Going forward, the government of Japan works on a culture of resilience and prevention based on continuous learning. So, most Japanese cities have a government–run experienced based disaster training centre which makes use of technology and simulators to give a real idea of what it feels like to be in an emergency situation.
3.2 The Fukuoka Citizens’ Disaster Prevention Centre.
The Fukuoka Citizens’ Disaster Prevention Centre was chosen to be presented as one of the most progressive curricula for disaster preparation worldwide. Based on extremely high technology and uniquely realistic simulations and innovative methods builds a culture of resilience starting from early ages.
Fukuoka City has a special advanced emergency response unit, which deals with massive disasters and accidents and provides training for a variety of emergencies. The unit exists in 18 major cities in Japan and works internationally, having been dispatched to disaster–stricken areas not only in Japan but in other countries also. The training menu consists of training in fire-fighting, rescue, emergency and prevention techniques. Lectures and practical training along with rescue activities and best survival strategies are also part of the curriculum.
The Fukuoka Citizens’ Disaster Prevention Centre is a facility where visitors learn techniques and develop abilities to take action in relation to disasters as well as being a facility that realistically simulates various disasters in case of emergencies(21). The General Experience Course (Experiential and Observation Zone) lasts one hour and attracts locals, tourists and children who must visit the Centre for training once a year. Training for care givers from retirement homes and hospitals, school teachers, day care staff and baby sitters is possible.
1,400 people, including prefectural and municipal government officials, firefighters, police and locals participated at the Fukuoka’s Prefecture Comprehensive Disaster Drill that was held in Itishima city to further enhance their preparedness for disasters such as earthquakes, tsunamis and nuclear disasters of Fukuoka.
Fukuoka Disaster Training Centre based on the hard–earned culture of preparedness, the progressive facilities and the latest in 3-D effects and computer graphics simulation machines has become a leading model on disaster readiness inspiring many other Training Centres around the world(21).
3.3 The American Red Cross Programme.
Because of its long tradition and experience as the world’s largest emergency response organization, the American Red Cross has played a major role in providing assistance during large scale disasters and therefore its presence in this paper was considered necessary. Believing that it’s through young people’s education that the impact of disasters can be minimized, it develops flexible emergency preparedness programmes for school–aged children across the country through the use of its own educational materials that can be easily integrated into the class curriculum.
The American Red Cross Masters of Disaster curriculum is centered on a series of ready–to-go lesson plans providing important disaster safety and preparedness information to children(22). The specific materials meet national educational standards and are specifically tailored for lower elementary and middle school classes(22).
The curriculum consists of a variety of activities and demonstrations on disaster–related topics along with lessons that can be incorporated into daily or thematic programming of any organization. One of the advantages of the curriculum is its non-sequential character that allows organizers to choose the lesson plans that best fit into their topics of interest(22).
"The education on essential preparedness skills that children receive through that program will carry them through life and help them reduce anxiety about unknown aspects of disasters’ tragic events and deal with life’s unexpected turns"(22).
"The series of topics is of the highest quality and most comprehensive available with almost 200 lesson plans. The curriculum materials cover safety and prevention for injuries and damage from hazards in the United States of America with topics on Disaster preparation and Personal Safety coping with issues like Terrorism, War and Pandemic Flu–Facing Fear, Recovering and Rebuilding from disasters–Aftermath, Home Injuries Prevention–Home Safety, Earthquakes, Fire Prevention-Safety, Floods, Hurricanes, Lightning, Tornadoes and Wild land Fires"(22).
3.4 The Disaster Training Curriculum ("DITAC").
DITAC was selected to be presented in this paper because it proposes to develop a holistic training curriculum, standardized strong as an efficient approach to increase the resilience in facing disasters and crises within the European Union(23). This curriculum will be accessible to pertinent organizations throughout the EU and will, become the first step towards building a European Emergency Response Centre(23).
This Disaster Training Curriculum is funded by the European Commission and deals with the key challenges in the management of disaster incidents by first responders and strategic crisis managers .
