Disaster Medicine: What’s the Reality? Thomas D. Kirsch, MD, MPH, and Edbert B. Hsu, MD, MPH W hat is “disaster medicine”? What are the essential health care needs following a disaster and how can we optimally respond to them? What ap- proaches can we take to address these areas? The article in this issue by Sharma et al 1 raises these important questions, and provides direction to some answers. Historically, disaster medicine was modeled after the emer- gency surgical response to war casualties, as emulated by the International Committee of the Red Cross’ response to con- flict. In the United States, the original Disaster Medical Assistance Teams focused on acute injury interventions, but as we began studying the health issues of disaster victims, particularly in international settings, the importance of pri- mary care, chronic diseases, and public health issues was gradually revealed. 2 International response to disasters, espe- cially humanitarian crises, has long focused on interventions addressing these issues, but domestically we still lag, often deploying specialist teams to care for potential acute injury and illness when different resources are in greater need. A new understanding of this reality is reflected in the title of this journal, Disaster Medicine and Public Health Preparedness, which highlights the increasingly recognized and essential roles of public health along with primary care and preventive medicine. Societal factors exacerbate the demand for primary care fol- lowing a disaster. From the outset, vulnerable populations have limited resources and access to health care. Medically underserved populations already bear higher rates of chronic illness and lack adequate preventive care and treatment. This leaves them especially susceptible to disruptions in the health care system, particularly those that affect the public health system. Disasters have a profound impact on these groups, greatly exacerbating needs arising from chronic illnesses or other tenuous baseline health conditions. Numerous reports from Katrina reflect the importance of primary care for the affected population. 3–7 Sharma et al noted that nearly one fourth of all health care visits were for chronic disease and related conditions (CDRCs). The pro- portion of visits for CDRCs increased with age, and hospi- talization rates among those with CDRCs were considerably higher than those for other groups. Our own experience with the American Red Cross when conducting a health assess- ment among sheltered populations after Katrina found even higher rates of chronic illness. 3 This raises the question of whether specific planning and resources could prevent wors- ening of chronic medical conditions, which may in turn reduce the burden on an already overwhelmed health care system. Hurricane Katrina was a unique event, with the complete disruption of a health care system and mass popu- lation movements not seen in the United States since the Civil War. However, other major disaster events have similar potential to wreak havoc on an even greater scale—a pan- demic outbreak or a massive earthquake readily come to mind. It is possible that the health needs following a disaster will vary greatly by location and type of event, but data remain limited. Clearly, many types of disasters can result in exten- sive injuries that may overwhelm an intact health care sys- tem. Some events may destroy large segments of the health care infrastructure by physically damaging building and trans- portation systems. Even then, after the immediate response phase and care for the injured, it will be the primary and chronic health care issues among affected populations that have the greatest long-term consequences. A major barrier to improvement of health care response following disasters is the difficulty of collecting accurate data. In the immediate aftermath of an event, implementing a practical study design and collection of accurate data is no simple task, affected in large part by factors ranging from the frenzied environment and highly mobile populations to un- clear denominators and lack of universally accepted indica- tors. This often limits our ability to generalize findings and determine effectiveness of health-related interventions. Moreover, during the midst of a disaster response, capturing information that will be of potential long-term benefit for future events often is the last thing on everyone’s mind. Although disaster response efforts cannot be hampered by investigation, it is only by adopting a systematic approach to determine what happens that we are able to obtain essential insight into actual needs, what was done to address those needs, and whether measures taken were effective. Too often, valuable information is lost in the chaotic aftermath of an event. For instance, in this study, gathering of surveillance data was only possible nearly 1 week after the hurricane made landfall. The authors faced other inherent difficulties of disaster research. Because the surveillance system was not intended to identify CDRCs, ambiguity of reported symptoms led to challenges concerning classification. Despite these EDITORIAL Invited Commentary Disaster Medicine and Public Health Preparedness 11