Disaster Management following the Chi-Chi Earthquake in Taiwan by min12172



Disaster Management following the Chi-Chi
Earthquake in Taiwan
Yu-Feng Chan, MD;1 Kumar Alagappan, MD;2 Arpita Gandhi, MD;3 Colleen Donovan;1
Malti Tewari, MD;1 Sergey B. Zaets1

1. Department of Surgery, Division of        The earthquake that occurred in Taiwan on 21 September 1999 killed >2,000
   Emergency Medicine, University of         people and severely injured many survivors. Despite the large scale and size-
   Medicine and Dentistry of New Jersey,     able impact of the event, a complete overview of its consequences and the
   Newark, New Jersey USA                    causes of the inadequate rescue and treatment efforts is limited in the litera-
2. Department of Emergency Medicine,         ture. This review examines the way different groups coped with the tragedy
   Albert Einstein Medical School, Long      and points out the major mistakes made during the process. The effectiveness
   Island Jewish Medical Center, New Hyde    of Taiwan’s emergency preparedness and disaster response system after the
   Park, New York USA                        earthquake was analyzed.
3. Department of Emergency Medicine,            Problems encountered included: (1) an ineffective command center; (2) poor
   Albert Einstein Medical Center,           communication; (3) lack of cooperation between the civil government and the
   Philadelphia, Pennsylvania USA            military; (4) delayed prehospital care; (5) overloading of hospitals beyond
                                             capacity; (6) inadequate staffing; and (7) mismanaged public health measures.
Correspondence:                                 The Taiwan Chi-Chi Earthquake experience demonstrates that precise
 Yu-Feng Chan, MD                            disaster planning, the establishment of one designated central command,
 Department of Surgery                       improved cooperation between central and local authorities, modern rescue
 Division of Emergency Medicine              equipment used by trained disaster specialists, rapid prehospital care, and
 ADMC 11 Room 1110                           medical personnel availability, as well earthquake-resistant buildings and
 30 Bergen Street                            infrastructure, are all necessary in order to improve disaster responses.
 Newark, NJ 07103 USA
 Email: chanyf@umdnj.edu                     Chan YF, Alagappan K, Gandhi A, Donovan C, Tewari M, Zaets SB:
                                             Disaster management following the Chi-Chi Earthquake in Taiwan. Prehosp
Keywords: Chi-Chi Earthquake; disaster       Disast Med 2006;21(3):196–202.
management; disaster planning; earthquake;
Nantou; Taichung; Taiwan
                                             The earthquake that occurred in Taiwan on 21 September 1999 killed >2,000
                                             people and severely injured many survivors. Despite the large scale and size-
EMAT = emergency medical assistance teams
                                             able impact of the event, a complete description of its consequences and the
EOC = emergency operations center
                                             causes of the inadequate rescue and treatment efforts is not available. This
TBC = Taiwan Building Code
                                             review examines how different groups coped with the tragedy and major mis-
                                             takes made during the process.
Received: 20 July 2005
Accepted: 13 September 2005
                                             Characteristics and Consequences of the Earthquake
Revised: 28 November 2005
                                             The Chi-Chi Earthquake, the strongest earthquake in Taiwan since 1935,
Web publication: 21 June 2006
                                             occurred when the Chelungpu fault ruptured. The epicenter was located in
                                             the small town of Chi-Chi in Nantou County. The registered amplitude of
                                             the earthquake was MS = 7.6 (Richter scale) or ML = 7.3 (Taiwan system).
                                                The impact of the earthquake was severe for several reasons. First, its epi-
                                             center was located unusually close to the surface. Most earthquakes that have
                                             struck Taiwan occurred several hundred kilometers below the ground and
                                             were a result of the collision of the Eurasian and Philippine Sea plates
                                             beneath the Pacific Ocean. However, the Chi-Chi Earthquake occurred only
                                             one kilometer below the surface, leading to more brutal consequences.
                                             Furthermore, it was followed by strong aftershocks, which also had enor-
                                             mously destructive impacts. The Central Weather Bureau registered >10,000
                                             aftershocks between 21 September and 27 September, and several of them
                                             measured >6.5 on the Richter scale.1,2

Prehospital and Disaster Medicine             http://pdm.medicine.wisc.edu                                   Vol. 21, No. 3
Chan, Alagappan, Ghandi, et al                                                                                                197

