different options for the use of land, including consideration of long term economic, social and environmental objectives and the implications for different communities and interest groups, and the subsequent formulation and promulgation of plans that describe the permitted or acceptable uses.

La Niña: the opposite of El Niño. The ocean becomes much cooler than normal.

Man-made disaster: a disaster caused not by natural phenomena, but by man's or society’s action, involuntary or voluntary, sudden or slow, directly or indirectly, with grave consequences to the population and the environment. Examples: technological disaster, toxicological disaster, desertification, environmental pollution, conflict, epidemics, fires.

Mass casualty: a discrepancy between number of victims and its treatment capacity.

Medical disaster: the result of a vast ecological breakdown in the relationships between man and his environment, a serious and sudden (or slow, as in drought) disruption on such a scale that the stricken community needs extraordinary efforts to cope with it, often with outside help or international aid.

Medical Rescue Capacity: the number of victims that could be rescued and stabilized at the disaster site per hour by doctors, nurses and paramedics.

Mitigation: a range of policy, legislative mandates, professional practices, and social adjustments that are designed to reduce or minimize the effects natural hazards on a community. Mitigation measures may include: 1) land use planning and management, 2) engineering codes, standards and practices, 3) control and protection works, 4) prediction, forecasts, warning, and planning, 5) recovery, reconstruction, and planning, and 6) insurance etc..

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Mobile medical teams: instead of bringing the patient to the hospital, the hospital comes to the patient for whom mobile medical teams are created in order to stabilize the patient on the spot. This could shorten the treatment delay.

Natural Disaster: a sudden major upheaval of nature, causing extensive destruction, death and suffering among the stricken community, and which is not due to man’s action. However, (a) some natural disasters can be of slow origin, e.g. drought, and (b) a seemingly natural disaster can be caused or aggravated by man's action, e.g. desertification through excessive land use and deforestation.

Natural hazard: a potential threat to humans and their welfare caused by rapid and slow onset events having atmospheric, geologic, and hydrologic origins on solar, global, regional, national, and local scales (e.g., floods, severe storms, earthquakes, landslides, volcanic eruptions, wild fires, tsunamis, droughts, winter storms, coastal erosion, and space weather).

Plans, procedures and protocols: a well thought-out and fixed way of acting in order to reach a certain goal. They are usually in a written format.

Policy environment: the forum and the process for making decisions about plans, laws, and practices to reduce unacceptable risk to people, property, and infrastructure in the community and strategic plans to implement them over time.

Post-traumatic stress disorder (PTSD): emotional illness that usually develops as a result of a terribly frightening, life-threatening, or otherwise highly unsafe experience. PTSD sufferers re-experience the traumatic event or events in some way, tend to avoid places, people, or other things that remind them of the event, and are exquisitely sensitive to normal life experiences

Prediction: statement of the expected time, place and magnitude of a future event.

Preparedness: the aggregate of all measures and policies taken by humans before the event occurs that allows mitigation of the impact caused by the event through responses

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Prevention: the aggregate of approaches and measures taken to ensure that human actions or natural phenomena DO NOT cause or result in the occurrence of an event related to the identified or unidentified hazard.

Primary health care: essential health care made universally accessible to individuals and families in the community by means acceptable to them, through their full participation and at a cost that the community and country can afford.

Public awareness: the extent of common knowledge about disaster risks, the factors that lead to disasters and the actions that can be taken individually and collectively to reduce exposure and vulnerability to hazards.

Public health: the discipline in health sciences that, at the level of the community or the public, aims at promoting prevention of disease, sanitary living, laws, practices and a healthier environment.

Public policy: a plan, a rule, professional practice, or a way of acting that has the force of law. The policy options encompass: a) stop increasing the risk to elements that will be exposed in the future to natural and technological hazards, b) start decreasing the risk to existing elements already at risk from natural and technological hazards, and c) continue to plan for the inevitable event.

Recovery: bringing all of the societal components back to their pre-vent functional status.

Relief: assistance in material facilities, personal needs and services given to needy persons or communities, without which they would suffer.