"DITAC, which is primarily coordinated by the University Clinic Bonn, brings together scientists from various academic institutions across Europe in order to develop a standardized strong, comprehensive and efficient EU-wide approach to crises and disasters to feature the added value by EU coordinated actions in the field of crisis response. The Curriculum will improve the preparedness and availability of trained personnel by providing a common language, common objectives and common tools, leading to better results in the protection and assistance of people confronted with large-scale crises.
Establishing a curricular training on how to respond to an international crisis and making it accessible to pertinent organizations throughout the EU will be a first step towards building a European Emergency Response Centre"(23).
A series of realistic training simulations is required to effectively prepare the trainees to perform accurately in difficult disastrous situations.
The major incident training systems being used across Europe are: the British Major Incident Medical Management and Support ("MIMMS") system and the European-based and Swedish-led Medical Response to Major Incidents and Disasters ("MRMI") course(23).
MIMMS’ Advanced Life Support Group is a leading course available for all aspects of dealing with a major incident and the whole chain of response: scene, transport, hospitals, coordination and command, including also training in triage and individual patient-management(23). Candidates should be from medical, nursing or paramedical background, officers or team leaders. The course is available as a 3 day face to face course or a 2 day face to face course with a pre-course learning element. Lectures, skill stations and workshops, practical and table top exercises are also included. The certification of the course is valid for 4 years.
Postgraduate course in Medical Response to Major Incidents ("MRMI") is organized in collaboration between the European Society for Trauma & Emergency Surgery ("ESTES"), International Association for Trauma Surgery and Intensive Care ("IATSIC") and Karolinska University Hospital, Stockholm, Sweden. The course is interactive based on an advanced simulation model and starts with one day of preparative training in groups, followed by two full days of simulation exercises with all participants active in their normal positions and with careful evaluation and analysis of the result of the response(23). Doctors and administrative staff, nurses, paramedics and ambulance staff, officers in fire–rescue, police and protection services as well as instructors are the groups of trainees(23).
3.5 Educational Guide and Resource for Medical Student Disaster Medicine Education.
Due to its comprehensive, interdisciplinary nature, instructive design, and flexible structure, this curriculum was selected to also benefit other health-care professional systems by serving as a model curriculum, or facilitating refinement and testing of other existing, and perhaps as yet unpublished models(24).
It’s a fact that the recent large-scale of natural and man-made disasters has increased the focus on disaster medicine. As a consequence, medical schools in many parts of the world have begun to incorporate disaster-related topics into their curricula(24).
Because a fully developed and comprehensive medical school disaster medicine curriculum wasn’t available, the German government commissioned the development of a core medical student disaster medicine curriculum, which could serve as a standardized template(24). The curriculum was finally adapted by nine universities into the 4th-year German medical school program.
The development of a disaster preparedness curriculum for medical students resulted in a course of 14 modules with each unit requiring approximately 2 hours time(24). The concepts of "disaster medicine, response, medical assistance, law, command, coordination, communication, and mass casualty management, are introduced(24). Life-saving emergency and limited individual treatment under disaster conditions are discussed. Specifics of initial management of explosive, war-related, radiological/nuclear, chemical, and biological incidents emphasizing infectious diseases and terrorist attacks are presented. An evacuation exercise is completed, and a mass casualty triage is simulated in collaboration with local disaster response agencies. Decontamination procedures are demonstrated at a nuclear power plant or the local fire department, and personal decontamination practices are exercised. Mannequin resuscitation is practiced while personal protective equipment is utilized. An interactive review of professional ethics, stress disorders, psychosocial interventions, and quality improvement efforts complete the training"(24).
Since the developed course offers a cross-professional design in a really adaptable structure, it also permits flexibility in addressing a multiplicity of disaster situations, including floods, hurricanes, earthquakes and surveillance–related health problems as well as care for vulnerable populations as children and hospitalized patients(24).
For the introduction to the practices of disaster medicine at the students in medical school program, during the pilot implementation, a core curricular team of physicians was assembled and scheduled all tasks(24). "Internal and external professionals with expertise in subject areas were identified and invited to become teaching faculty. After coordination with medical school program planners, facilities for the in-house curriculum units (rooms, equipment) were organized with the lecture support staff. For the external units, collaborations with rescue and disaster response agencies were established to permit common exercises. For exchange and drill of non-physician professionals and students, agencies provided equipment, faculty, and their trainees to serve as mock victims for a mass casualty simulation. Finally, feedback on the curriculum from all participants was utilized to make alterations and improvements as needed"(24).
