US, Israel cooperation leads the way in pediatric disaster preparedness

Physical and psychological factors make children particularly vulnerable but their specific needs are now being addressed, thanks to a close partnership between American and Israeli experts.

Children sit in an auto rickshaw in Tal Abyad, one of the cities in which Turkish President Tayyip Erdogan plans to resettle Syrian refugees (photo credit: KHALIL ASHAWI / REUTERS)
Children sit in an auto rickshaw in Tal Abyad, one of the cities in which Turkish President Tayyip Erdogan plans to resettle Syrian refugees
(photo credit: KHALIL ASHAWI / REUTERS)
Historically, disaster preparedness barely considered the needs of children, essentially treating young people affected by catastrophic events as if they were small adults. As recently as 2014, the NGO Save the Children reported that for every $10 spent on disaster preparedness, just one cent was spent on pediatric disaster preparedness.
As a deeper understanding of children’s needs emerges, this approach is beginning to change. A close partnership between American and Israeli disaster-preparedness experts is leading the way.
This cooperation was highlighted at the Sixth Israeli International Conference on Preparedness and Response to Emergencies and Disasters (IPRED), which was held this week in Tel Aviv. The conference, hosted by the Israeli Health Ministry and the Israel Defense Forces Home Front Command, brings together more than 1,000 professionals from around the world to share the latest findings on health system readiness for disasters and emergencies of all types.
Nearly 30% of the world’s population is under age 18. In the Middle East, the percentage is even higher. Children suffer from many age-specific vulnerabilities and the victims of war, terrorism and natural disasters are frequently children.
Anatomical, physiological, developmental, psychological and other factors put children at particular risk in a disaster. They are more likely to suffer from a wide variety of injuries and they have distinct, non-adult needs. Children are also disproportionately represented in poverty-stricken families. For these reasons, “as many as 40-50% of victims in major disasters are children,” according to Dr. Arthur Cooper, professor emeritus of surgery at Columbia University and staff member of the New York City Pediatric Disaster Coalition.
Israel has been pushed to the forefront of pediatric disaster preparedness. This is largely a result of the bitter experience of decades of terrorism, in particular, the Second Intifada, in which buses, restaurants and clubs frequented by young people were often targets of attack.
Dr. Kobi Peleg, director of the Israeli National Center for Trauma and Emergency Medicine Research at the Gertner Institute, told The Media Line that in such terrorist attacks, “the type of injuries are totally different from normal injuries. … You can find people [injured by] a huge number of shrapnel and nails, so it’s very complicated." At the time of the Second Intifada, multi-slice CT scanners were just being introduced. The machines didn’t exist in every hospital, were far less advanced than today’s models, and using them to produce a full-body image took precious time that severely injured patients didn’t have.
When, a year after the Second Intifada began, the US was shaken by the 9-11 attacks and recognized an urgent need to prepare for mass-casualty disasters, American emergency professionals turned to their Israeli colleagues, who had accrued valuable recent experience.
“The Americans did great work with us,” says Dr. Peleg. “We studied from them; they studied from us." Peleg points to the response to the 2013 Boston Marathon bombing as an example of the documented positive effects of this cooperation. Dr. Atul Gawande, a surgeon and public-health researcher, wrote in The New Yorker that "according to data from the Israeli National Trauma Registry, explosives used in terror attacks have tended to be three times deadlier than those used in war – because civilians don’t have armor, because victims span a wider range of age and health, and because preparedness tends to be less systematic.” But, writing two days after the Boston bombing, “it now appears that every one of the wounded alive when rescuers reached them will survive.” And that was, in fact, the case: Three people were killed when the bombs went off but all 264 who were injured – including many with shrapnel wounds and 16 who lost limbs – survived. “What prepared us?” asked Dr. Gawande. His answer: 10 years of war, in
ternational disaster relief cooperation in places like Indonesia and Haiti, and "the Massachusetts General Hospital brought in Israeli physicians to help revamp their disaster-response planning."
The American Health Professionals and Friends for Medicine in Israel (APF) organization runs a five-day emergency preparedness course in Israel for medical and other relevant professionals from all over the world. The course works in close cooperation with the Israeli Health Ministry and IDF Home Front Command.
In 2003, at the height of the Second Intifada, Dr. Michael Frogel, a professor of pediatrics at Albert Einstein College of Medicine and a pediatrician at Cohen Children’s Medical Center, came to Israel to participate in the course. This sparked an ongoing interest in disaster medicine in general and pediatric disaster medicine in particular. Frogel told The Media Line, “I liked the course so much that now, I'm the one who coordinates the course every year."
With a multiyear US federal government grant and the lessons learned from pediatric disaster preparedness in Israel, Dr. Frogel has played a leading role in the New York City Pediatric Disaster Coalition's effort to prepare the city for a large-scale disaster affecting children, including work on pediatric triage, transport, intensive care, neonatal evacuation, surge capacity, training, exercises and disaster mental health.