Damage                                                               building collapse.5 These authors also reported other death
The rainy, tropical climate exacerbated the damage as heavy          risk factors, namely the distance from epicenter, population
post-earthquake rains promoted massive landslides and rock           density, and number of hospital beds and physicians per
falls (secondary events). Thousands of landslides, typically         10,000 people. The total number of deaths, according to
2–5 meters deep, occurred in the mountainous areas around            different databases, has ranged from 2,347–2,405.1,2,4,8,9,11
the epicenter, and many of these crossed adjacent rivers lead-       The difference in the reported death toll may be attributed
ing to the creation of large dams. The resultant river blockage      to the authors’ variation in the period of follow-up after the
formed lakes that flooded the upstream river valleys and             earthquake. More significant differences exist in the
threatened to overflow dams. The landslides also blocked             reported number of injuries. Some authors reported that
many mountain roads and tunnels. The Tsao-Ling, the                  there were 7,600–8,700 injured people.1,4,9 Others quoted
largest landslide, traveled a distance of several kilometers, car-   higher numbers (9,400–11,300).2,3,8,11
rying houses with it and destroying everything in its path.1,2           According to the registry, 76.9% of all deaths occurred
    The effects of the earthquake were widespread and caused         indoors due to the collapse of houses.9 Most victims who
significant damage in five counties. However, 90% of the             were not extricated during the first six hours after the
destruction occurred near the epicenter in Nantou County             earthquake were found dead.13 The analysis of lethal out-
and in Taichung County along the Chelungpu and                       comes in 1,826 earthquake victims presented by Chan et al
Shunantun fault lines. The reported amount of damage differs         showed that the main causes of death were asphyxiation
significantly and the majority of authors have reported that         and intracranial injuries.10 A more detailed list of fatal
81,000–106,000 buildings were damaged, including private             injuries presented by Liang et al included head injury
homes, apartment and office buildings, stores, and hospitals.        (33%), traumatic shock (29%), asphyxiation (29%), and
Approximately half of these buildings collapsed completely.3–6       other injuries (9%) such as organ damage, spinal cord
    The Taiwan Building Code (TBC) last was revised in               injury, burns, and carbon monoxide poisoning.9 The death
1996; however, the majority of collapsed houses were                 rate was higher in females, the disabled, and the elderly.4,6
designed in accordance with the TBC of 1982.1 Traditional,
one-story buildings in rural areas, which were 30–80 years           Disturbances in Function
old, did not tolerate the intense ground shaking of the earth-       People who survived the earthquake remained homeless
quake. Taiwanese architecture entails 3–4-story, arcade-style        and were forced to live in shelters. According to various
buildings, in which the first floor is used for commercial pur-      sources, the number of earthquake victims who needed
poses, and the upper floors are residential apartments. Many         shelters ranged from 100,000–320,000, corresponding to
of these buildings were ruined during the earthquake, due            the number of houses destroyed and people left homeless.3,4
mainly to the loss of stability of the first floor. Many mid-rise       Destroyed highway transportation systems resulted in
12–15-story apartment buildings that had no anti-earthquake          the isolation of many communities in the central, moun-
protection, also collapsed. However, none of the high-rise,          tainous regions.
20-story or taller buildings, collapsed or sustained severe             Damage to electric power transmission towers led to
damage.1,2 Thus, it is evident by the number of collapsed and        blackouts in the central and northern regions of Taiwan
damaged buildings that many of the apartment buildings               that began immediately after the earthquake. Wire and
were not designed systematically to withstand such a disas-          wireless telephone communication also were interrupted
trous earthquake. Although Taiwan had strict rules about the         and not restored until 36 hours after the earthquake.1,2
manner in which buildings in seismic areas must be con-
structed, contractors often ignored these rules. The worst case      Acute Phase of the Disaster and First Responders
of such a rule violation was a 14-story building, in which gaps      Needs Assessments and Planning Coordination and Control
in the structure were filled with salad oil cans.7                   During the minutes following the earthquake, the Ministry
    Landslides, soil settlement, and slope failures also             of the Interior activated the National Emergency
caused substantial damage to the highways. More than                 Operations Center (EOC) and the National Disaster
10% of bridges were completely or partially destroyed.1 A            Prevention Center. These Centers included Taiwan’s top-
significant number of electric power transmission towers             level governmental and senior officials with emergency
also suffered serious structural problems, along with dam-           responsibilities from the police department, the fire depart-
age to several substations and switchyards.                          ment, and other ministries. The day following the event,
    The worst consequence of the Chi-Chi Earthquake was              EOCs in the most affected areas were implemented.
the thousands of people killed or injured by the event. The          President Lee and Vice-Minister Chien visited Nantou
earthquake casualties were concentrated predominantly in             County 7–9 hours after the earthquake.
Nantou County, Taichung County, and Taichung City. All                   The major response operations were not coordinated
of these areas are located close to the epicenter. Ninety per-       efficiently. During the important hours soon after the cat-
cent of all mortalities and 85% of all injuries were regis-          astrophe, the military and fire administration radios were
tered in these areas.8,9 The death rate was proportional to          the only communication tools able to reach local officials.
the percentage of completely collapsed houses.10                     Therefore, the Central Response Center underestimated
According to the statistical analysis performed by Liao et           the early scope and gravity of the disaster due to a lack of
al, the peak ground acceleration during the earthquake was           information and communication from these sites. This led
a better predictor of lethal outcome than was the rate of