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Resilience: pliability, flexibility, or elasticity to absorb, buffer, and manage the event. Resilience is the inverse of vulnerability. Resilience composes of absorbing capacity, buffering capacity, and response.

Response: answer to a defined need or a request.

Risk: the objective (mathematical) or subjective (inductive) probability that the hazard will become an event.

Risk Management: the public process of deciding what to do when risk assessments indicate that there is risk, or the chance of loss.

Risk map: cartographic representation of the types and degrees of hazards and of natural phenomena that may cause or contribute to a disaster.

Risk reduction: a selective application of appropriate techniques and management principles to reduce either the likelihood of an occurrence or its consequences, or both.

Shelter: anything that serves as a shield or protection from danger, bad weather etc.

Social Capital: the collective value of all 'social networks' and the inclinations that arise from these networks to do things for each other.

Stockpile: a place or storehouse where material, medicines and other supplies needed in disaster are kept for emergency relief.

Storm surge: a sudden rise of sea as a result of high winds and low atmospheric pressure.

Strategic planning: preparing the organization to respond to disaster threats in locations that are not specified and not immediately threatened.

Stress: any strain, anxiety, psychological shock or excessive pressure that disturbs the smooth functioning of a person or organism (and by extension, a group).

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Surveillance: continuous observation, measurement, and evaluation of the progress of a process or phenomenon with the view to taking corrective measures.

Susceptibility: the degree of ease by which a person or a population is affected by a given phenomenon.

Technological disaster: man-made disaster due to a sudden or slow break-down, technical fault, error or involuntary or voluntary human act that causes destruction, death, pollution and environmental damage.

Triage: selection and categorization of the victims of a disaster with the view to appropriate treatment according to the degree of severity of illness or injury, and the availability of medical and transport facilities.

Victim: casualty with sustained lesions of mechanical, chemical or nuclear nature or combinations.

Victim Distribution: victims should be transported to and distributed among neighbouring hospitals according to their hospital treatment capacity, while the nearest hospital should be avoided, since walking T3 victims will overcrowd this one. For this a pre-planned victim distribution plan is required.

Vulnerability: degree of loss (from 0% to 100%) resulting from a potential damaging phenomenon. Vulnerability is the opposite of resilience, i.e. vulnerability=1-resilience.

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Bibliography for Disaster Related Terms:

Ardalan, A., Masoomi, G., MM, G., Ghaffari, M., Miadfar, J., Sarvar, M., et al. (2009). Disaster health management: Iran’s progress and challenges. Iranian J Publ Health, 38(Suppl. 1), 93-97. EM-DAT. (2009). The EM-DAT Glossary Retrieved May 29th, 2010, from http://www.emdat.be/glossary/9 Emergency Management Australia. (2009). Australian emergency management terms thesaurus Retrieved May 29th, 2010, from http://library.ema.gov.au/emathesaurus/ Noji, E. K. (1995). Disaster epidemiology and disease monitoring. J Med Syst, 19(2), 171-174. ReliefWeb. (2008). ReliefWeb glossary of humanitarian terms Retrieved May 29th, 2010, from http://www.reliefweb.int/rw/lib.nsf/db900sid/AMMF- 7HGBXR/$file/reliefweb_aug2008.pdf?openelement Sundnes, K. O., & Birnbaum, M. L. (2002). Health disaster management: guidelines for evaluation and research in the "Utstein Style"--Volume One. Prehospital and Disaster Medicine, 17(Supplement 3). United Nations, & International Strategy for Disaster Reduction. (2009). 2009 UNISDR terminology on disaster risk reduction (pp. 30). Geneva, Switzerland. United States Agency for International Development. (2001). A glossary on violent conflict (4th ed.).

