This new Journal, starting with volume 1, number 1, Spring 1985, is an official publication of the World Association for Emergency and Disaster Medicine (WAEDM), formerly called the Club of Mainz. The Journal is cosponsored by the League of Red Cross and Red Crescent Societies (LRCS). The Journal is owned and published by the WAEDM. There will be 4 Journal numbers per year, plus an occasional supplement.

We initiated this Journal and its predecessor (see below) because existing journals on disasters focus on sociologic and epidemiologic topics, and more on aid to uninjured survivors and rehabilitation of disaster-stricken regions, than on the resuscitation and life support of severely injured victims. Disaster medicine is not yet a science, and thus based primarily on anecdotal reports. It is in need of international communication and the acquisition of quantifiable facts. The Journal will help meet these needs by examining the potentials of resuscitation, emergency medical care and critical care (intensive care) medicine for everyday Emergency Medical Services (EMS) and for disaster medicine. The disasters to consider range from multi-casualty incidents to mass disasters and endemic disasters. Other organizations emphasize response to mass disasters after days or weeks; the WAEDM emphasizes response within minutes to hours. This Journal will benefit medical and nonmedical members of the WAEDM and the LRCS, as well as non-member specialists in anesthesiology, critical care medicine, cardiology, emergency medicine, epidemiology, forensic medicine, government medicine, infectious diseases, military medicine, nuclear medicine, nutrition, pathology, public health, resuscitology, surgery, toxicology, and traumatology.

The “Club of Mainz” for Improved Emergency and Disaster Medicine Worldwide was conceived in 1973 and founded in 1976 by about 10 reanimatologists under the leadership of the late Rudolf Frey (Crit Care Med 6:389, 1978). Its objectives are: “(1) to foster optimal resuscitation and life support methodologies worldwide; (2) to concern itself with a range from everyday emergencies to mass disasters, with appropriate consideration for differences in populations, available resources and other factors; and (3) to informally pursue the objectives by combining the resources of scientific, social and related information and experiences, together with international communication and collaboration.”

The Club of Mainz recognizes the experiences and contributions of other organizations for public health related disaster relief, which particularly helps uninjured survivors and rehabilitates regions, but wishes to add the potentials of modern resuscitation (emergency and critical care medicine), focusing on the acutely ill or injured individual victim in distress.

The Club of Mainz was inspired by the Club of Rome, which was initiated in 1968 by the late Aurelio Peccei and some other concerned non-medical leaders and scientists. The 10 non-medical key problems identified by the Club of Rome have equivalents for disaster medicine: (1) overpopulation (starvation); (2) no long range planning; (3) destruction of the environment (destruction of people); (4) business crises; (5) competitive armament leading to wars; (6) poverty (starvation, epidemics); (7) chaotic development in science and technology; (8) antiquated institutions; (9) schisms between East and West and between North and South; and (10) lacking moral leadership.

The “International Red Cross” is composed of: (1) The International Committee of the Red Cross (ICRC) which focuses on war victims; (2) the LRCS; and (3) the 130 National Red Cross and Red Crescent Societies worldwide which are federated by the LRCS. The LRCS was founded to facilitate, encourage and promote the humanitarian activities of its member societies and thus contribute to the promotion of peace in the world. The LRCS considers health as one of the keys to a better world for everyone. Red Cross programs include the training of nursing personnel, the provision of health care in rural areas, the organization of assistance to the sick, aged, and handicapped, and teaching first aid skills to lay people.

The Red Cross bases its actions on seven principles: (1) Humanity; (2) Impartiality; (3) Neutrality; (4) Independence; (5) Voluntary Service; (6) Unity; and (7) Universality.

The LRCS assists national societies in improving their disaster relief preparedness through the following functions: (1) to encourage, facilitate and assist in the establishment of a national disaster relief plan; (2) to give technical assistance to national Red Cross societies by sending delegates and equipment and/or by giving cash grants; (3) to convene seminars and conferences to help exchange opinions and share experiences; (4) to train qualified personnel; and (5) to maintain contact with other international governmental and non-governmental organizations. These include the United Nations Disaster Relief Organization (UNDRO); the World Health Organization (WHO); the International Children's Fund (UNICEF); the World Meteorological Organization (WMO); the Food and Agricultural Organization/World Food Program (FAO/WFP); the UN High Commissioner for Refugees (UNHR); and the United Nations Education Scientific and Cultural Organization (UNESCO).

