SUMMARY
Natural disasters frequently cause major problems that affect the health of  a population and hinder the socioeconomic development of a nation by draining its scarce financial resources in an effort to repair damages.
The health system and public health infrastructure of a country must be organized and ready to act in disaster situations as well as under normal conditions. Furthermore, it should be cognizant of the type of measures to be taken in  a disaster situation .
 As a consequence of an existing unprepared and disorganized system and infrastructure, Turkey is a country which loses life and property due to the natural catastrophes caused by geological and topographic structures, and climate conditions.

INTRODUCTION
Disasters exact an enormous toll in lives, physical destruction, and social and economic disruption. Poor countries and their people disproportionately suffer from large losses. Development efforts are set back as economic assets and export revenues are lost, and resources - human, financial, and material - are diverted to relief and reconstruction (Nelson,1990).  To the extent that disasters may happen, they will be costly in terms of lives lost, of injuries suffered, in economic losses, in social disruptions and psychological stresses, in slowing the development process, and in creating other long lasting negative social effects. After disasters, 8-9 % of people need psychological help in the area (Everly, 2002).

 Each year natural disasters cost billions of dollars in damages. But the toll does not end there. The human misery that inevitably follows in the wake of disasters cannot be measured in dollars.
Emergency Management is important to decrease loss of  property in the event of disaster. To decrease loss of life and property, emergency plans must be prepared for the country, region, city level and these plans must updated and exercised regularly.
Emergency Management is; problem solving in
    1- incomplete information
    2- compound time
    3- inadequate resources

Turkey is one of the countries, which suffers from huge loss of life and property due to natural catastrophes.  Earthquakes are one of the major and the most destructive natural catastrophes in Turkey since the country is on the most active earthquake zone of the world, called “Alpine- Himalayan Zone”. Ninety two percent of Turkey lays in the earthquake zone. Turkey has destructive earthquakes almost  every one or two years. During the last century, 131 high scale earthquakes have been recorded resulting in over 110.000 deaths and 250.000 hospitalised injuries. About 600.000 buildings were also destroyed. Ninety-five percent of the population lives on the earthquake zone, of which 44 percent is still highly active (Başbakanlık Raporu, 1997. World Forum, 1998).
As mentioned above, the health system and public health infrastructure of a country must be organized and ready to act in disaster situations as well as under normal conditions and must be cognizant of the type of measures to be taken in  a disaster case. These will differ according to the impact severity of the disaster on the national health system.

DISASTER MANAGEMENT
Disaster management is a multi dimensional issue and is composed of highly integrated components. It is possible to identify at least 15 major functional components of a society that may be affected either directly or indirectly by an event resulting in a disaster: 1) Medical; 2) Public health; 3) Sanitation and water supplies; 4) Shelter and Clothing; 5) Food; 6) Energy supplies; 7) Search and rescue; 8) Public works and engineering; 9) Environment; 10) Logistics and transport; 11) Security; 12) Communications; 13) Economy; 14) Education; and 15) Employment and job losses. These functional components are composed of many sub-components( METU 2001, ; Ceri,2001).

During a disaster, each of these components will be affected (damaged) to a varying degree depending upon the nature of the event and the absorbing capacity of the component to function in the affected society. When the absorbing capacity of any given function is insufficient to allow the component the provision of services can not exceed a minimum level. In order to establish an  effective disaster management capacity, all components must be involved and function sufficiently and adequately.

Over recent years, the emphasis of disaster management has shifted from post- disaster improvisation to pre- disaster planning. There is a strong belief that one should be able to prevent or mitigate the human consequences through improved preparedness. The decade 1990- 1999 has been proclaimed by the United Nations as the International Decade for Natural Disaster Reduction (IDNDR) (Lechat,1993.; NAE,1988).

IMPORTANCE OF DISASTER  MANAGEMENT IN HEALTH CARE
A country’s health systems and public health infrastructure must be organised and ready to act in disaster situations as well as under normal conditions and must be cognizant of the type of measures to be taken in the event of a disaster. These will differ according to the severity of the disaster’s impact on the national health system.

