Disaster Reports Number 5: Hurricane Gilbert in Jamaica, September, 1988

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1 Disaster Reports Number 5: Hurricane Gilbert in Jamaica, September, 1988

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3 Table of Contents Disaster Reports Number 5: Hurricane Gilbert in Jamaica, September, Introduction...1 Prologue...1 Background...2 The hurricane and its effects...3 The surveillance system...5 Relief shelters...15 Preparedness and response...18 Lessons learned...19 Appendix Appendix References...21 i

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5 Disaster Reports Number 5: Hurricane Gilbert in Jamaica, September, 1988 Introduction Pan American Health Organization Emergency Preparedness and Disaster Relief Coordination Program Disaster Reports is a publication of the Emergency Preparedness and Disaster Relief Coordination Program of the Pan American Health Organization. The reported events, activities and programs do not imply endorsement by PAHO/WHO, nor do the statements made necessarily represent the policy of the Organization. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the Pan American Health Organization concerning the legal status of any country, territory, city, or area of its authorities, or concerning the delimitation of its frontiers or boundaries. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the Pan American Health Organization in preference to others of a similar nature that are not mentioned. This publication was made possible by the financial support of the Canadian International Development Agency (CIDA) and the Office of U.S. Foreign Disaster Assistance of the U.S. Agency for International Development (OFDA/AID). Photographs: Carlos Gaggero/PAHO Prologue There is no doubt that disasters can yield valuable lessons. These lessons, when shared with other countries with similar vulnerabilities, are an important step toward avoiding costly mistakes in the future. Yet postdisaster data is perishable. If it is not collected and analyzed soon after a disaster, valuable information will quickly disappear. With this in mind, the Pan American Health Organization commissioned the University of the West Indies to collect information and data in the wake of Hurricane Gilbert and prepare a report for the Organization's Disaster Reports series. The report that follows was compiled under the competent, dedicated supervision of Dr. Wilma Bailey of the Department of Geography of the University of the West Indies, Kingston. We wish to thank Dr. Bailey and the University for their efforts. Part of the material contained herein originated in a report prepared by a team from the Pan American Health Organization (June, 1989) at the request of the Ministry of Health. The team was comprised of Dr. Norma Andrews, PAHO/WHO Representative at the time of Hurricane Gilbert, Ms. Sybil Brooks, Mr. Ernesto Dobrovsky, Mr.James Murray, Mr. Cortez Nurse, Dr. Homero Silva and Mr. David Taylor. This group acknowledged the valuable cooperation provided to them by the personnel of the Ministry of Health both in Kingston and in the parishes. The Emergency Preparedness Program thanks Mr. Taylor and Dr. Silva for their review of the final manuscript. 1

6 Background Jamaica is a small tropical island with an area of roughly 11,310 sq. km. Much of the island is hilly or mountainous and there are large areas of volcanic rocks in the east in the Blue and Port Royal Mountains which rise above 1000 m in altitude. The mountains of the west are lower and composed largely of limestone. The island's rainfall derives from four weather phenomena. Cold fronts moving southwards from North America bring rain in the period November to April. Convective activity also results in localized showers. The third source comprises troughs and waves of low pressure related to local and regional atmospheric systems such as the Intertropical Convergence Zone. Perhaps the most important weather phenomena, however, are tropical disturbances depressions, storms and hurricanes. Fig. 1 shows the monthly distribution of hurricanes in the period 1900 through In 1988 the population of Jamaica was just under 2.3 million. There was a marked decline in fertility in the intercensal period 1970 to 1983 when births per woman declined from 5.6 to 3.3. The birth rate is now estimated at 25 per The death rate is aproximately 6 per 1000 and official estimates of infant mortality There is reason to believe, however, that infant mortality is grossly underestimated. The decline in the fertility rate is reflected in a decline in the proportion of the population in the age group less than 15 and an increase in the over 65 year old age group. The dependency ratio is 83. That is, there are 83 persons in the dependent age groups (less than 15 and over 65) for every 100 persons in the working age group. Figure 1. Monthly distribution of hurricanes in Jamaica ( ). Administratively, the island is divided into fourteen parishes. Two parishes, Kingston and St. Andrew, form the capital region. The Kingston and St. Andrew Metropolitan Area (K.M.A.) has a population of 586,930 which represents 28 percent of the island's population. The population of the K.M.A. is declining, however, and the area of growth is in the neighboring parish of St. Catherine. The only other parishes to gain population between 1970 and 1983 were St. James, where tourism is important, and St. Elizabeth. The island has a well developed system of primary health care based on a network of 377 interlocking clinics. These clinics deliver maternal and child health care, dental care, and curative and family planning services. Secondary and tertiary care are provided by 25 public and seven private hospitals. The island appears to be 2

