On November 23, 1980, an earthquake equivalent to 10 degrees on the Mercalli scale struck two regions of Southern Italy: Campania and Basilicata. Its epicenter was identified in the area of Colliano. The destruction caused by the earthquake extended to 7 provinces and affected 685 communities distributed over an area of 23,570 Km with a population of approximately 4 million. The material damages ascertained —not counting the consequences to industrial, agricultural and commercial activity—amount to approximately 17,000 billion Italian lire. In terms of the medical sector, 3 regional hospitals (722 beds) and 20 smaller hospitals were totally destroyed; another 16 hospitals (for a total of 9,495 bedsl suffered varying degrees of serious damage. In economic terms, the damage sustained by the medical structures amounted to 88 billion lire.

The medical and nursing staff of the Niguarda-Ca' Granda Hospital of Milano has been involved in three major disasters that occurred in Italy in the years 1976 and 1980: (1) the earthquake of May 6, 1976 in a northeastern region (Friuli); (2) the ICMESA plant explosion of July 10, 1976 in Seveso (Milano) and (3) the earthquake of November 23, 1980 in the region of Irpinia (Southern Italy).

Friuli Earthquake 1976

On May 7, 1976, about 12 hours after the earthquake struck, the Udine Hospital, located at about 15 km from the border of the disaster area, contacted by phone the director of the Ca' Granda Hospital in Milano, requesting a relief staff of operating room and ICU nurses. The Udine Hospital was undamaged and was overburdened by work for the surgical, orthopedic and medical treatment of the rescue victims. The staff requested was needed to relieve the exhausted local nursing staff. Extra staff was needed also to accompany ambulances with patients that, after initial triage and treatment, were evacuated to other hospitals outside the seismic area.

On October 10, 1980, the town of El-Asnam (130,000 inhabitants) and villages within a 50 km radius (229,000 inhabitants) were 80% destroyed by an earthquake of intensity 7.5 on the Richter scale (Figure l). The first unofficial estimates reported 50,000 dead and 100,000 injured. These numbers were probably based on data from the Agadir earthquake of February 29, 1960, when 12,000 out of the 30,000 inhabitants were killed. The official figures now list for the El-Asnam earthquake 2,600 dead and 8,250 injured. That was nevertheless a sufficiently heavy toll to fully justify the volume of relief that came from practically all over the world. The relief of Baden-Wurttenberg was organized by the German Air Rescue Guard of Stuttgart, in collaboration with the German Red Cross in Karlsruhe, as well as with physicians from Karlsruhe, Stuttgart and Tubingen. In a very short time the necessary aircraft (Merlin IV/Metro and BAC 1–11) for the transport of material and personnel from the German Headquarters were ready for takeoff.

Of the more than one million earthquakes which occur each year on our planet, very few involve areas of major population concentration. During the last decade, however, a significantly large number of earthquakes involved populations in cities or areas of large population density. The injuries, therefore, are multiplied by the collapse of large buildings or of walls of houses of poor design and construction of adobe brick. Crashing upon people asleep, they entrap, entomb or mutilate defenseless and often aged, ill, and diseased and helpless pediatric victims. The three earthquakes we witnessed recently have resulted in 70,000 deaths in Peru;, 12,000 in Managua, Nicaragua;, and 22,000 in Guatemala City and large suburban cities.

Most of the injuries are orthopedic fractures. Fatalities often occur from compression and permanent restriction of respiratory movement. These megaton disruptions of the environment cause the following types of respiratory challenge: (l) The unbelievably large and dense dust clouds from falling buildings, created by pulverization of the walls of mud, straw, and limestone, create suffocating chemical damage of some degree to the nasal mucosa, the bronchial tree and the respiratory bronchioles, immediately initiating endothelial edema, airway obstruction and collapse, and irritational bronchitis.

A strong earthquake occurred in the Tangshan-Fengnan area in Hopei Province of North China at 03:42 hours on July 28, 1976. A general headquarter was set up immediately to perform the functions of organization and administration. This was the most essential authority in keeping everything in order in such a disaster area. Mine Rescue Corps and mobile medical teams from many parts of the country were called and rushed to the scene. Critical care was organized into 3 stages: (1) digging and rescue; (2) preliminary treatment and transfer; and (3) treatment after transfer.