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Appendix B: Detail List of ABC News Reference

ABC News. (2008a). Aircraft arrive in Charleville with levee repair gear Retrieved December 18th, 2008, from http://www.abc.net.au/news/stories/2008/01/18/2142069.htm ABC News. (2008b). Charleville braces for flood peak Retrieved December 18th, 2008, from http://www.abc.net.au/news/stories/2008/01/20/2142376.htm ABC News. (2008c). Charleville flood peak to hit tomorrow: bureau Retrieved December 18th, 2008, from http://www.abc.net.au/news/stories/2008/01/19/2142188.htm ABC News. (2008d). Charleville flood threat eases, Emerald awaits peak Retrieved December 18th, 2008, from http://www.abc.net.au/news/stories/2008/01/22/2143819.htm ABC News. (2008e). Charleville town inundated with water from Bradley Gully Retrieved December 18th, 2008, from http://www.abc.net.au/local/stories/2008/01/18/2141596.htm ABC News. (2008f). Emerald engulfed by spreading flood waters Retrieved December 18th, 2008, from http://www.abc.net.au/news/stories/2008/01/22/2144247.htm ABC News. (2008g). Emerald evacuates as Nogoa rises Retrieved December 18th, 2008, from http://www.abc.net.au/news/stories/2008/01/20/2142508.htm ABC News. (2008h). Emerald evacuation centre reaches capacity Retrieved December 18th, 2008, from http://www.abc.net.au/news/stories/2008/01/22/2144163.htm ABC News. (2008i). Emerald on flood alert as dam overflows Retrieved December 18th, 2008, from http://www.abc.net.au/news/stories/2008/01/19/2142306.htm ABC News. (2008j). Emergency services meet over further Emerald evacuations Retrieved December 18th, 2008, from http://www.abc.net.au/news/stories/2008/01/23/2144261.htm ABC News. (2008k). Flood threat moves from Emerald to Rockhampton Retrieved December 18th, 2008, from http://www.abc.net.au/news/stories/2008/01/23/2145124.htm ABC News. (2008l). Flooded river continues to threaten Emerald Retrieved December 18th, 2008, from http://www.abc.net.au/news/stories/2008/01/21/2143406.htm ABC News. (2008m). Floodwaters start to recede at Charleville Retrieved December 18th, 2008, from http://www.abc.net.au/news/stories/2008/01/18/2141693.htm ABC News. (2008n). Mackay declared a disaster zone as flooding drowns suburbs Retrieved December 18th, 2008, from http://www.abc.net.au/local/stories/2008/02/15/2163687.htm ABC News. (2008o). Mackay region declared 'disaster area' Retrieved December 18th 2008, from http://www.abc.net.au/news/stories/2008/02/15/2163430.htm ABC News. (2008p). Patients airlifted as Charleville awaits flood peak Retrieved December 18th, 2008, from http://www.abc.net.au/news/stories/2008/01/18/2141350.htm ABC News. (2008q). Seeking financial help as the flood waters recede Retrieved December 18th, 2008, from http://www.abc.net.au/local/stories/2008/02/18/2165143.htm ABC News. (2008r). SES builds Charleville flood barrier Retrieved December 18th, 2008, from http://www.abc.net.au/news/stories/2008/01/19/2142097.htm ABC News. (2008s). SES sends more boats to flooded Charleville Retrieved December 18th, 2008, from http://www.abc.net.au/news/stories/2008/01/17/2141123.htm ABC News. (2008t). Water laps Charleville flood barrier Retrieved December 18th, 2008, from http://www.abc.net.au/news/stories/2008/01/21/2142907.htm

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Appendix C: Questionnaire for Health Management in the Floods

Questionnaire for health management in the Floods 洪水中的卫生管理问卷

Time 时间:

Place 地点:

Hi, my name is Donald, and I am currently a PhD student doing research of emergency and disaster management in QUT. Today, I am doing a case study of the health management in the floods. I am wondering if you could spare 15 minutes to answer a few questions. 您好，我叫杜伟伟，是澳大利亚昆士兰科技大学的一名博士研究生，我的研究方向

是灾难与危机管理。我现在在做一个洪水中的卫生管理案例研究。我的问卷约需十

五分钟，谢谢！

Information of Interviewee 受访者信息

Phone 电话:

Email 电邮:

Can you tell me briefly about your role in disaster management? 请您大概说一下您在灾难管理中的角色是什么？

Section A Preparedness 第一部分 准备

1. What’s the policy framework for disaster management? (What’s the local policy? What’s the general disaster plan? Were there any specific plans for flood? Can you name the policies which came into play before, during and after a disaster? ) How familiar, on scale of 1-10 are you, with each of these policies?