7 experiencing elements of epidemiological change which are bringing its morbidity and mortality pattern in line with those of more developed countries. This involves changes from acute to chronic ailments as causes of morbidity and mortality. To some extent, however, an uncomfortable balance has been reached, since infectious diseases remain important causes of ill health among young children. Moreover, there has been an increase in hospital admissions for malnutrition and an increase in the case fatality rate [Landman and Walker, 1987]. Marchione [1984] relates this to the fact that while the primary care programme relies upon the increasing use of health centers, the epidemiology of malnutrition tends to be linked to access to income and social support systems. Moreover, economic stabilization programmes imposed as preconditions for International Monetary Fund assistance have led to demoralization of health personnel, widespread migration and underfunding of the health system. There was a serious manpower shortage when Hurricane Gilbert struck the island. It is estimated that between 1987 and 1989, nurses left the service at the rate of seventeen per month. In fact the only health sector group for which there was adequate staffing was porters and other ancillary staff [PAHO/WHO, 1989]. The hurricane and its effects At 5.00 a.m. (EST) on Friday September 9, the National Meteorological Service issued the first level of warning, the Hurricane Alert. The Warning was issued on Sunday, September 11 at 3.00 p.m. Collymore [1988] argues that, given the fact that the majority of the island's population had never experienced a major hurricane and the severity of the threat, there was undue conservatism and caution in the nature of the forecasts. The time between the issuing of the Warning and the impact was inadequate for preparation in view of the fact that only three hours of daylight remained. Many felt that preparations could be suspended until the following morning, but work was impossible since storm force winds extended 200 miles in all directions from Gilbert's colossal eye. The storm made its first landfall on the east coast of Jamaica at a.m. on Monday, September 12. As it began its passage over the island the eye measured about 15 miles across. Wind speeds averaging 75 mph gusting to 127 mph, were recorded in the Kingston Metropolitan Area. As the eye exited western Jamaica at 6 p.m., it intensified further (888mb) and was identified as a Category 5 Hurricane, the most severe. Jamaica's last experience of a direct hit by a hurricane was in 1951 Hurricane Charlie. Hurricane Gilbert differed from Charlie in several respects. Unlike Charlie, Gilbert, in its eight hour rampage, traversed the entire length of the country. Fig. 2 shows the path of the eye across the island. The eye passed over the Kingston Metropolitan Area around noon. Moreover, Gilbert was the largest cyclonic system ever observed in the western hemisphere [Eyre, 1989]. It was also one of the wettest synoptic systems experienced although, fortunately for Jamaica, most of the precipitation generated fell on the sea [Eyre, 1989]. Between 200 and 250 mm of precipitation fell on September 12 and this reached more than 400 mm in central areas. Most of the rain, however, fell between 1.00 p.m. and 7.00 p.m. (EST) after trees had been defoliated and uprooted and so surface wash and soil erosion were widespread [Barker and Miller, 1989]. 3 Figure 2. The track of the eye of Hurricane Gilbert.

8 The impact of Hurricane Gilbert was devastating on all sectors of the society and the economy. Damage was estimated at US$4 billion, with the damage to agriculture accounting for over 40 percent of this total. Ninety five percent of all health facilities suffered damage. Of the 25 public hospitals only two escaped with minimal damage. Two were destroyed and eleven suffered severe damage. There are 377 Health Centers in the island and more than half of these (55 percent) were severely damaged. The cost of emergency repairs was estimated at US$13 million with roughly 55 percent of this representing the cost of repairs to secondary care facilities. As Fig. 3 shows, the parishes of Kingston/St. Andrew and Hanover sustained the heaviest damage to health facilities. Figure 3. Cost of repairs to health facilities. The storage and distribution of domestic water are managed by the National Water Commission. The hurricane damaged over 50 percent of these facilities to a degree which varied from minor to complete destruction. Pipelines, storage tanks, pump and chlorinator houses were all affected. There were instances in which rivers changed their courses, threatening supplies and facilities. The Kingston Metropolitan Area is supplied with water from four water treatment plants and one spring. Only one of the treatment plants Mona was fully operational after the storm. This plant, described as the best equipped surface treatment plant in the island [Barrett, 1989], was able to generate its own electricity and supply over 30 percent of the water demand of the city. For the other plants the problems of high turbidity, poor filtration and the lack of stand by generators in the face of the total loss of power supplies were particularly urgent in view of the fact one, the Hope Treatment Plant, supplied water to the University Hospital. Although the Ministry of Social Security was responsible for distributing relief supplies, this task, initially, was taken over by the Office of Disaster Preparedness (ODP). Before relief supplies arrived in the island, the ODP had made purchase agreements with several large distributors in the island for the purchase of food for the parishes [Carby, 1989]. The largest of the distributors, however, was looted and supplies drastically cut. Attempts were then made to distribute incoming supplies directly from the support. However, distribution of relief supplies was soon taken out of the hands of the ODP. The responsibility for distribution was taken over by the Prime Minister's Office and, eventually, by an interdenominational group Project Accord which was funded by international and local donor agencies. This was seen as one means of avoiding charges of political interference in the distribution of relief supplies. The ODP paid for and organized the clearance of goods from the wharves and airport and the expenses of distribution were borne by Project Accord [Bent, 1989, Carby, 1989]. In addition, supplies received by the government were controlled by the Jamaica Commodity Trading Company. The supplies food and building were sold to the distributive sectors. Those in need were issued with food and building stamps with which to purchase the donated items. Much time was spent in 4