Frogel is now the chairman of the US National Pediatric Disaster Coalition. In that capacity, he has been a key player in securing multimillion-dollar federal grants for UCSF Benioff Children's Hospital in Oakland, California and University Hospitals Rainbow Babies & Children’s Hospital in Cleveland, Ohio, to make them “centers of excellence” leading comprehensive regional pediatric disaster response efforts. Each hospital heads a multi-state consortium of agencies, bringing together trauma centers, pediatric medical centers, health care systems, government agencies, the National Guard, NGOs, and industry experts to develop coordinated, collaborative regional disaster response plans for mass casualty events. “It’s very, very comprehensive," says Frogel, "because it's for a regional response [to an event] like a major earthquake that could affect millions of people. ... Hopefully, we'll eventually have a great regionalized plan for the whole country.”
Israel, Frogel says, already has “a specific pediatric disaster plan. … A lot of the stuff I do and I plan was based on my knowledge of [the Israeli plan].”
The influence goes both ways. "I helped do some of the original pediatric-specific drills in Israel,” says Frogel. “These were based on some of the work we did in New York. We've done probably more than anyone else in pediatric disaster drills. And we work together.”
Frogel mentions, in particular, a major drill he participated in a number of years ago – “the most amazing drill I’ve ever seen” – that included US Homeland Security, the IDF Home Front Command, the Israel Police and Fire and Rescue Services, and the Environmental Protection Ministry: "A mock terrorist went into a high school, shot people, and then threw a chemical weapon into the mix."
Frogel says that in areas of Israel adjacent to the Gaza border, such as the city of Sderot, which have been hit by more than 20,000 rockets over the past 15 years, about half of the children suffer from psychological distress. “There are a lot of mental health problems there, but there is also learning from what they do and how they address [the situation]. The resiliency they have – to live there for years and years and not leave, and more people are moving in – really says a lot. Israel is great at building resiliency.”
According to Dr. Cooper, all children who are victims of major trauma – whether from natural or manmade disasters, such as war – “are prone to serious mental health disorders.”
Cooper has shared his vast pediatric disaster medicine experience with Israeli colleagues on seven trips to Israel in recent years – six IPRED conferences and a stint as a visiting professor at Ben-Gurion University in Beersheba. But, he tells The Media Line, he has learned as much as he's taught: "We in the United States have a lot to learn from Israel, and I think there are some things that Israel can learn from us.”
Like Frogel, he attributes Israel’s expertise to its experience with war and terror: “With the intifadas you’ve had to face, working together in disaster mode became an absolute necessity. It’s arguable that Israel is one of the world leaders, if not the world leader, in terms of disaster preparedness and response, including pediatrics, in large measure because of the work that Michael [Frogel] has been doing with his [APF] foundation to train Israeli physicians.”
Cooper says, however, that Israeli pediatric surgeons could learn from American practice to work more collaboratively with intensivists and emergency medicine physicians in the management of patient care.
Surgery itself “has a very limited role in the hours and days following a disaster. There are a few truly catastrophic situations where a surgeon may be involved within the first minutes, up to an hour or two. But those circumstances are very rare. Most of what surgeons are going to be involved with is treating wounds hours to days later. And most patients are not going to be physically wounded but are going to be dealing with other issues.”
Many people, he says, have romanticized misconceptions about the nature of disaster medicine. “They think of the heroes flying in, setting up the field hospitals, and doing all this major surgery. But that’s not chiefly what it’s about. Most of the surgery, if it’s going to be done, will be done in the first 24 to 48 hours – before the ‘cavalry arrives,’ so to speak. What’s really chiefly needed in the aftermath of a disaster is extended primary care … some combination of primary care/urgent care/emergency medicine. In many cases, it’s ongoing care for pre-existing conditions that exacerbate following disasters. Think of the diabetic whose diabetes may get out of control or the seizure patient who doesn’t have access to medicines. … And the mental health aspects are also really important.”
The lessons learned from Israeli-American cooperation on pediatric disaster preparedness not only benefit those countries but are also being applied more broadly. This includes Israel’s neighbors in the Palestinian territories, Jordan, and additional countries to the limited extent that regional cooperation happens. According to Dr. Peleg, Palestinian students have occasionally studied disaster and emergency management at Israeli universities and there have been “several" collaborations between Israeli, Palestinian, and Jordanian medical professionals, search and rescue teams, and other personnel on emergency and disaster preparedness. Peleg says that politics sometimes gets in the way and neighboring governments don’t always allow for as much cooperation as is needed: “It depends on orders from above. … We should do it much, much more. … I think it can be a great bridge.”
Nevertheless, according to Dr. Frogel, at times of crisis, people do cooperate. And the impetus for cooperation is perhaps strongest when it comes to pediatric medicine. Dr. Cooper notes that his work with Bedouin patients in Beersheba underscores a lesson: “We were dealing with a very different kind of nomadic culture that was very, very difficult to reach, linguistically, culturally, and in every other way. But … everybody wants the best for their kids and is willing to make big sacrifices to make sure that their kids get what they need.”
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