灾难管理的政策框架是什么？（地方政策是什么？一般灾难预案是什么？对洪水有

没有特定预案？您能不能说说一个灾难之前、之中、之后的政策？）按 1-10 的尺

度，您对这些政策的熟悉程度如何？

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Not at all familiar ① ② ③ ④ ⑤ ⑥ ⑦ ⑧ ⑨ ⑩ extremely familiar

不熟悉 非常熟悉

2. What’s the system and structure for the disaster management? Are there any committees for disaster management? Are you aware of the names and functions of the disaster management committees?

灾难管理的系统和结构是什么？有没有灾难管理委员会？您是否了解灾难管理委员

会的名称和功能？

3. Are there any measures such as construction requirements in place in preparation to mitigate the consequences of flooding? Any stockpile of disaster preparedness materials (sandbag, levee etc.)? What has been done since the last big Flood?

有没有减轻洪水影响的准备措施，例如建筑规范？有没有灾难准备材料储备（沙包、

临时堤坝等）？上一次大洪水之后有些什么措施？

4. Are there any equipment and drugs stored for disaster purpose? What other health preparedness strategies (if any) are in place?

有没有为了预备灾难而储备的设备和药品？有没有其他卫生准备策略？

5. What kind of surveillance system was set up for the flood? How are warnings issued?

对洪水有什么监控系统？洪水预警是怎么发布的？

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Section B The Event 第二部分 事件

1. Was the warning timely? Was it sufficient for the disaster management?

预警是否及时？预警对灾难管理是否留够时间？

2. Was the preparedness for this event adequate? What, in your view, could have been done better? On scale of 1-10, how would you rate the preparedness for this event?

事件的的准备工作是否充分？在你看来，那些方面能做得更好些？按 1-10 的尺度，

您对这次事件的准备工作如何评分？

Poor level ① ② ③ ④ ⑤ ⑥ ⑦ ⑧ ⑨ ⑩ excellent level

不够好 非常好

3. How many people were rescued? How many people were evacuated? How many patients were transferred to other hospitals? Morbidity? Mortality? How much food and water were provided to the people affected?

有多少人得到援救？疏散多少人？多少病人被转移到起他医院？发病率？死亡率？

对受灾的群众提供了多少食品和水？

4. What kinds of assistance were received from outside the region? Were they adequate?

从起它地区收到了何种援助？是否足够？

Local 本地:

Regional 本区域:

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State 省:

National 国家:

Non-Government (e.g. Salvation Army)非政府组织:

Media 媒体:

5. How was it organized? Were the roles of command and control clear enough? Was the communication clear?

应急的组织如何？指挥和管理的角色是否清晰？信息沟通是否清晰？

6. Did the non-government sector play a role (e.g. Salvation Army; St Vincent’s)— please describe? Did the media assist or hinder the disaster response?

非政府组织（如红十字会）是否也扮演了角色？--请描述。媒体对灾难应对是促进

还是阻碍？

Section C Recovery 第三部分 恢复

1. Are there any significant increases in the incidence of illness (viral meningitis?) after the disaster? Any change in the sorts of problems that patients are presenting/presented with? What kinds of preventative measures have been taken (such as spray mosquito etc.)?

灾后疾病是否有显著增加（如脑膜炎）？病人遇到的问题种类是否有改变？采取了

何种预防措施（例如喷药除蚊等）？

2. What’s the secondary health consequence of the flood?

洪水的次级卫生影响是什么？

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3. What actions have been taken to support people in terms of mental health?