9 implementing these procedures and crucial supplies remained on the wharves, incurring storage fees and plagued by theft [Bent, 1989]. The response from the international community was immediate and large quantities of supplies flooded the country. Daily meetings were coordinated by the UNDP in an effort to coordinate donor response and the needs of the country. This achieved some measure of success [Bullock DuCasse, 1989]. However, it was felt that pre arranged needs lists would have speeded up the process of acquiring necessary supplies [Bullock DuCasse, 1989]. Moreover, the major part of the relief effort centered around the transportation of goods. The cost of mobilizing distribution was, at times, greater than the value of the goods [Bent, 1989]. A great deal of time was also spent in clearing, documenting and sorting goods. There was a shortage of warehousing facilities in urban areas and a lack in rural areas. Some of the goods sent were inappropriate. There were problems with drugs which required refrigeration. The Project Manager of Operation Accord was of the opinion that it would have been easier to handle cash donations than goods. The surveillance system Background Information The Office of Disaster Preparedness and Emergency Relief Coordination has the overall responsibility of co ordinating the relief effort and response. They are assisted in this task by the National Disaster Committee comprised of representatives from the security forces, government ministries, voluntary agencies and the ODP. The Prime Minister is the Chairman of the Committee. It was convened for the first time since the issuing of the Hurricane Alert in June Within the Ministry of Health there is a Health Action Committee for Disaster Preparedness involving Medical Officers of Health in charge of parishes and hospitals. Hospital management teams were trained in disaster preparedness activities which included developing and writing hospital plans. In addition, disaster plans were developed for parish health teams and, in a few parishes, the process extended to the district/community level [Bullock DuCasse, 1989]. These disaster plans were never implemented. "The impact of the hurricane... overwhelmed many health workers as they sought to cope with damage to and loss of Ministry of Health facilities, equipment and records as well as personal shelter and belongings" [Bullock Du Casse, 1989]. Health workers had suffered heavy losses as a result of the storm and were expected to assist in the task of restoring order in the public sector. Yet they enjoyed no advantage in terms of personal relief [PAHO/WHO, 1989]. A Command Post was established at the Ministry of Health with the announcement of the Hurricane Watch on September 10 and efforts made to contact Medical Officers of Health to activate disaster plans. Because of inadequate communication links, these efforts were not all successful. The Ministry issued a press release on Sunday, September 11 urging all facilities to finalize patient discharge. The Command Post was manned until a.m. on September 12 when health workers left to look after their homes and belongings. Because of the lack of road worthy vehicles and damage to radio equipment, there was no contact between the Ministry of Health and the parishes until September 14. Neither was the Ministry able to assist in damage assessment or the distribution of relief supplies. In fact, the emergency found the island's health service so short of medical supplies that the Salvation Army made supplies available to medical personnel. While in some cases the shortage was absolute, in others it stemmed from the poor distribution system [PAHO/WHO, 1989]. The few health centers that were not damaged were besieged as relief centers, so priority was given to the restoration of services in the hospitals to enable them to offer emergency care. Emergency Surveillance for Infectious Diseases One week after the impact, the Caribbean Food and Nutrition Institute was requested by the Ministry of Health to co ordinate teams for a health and nutrition surveillance of the island. The instructions were to visit parish Medical Officers of Health and obtain information on health and nutrition and to make a rapid assessment of public health concerns. Under normal conditions epidemiological data from sentinel stations, which may be either hospitals or health centers, are supplied to the Ministry of Health once per month. This system was expanded to allow for the inclusion of disaster related data as well as data from three hospitals that are not normally sentinel stations. Forms A (disease surveillance) and B (public health) were distributed during the 5