3.6 The National Disaster Life Support Courses.
"The National Disaster Life Support Foundation, Inc. ("NDLSF") oversees the National Disaster Life Support ("NDLS") courses, a series of education programs to better prepare health care professionals and emergency response personnel for mass casualty events. The NDLS courses are comprehensive, all-hazards, competency-based, standardized, and multi-disciplinary"(25).
The NDLS courses were developed by four academic centers Georgia Health Sciences University, University of Georgia, University of Texas Southwestern Medical Center at Dallas, and Texas A&M School of Public Health.
"The NDLS courses stress a comprehensive all-hazards approach to help physicians and other health professionals deal with catastrophic emergencies from terrorist acts as well as from explosions, fires, natural disasters (such as hurricanes and floods), and infectious diseases"(25).
"Pacific EMPRINTS is approved as a National Disaster Life Support Regional Center-Pacific under the National Life Support Foundation ("NDLSF"). Pacific EMPRINTS and its associated NDLS Faculty are able to offer the following two courses in Hawaii and other locations in the Pacific region. The first course is the Basic Disaster Life Support course which lays out the conceptual framework for the second course, Advanced Disaster Life Support, which uses hands-on exercises and scenarios to train participants"(25).
Basic Disaster Life Support ("BDLS").
BDLS is targeted to multiple disciplines including emergency medical service ("EMS") personnel, hazardous materials personnel, public health personnel, and health care providers. The goal of teaching multiple disciplines simultaneously is to develop a commonality of approach and language in the health care community, improving the care and coordination of response in Weapons of Mass Destruction ("WMD") disasters and public health emergencies. The BDLS course is a review of the "all-hazards" topics including natural and accidental man-made events, traumatic, explosive, nuclear, radiological, biological and chemical events. There is also included information on the health care professionals’ role in the public health and incident management systems, community mental health, and special needs of underserved and vulnerable populations(25). "The recognition and management of the disaster scene and victims are reinforced through a unique approach, introduced in the Core Disaster Life Support Course called the D-I-S-A-S-T-E-R Paradigm, which helps to organize the students' preparation and response to disaster management. The paradigm emphasizes an "all-hazards" approach to mass casualty incident management and facilitates ongoing qualitative and quantitative assessment of an incident"(25).
The target audiences are Physicians, Nurses, Paramedics, Health Professionals, Dentists, Pharmacists, Veterinarians, Health Profession Students, First Responders and Mental Health Professionals. The course length is 8 hours and a recertification is required every three years.
Advanced Disaster Life Support ("ADLS").
"ADLS is an advanced practicum course for those who have successfully completed the BDLS course. It is an intensive, two-day course that allows students to demonstrate competencies in casualty decontamination, specified essential skills, and mass casualty incident information systems/technology applications. Using simulated, all-hazards scenarios and mass causality incidents, ADLS makes use of four interactive sessions in which participants treat simulated patients in various disaster drills and situations. Training is focused on the development of hands-on skills to allow participants to apply the knowledge learned in BDLS"(25).
"ADLS’s interactive scenarios and drills utilize high-fidelity mannequins and volunteer patients to simulate a realistic experience in treating pathologic patient conditions not routinely encountered by the responders and health care providers. Hands-on exercises teach practical skills, such as decontamination and use of protective equipment, and provide instruction in topics that traditionally are not addressed in health care education curricula"(25).
"Day 2 of ADLS is the "hands on" day of training. Four skills stations reinforce the previous day’s learning. These skills stations are as follows:
S.A.L.T. Triage - Simulated disaster victims must be triaged and treated correctly while attempting to manage a chaotic scene and request appropriate resources.
Personal Protective Equipment (PPE) and Decontamination - This station teaches important concepts about the use of personal protective equipment and decontamination techniques.
Disaster Skills - This station teaches vital skills necessary for medical disaster management.
Human Patient Simulator - Recognition of victims of a chemical and biological disaster is paramount. This station is designed to reinforce the detection and proper treatment of conditions that may occur during disasters that we do not normally treat. Treatment of chemical, biological, and traumatic patients is covered. The use of high fidelity human patient simulators allows the student to see, hear, and feel information that would normally be provided by an instructor, creating a more realistic experience than standard mannequins can provide"(25).