在精神健康方面，采取了什么措施来帮助群众？

4. How satisfactory was the flood managed on scale of 1-10?

按 1-10 的尺度，您对这次洪水的管理满意度如何？

Poorly managed ① ② ③ ④ ⑤ ⑥ ⑦ ⑧ ⑨ ⑩ well managed

管理不善 管理很好

5. What policies need to be changed? What other things should be improved?

哪些政策需要改变？有什么其他方面需要改进？

6. With the benefit of hindsight, is there anything about how the floods were managed that should have been done that wasn’t done?

从事后来看，洪水管理中本来应该做得事有没有没做到的？

Section D Evaluation 第四部分 评估

1. How adequately, on a scale of 1-10, do you think the formal policies were, for preparing for the disaster? 按 1-10 的尺度，您认为正式政策对灾难准备是否充分？

Not at all adequate ① ② ③ ④ ⑤ ⑥ ⑦ ⑧ ⑨ ⑩ extremely adequate

不充分 非常充分

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2. How adequately, on a scale of 1-10, do you think the formal policies were, for managing the disaster? 按 1-10 的尺度，您认为正式政策对灾难管理是否充分？

Not at all adequate ① ② ③ ④ ⑤ ⑥ ⑦ ⑧ ⑨ ⑩ extremely adequate

不充分 非常充分

3. How adequately, on a scale of 1-10, do you think the formal policies were, for recovery from the disaster? 按 1-10 的尺度，您认为正式政策对灾难恢复是否充分？

Not at all adequate ① ② ③ ④ ⑤ ⑥ ⑦ ⑧ ⑨ ⑩ extremely adequate

不充分 非常充分

4. To what extent, on a scale of 1-10, do you think the formal policies were successfully implemented at the field level? 按 1-10 的尺度，您认为正式政策在实践中

运用的成功程度如何？

Not at all adequate ① ② ③ ④ ⑤ ⑥ ⑦ ⑧ ⑨ ⑩ extremely adequate

不成功 非常成功

THANK YOU FOR YOUR ASSISTANCE！谢谢您的协助！

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Appendix D: Questionnaire for Disaster Management Policy

This diagram is a policy framework for disaster management (Health) policy. The “Disaster management (Health) policy framework” guides the “policy development” and “policy implementation”, which then lead to “effective disaster management (Health)”. “Other determinants”, including the nature of the event, political structure, culture, economics etc, contribute to the “effective disaster management (Health)” as well. The final goal of this framework is to “minimize the human health impact of disasters”. I have 7 questions in regarding to this diagram as highlighted in blue in this diagram:

Question 1: In respect to the overall framework, what do you consider would be the top four or five key characteristics of an effective policy framework for disaster management for health? (I.E. what would you consider to be the guiding rules and principles?)

Question 2: What do you consider would be the critical elements of successful policy development in this field?

Question 3: What would you consider are the keys to successful policy implementation in this field? (What things assist? What things inhibit?)

Question 4: What would you use to measure the effectiveness of policy in this field?

Question 5: Apart from effective policy, what do you consider are the other things that determine effective disaster management for health?

Question 6: Now that you have looked at the whole diagram, does this accurately capture the rationale for effective disaster management for health?

Question 7: This diagram identifies the relationships between flood and health consequences. Do you think these relationships are correct?

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Disaster Management (Health) Policy Framework

Policy Framework of Disaster 1: Characteristics Framework for Health 7: Validation Management (Health) Impacts (E.g. Flood)

2: Elements of Good Disaster Policy Policy 3: Elements/ Factors Impact Management (Health) Policy Development Implementation Policy Implementation

Nature of Event

Political sturcture Effective Disaster 4: Policy Effectiveness 5: Other Determines Management (Health) Evaluation Culture

Economics

…… Minimize the Human Health Impact of Disasters

310

Relationships Between Floods and Health Chronic Consequences diseases Infection— skin and eye infections, Sunburn etc. faecal-oral infections Overcrowding Hypothermia Exposure to thermal stress vector Communicable Complications diseases of injury repairing Drowning Contact with houses etc. Building Debris in Floodwater collapse the water Damage to water and sanitation Car, motorbike Civil Trauma Injury infrastructure Crash etc. Disturbance and deaths Disruption of Trauma Injury Fallen Power line, livelihood and income and deaths electricity in the Flood water etc. Disruption of Burns and food supply Starvation and explosions of Malnutrition Chemical chemicals etc. Population contamination Displacement Poisoning Scared animals Disruption of health Displacement of systems, including loss Animal Bites patients, disabled of health workers and persons, senior essential drugs Disability people, children etc. Poor health outcome Mental health heart attack, illness deterioration etc.

