I’ve been glued to the internet this a.m. waiting for news and pictures to come in from Port-au-Prince, Haiti where a powerful earthquake struck just before sunset last evening causing massive destruction and undoubtedly the loss of hundreds, and likely thousands, of innocent lives. Haiti, the poorest country in the Western Hemisphere, was already in shambles and this newest disaster is certainly not going to help. Haiti seems to go from diaster to disaster. I am praying for the citizens of this country.

When I was a student at the Harvard School of Public Health, I took a class from Professor Jennifer Leaning entitled Disaster Management. The course provided an overview of how public health professionals should think about responding when faced with disaster to minimize loss of life and morbidity. I was trying to think back to the lessons I learned in class and how they might apply to what is unfolding in Haiti: given the physical damage caused by the earthquake first responders should be mindful of obvious and non-obvious crush injuries, from broken legs to head trauma, and they should immediately begin preparations for the next phase of the response, which will likely involve significant dehydration, hunger, and food and water born illnesses from the breakdown of water, sanitation, and food supplies. I also recall being taught that the best way to manage such a response is to set up a clear centralized command and control center where the disaster response can be coordinated and managed. I suspect much of these actions are already underway.

Over the holidays, I had a chance to read the new book by Atul Gawande entitled “The Checklist Manifesto“. The basic argument articulated by the articulate Dr. Gawande is that checklists have transformed the way in which many other fields and industries deal with complexity and unpredictability and that that medicine, in particular surgery, could also benefit from the use of these simple, low-cost tools. I’ve blogged about some of the published results of a study Dr. Gawande and his colleagues at the WHO conducted on this over the past few years, but the book provides more background and insight into the value of these lists.

I had been struck while reading the book about how much he dumped upon the centralized command-and-control model to deal with disasters. He provides a example from when Hurricane Katrina stuck New Orleans. He argues that the traditional command-and-control model had failed and rather than recognizing that when faced with extraordinary complexity, which was further complicated by the breakdown of communication lines, power needed to be pushed out of the center to where people with local knowledge and expertise could be better utilized. The knowledge that was required to respond to this crises far exceeded the knowledge of any one person. Yet he also argues that individuals cannot act completely in isolation, they needed to be coordinated in some way, and he argues that a checklist could provide this overall coordination. In the book, he also provides examples of how successful general contractors and money managers also use checklists to manage this complexity.

It has now been almost 5 years since Hurricane Katrina, and the citizens of New Orleans are still rebuilding. Physically there are only about 1300 miles that separate New Orleans and Port-au-Prince but these two cities are almost a century apart in terms of their wealth and level of development. Dr. Gawande has shown that the same checklist can be effective in saving lives in rich hospitals in Boston and poor ones in Tanzania so I believe that many of the lessons from Katrina will be able to save lives in Haiti as well. Let’s hope that those in charge of this response are thinking about the past as much as the future.

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