The Dutch experience with Health Impact Assessment of disasters

Over the past decade, the Dutch government has learned that a crisis/disaster is not over when the fire has been extinguished, chemical spills have been contained or affected livestock has been cleared. Examples are as follows: The crash of an El Al airplane in a residential area in Amsterdam (1992, 39 fatalities), where a disaster Health Impact Assessment (HIA) amongst 7300 victims was initiated after 8 years under political and societal pressure.1 Fireworks explosion in Enschede (2000, 22 fatalities): integral aftercare programme for the 20 000 involved people including HIA was started within weeks, and lasted 5 years.2,3 Café fire in Volendam (2001, 14 fatalities, 350 youngsters injured), where an integral aftercare programme was initiated within days.4 Avian flu epizootic (2003, 1 human fatality) with an immediate health response including infectious disease outbreak investigation and mental health aspects.5 After the learning experiences with more reactive approaches to disasters, the Dutch government has adopted a three-pronged pro-active approach to health care provision and follow-up of disaster victims as follows: This article only deals with the disaster HIA. A disaster HIA is usually set in very complex political and societal circumstances. Some stakeholders may wish to put the incident behind, while others are concerned about (health) effects, and yet others are focused on criminal investigations and/or questions of guilt. A HIA may not appear to be necessary or even undesirable to some shortly after an incident. Development of a single information and assistance authority. Development and implementation of an integrated mental (health) care programme. Disaster HIA to develop an information basis for health care provision. The underlying goal of disaster aftercare is to contribute to the restoration of control at both individual and societal level. A disaster HIA may contribute to a pro-active government response by providing information on the needs of the victims and, consequently, on the relief facilities required to support individual and collective post-disaster care activities. It may also serve to recognize and acknowledge the victims and their post-disaster problems. The following three main objectives of disaster HIA are recognized: Provision of (health) care information: Determining victims' health state: type, numbers, development, and possible trends/patterns of health problems, either directly related and/or attributed to the disaster. Identifying groups at increased risk, need for special health care (provisions). Monitoring the effects of interventions. Provision of (health) care policy information: Initiation, adaptation and co-ordination of suitable (health) care provision. Co-ordination and dissemination of information on the public health consequences of the disaster. Development of protocols to improve disaster relief in future events. Scientific objectives: Improving understanding of mechanisms that affect the health and well being of disaster victims. Improving understanding of the possibilities to prevent or minimize (persistent) health problems resulting from disasters. In the above-mentioned Dutch disaster HIAs different approaches have been applied, ranging from surveillance of existing or ad hoc health care registries, surveys of health and exposure end points, exposure assessment in contact media, screening, and evaluation or effect studies. Each study type has distinctive strengths and weaknesses depending on objectives, circumstances, and burden to participants. In The Netherlands, disaster preparedness and response are managed by the regional public health authorities, fire brigades, police, and the municipalities. The mayor has overall command over disaster control, usually the fire chief has operational control. Depending on the severity, or if the (consequences of the) crisis or disaster cross administrative boundaries, the command and control can be scaled up to national level. Therefore, any preparedness planning for disaster HIA needs to include all these players in local government, emergency response and public health organizations, and health care providers. This is a challenge in itself. Disasters are rare, and hence the complicated undertaking of a HIA is not often needed. It would be unrealistic to expect that every regional public health authority prepare for such events. For this reason, a national Centre for Health Impact Assessment of Disasters (CGOR) was founded by the Ministry of Health, Welfare, and Sports to serve as a clearing house and support unit for local authorities. One main function of CGOR is to provide the government with rapid and authoritative advice on whether or not to initiate a disaster HIA, its possible objectives, and an outline of the study programme. To this end an independent Expert Advisory Committee has been set up to provide such advice within 24 h after alert, on the basis of previously agreed rules of engagement.