In discussions of the pathogenesis of posttraumatic respiratory distress syndrome (adult respiratory distress syndrome, ARDS), thromboembolism or microembolism (6) is the most frequently suggested mechanism. Embolic material released from the site of injury and/or intravascularly formed aggregates of platelets and fibrin are thought to plug the pulmonary capillaries, giving rise to diffuse pulmonary damage. Pulmonary trapping of platelets and fibrin has been studied in various animal models in which intravascular aggregation was induced pharmacologically, without trauma (2). Studies in patients with ARDS are difficult to standardize, and the results therefore are often inconclusive. We have evolved an experimental model (5) by means of which changes identical to ARDS can be induced from reproducible musculoskeletal trauma in anesthetized pigs. The pigs are observed under anesthesia for three days after the trauma under standardized and carefully controlled conditions. The aim of the present study was to use this model for registration and monitoring of pulmonary trapping of platelets and fibrin in animals with ARDS following standardized trauma, without adding any pharmacologic substance that could influence platelet aggregation or fibrinolysis. Pulmonary trapping was determined by external detection of 51Cr-labeled homologous platelets and 125I-labeled human fibrinogen, intravenously administered before anesthesia and trauma.

Adult respiratory distress syndrome (ARDS) is the most fatal complication after severe trauma (1,3). ARDS is seen in multiple injured patients with fractures and the risk for ARDS increases with the number of fractures (9). One of the theories concerning the etiology in ARDS is, that tissue thromboplastine from the site of the fracture and surrounding soft tissue activates the coagulation system resulting in pulmonary microembolism (6). Riska (8) has noticed by clinical experience that increased frequency of early fracture stabilization by internal fixation in multiply injured patients has dramatically reduced the frequency of post-traumatic respiratory insufficiency. The aim of the present study was to investigate the effect of primary fracture immobilization on post-traumatic pulmonary changes in pigs. We used a model in which anesthetized pigs can be subjected to trauma and then observed for several days, while still under anesthesia, under careful respiratory and circulatory control, by means of repeated chest x-rays and postmortem macroscopic and microscopic examination of lung tissue.

Twenty-six pigs (Swedish Landrace), weight 17–23 kg were used. Chest x-rays were done in all animals before the experiment excluding those pigs with any pulmonary changes. The pigs were anesthetized with pentobarbital and pethidine, and tracheostomy, carotid artery cateterization and cystostomy were performed.

There has recently been a steady increase in the number of patients treated in intensive care units (ICUs) and requiring resuscitation. This number has risen from 1 to 3% in patients after cardiac arrest (19) and from 7 to 13% in those with severe injuries (18). The immune system investigations, introduced more and more widely in intensive care medicine for prophylactic, therapeutic and prognostic reasons, did not, in principle, concern the cases of post-resuscitation disease after cardiac arrest. Only a few reports have been published on this subject (11).

The aims of our investigations were the analysis of selected humoral and cellular factors in patients after cardiac arrest in comparison to those with multiple injuries, evaluation of the host resisctance against infection and of prognostic values of some immunological indices.

Examinations were carried out in 50 patients, treated in an ICU of 15 beds, from 1981 to 1982, and in 20 healthy volunteers. The patients were divided into two main groups (Fig. 1): The first group consisted of 25 patients after cardiac arrest, age 47±12. The second group consisted of 25 patients after severe multiple injuries, age 42±18 y; they corresponded to an abbreviated injury scale (AIS) of 4–6 (8). 56% of the patients with cardiac arrest could not be resuscitated. In 64% of the trauma patients treatment was unsuccessful. Infection complications, influencing recovery were observed in 10 (40%) after cardiac arrest and in 12 (48%) after trauma. The cardiopulmonary-cerebral resuscitation methods used were standard (16).

Drugs for CPR need reinvestigation; at the present time their use is as much an art as a science (14). American Heart Associations standards and guidelines and other recommendations for CPR call for the administration of 500 mg CaC12 i.v. routinely, in attempts to resuscitate patients with asystole or electromechanical dissociation (1). However, calcium's popularity for use in restarting the arrested heart has fallen (3,6,14).