The Mine Rescue Corps, existing normally in every coal mine, was the most efficient and valuable element in digging out victims and carrying out the most urgent resuscitative management. They dug and rescued, and also patrolled in the pits. They cleared the way for the coal miners. More than 10,000 miners, who were working in the pits during their night shift, were less able to return to the ground safely. As it was very difficult to locate every working group in such a labyrinth pits system, some coal miners had been left in the pits for long periods of time. There were, for instance, five coal miners who were working 850 meters underground and could not find their way out because the pits were badly damaged.

Once an earthquake or similar disaster has occurred, and the salvage operation begins, it must be viewed as something that can do further damage to the victims as well as help them. The more ambitious the rescue and salvage effort—the effort to minimize the human casualties—the more serious the problem becomes of preventing the salvage operation from doing more harm than good after the obvious and easy cases have been located and treated. The key engineering elements can be reviewed from the position of the rescuer or of the victim and his ability to participate actively or passively in his own rescue and treatment. In either case, the main improvement would appear to result from, first, improved sensors and receptors; second, improved methods for timely debris removal; third, improved aids to active self-indicated survival efforts, including rescue and treatment; and fourth, improved methods of restoring vital services (water, sewage, heat, light, food, transportation and communication).

Anesthesia in disaster medicine, especially as practiced in developing countries, is fundamentally different from the anesthesia that is practiced during normal situations. Anesthetic procedures suitable for disaster situations must often take place under minimal conditions of instrumental availability and in a setting of less than modern technology. Such conditions, of course, limit the use of inhalatory anesthetics.

The key factor present in disaster situations is the disturbed relationship between the number of injured, on the one hand, and the available resources to treat them, on the other. This includes medical personnel—both professional and para-professional. This has been substantiated by the earthquakes in Iran, Guatemala, China and Turkey. The earthquake which occurred in Tabas, Iran in December 1978, for example, lasted only thirty seconds, but left behind more than 20,000 dead and countless thousands of injured.

In order to analyze the cause, effect and relief efforts of the Johnstown floods of 1889,1936, and 1977, existing literature, journalistic accounts, and official documents concerning the floods were investigated.

At 4:00 PM on May 31, 1889, the South Fork Dam burst, releasing 60 million tons of water into the Conemaugh Valley. The flood destroyed Johnstown and the surrounding communities within a few minutes. The official totals were 2209 persons killed, 30,000 homeless, and 17.2 million dollars property damage. From Sang Hollow, a community four miles from Johnstown, the first description of the disastrous flood was sent to Pittsburgh by telegraph about two hours after the catastrophe. Several journalists set out by train for Johnstown immediately. A fire started in the flood debris and burned throughout the night. By morning rescue squads of survivors were trying to get through to those still marooned and to identify the dead.

The eruption of Mount Saint Helens in the Cascade Mountain Range of Washington State on 18 May 1980 resulted in a life-threatening and economically disruptive natural disaster that required the mobilization of supportive agencies from the State and Federal government for control. Because of the potential for further eruptions, the mechanism of death for those persons exposed to the initial blast was examined to aid in contingency planning.

Fatalities as a result of the eruption could be attributed to lack of understanding of the danger in the area of the mountain. Although several scientists were killed during the eruption, most were sight-seers who ignored the warning seismic activity and the precautionary blockade of the area. A few were outside of the well-publicized danger zone, but were caught in the rapidly moving mudslides or the ash cloud.

Cholera, which was unknown in Africa south of the Sahara, became an identifiable disease in South Africa in 1919. In the 1970's, 5 cases were diagnosed in people coming into South Africa from countries to the north. Instructions regarding Cholera surveillance were circulated in 1979 following an outbreak in Maputo. There was no evidence of any case of cholera acquired in South Africa before September 1980. Within 12 days, there were 23 proven cases of Vibrio cholera, El Tor biotype, among Africans who obtained drinking water from an irrigation canal off the Crocodile River midway between Nelspruit and Kaapmuiden. Five hundred forty-six cases had been identified by the end of February 1981 and more are expected.

On 13 October 1980, a team of health officials collected at Nelspruit to coordinate measures to contain the epidemic. They included chlorination of the irrigation canal, water surveillance of local rivers by sampling or leaving Moore pads in situ, increasing the number of staff and strengthening equipment at local laboratories, educating local medical and nursing staff in patient management and providing adequate stocks of intravenous fluids and tetracycline. Patients' contacts were traced, their homes inspected, their water supply sources and means of sewage disposal checked and the public educated in cholera prevention. There were regular press statements, radio talks, television programs and the broadcasting of educational leaflets to warn the population to take precautions. It was decided not to hold a mass immunization campaign nor to administer preventive antibiotics.