The health care preparedness plan for disaster management should be an integral part of the overall national disaster preparedness plan. In addition, there should be all the necessary elements to ensure the greatest possible coordination and timing, thereby avoiding misuse of resources and duplication of effort and promoting optimal benefits. Many sectors must be placed in this plan and they must develop their own specific action plan for executing the task assigned to it within the national plan (PAHO, 1982).

In the past decade, the interest in the operational epidemiological aspects of disaster medicine has increased dramatically. State, and local organizations have created vast emergency response networks capable of responding to disasters. Hospitals have developed extensive disaster plans to address mass casualty situations (Lillibrige, 1993). Medical care will have to take place where the patients are located in the first few days until medical support and reinforcements can arrive(Icdl,2001).

Disease control and environmental health are very important to prevent possible epidemics of water and food borne diseases.  Teams must be established  to carry out  activities such as;
·    Control of all kinds of water to ensure and provide clean and safe water for drinking and use,
·    Control of  all foodstuff, provision of safe food and disposal of the unsafe foodstuff,
·    Control of the disposal of garbage and wastes, and control of the areas for environmental health where people are crowded.
·    Vector control and disinfection .
·    Follow up potential high risk cases for diseases and informing the people about environmental health and infectious diseases,
·    Provision of necessary immunization,
·    Information, education, communication activities for the people about personal hygiene. Provision of  clean toilets and  keeping hygienic conditions.

In a disaster situation, primary health care has a strategic importance. This is the crucial level at which first medical aid is given.
In disasters the problems faced can be divided into four different levels;
a-    The nature of the injuries and their seriousness according to the nature of disaster: the emergency medical system will have to deal with wounded, burned, blasted, intoxicated or contaminated victims, with multiply injured trauma patients or with casualties with combined injuries.
b-    The number of victims: in mass casualties priority of evacuation must be given to casualties with a chance of survival. The difficulty of implementation of such a directive relies on the evaluation of the probability of survival.
c-    The tempero-spatial spreading of the casualties:
1-    the spatial spreading depends on the extent of the disaster area: the greater the distances,  the more difficult the rescue of the casualties and their transport to a triage station.
2-    the spreading in time : a massive influx of casualties at the same time versus a steady flow of a limited number of victims.
d-    Management of the casualties in an emergency medical system :
1-    technical actions: fight against or neutralization of the casual agents and the immediate consequences ;
2-    rescue : withdrawal of the casualties from the aggressive environment ;
3-    first aid measures which may allow an immediate survival pending more specialized care. It is essential that these measures are started on the scene and carried on during transport to the triage station ;
4-     setting-up of a triage : its role is to categorize the casualties and to establish priority regarding medical care, conditioning and evacuation ;
5-     evacuation : the evacuation of casualties can present several problems;
a-number of victims,
b-priority of evacuation,
c-aptitude for transport,
e-destination,
6-    admission to medical facilities.

The quality of care to casualties of disasters depends to a large extend on their evacuation to appropriate treatment facilities, consequently on the way that triage of the victims is performed on the scene.
The disproportion between the needs and the resources, the sudden nature of the losses, the logistic difficulties and the psychological climate generated by disaster may change the principles of sorting.
Not each individual victim can therefore receive immediately the necessary care, a certain selection of casualties can not be forgone (Debacker,1989).

DISASTER MANAGEMENT IN HEALTHCARE IN TURKEY
The common practice of disaster management in healthcare in Turkey is based on rescue and relief operations in the aftermath of the disaster. However, damage reducing measures, related risks and enhanced preparedness should be taken in to account before the disaster occurs.