There is a lack of evidence in the literature for calcium's supposed beneficial role in cardiac resuscitation. Calcium in combination with epinephrine — the traditional drug of choice in CPR — was not experimentally investigated before. On the other hand, the effects of calcium antagonists were never examined in CPR, but several theoretical considerations seemed to favor their use. However, a proposed use of calcium antagonists during CPR would lead to the withdrawal of current recommendations for the use of calcium.

Rapid and repeated administration of concentrated NaHCO3 solutions during cardiopulmonary resuscitation (CPR) has become routine since the advent of modern resuscitation techniques (1), although it has been pointed out since the early 1960s that acidemia results from prolonged arrest time and that brief arrests may not require NaHCO3 administration (6,8,13). In spite of the widespread use of large amounts of NaHCO3 there is no convincing evidence that the routine use of this drug offers a clear benefit. Only a few studies have been undertaken to ascertain the role of acidosis and acidemia in survival from cardiac arrest, and the possibility of overcorrecting with NaHCO3 in CPR cases (3,4,8,11). Therefore, the intention of this study was: 1) to clarify the role of acidemia in CPR; 2) to investigate the effects of overcorrection of acidemia (leading to metabolic alkalemia; 3) to test the accurate doses of NaHCO3; 4) to examine the optimal sequence of drug administration in CPR, i.e., whether NaHCO3 or epinephrine should be administered as the first drug.

During attempts at restoring spontaneous circulation (CPCR Phase II, advanced life support) (12), and during post-CPR prolonged life support (CPCR Phase III) (12), measurements were made in dogs following resuscitation from asphyxial cardiac arrest. The model and methods used have been described in the preceding paper of this Journal. Asphyxial cardiac arrest (mechanical asystole, electromechanical dissociation) was reversed with open-chest CPR and defibrillation as necessary to 20 min max.

Profound hypothermia has a high mortality if not treated with active rewarming. Most successful is central core rewarming. Many methods have been designed for this purpose: mediastinal irrigation, colon irrigation, peritoneal dialysis, and warm water via a Sengstaken-Blakemore esophageal tube.

A new esophageal tube was constructed for this study. The tube consists of a small, stiff and narrow inner tube, placed inside a larger thinwalled outer tube. Warm water (41-42°C) is circulated from a waterbath via the inner tube to the outer tube and then back to the waterbath. Five healthy mongrel dogs were anesthetized, intubated and made hypothermic. All dogs were paralyzed with pancuronium to eliminate shivering. The only fluid given was isotonic saline to compensate urine loss (50-75 ml/hour). At a core temperature below 30°C the esophageal tube was inserted, and rewarming started when temperatures had reached 27.1-24.7°C. Rectal and peripheral temperatures were monitored, and in 3 dogs blood temperature was also followed.

Up to the cardiac safety temperature (31°C) the blood temperature increased 4.6°C ± 0.79 (SD) (Fig. 1, whereas the rectal temperature rose 3.74°C ± 0.76 (SD) (Fig. 2). The peripheral temperature showed only a minor increase below a central core temperature of 30°C. This means that a secondary temperature decrease is eliminated with this method. No cardiac arrhythmias or other complications were noted. these results correspond to those with peritoneal dialysis (1), and show a greater temperature rise than with use of a modified Sengstaken-Blakemore tube (2). (Supported by the Danish Medical Research Council.)

The Critical Care Medicine department, St. Jans hospital, Brugge, has a prehospital emergency medicine service (EMS) staffed by experienced intensive care specialists. We have been involved in clinical research for the improvement of cerebral outcome after circulatory arrest (CA) and cardiopulmonary resuscitation (CPR) since 1977. In 1982, 250 patients in CA were resuscitated from an area of about 150,000 people. There were 70 short-term survivals, 30 longtime survivals. Although the success rate of CPR is highly influenced by important EMS related factors, including response time, a substantial proportion of hearts are restarted also after prolonged CA, but the patients die later in brain failure. There is evidence that the brain is not only damaged by the CA itself, but that lesions after restoration of spontaneous circulation (ROSC) progress and are amenable to therapy. We can illustrate the progressivity of brain lesions by two phenomena: 1) Animal experiments in other centers (P. Safar, J. Michenfelder) and our research at Janssen Pharmaceutics, Beerse, Belgium. Cerebral venous blood was sampled from the sagittal sinus after a prolonged CA (10 min); cerebral venous PO2 of 40-60 mmHg before CA, rose to 80-100 mmHg immediately after ROSC and about 1-2 h after ROSC decreased to 20-30 mmHg — indicating progressive failure of oxygen transport. 2) Cerebrospinal fluid (CSF) enzyme activity was studied after CA in humans. We correlated final neurological outcome with the early appearance (at 2k h) of lytic enzymes in the CSF. In some patients who later recover neurologically only partially, CSF enzymes are still low at 2k h, as if the cells are still viable at this stage.