10 visits. (See Appendix 1 and 2). Four teams visited l2 of the parishes during the week of September 19, while ten parishes were visited by three teams in the week of September 26. Each parish was visited at least once. Nine were visited twice. The teams were composed of physicians nurses and other members of the staff of the Epidemiological Unit of the Ministry of Health. A report was made to the Ministry at the end of the first week and a surveillance report was subsequently published [Patterson, 1988]. This system operated for ten days, from September 19 through 29. Data were collected from what was, in effect, a non random sample of sentinel stations and relief centers and this must be borne in mind when considering the number of reported cases. The surveillance report that was produced [Patterson, 1988] recorded the occurrence of specified diseases in "selected sentinel stations, three other hospitals and a few reporting shelters." A breakdown of the numbers of cases by the type of facility was not given. Neither were the number of sentinel stations, shelters and their locations known. In any case, as Patterson recorded, sentinel stations established in normal times are not appropriate in times of disaster. Key hospitals such the University Hospital of the West Indies are not designated sentinel stations although the U.H.W.I. was among the locations treating a large number of injured and ill persons. In addition, as mentioned earlier, the vast majority of shelters used during the emergency period comprised what was termed "unofficial shelters" without identifiable managers. Few parishes were able to give an accurate number of the shelters that had been established. Moreover, by the week beginning September 19 when the surveillance teams were mobilized, many of the centers had been closed. In two parishes all the centers had been closed by September 26. To these one must add the fact that many rural areas were inaccessible and a large number of persons isolated in these areas would have been unable to seek medical attention outside of the local areas [Patterson, 1988]. Data were collected during the two weeks beginning September 19 and September 26. Different centers, and in some cases, parishes, reported during those two weeks on occurrences commencing September 13. Only the findings of the second week were available for inclusion in the surveillance report. Original data had been given to the Ministry of Health because of an expressed urgency and had been misplaced and unavailable for inclusion. Discrepancies between the surveillance report and the figures subsequently produced by the Ministry of Health [Bullock DuCasse, 1989] create problems of interpretation. Although the Ministry's figures for the second period are identical to those given in the surveillance report, the two weekly reports are represented as a "trend" over the two week period [Bullock DuCasse, 1989]. Patterson stressed that even if the report of the first week should become available, the fact that the figures came from different centers means that the data are not comparable. There are other reasons why the suggestion of a trend should be avoided. The figures presented for the earlier period relate to 12 parishes those for the second week, ten parishes. The number of days covered by the two reports also differed. As the surveillance report concluded, "Accurate surveillance data were very difficult, if not impossible, to obtain during the emergency period..." Unfortunately, the results of the Ministry of Health's hospital survey which, under the circumstances, could have been most useful, and was reported as being "underway" in April 1989, were not available in August. No significant increase in the rate of communicable diseases was noted during the period [Bullock DuCasse, 1989]. There were, however, isolated outbreaks of gastroenteritis and an increase in the number of cases of trauma immediately after the hurricane. Table 1 provides the data collected during the two weeks during which the surveillance system operated. Table 1. Number of cases reported during the weeks beginning September 19 and September 26. Sept. 19 Sept. 26 Trauma Fever Gastroenteritis Skin rash Fever and cough Wheezing, SOB

11 Because of the shortcomings of the surveillance system already noted, no meaningful analysis of these figures could be undertaken. A retrospective analysis of attendance at three hospitals in the K.M.A. during the month of September 1988 was undertaken by the author. For the Bustamante Hospital for Children (BHC ) where disruption was minimal, both Casualty Department and Admissions records were studied. Analysis was restricted to the records of the Casualty Departments of the University Hospital of the West Indies (UHWI) and the Kingston Public Hospital (KPH). However, the PAHO/WHO study looked at hospital admissions in these two as well as in the Cornwall Regional, among Type A hospitals. Their sample also included Type B and C hospitals. The Bustamante Hospital for Children Casualty Department Gastroenteritis is, numerically, the single most important complaint seen at the BHC in normal times and this was true of the immediate post disaster period also. As Fig. 4 shows, the number of cases of gastroenteritis treated at the hospital on September 19, that is, one week after the storm increased sharply. The number treated on that day was 2.5 times the average for the seven days which preceded Hurricane Gilbert. From September 14, when near normal casualty services were restored, through September 30, about 324 cases were seen. As a percentage of total attendance, gastroenteritis increased in the same period (Fig. 5). The PAHO/WHO report also noted increases in Casualty attendance at the Spanish Town Hospital among children and adults. Vigorous treatment, which included administering of intravenous fluids and holding patients for twenty four hours observation, reduced the number admitted to the wards. Figure 4. Casualty attendance Bustamante Hospital for Children, September 5 30, 7

12 Figure 5. Casualty attendance Busbmante Hospital for Children, % of all case seen (3 day period). The number of cases of fever and skin ailments is shown in Fig. 6. The numbers are given for three day periods except for the last two days of the month. Three cases of conjunctivitis were treated between September 21 and 28. Figure 6. Casualty attendance Bustamante Hospital for Children (3 day period). Hospital Admissions Fig. 7 shows the number of admissions to the BHC over the 26 day period. The only unusual feature was the sharp drop in admissions on September 12 and 13 when only emergency cases were seen. The discharge rate for gastroenteritis for the month of September was 14.6 percent. This compares with a rate of 15.1 percent for 1986, the most recent figures available [Social and Economic Survey, 1988]. The 56 cases of gastroenteritis admitted during the month compares with a six month average of 57.6 for the K.M.A. in 1983 [Bailey, 1988]. 8

13 Casualty Departments, UHWI and KPH Analysis of the records of the Casualty Department of the UHMI is hampered by the fact that all or a part of the records of four days in September were missing (Fig. 8). However, in both institutions there was a rise in the number of injuries treated immediately after the hurricane. Figure 7. Admissions to Bustamante Hospital for Children (3 day period). Figure 8. Casualty attendance Univesity Hospital of the West Indies (3 day period). Fig. 9 shows the cases of asthma and trauma as a percentage of all patients treated at the KPH. In addition, at KPH, the number of gun shot wounds (10) seen on September 12, the day of Hurricane Gilbert, was five times the average treated in the seven days preceding the hurricane. These were mainly wounds inflicted by the security forces on looters. 9