Although related organizations and institutions, like Turkish Red Crescent Society, military units, governmental and voluntary organizations mobilize their relatively limited efforts in responding to the effects of disasters, not much has been done so far in order to reach satisfactory solutions (Sarp, 2000). Therefore as a consequence, ineffective disaster management --the lack of organized and coordinated efforts--many people have been killed and injured by recent massive earthquakes.  For example according to the statistics of Prime Ministry Crisis Management Center (MOH, 2000), 18.243 people died in Marmara earthquake dated August 17,1999 and about 50.000 were hospitalized injured. About 120.000 families were in need of housing. Total economic loss was about USD 20 billion. Another earthquake occurred on 12th November 1999 in Bolu and Düzce resulting in the death of 763 people with a further 4948 injured. As known, delayed medical care is the need to first extricate trapped patients because passage of time is the worst enemy of the seriously injured patient.

Significant number of health care facilities were damaged in the earthquake. Nine state hospitals, 48  health centers were damaged and 28 of them were totally destroyed.
A total of 44 health personnel died in the region, including 12 physicians, 18 nurses, 4 health technicians and 10 other personnel (MOH ,2000 ) .
Some of the important  problems that country faced in  Marmara earthquake are as follows;
·    Communication between damaged region and national authorities failed for a while,
·    In the first few days following the disaster some conflicts and disorganization were experienced mainly due to independent actions and tries of some international and domestic donors  to help the affected people that caused duplications and wasted some of the necessary resources. The Red-Cross was not able to provide necessary rescue materials immediately. Later, food supplies and tents, etc.  could not be provided in time.
·    Too many supplies of medicine were sent to the region by other countries . Most of which were not needed in such situations while  some of them were not possible to be understood and used because of the language barrier or  expiration. This caused additional unnecessary burden on the local staff. All donations could not be  organized or distributed through the relevant crises management units.
·    Some of international aids were not compatible with the needs of the disaster area. Information provided by the media related to the events or activities in the disaster area sometimes were inaccurate or biased which created frustration and misdirected the aids.
·    Knowledge and skills of the local people on rescue operations/first aid were not sufficient.
·    The concept of triage was not known well by the involved health personnel in general (MOH,2000).

REFERENCES

Başbakanlık Doğal Afetler Koordinasyon Başmüşavirliği “ Doğal Afetler Genel Raporu “ (General Reports on Natural Disasters) . May, 1997

Debacker,M. “ Triage in Case of Disaster “. CEMEC, San Marino . 1989, p : 1-2

Erdik,M.,Aydınoglu,N.”Earthquake Performance and Vulnerability of Buildings in Turkey” . PROVENTION Consorsium, The World Bank, 2002

Every,G. FEMA Course. E900, 2002

Karancı, N.; Akşit,B.; Anafarta,M.; Oğul,M. “ Educational Handbook and brochures” (Educational Material on Earthquakes ). METU Disaster Management Center, 2000

Lechat, M.F. “Accident and Disaster Epidemiology, Public Health Review”, 1993. 21     (3-4)  p: 243-53

Lillibrige, SR; Noji, Ek; Burkle FM Sr. “Disaster Assessment: The Emergency Health Evaluation of a population Affected by a Disaster”. An Emerg. Med. Nov. 1993. 22 (22)  p: 1715- 20

Ministry of Health, Earthquakes in Turkey. WHO/EURO, Copenhagen 2000.

National Academy of Engineering, Advisory Committee on International Decade of Hazard Reduction, Confronting Natural Disaster: An International Decade for Natural Hazard Reduction, Washington D.C., 1988.

Nelson, O. “Mitigating Disasters: Power to the Community” Int. Nurs. Rev. Nov. Dec. 1990 37 (6)  p : 371

PAHO. Health Services Organization in the Event of Disaster. Publication No:443, 1982
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Sarp, N. “What Should We Teach About Earthquake Pre and Primary School Children”. Civil Defence, 1992 ; 34 (130) : 12-13

Sarp, N. “Effects of Earthquake on Children and Assistance Provided”. Bulletin of Earthquake Researches”. 1999 ; 26 (81): 101-111

Sarp, N. “How Should We Help  Children to Prevent Them The Effects of Earthquake” Journal of National Education.1999 ; 144 : 25-27

Seismic Safety of Big Cities, Earthquake Prognostics World Forum. Istanbul, 21-25 September 1998

www.ceri.memphis.edu

www.fema.gov

www.icdl.open.ac.uk

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