Present national and international guidelines for resuscitation call for open-chest cardiopulmonary resuscitation (CPR) instead of standard external CPR under the following circumstances associated with pulselessness:

1) chest already open;

2) penetrating thoracic trauma;

3) suspected intrathoracic hemorrhage;

4) suspected pulmonary embolism (thoracotomy permits disruption or removal of emboli);

5) deep hypothermia (open chest allows direct warming of the heart for defibrillation); and

6) no palpable artificial pulse during standard external CPR basic life support, as is sometimes encountered in cases of barrel chest or spine deformities.

We will present evidence in support of a 7th indication, that is when standard external CPR advanced life support efforts do not result in the prompt restoration of spontaneous circulation, as may be the case after prolonged unwitnessed cardiac arrest or in patients with severe myocardial disease.

Historically, open-chest CPR has been used effectively to reverse cardiac arrest in laboratory animals since the 1980s and in patients since 1900. We conducted interviews with Drs. DelGuercio, Johnson, Stephenson and Leighninger (for Beck), who have had extensive experience with open-chest CPR. All confirmed personal experience of one of us (PS) with open-chest CPR in the 1950s, and anecdotal reports, that during direct cardiac massage, the heart usually regained color, spontaneous breathing returned, survivors had a very low incidence of neurologic deficit, and complications were almost non-existent. Stephenson's review of 1200 cases of open-chest CPR hospital-wide between 1900 and 1950 (1) report an overall recovery rate of 30%. However, after Kouwenhoven's report on closed-chest CPR in 1960 (2), open-chest CPR became a forgotten art.

Since standard cardiopulmonary resuscitation (SCPR) cannot reliably preserve the brain during resuscitation, a “New” CPR has been proposed, which seeks to augment blood flow by increasing peak intrathoracic pressure (ITP) during chest compression. This “New” CPR (NCPR) consists of a) high pressure ventilation (70-110 cmH2O) simultaneous with chest compression, b) compression rate of 40/min, c) compression duration of 60% of the compression relaxation cycle, and d) abdominal binding. Although laboratory evidence suggests that NCPR may be capable of augmenting cerebral blood flow (1), the effect on cerebral outcome remains to be demonstrated.

Although the hemodynamic superiority of open-chest CPR has long been recognized, its advantages with respect to the brain have only recently been recognized. It can reliably sustain EEC activity and pupillary light reflexes during CPR (2) as well as providing better cerebral blood flow (3,4). The objective of this two phase study was to establish the relative efficacy of standard, “new,” and open-chest CPR with respect to preserving the brain during CPR.

The objective of phase I of this study was to compare standard and “New” CPR with respect to maintenance of hemodynamic, respiratory, and cerebral variables during prolonged resuscitation. Methods: Ten 10-15 kg dogs were anesthetized with halothane and 50% N2O/O2. Catheters were placed in the carotid artery, aortic arch, right atrium, external jugular vein and the sagittal sinus. An electromagnetic flowprobe was placed on the common carotid artery. Intracranial pressure was monitored with a subdural catheter. EEG electrodes were secured to the skull.

Reduced glytathione (GSH) is the tripeptide of glycine, cysteine and glutamic acid and is widely distributed in the body. FSH has been reported to comprise at least 90% of the nonprotein sulfhydryl (NPSH). Although the role of GSH in the tissue has not been clearly established, it is known to be a cofactor for enzymes, a substrate in detoxifications, and a free radical scavenger.

Several investigators have reported that the level of NPSH, mainly GSH, in the tissue was decreased in several types of shock and that exogenous administration of GSH has beneficial effects on shock (1,2). This study was designed to evaluate the effects of GSH on the survival rate in mice and the hepatic energy metabolism in rats after administration of endotoxin. These results were compared with those of methylprednisolone sodium succinate (MP), since many investigators have reported that the large doses of glucocorticoid have beneficial effects in several types of shock in experimental animals and in man (3,4).