ADLS is targeted to Physicians, Nurses, First Responders, Paramedics, Pharmacists, Health Professionals, and Medical Students.
The length of the course is 16 hours and every three years recertification is required. Participants must attend both days of training to receive the certificate of completion(25).
Antonine Plague was an ancient pandemic that devastated the Roman Empire from AD 165-180, currently thought to either be smallpox or measles. The second siege of the plague claimed 2,000 lives per day only in Rome.
A Centre for Modern Research and Education in Disaster Medicine in Southeastern Mediterranean
Bearing in mind all disasters that have at times devastated Greece since the beginning of time, we stress hereby the vulnerability of the whole South Eastern Mediterranean area towards disasters  . Apart from the disasters themselves, we should also consider that in this area we find large low income populations that would suffer most in case of a catastrophe; these are communities with the least coping capacity towards disasters. In addition, armed conflicts and riots in this region give rise to critical and complex humanitarian issues. This is yet another reason for taking special precautions when structuring a plan against any predictable distress in this part of the world.
Further considering that in this area there exist no entity concentrated on directing research projects and on offering educational curricula on the broader field of disaster medicine covering the whole Southeastern Mediterranean territory, we realize the urgency and the necessity of incorporating such an institution. And especially an institution based in Greece which among its Southeastern Mediterranean neighbors is probably the country most exposed to various disastrous hazards. More to the point, experience of past disastrous incidents may prove valuable in structuring any prevention or contingency planning. In addition, Greece is the crossroad of three continents and may undertake the role of uniting populations and diverse cultures from neighboring countries in a common effort to respond to disasters. Even more, Greece as a member of the European Union has access to funds that may provide the resources to adequately support a research and education centre in the field of disaster medicine.
In particular, this area necessitates a Centre for Research and Education in Disaster Medicine ("the Centre"), the educational and research objectives of which ought to be adjusted to the requirements posed by the multiple disaster risks threatening this geographic region. It is essential to create a Centre of high international caliber able to collaborate with other national or international organizations with the same scope of work. Such a Centre would help the area to better prepare for handling imminent disasters and to learn from analyzing past catastrophic events in order to mitigate any foreseeable adverse disaster effects.
An institution as this should be located in an area with an international imprint, capable to play a geostrategic role in the Southeastern Mediterranean basin. It should have the capacity of accommodating large numbers of visitors with appropriate supporting infrastructure, i.e. airports, ports and hotels. In an area with moderate climate for it to operate all year round; easily accessible from all countries in the region; with local authorities that have demonstrated their commitment to embrace the operation of such a centre; and with the capability of guaranteeing its uninterrupted and safe function through the collaboration with experienced local field professionals such as the police, armed forces, fire-fighters, medics, paramedics, rescuers, and ambulance crews.
A Centre for Research and Education in Disaster Medicine should operate under the auspices of a University institution which specializes in providing education in the broader area of disaster management. This is vital since such a Centre would require substantial experience in deploying educational, training and research projects. As such, it will be requested to certify undergraduate and post graduate studies, to receive medical and other students interested in pertinent to disasters studies; to function as an international pool of teaching and research personnel; to verify its applied experience in introducing educational curricula and research projects; to cooperate with other international teaching and research institutions; as well as to function as a beacon for scientists, researchers, students and scholars from around the world.
Of utmost importance would be the ability of such a Centre to liaise with national and international Institutions and Organizations recognized for their work on the subject-matter of disaster medicine. The functioning of such a Centre as a model - prototype research and education centre, with international and acknowledged impact on the field, would be of essence. The academic spectrum of this Centre would be to train attendees on how to react when multiple disasters strike as well as to cope with all resulting humanitarian issues.
Though a particular study is required to define such a Centre’s funding, we should note here that analogous centres abroad are supported either by the European Union, International Organizations, and charitable institutions or even by taxes and duties imposed on each individual visiting the centre’s location. Other funding sources could be Greeks living abroad, tuition fees, the state itself and competent agencies and ministries.
Lastly, not being within the scope of this paper, a study on all legal issues related to the incorporation and functioning of this Centre should be initiated.