Direct consequences of flood

Mid-term Health Outcome Long-term Health Outcome Immediate Health Outcome

Direct Health Consequences Drowning Complications of injury Mental Health-death of relatives etc.

Injury Infection--skin and eye infections, faecal- Chronic diseases •Trauma Injury--debris collapsed oral infections building, car crash etc. •Electrical Injury •Burns and Explosions Injury

Hypothermia Poisoning—Chemical contamination Disability

Animal Bites Mental health--shock

Heath risks associated with the Communicable diseases— Malnutrition—poverty, damage of displacement of patients, disabled •overcrowding, property

Indirect Health Consequence persons, senior people, children etc. •vector, (e.g., heart attack, illness •exposure to infectious disease deterioration) •Animal displacement •Contamination of water

Loss of health workers and essential Poor health outcome—health services Mental health—livelihood, income, drugs disruption homes destroyed Starvation— Trauma—Civil disturbance •Failure of distribution system, •Damage to crops •Damage to water and sanitation infrastructure

Injury—from repairing houses etc. Exposure to thermal stress, e.g. sunburn— damage of homes

Health Consequences of Floods

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Appendix E: Ethical Clearances

- 313 -

Ethics Application Approval -- 0800000484 - Enterprise Vault Archived... http://qutexevsrv02.qut.edu.au/EnterpriseVault/ViewMessage.asp?Vaul...

From Research Ethics Date Wednesday, 30 July 2008 7:45:44 AM To WEIWEI DU Cc Janette Lamb Subject Ethics Application Approval -- 0800000484

Dear Mr Weiwei Du

Re: Policy analysis of disaster health management in China

This email is to advise that your application has been reviewed and confirmed as meeting the requirements of the National Statement on Ethical Conduct in Human Research. Your ethics approval number is 0800000484. Please quote this number in all future correspondence.

Whilst the data collection of your project has received ethical clearance, the decision to commence and authority to commence may be dependant on factors beyond the remit of the ethics review process. For example, your research may need ethics clearance from other organisations or permissions from other organisations to access staff. Therefore the proposed data collection should not commence until you have satisfied these requirements.

If you require a formal approval certificate, please respond via reply email and one will be issued.

Decisions related to Low Risk ethical review are subject to ratification at the next available Committee meeting. You will only be contacted again in relation to this matter if the Committee raises any additional questions or concerns.

This project has been awarded ethical clearance until 30/07/2011 and a progress report must be submitted for an active ethical clearance at least once every twelve months. Researchers who fail to submit an appropriate progress report may have their ethical clearance revoked and/or the ethical clearances of other projects suspended. When your project has been completed please advise us by email at your earliest convenience.

Please do not hesitate to contact the unit if you have any queries.

Regards

Research Ethics Unit | Office of Research O Block Podium | Gardens Point Campus p +61 7 3138 5123 | f +61 7 3138 1304 e [email protected] w http://www.research.qut.edu.au/ethics/

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Appendix F: Participants Consent Form and Information

CONSENT FORM for QUT RESEARCH PROJECT

A Policy Analysis of Disaster health management in China

Statement of consent

By signing below, you are indicating that you:

• have read and understood the information document regarding this project

• have had any questions answered to your satisfaction

• understand that if you have any additional questions you can contact the research team

• understand that you are free to withdraw at any time, without comment or penalty

• understand that you can contact the Research Ethics Officer on 3138 2340 or [email protected] if you have concerns about the ethical conduct of the project

• agree to participate in the project

• understand that the project will include audio and/or video recording

Name

Signature

Date / /

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PARTICIPANT INFORMATION for QUT RESEARCH PROJECT