14 Figure 9. Casualty attendance Kingston Public Hospital (3 day period). There were no significant increases in communicable disease patterns in the post disaster period. The PAHO/WHO report [1989] sees this as the result of the rapid institution of preventive measures which included the prompt attention to water quality monitoring and waste management, emergency measures for vector control, the focused activity in typhoid endemic areas, the rapid clearance of shelters, intensification of health education activities and the provision of funds to meet emergency needs at parish levels. Surveillance of Environmental Health and Water Quality With the assistance of PAHO, a surveillance system was put in place to monitor water quality and the water distribution system as well as sewage treatment plants and environmental conditions at hospitals and shelters. Teams composed of two members each visited water supply and treatment plants where samples for bacteriological analysis were taken and free residual chlorine determinations made. These activities continued until the end of October. There was also surveillance for vectors, especially the Aedes aegypti mosquito. Routine surveillance continued especially in known typhoid endemic areas. Except for those systems that were fed by gravity, all water systems were affected by the hurricane. Priority in restoration was given to those systems in which hospitals were located. Within two days, 30 percent of the service in the metropolitan area had been re established an intermittent basis [PAHO/WHO, 1989]. Within ten days of the hurricane, about 50 percent of the country's normal water supply had been restored. There were delays in rural areas largely because of the shortage of transportation and problems of access to plants in rugged localities [Barrett, 1989b]. Assistance with transportation was given by the Jamaica Defence Force and the USAID. In addition, PAHO and Medecins sans Frontieres provided 22 portable water tanks which helped to free up the hard pressed water trucks. The tanks were placed at central locations in rural communities and were filled by the water trucks. Canada donated two portable treatment plants which were located near Maggoty in St. Elizabeth and in Duckenfield in St. Thomas [Barrett, 1989]. These two areas have, in the past, had a high incidence of typhoid [PAHO/ECD]. Initial results indicated that water was unsafe for human consumption and monitoring began on September 14, with assistance from PAHO [PAHO/WHO,1989]. Tests were performed by four teams, first, in Kingston, and later in the rural areas. In the first round of sampling (September 26 30) a very high percentage of samples were found to have high bacteriological content and a low concentration of chlorine (Table 2). The Nwc was advised to increase and ensure continuous chlorination, to initiate sanitary surveys at points of high coliforms concentration and to recommend that the public boil water and use chlorine products. 10

15 Purification tablets were made available to members of the public by the Ministry of Health and the Jamaica Red Cross since the boiling of water was impossible in many cases. Considerable effort had to be exerted to counter alternative and ineffective suggestions in the news media for purifying water. In the second round of sampling, eight of the fifteen hospitals sampled had unsafe bacteriological water and nine low chlorine content [PAHO/ECD, Oct. 3 6).This represented an improvement in the bacteriological quality of the water (Table 2). However, at three hospitals the quality had deteriorated while at two others the quality, though improved, was still unsafe. Purification tablets, chlorine comparators and manual filter pumps were given to the ECD for distribution to the most needy hospitals. The third round of sampling found improved conditions and tests in November and December indicated that the water quality was back to normal [PAHO/WHO, 1989]. Table 2. Variation of Bacteriological Quality (bq) (% Pos.) and Low Chlorine Concentration (Ic) (% Low). PARISH SEPT OCT.3 6 OC (bq) (Ic) (bq) (Ic) (bq) (Ic) Clarendon Hanover Kingston/ St. Andrew Manchester Portland St. Ann St. Catherine St. Elizabeth St. James St. Mary St. Thomas Trelawny Westmoreland Source: PAHO/ECD, Oct With regards to excrete disposal and sanitation, many latrines were destroyed and sewage treatment plants made inoperative by a lack of electricity. There was, therefore, an increase of pollutants reaching water bodies. Of the 42 treatment plants visited by PAHo/EcD, only fifteen were fully and two partially operating. Fourteen samples were analyzed for Biochemical Oxygen Demand (BOD) and Suspended Solids (Ss). None of the discharges met the recommended discharge limits for BOD and only two met the discharge limits for SS. It was recommended that monitoring should continue until the end of 1988, expanded to cover all parishes and monthly reports on the characteristics of the effluent made. Maximum discharge limits were set at: BOD SS Total Coliform 20 mg/1 30 mg/1 200/100 ml Free Chlorine Residual 0.5 mg/1 Source: PAHO/ECD. The surveillance report found that few areas had addressed the problem of garbage disposal and that the numbers of vectors, especially flies and mosquitoes, were increasing [Patterson, 1988]. Some parishes had started oiling and fogging. PAHO/WHO [1989] recommended that an environmental health activities plan should be elaborated for public health inspectors based on water systems, sewage plants and dump sites. Survey and sampling forms should be created and the importance of reporting on these forms emphasized. They also recommended that equipment for monitoring, such as ph meters and chlorine comparators be acquired as soon as possible. They saw a need for the approval and gazetting of regulations for drinking water, soil and air pollution. Finally, 11