The aim of primary air rescue is to assist the ground-level rescue services by bringing emergency physicians and rescue assistants more quickly to the scene of the accident, and, if necessary, to carry but the swiftest possible and most careful transport of emergency patients to the nearest suitable hospital. Furthermore, the rescue helicopter can substitute for the ambulance car in case of unsuitable terrain, or in certain climatic conditions.

Limitations of helicopter services include night, certain weather conditions, cost and distance. Helicopters are centered in Air Rescue Centres which have an operational radius of 30-50 km. Expense permits only one helicopter to be stationed in each center, but if the helicopter is not able to fly, a replacement machine must be available immediately. Secondary rescue operations should be taken over by neighboring centers.

In 1983, the Federal Republic of Germany had 36 officially recognized helicopter centers concerned with primary air rescue. They are supported by the Federal Home Office (emergency control) (18 centers), the Army (6), the German Air Rescue (5), the ADAC (German Automobile Club) (4), and other organizations (3). The Swiss Air Rescue in Basel, Switzerland covers Germany's area of South Baden, and the French Air Rescue in Strasbourg covers middle Baden.

Eugene Ionesco once remarked that an excess of politics and an exaggeration of sports are characteristics of our contemporary civilization. The excess of politization affects all parts of our public life, including medicine and its specialty Disaster Medicine. Political ideologies try to usurp a field that has solely humanitarian objectives, that depends on providing for and applying relief to many people in acute distress. There are already many relief organizations and ambulance services, physician staffed emergency medical services systems and first aid trained laymen. There are state and federal disaster relief authorities. Why then was it necessary to add another organization to this sometimes confusing manifold, the German Society on Disaster Medicine?

Emergency medicine is for the individual. It must provide optimal care for each single injured or sick person — except for the shortterm management of multiple casualties. Emergency medical missions are limited by time and locality. These missions are hospital services extended to the scene of the accident and work in connection with hospitals. Disaster medicine is for the masses. Its task is to do the best possible for the largest number of people at the right time and at the right place. This implies that in a disaster situation, optimal care for every single individual can and should not be the goal, but rather the best possible care for the largest number. Disaster medicine has to work in large areas, supraregional and long-term. It needs numerous treatment facilities and several steps or levels of treatment. Therefore it requires a firm medical coordination of lay help, primary professional help, transportation, and specialized hospital treatment with maximal efficiency.

In Sweden as in most countries there has been an increasing use of airborne transports for medical purposes during the last decade (Fig. 1). The majority of these transports have been made by helicopters. The climate and the geographical position of Sweden in the far north of Europe presents problems to a helicopter rescue organization. The area of Sweden is approximately 400,000 square kilometers, which is a little more than that of Italy and less than that of France. There are about 8.5 mill, inhabitants which means an average of 20 per square kilometer. The population is unevenly distributed. There are only three densely populated areas: around Stockholm, around Gothenburgh and in the southern most part of Sweden with 250 respectively 150 inhabitants per square kilometer. In the middle and in the north of Sweden there are less than 5 persons per square kilometer. In the mountain regions there are even less. Temperatures ranging from about +25°C in summertime to below - 20°C in the winter are not uncommon.

There is a nationwide alarm system with a common telephone number for all emergency situations and alarm centers, which direct a call for assistance to the proper rescue organization. Almost all medical services in Sweden are provided by regional governments. Adequately equipped and staffed hospitals exist all over the country. The roads are generally of good quality, but outside the urban areas the distance from the place of an accident or a medical emergency to a hospital is usually great.

The aim of this planning project is to ensure prompt and efficient emergency health services to all people in the regional territory of Tuscany, and to establish suitable conditions for an efficient intervention by the National Health Service in situations brought about by unforeseen events which may have serious, often disastrous, consequences. This effort — quite demanding from an organizational and economic point of view — may be successful only if we assume that the time-space unpredictability of emergencies cannot be understood in absolute terms, but in relation to a series of conditions and situations present in everyday reality. Only by reducing to the minimum the unpredictability factor both quantitatively and qualitatively this purpose can be achieved. Risk factors should thus be accurately related to the territory's population distribution, geomorphology, and socio-health conditions.