In the following chapters we elaborate the dual character of a Southeastern Mediterranean Centre in Disaster Medicine providing an outline of its syllabus in the fields of research and education.
Organizing a Research Centre in Disaster Medicine
5.1 Initiating a Disaster Research Centre.
The systematic study of disasters and the response of human beings to them provides a scientific and valid basis on which to build prevention and mitigation policies(26). A hazardous event never resembles a subsequent event and accordingly different response requirements arise from each incident. Each disaster requires a unique management, resource and treatment approach thus posing each time new issues to be addressed by researchers. The epidemiological research will indicate the profile of each disaster and the characteristics of its pathology. Epidemiological research is the basis for formulating a community’s policy viz–à-viz disasters.
In J. Handmer and S. Dovers view, "vulnerability to disasters is determined by factors located deep in social and economic situations (indirect and systemic causes) – patterns of settlements, resource dependency, economic condition, livelihood security, infrastructure and health systems – as well as more immediate causes such as building quality"(27). Therefore, if vulnerability is to be diminished, research on and analysis of the above elements and on how a community is to respond to the challenges posed by disasters is needed.
5.2 When is the Right Time to Deploy a Disaster Research Programme.
As David Hogan and Jonathan Burstein propose(26), disaster research can and ought to be materialized in three stages: before, during and after a disaster.
Before a disaster, the goal of every research effort is to examine the hazards threatening disaster prone communities and the factors that help build its resilience capacity.
All through a disastrous event, research should concentrate on reviewing the effectiveness of all management efforts, the anticipation process of current and upcoming community requirements, as well as the preparedness for a possible deterioration of any disaster situation.
Following a disaster, examination of all disaster consequences on the affected community should lead to understanding what steps are to be followed or not when preparing for a new disaster, spanning from personal treatment requirements to the overall management of the event. In this context, a valuable tool for disaster research is debriefing. And an essential instrument for the detailed assessment of past events in a debriefing is any recorded footage from the disaster field; by the help of which the role and efficacy of all participants will be estimated.
5.3 The Philosophy of a Disaster Research Centre.
According to David Hogan and Jonathan Burstein(26), the main structure of all research efforts should be founded on the following principals:
Commencing a Research Programme
Disaster research should commence with the assessment of each incident, incorporating hazard analysis and comprehension of each community’s vulnerability factors. Researchers should proceed with the collection and examination of data in order to proceed with advising all policy makers on how to design and execute a disaster reaction policy.
Research timing is of paramount importance for all disaster assessment. Contrary to everyday epidemiological investigation where research is designed in prospect or in retrospect according to the selected research strategy, disaster research is always designed and executed in retrospect. However, a researcher may draw questionnaires ahead of a disaster in order to be prepared to collect valuable information while a disaster incident unfolds; otherwise valuable data and information may be lost in the process of responding to and recovering from a disaster.
Participants in a Research Programme
If a disaster research is to be of essence, a researcher needs to involve inhabitants and indigenous health care practitioners as investigators. Only they shall specify suggestions suitable for each country’s profile. Information to be gathered should include all elements on the needs and the physical social status of the specific community at risk or already affected by a disaster. Furthermore, careful consideration for local necessities and empathy with the affected community will ensure an effective research process.
In order to succeed in gathering the necessary information, all competent stakeholders should be involved in the process of delivering the required data; without excluding the affected citizens, local and central governmental organizations, NGO’s and other agencies.
All researchers involved in the process of gathering and analyzing data should cooperate with one another so as to deliver a unanimous scientific tool to be utilized in each disaster setting.
Hazard Assessment and Management
By assessing all hazards associated with foreseeable disastrous events for a community we are able to improve our strategy in order to mitigate any adverse effects. Risk assessment would require the examination of all human risks as well as the vulnerability of the community exposed to specific threats.
For example, so far as human constructions are concerned, the research on land use and on the types of settlements built in areas susceptible to disaster distraction will lead to policies focused on ways to lessen all of detrimental effects of an earthquake, landslide, flood or volcano eruption.
Hazard Reduction Research
Research on this field investigates all implications from natural, man-made and complex disasters. Psycho-sociological, financial and managerial acts in response to a disaster and a community’s coping ability are examined under this process.