A Policy Analysis of Disaster health management in China Research Team Contacts Weiwei (Donald) Du Gerard FitzGerald (principal researcher) (Research supervisor) +61 7 31383540 +61 7 3138 3935 [email protected] [email protected]

Description This project is being undertaken as part of PhD project for Weiwei Du. The project is funded by Queensland University of Technology. The funding body will not have access to the data obtained during the project. The purpose of this project is to develop and validate a policy framework for disaster health management in China which is most appropriate to the social, economic, and political environment, and reflects the capacity of the health system to respond to major incidents and disasters. The methods of this research include: exhaustive review of the literature, detailed case studies of the health impacts of floods in China and Australia, and undertaking key information interviews with a panel of international experts. The research team requests your assistance because …

Participation Your participation in this project is voluntary. If you do agree to participate, you can withdraw from participation at any time during the project without comment or penalty. Your decision to participate will in no way impact upon your current or future relationship with QUT or with any other organizations. Your participation will involve an interview. The length of the interview is approximately 15 minutes. Expected benefits It is expected that this project will not benefit you personally. However, improvement of the disaster health management policy, which will result in better health management of future potential disasters, will benefit people’s lives and properties. Risks

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There are no risks beyond normal day-to-day living associated with your participation in this project. Confidentiality Any information will be treated confidentially and information gained from the interviews will be described in thematic, summary form so that the identity of particular individuals will be un-identifiable. Comments are to be verified by the participants prior to final inclusion. The audio recordings are to be verified by the participants prior to final inclusion. The audio recordings will be destroyed after the contents have been transcribed. The Audio recordings will not be used for any other purpose. Only the research team will have access to the audio recording. If you don’t want to be recorded, please let the researchers know prior to the interview.

Consent to Participate We would like to ask you to sign a written consent form (enclosed) to confirm your agreement to participate. Questions / further information about the project Please contact the researcher team members named above to have any questions answered or if you require further information about the project. Concerns / complaints regarding the conduct of the project QUT is committed to researcher integrity and the ethical conduct of research projects. However, if you do have any concerns or complaints about the ethical conduct of the project you may contact the QUT Research Ethics Officer on 3138 2340 or [email protected]. The Research Ethics Officer is not connected with the research project and can facilitate a resolution to your concern in an impartial manner.

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Appendix G: Flood Fatalities in Contemporary Australia (1997-2008)

FitzGerald, G., Du, W., Jamal, A., Clark, M., & Hou, X.-Y. (2010). Flood fatalities in contemporary Australia (1997-2008). Emergency Medicine Australasia, 22(2), 180-186.

FitzGerald, G., Du, W., Jamal, A., Clark, M., & Hou, X.-Y. (2009, 23-24 July). Flood Fatalities in Contemporary Australia (1997-2008). Paper presented at the Public Health Association of Australia Queensland State Conference, Brisbane, Australia.

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Appendix H: Health Impacts of Floods

Du, W., FitzGerald, G., Hou, X.-Y., & Clark, M. (2010). Health Impacts of floods. Prehospital and Disaster Medicine, 25(3) , 265-272.

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Appendix I: Characteristics of Disaster Management in China—A Preliminary Evaluation of Flood Management in Jinan, 2007

Du, W., Hou, X.-Y., Xu, A., Lei, J., Clark, M., & FitzGerald, G. (2009). Characteristics of disaster management in China—A preliminary evaluation of flood management in Jinan, 2007. Paper presented at the 16th World Congress on Disaster and Emergency Medicine, Victoria, BC, Canada.

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Appendix J: Health Consequences of Flooding In China and Australia

Du, W., FitzGerald, G., Hou, X.-Y., & Clark, M. (2009). Health consequences of flooding in China and Australia. Paper presented at the 16th World Congress on Disaster and Emergency Medicine, Victoria, BC, Canada.

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Appendix K: Preventing Flood Death and Injury in Queensland—Issue Paper

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Project Funded by National Climate Change Adaptation Research Facility (NCCARF)

Preventing Flood Death and Injury in Queensland

----Issues Paper

Prepared by Mr. Weiwei Du*

January 2010

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