16 they emphasized the need for co operation and co ordination of activities between ECD and the PHC Unit and for a disaster plan involving public health inspectors. Routine Surveillance Routine surveillance based on operative sentinel stations and reports from physicians on the occurrence of a number of infectious diseases continued. Endemic areas for typhoid and leptospirosis were closely monitored and a close check was also kept on the incidence of malnutrition in children. Gastroenteritis: The reported incidence of gastroenteritis increased sharply in October. In fact, the figure for October was almost 26 percent that for the same month in The Surveillance Report [Patterson, 1988] maintains that there were almost as many cases among adults as among children. PAHO/WHO [1989], in a study of selected conditions in seven parishes, also reported an increase in admissions to hospitals in the period October 1988 to March 1989 (Table 3) over the period October 1987 to March 1988, despite a decline in annual totals between 1987 and This increase took place in all the institutions studied except the University and Noel Holmes hospitals where there has been a consistent decline, and in the Spanish Town Hospital for reasons previously mentioned [PAHO/WHO, 1989]. The parishes covered by the survey were Kingston/St. Andrew, St. Thomas, St. Mary, St. James, Hanover, Manchester and St. Catherine. Table 3. Admissions from a sample of hospitals, TOTAL TOTAL % OCT '.87 OCT ' 88 % CHANCE MARCH 88 MARCH 89 CHANCE Source: PAHO/WHO, In view of the declining trend in admissions for gastroenteritis prior to Hurricane Gilbert, and the damage to hospitals which would have discouraged admissions, the increase in admissions is significant [PAHO/WHO,1989]. Febrile Illness: Figures for febrile illness for 1987 are incomplete and this makes comparisons difficult. However, the figure for October 1988 was, roughly, 5 percent below that for The figures for early 1989 were also below those for the corresponding months of One suspects that the decrease in the post Gilbert period is not so much a reflection of an overall improvement as the dislocation in the health system and the inadequacy of the reporting system based on sentinel stations in situations such as these. The case of typhoid provides an excellent example of the problem. Typhoid: Seventeen cases of typhoid were reported between April and December 1988, nine in the period following the storm. Up to September 1989, the Epidemiological Unit of the Ministry of Health had no case on record for Yet, there was an outbreak in the parish of Westmoreland. It occurred in areas where the disease is endemic [Silva, 1989]. However, the first case, on November 23 was diagnosed as a viral illness [Dalina, 1989]. It was not until January that the disease was identified and by the end of March eleven of the suspected thirty six cases had been confirmed by laboratory. The outbreak occurred in three subdivisions of the Savanna la Mar Health District: Savanna la Mar, Smithfield, on the outskirts of the town, and Petersfield, to the northeast. It has been associated with the destruction of pit latrines by the hurricane and open defecation which followed. In so far as hospitalization was concerned, the number admitted has always been small and this makes the interpretation of the data difficult [PAHO/WHO, 1989]. Thirty cases were admitted between October 1987 and March 1988 in the hospitals visited. Only 12, however, were admitted between October 1988 and March 1989 [PAHO/WHO, 1989]. The emphasis on the rapid improvement in water quality, especially in endemic areas, and public education undoubtedly kept the situation under control. Immunization: There was a small increase in the number of BCG immunizations done in the post Gilbert period in most parishes. The increase in this activity in St. Mary, as shown in Table 4, was marked and involved health centre staff and volunteers including school principals who had previously received training in identifying and motivating families who could benefit from this programme [PAHO/WHO, 1989]. 12

17 Table 4. BCG Immunization by Parish Oct March 1988 and Oct March PARISH BCG IMMUNIZATIONS % CHANGE (1) (2) +/ Kingston/St. Andrew 5,694 7, St. Thomas 1, St. Mary 1,404 2, St. James 2,420 2,332 4 Hanover Manchester 1,733 1, St. Catherine 4,115 4,359 6 TOTAL 17,000 20, (1) Oct March 1988 (2) Oct March 1989 Source:PAHO/WHO, 1989 There was a decline in all other immunization programmes ranging from 10 percent in the case of measles to 21 percent in the case of polio. Here, too, the achievement of St. Mary was outstanding, it being the only parish to show an increase in the number of immunizations done in the post Gilbert period [Table 5]. Table 5. Changes in the level of Immunization against OPT, polio and measles by selected Parishes Oct March 1988 and Oct March PARISH IMMUNIZATIONS ( %+/ ) DPT POLIO MEASLES Kingston/St. Andrew St. Thomas St. Mary St. James Hanover Manchester St. Catherine Source: PAHO/WHO, 1989 The PAHO/WHO report warned that, in view of the decrease in the number of post disaster immunizations and the fact that the percentage of the 0 11 target population immunized against these diseases by the end of 1988 was well below expected levels (Table 6), a special effort should be targeted on Kingston and St. Andrew, St. Catherine and Hanover. A measles epidemic began in December 1989 and by January 31, 1990 more than 5,000 children had been infected and eight had died. [Epidemiological Unit]. The parishes that were most affected were Kingston and St. Andrew where the epidemic began and St. Catherine. Few cases have been reported from St. Mary. Table 6. Percentage of 0 11 year old age group immunized against DPT, polio and measles, 1987 and PARISH DPT POLIO MEASLES Kingston & St. Andrew St. Thomas St. Mary