May – June 2006                                    http://pdm.medicine.wisc.edu               Prehospital and Disaster Medicine
198                                                                      Disaster Management following Chi-Chi Earthquake

to inadequate mobilization of human and material                       The first military unit, the 99th Division of Marines,
resources. For example, only local militaries, not national        arrived in the affected area two days after the earthquake. By
military units, were mobilized during the first day after the      that time, almost all the survivors had been rescued and the
earthquake. The National EOC also did not coordinate the           majority of the dead bodies had been extricated from the rub-
dispatch of emergency medical assistance teams (EMATs)             ble. Militaries were involved in providing shelter to the vic-
to the affected regions properly.11,12 The efforts of interna-     tims, transporting dead bodies for identification, inspecting
tional rescue teams and other international assistance were        damaged buildings for safety, and demolishing unsafe build-
less effective because of deficient central supervision. A         ings. They also transported a large quantity of medical equip-
large amount of goods donated by other countries (70 tons          ment, medications, and food into the disaster regions.16
of rice, six million vitamin tablets, 35,000 cans of milk              Thus, there was a shortage of trained, skilled personnel
powder, 500,000 bottles of water) were delivered without           and equipment necessary to perform adequate rescue opera-
any coordination to the areas affected by the earthquake,          tions in the early-days following the earthquake. The EOC
which caused significant difficulties in transporting to           did not utilize the full potential of national military units
these regions for other emergency services.4 Many defects          during the acute phase of the disaster.
in emergency procedures after the earthquake were caused
by the ineffectiveness of the EOC.                                 Emergency medical assistance teams (EMATs)
                                                                   A total of 104 hospitals, including nine major medical centers
Responses                                                          and 12 regional hospitals, dispatched EMATs during the first
Rescue procedures and evacuation                                   72 hours after the earthquake.11 The majority of them (79%)
According to the Taiwan National Emergency Plan (estab-            were sent to the scene as a result of the initiative of a partic-
lished in 1989 and revised in 1994), the island was divided        ular hospital, and only 21% of the EMATs were dispatched
into 17 Emergency Medical Services Regions.9 Emergency             directly by the National EOC or the healthcare authorities in
medical assistance was provided by emergency healthcare            charge of the rescue operations.
facilities and local fire departments. Firefighters were               Emergency medical assistance teams played a key role in
responsible for out-of-hospital medical care and ambulance         providing primary medical care after the earthquake. However,
service. All of the firefighters were certified as emergency       only 10% of them arrived on-scene within the first six hours
medical technicians following a 60-hour training course. In        after the earthquake.12 According to Hsu et al, only 7% of the
addition, 50% of the firefighters had completed a 240-hour         EMATs were able to start providing emergency care within the
medical emergency training course.9 Firefighters and volun-        first 12 hours after the event, 17% could provide care within 18
teers formed the main body of the rescue teams, which con-         hours, and 20% could provide care within the first 24 hours.11
ducted rescue efforts from the first hours after the earthquake.   There were several reasons for the relatively slow response of
However, these teams did not have experience operating dur-        the EMATs to the earthquake. First, they were not notified to
ing disasters involving multiple casualties. The Taiwanese         report to the earthquake-affected area immediately after the
rescue teams were unable to extricate people from the ruins        disaster. Only 10% of the EMATs received notification within
of collapsed buildings quickly, due to the lack of necessary       the first three hours after the earthquake, 17% were notified
heavy equipment and special skills training.                       within six hours, and 53% were notified within 12 hours after
    Although military helicopters were mobilized eight hours       the earthquake. The majority (61%) of the EMATs departed
after the earthquake, only local military personnel assisted in    within three hours after notification. However, it took 6–12
rescue operations during the first two days following the          hours for the EMATs to reach their final destination, due to
earthquake. There is no public information available stating       insufficient air transport usage and slow ground transportation
the number of military helicopters involved in the evacua-         due to damaged roads and bridges.
tion of victims. However, it may be concluded that there was           Previous experiences in providing urgent medical assis-
a shortage of helicopters because only 12% of the injured vic-     tance to the victims of earthquakes in Italy (1980),
tims were evacuated by air.14 The majority of earthquake vic-      Armenia (1988), and Costa Rica (1991) have shown that
tims (75%) were evacuated by ambulances and 13% by pri-            mortality can be reduced significantly if treatment is pro-
vate cars. More than 200 ambulances were used for the evac-        vided during the first six hours after the catastrophe.17–19
uation, but many roads and bridges were damaged, causing           Traumatic injuries, hemorrhagic shock, crush syndrome,
delayed ground transportation of patients. The median peri-        and chest and head injuries usually cannot be treated ade-
od of time from the moment of the earthquake until admis-          quately if help does not arrive within six hours following
sion to a back-up hospital was 17.5 hours.14 In Taipei, the        the earthquake. Therefore, the greatest demand for quali-
capital of Taiwan, the evacuation times were significantly         fied medical assistance occurs during the first day after the
shorter and did not exceed three hours.13 There is no infor-       event.3,20,21 In the case of the Taiwan earthquake, the
mation indicating how many people died during evacuation.          majority of EMATs did not arrive in time to save the lives
The majority of the 378 outdoor deaths occurred at the             of most victims with life-threatening injuries.
moment of the earthquake before the evacuation procedures              Thus, the value of qualified emergency medical assis-
began.9 Data of Ko et al showed that the majority of victims       tance during the earthquake was less than was possible.
were transported to nearby hospitals regardless of the sever-      The absence of a coordinated dispatch mechanism did not
ity of injury, thus resulting in overcrowded conditions in the     allow EMATs to begin emergency medical procedures dur-
emergency rooms.15                                                 ing the crucial first few hours following the earthquake.