Since emergency medical care must be carried out without delay, each response must involve all components, concomitantly or in sequence so that the intervention is not regarded as concluded at any one stage. It must be open to integration best suited to the situation. There is need for a multidisciplinary approach to emergencies from the first response to definitive care.

The model of health services planning necessary to achieve all this envisages a series of interventions — 1) to develop interconnections between intramural medicine and health services carried out in the field in order to allow rational use of existing structures, such as the emergency department; 2) to establish coordination focal points which can ensure, outside a hospital, the same level of treatment in emergency situations that will be carried out intramurally, despite the unavoidable changes in methodology; and 3) to activate information and self-training programs designed to encourage the development of a cultural and operative relationship between the health services and the needs of the community.

By definition, hospitals should be among the places with the highest safety index (1). But often, on these premises, we have occasional accidents which may be dangerous and which illustrate the way hospitals are exposed to various and often undervalued risks.

The incidences of unforeseen, dangerous situations involving sudden accidents, of uncontrollable emergency conditions and also of larger catastrophes are awful. Recent accidents proved inadequate safety inside hospitals. In Parma (2) escaping gas was followed by an explosion that destroyed a division of the hospital and resulted in wounded and dead. In Mondovi, an explosion in the central heating system of the hospital caused the death of an employee. A fire that broke out in an old people's home in Southern Italy brought about the death of three persons. The first shocks of the earthquake in 1980 caused the death of many patients and staff (including six physicians) in the so called “safe” hospital of San Angelo Dei Lombardi. In the earthquake in 1976 many patients and some personnel of the hospital staff in Gemona, Friuli lost their lives (3)

Apparently these facts are not closely linked together. Some were caused by human error, others by inadequacy of buildings, age of structures, even where the disaster was due to natural causes. However all these events show the presence of the common denominator of “high risk,” typical of hospital structures (4,5). The principle dangerous situations are: (a) risks coming from the structures of the premises (no earthquake-proof principles of modular structure); and (b) risks connected with the working activities (6,7).

Our belief that there is a superagency that goes to work when a disaster occurs is unfounded. What does exist is a network of integrating expertise and resources that are escalated from different routine activities to cooperatively respond to one event. This paper concerns the governmental approach in one area, New York City.

In the United States, federal and state laws exist to minimize the effects of disasters, by identifying measures to prevent or mitigate them, developing mechanisms to coordinate the use of resource and manpower during disasters, and by providing recovery and redevelopment following a disaster. These functions and services are coordinated to the maximum extent with comparable activities of local state and federal governments, and many voluntary private agencies. Organizational responsibility follows a bi-directional flow from federal to state to county-, city-, town- and village level, and in the reverse (Fig. 1). The roles and responsibilities depend on the type of disaster (Fig. 2) and hence the response and activity needed. Response activities include need for clothing, crisis counseling, debris removal and disposal, disease and pest control, equipment and supplies, evacuation, food provisions, fuel provisions, housing and shelter, identification and disposition of the dead, labor pools, law and order, medical care and treatment, power provision, protective measures, search and rescue, sewage control, transportation, the need to waiver codes, water provisions, and weather forecasting.

International organizations such as the World Association for Emergency and Disaster Medicine (Club of Mainz) have brought attention to the need for improved worldwide emergency medical services (EMS) systems and disaster preparedness (1). Similar concerns in the United States (US) for improved emergency medical care have resulted in the organization of emergency medicine as a new medical specialty (2). The practice of this specialty of medicine in some ways differs from the practice of emergency medicine, reanimation medicine, or resuscitology, in Europe. In the United States, emergency medicine specialists provide emergency care for the full range of emergency health conditions, including accidents and trauma, medical emergencies, toxicologic emergencies, psychiatric and social emergencies, and disasters. This care is provided primarily in hospital emergency departments and includes the immediate initial recognition, evaluation, treatment and disposition of these patients with acute illness and injury. For continuing care, patients are referred to their own physicians.

Emergency medicine physicians provide medical direction for community EMS and supervise the prehospital emergency medical care provided by non-physicians (emergency medical technicians and paramedics). Emergency physicians engage in the administration, research and teaching of all aspects of emergency medical care. They also provide consultation to governmental and nongovernmental organizations on emergency health care issues. Recently, with the basic framework of emergency medicine established, attention is being given to disaster planning and management.