18 St. James Hanover Manchester St. Catherine Thus, there was no significant increase in communicable diseases in the immediate post disaster period. This was due to the rapidity with which the surveillance of the environment was initiated, the attention given to the management of waste and vector control as well as an intensification of health education activities [PAHO/WHO, 1989]. Parishes were provided with the means to meet their emergency needs. An important element also was the fact that the population in relief shelters very quickly returned to their homes. Malnutrition: Fig. 10, based on figures obtained from the Nutrition Division of the Ministry of Health, shows the trend in moderate and severe malnutrition (Gomez Grades 11 and 111) ¹ It is clear from the figure that the upswing occurred well before the hurricane. The survey of seven parishes [PAHO/WHO, 1989] revealed a total of 5,900 reported cases in 1987 and 7,809 in 1988, an increase of 32 percent (Table 7). These figures refer to mild and moderate malnutrition (Gomez Grades I and 11). The increase in the period October 1988 to March 1989 over October 1987 to 1988 was marked in most of the parishes surveyed, but was particularly so in the parishes of St. Mary (134 percent! and Kingston/St. Andrew (72 percent). The average for the seven parishes was a 51 percent increase for the period. This could have resulted from increased vigilance in the wake of Gilbert or from improved record keeping [PAHO/WHO]. However, the level of the increase demands attention, especially since clinic statistics tend to underestimate parish wide prevalence [Rainford, 1987]. 1. The Gomez Classification is used to evaluate the nutritional status of children. It compares a child's actual weight, at a specific point of development, with the weight he/she should have, or normal weight, according to his/her chronological age. This determination is based on standardized international values. According to this classification, the severity of malnutrition is classified by grades: Grade I Grade II 75 85% of normal weight 60 75% of normal weight Grade III less than 60% of normal weight Figure 10. Jamaica children severely malnourished (Gomez Grades II & III). 14

19 There was no corresponding increase in hospital admissions, however. The reduction in available beds and the necessity for greater selectivity may could have contributed to this decline. Table 7. Reported cases of malnutrition in selected Parishes: 1987 and 1988; Oct March 1988; Oct March PARISH TOTAL TOTAL % CHANGE OCT.87 OCT.88 % CHANGE / MAR.88 MAR.89 +/ Kingston/ St. Andrew 2,009 2, , St. Thomas St. Mary St. James Hanover Manchester 752 1, St. Catherine 1,408 1, TOTAL 5,900 7, ,985 4, Summary There was an upward trend in the reported cases of gastroenteritis and malnutrition. The size of the increase in the cases of malnutrition was cause for concern and it was strongly recommended [PAHO/WHO, 1989] that further investigation be targeted on the parishes of St. Mary, Kingston/St. Andrew, Manchester, St. Thomas and St. James. In addition, the decline in the number of immunizations done post Gilbert suggested that special effort be targeted on Kingston/St. Andrew, St. Catherine and Hanover. Relief shelters A bout 44 percent of the housing stock in the island suffered some form of damage. Nearly 40 percent of the damage was sustained by the three populous southern parishes of Kingston/St. Andrew, St. Catherine and Clarendon. But Kingston/St. Andrew had, in fact, the lowest but one percentage damage to its stock [Ministry of Social Security]. It has been estimated that over 800,000 persons sought shelter, (Fig. 11) some as a precautionary measure before the storm [Reese, 1989]. 15

20 Figure 11. Number of persons in shelter September 14,1988. In the K.M.A. alone there were about 104 shelters [PAHO, Sept. 19, 1988] and 1,135 island wide (Table 8) [PAHO/WHO, 1989]. Table 8. Number of shelters In Parishes. PARISH 13 SEPTEMBER SEPTEMBER 1988 NO. OF SHELTERS Kingston/St. Andrew St. Catherine St. Thomas St. Mary Trelawny Clarendon St. James Hanover Manchester Westmoreland St. Elizabeth St. Ann Portland TOTAL 555 1,135 Source: PAHO/WHO, /989. NO. OF SHELTERS However, many whose homes had not been affected or who were able to find accommodation with relatives, left immediately after. Within three weeks of the hurricane, most shelters had been closed. In Port Maria, for example, of the 4,250 persons in shelters on September 13, 575 remained on September 25 [PAHO/WHO, 1989]. This action, it was felt, averted a potentially grave situation [Patterson, 1989] for the schools and churches which served as shelters were not, for the most part, designated as such and had neither the services nor the managerial staff to cope with the large numbers seeking shelter. Even where shelters were designated, 16

21 shelter managers did not report for duty because of personal losses [Reese, 1989] or impassable roads. The high level of vandalism to shelters and the unsanitary conditions which prevailed at so many can be directly attributed to the absence of trained managers at the shelters [Collymore, 1989]. TWO days after the storm PAHO engineers and the staff of the Environmental Control Division of the Ministry of Health made a rapid survey of shelters. They found sanitary conditions at the shelters critical as a result of the lack of water. Open defecation was common. They recommended that Public Health Inspectors be assigned to organize shelters for the digging of pits for the disposal of both excrete and solid waste. An assessment of environmental health problems in 23 shelters in urban and rural areas is given in Table 9. Nearly 61 percent of shelters in the metropolitan area visited during the first week had serious environmental health conditions. Rural shelters were worse with respect to water quality, refuse collection and disposal [PAHO/WHO,1989]. Table 9. Environmental conditions in shelters. URBAN SHELTERS RURAL SHELTERS VISITED SEPT VISITED SEPT Adequate amount of water 59% 53% Adequate quality of water 49% 30% Excreta disposal through water closets 82% 93% Adequacy of disposal 71 % 66% Adequacy of refuse disposal 58% 40% Collection of refuse 42% 46% The condition of those families which remained in relief centers was the subject of numerous reports in the news media. A tent settlement at Poor Man's Corner in St. Thomas and a number of families in the National Arena in the K.M.A. remained until April They were made homeless by the storm. The earliest occupants of the National Arena arrived on the evening of Sunday, September 11 from the nearby communities of Mountain View Avenue and Vineyard Town. In the days that followed, the homeless in those shelters, both within the K.M.A. and nearby parishes, (Fig. 12) that were either damaged by the hurricane or needed for their normal activities, were sent to the Arena. On September 19, a PAHO/ECD report put the number of victims in the Arena at 160. On January 21 there were 32 families being housed at the National Arena comprising 131 individuals [Department of Geography, 1989]. 17