Analysis of Disaster Management
In order for future planning and response to be established, research on risk management must come first. The ability to foresee the unforeseen and to cope with an uncontrollable event are the subject matters of research on this topic. The incident in itself and the response mechanisms are studied for the better handling of future hazards.
Although recovery is many times ignored in the process of risk assessment, re-establishment of security, shelter, transportations, communications, food, water and medical supplies should be a primary area for disaster research. By restoring a community’s access to all these resources will help the community return to its routine living mode.
Disaster research vastly varies from conventional medical research due to the many challenges posed by the limitless facets of disasters. Hence, other non-medical research methods should be incorporated in each research effort. In that sense, operation research, risk analysis, cost analysis and decision-making analysis should be part of every research project(26).
Taking into account all differentiated circumstances involved in every disaster situation, disaster epidemiology addresses all medical conditions that may be of relevance in the aftermath of a disaster. Incidence and spreading of diseases, mortality and morbidity patterns, comorbidity, further illnesses and epidemics ought to be part of disaster epidemiological research. This would lead to examining populations’ requirements as well as deficiencies caused by different disasters.
"In previous years, disaster planning has been based on emotion, subjective understanding, and anecdotal reports. Planning based on such capricious elements is no longer acceptable"(26). Instead, solid scientific data and assumptions should be the pillars of every research programme in order for valid evidence based decision-making to be shaped.
5.4 What Issues are to be Addressed by a Research Centre.
A Research Centre is focused on providing knowledge on a disaster situation to be used by those who design preparation, recovery and contingency plans. If the decision makers are to be assisted in improving their policies on handling the chaos of a disaster; if medical professionals are to be guided when caring for those in need; if rescuers are to be prepared and equipped to save lives, the primary aim of a Disaster Research Centre should be to provide evidence based responses to the following key questions:
Preparing for a Disaster
How should we appreciate the disaster risks for each community?
Which are the specific hazards threatening a community?
What would be the nature and magnitude of the expectable incident?
For how many victims are we to be prepared and equipped for?
For what kind of casualties, injuries and diseases should we be ready for?
What kind of personnel will be involved in caring for the affected population?
What type of resources and logistics would suffice to cope with a disaster?
What type of infrastructure is damaged by the disastrous incident?
What type and how many victims do we have to respond to?
What is the gravity and acuity of injuries and diseases following the disaster?
What type and how many health care facilities are required in the present situation?
What type of logistics are needed to respond to the situation?
Which are the competent stakeholders that have to cooperate with one another and coordinate their efforts to respond effectively to the disaster?
How is the management of the disaster progressing?
How are the command and control of the situation implemented?
Which are the social profile and the pathology of each community that will shape specific necessities before, during or after a disaster?
How are we to fortify a society to better prepare for foreseeable perils?
How shall a community return to its routine and everyday function?
After preparing for a disaster how are we to organize a recovery plan?
On what evidence should we formulate a mitigation plan?
5.5 Which Disaster Risks should be the Subject-Matter of a Research Schedule.
The spectrum, unpredictability and variability of disasters call for a detailed study on all types of potential hazards threatening a given geographical area or region. Hence, a meticulous study of what kind of disasters are to be the subject matter of a research curriculum is required. For a South Eastern Mediterranean Research Centre, we propose that initially all risks related to previous disasters  as well as risks related to a community’s potential exposure to disasters should be investigated.
5.6 An Evidence Based Approach.
As seen in previous chapters, no disaster resembles a previous one and no disaster shall be identical or not just similar to a subsequent disaster. Different elements characterize each disastrous incident making it problematic to hold an identical approach towards the perils that emerge from disasters every single time. Non anticipated factors evolve each time distinguishing a hazardous event from the next even if a disaster strikes the same region twice. This is an endogenous characteristic that poses extra complications and perplexities for any research effort. On the other hand, there exists no unified evidence based approach in studying disasters and thus a contemporary research centre should promote pilot programmes for examining all disaster challenges and new disaster parameters. In this way, it may determine an evidence based method for advancing research on disasters.
RMS Titanic sunk on April 15, 1912 leading 1,502 people to their death in one of the worst peacetime maritime disasters of our times.