22 Figure 12. Origin of hurricane victims at National Arena, February There were twenty one reported cases of illness in the two week period ending January 21, 1989, eighteen of which were in the under fifteen population [Department of Geography, 1989]. This amounted to an incidence rate among children of 300 per thousand. This compares with a rate of 108 per thousand for the same period in Enumeration District (ED) 73 of the nearby low income community of Swallowfield. Colds, asthma and gastroenteritis were the most common complaints. The average family size in ED 73 was almost identical to that in the Arena at 4.1. The survey here was restricted to those households that had suffered loss from the hurricane. A similar survey of ED 73 in February 1987 [Department of Geography, 1987] revealed an incidence rate among the under fifteen population of 162 per thousand. Thus, the incidence of disease in low income Swallowfield was lower than one year earlier and less than one third of the rate reported for the National Arena. Preparedness and response The PAHO/WHO [1989] survey of seven parishes revealed an information gap with regard to disaster management in the health sector. At the primary care level, 17 percent of the staff knew of the disaster management structure at the Ministry Headquarters. Fifty seven percent knew of the structure at the local level. The situation was better in the secondary care system in that 50 percent of staff knew of the structure at Ministry Headquarters and 75 percent in their own institution. 18

23 Other serious limitations were identified. emergency medical and non medical supplies were inadequate and irregular there were serious deficiencies with regard to medical equipment serious deficiencies with regard to transportation and communication existed there was a shortage of manpower and an inadequate mix The relative lack of preparedness of the health sector was underscored by the fact that the Disaster Plan at the Ministry of Health had not been completed. Where one existed at the parish level, it could not be brought into operation because of a resource gap. Disaster plans for some hospitals existed but they had not been activated. In addition, simulation exercises had not been carried out. Devolution of authority was seen as being necessary in a disaster. There was the feeling among field staff that they had to await directives from the central level before taking administrative actions. Devolution, however, would call for access to emergency funds, clear guidelines as to the type of responses that were appropriate at the local level and close co ordination with the Parish Disaster Preparedness and Response Programme. The survey also emphasized the need for greater speed with initial damage and needs assessments and for greater accuracy in identifying real emergency needs. Backup systems for water supply, power and radio communication should be provided at all hospitals and health centers. The report recognized the dedication of health service personnel who, though lacking the necessary support, proved an important resource in the wake of Hurricane Gilbert. The will to continue in the face of adversity should be encouraged by the development of local self sufficiency. Lessons learned This hurricane has taught us all that a system that is unable to cope in normal times should not be expected to work in disaster situations" [Bullock DuCasse, 1989]. The Caribbean region has had to cope with the effects of several tropical storms, surface flooding and landslides in recent decades. These events have sensitized leaders to the need for disaster planning and emergency management. As Collymore [1989] observes, Hurricane Gilbert has provided the region with a number of lessons which can inform the character of disaster planning in the region. Epidemiological surveillance is of fundamental importance in any program of disease control following a disaster. Since the hurricane affected the entire country, data collection was difficult. The emergency surveillance of infectious diseases started late and ended far too early. Leus believes that the system should continue at least two months after the disaster, "or at least as long as disaster relief activities take place on any scale." The system following Hurricane Gilbert lasted barely two weeks, ending before the admittedly tardy relief program got off the ground. This was all the more regrettable in view of the inadequacies of the normal surveillance system in disaster times and the fact that limited resources prevented its strengthening. The preparedness and capability of the health sector for disaster response must be enhanced. To this end there is an urgent need to finalize the Disaster Plan of the Ministry of Health and to prepare hospital as well as parish disaster plans for the health sector. Simulation exercises should be conducted regularly in all parishes. Planning must be decentralized. The destruction of the communication system road, radio, telephone meant that it was impossible for the Ministry to communicate with the field for many days after the storm and many communities were isolated in the critical emergency period. Hence, disaster plans which depend on communication and transportation should be avoided. The affected communities must be in a position to respond to their own needs in the immediate post disaster period. The transport capability of the health sector should be improved. Consideration should be given to a standardization policy for the purchase of new vehicles. The appropriate staff should be trained in the use and the maintenance of these vehicles and a replacement policy for vehicles should be introduced. Transportation agencies within communities should be encouraged to give support to the health sector in an emergency. 19