Prehospital and Disaster Medicine                      http://pdm.medicine.wisc.edu                                  Vol. 21, No. 3
Chan, Alagappan, Ghandi, et al                                                                                               199

International search and rescue teams                               in Nantou County, was closed after the earthquake even
Almost immediately following the Earthquake, 21 countries           though the facility remained structurally intact.1 Located 120
mobilized 37 search-and-rescue teams in an effort to help the       meters from the Tsa-Lung-Pu fault, the hospital weathered
Taiwanese victims.8,22 International assistance required cer-       significant, non-structural, changes in the operating and
tain diplomatic arrangements because Taiwan was not a mem-          recovery rooms, the administration closed the hospital.
ber of the United Nations or the World Health Organization.         Several patients were injured during evacuation and seven
Combined, the rescue teams were composed of a total of 728          patients died because their life-support systems were inter-
personnel and 103 specially trained dogs. The teams had             rupted during evacuation. Other 400–450-bed hospitals,
modern equipment required for rescue and providing medical          such as Christian Hospital and Veterans Hospital located in
assistance.8,22 Japan and the US sent the teams with the            Puli, reduced their capacity down to 10–50% due to severe
largest number of members, which consisted of 135 and 92            non-structural damage (damaged equipment and failure of
members, respectively.                                              the power and water supply).1 Thus, the number of beds in
    Japanese rescue teams were the first to arrive in Taiwan, but   local hospitals available for the treatment of earthquake vic-
were unable to help immediately. The first team arrived in          tims was reduced substantially.
Taipei 16 hours after the earthquake, but was unable to reach           During the first 10 hours after the Earthquake, approx-
Chung Hua until the next day because of difficulties with           imately 2,900 victims were sent to local hospitals. This
transportation and unanticipated detours. Moreover, it took an      number increased during the first three days following the
additional day for the personnel to start their activities due to   Earthquake.9 A total of 7,605 injured patients received
a lack of coordination with local authorities.23 American res-      emergency and ambulatory care after the event. However,
cue teams arrived in the area 40 hours after the earthquake         this does not necessarily indicate that all of these patients
and were involved mainly in searching for possible survivors        were hospitalized. Some victims with minor injuries
under the ruins of multiple-story buildings.                        received required medical care in a hospital emergency
    From the perspective of the international rescuers, one         department without the need for hospitalization.
of the biggest problems they faced was the lack of a central            The majority (90%) of hospitalizations were injured,
command center to coordinate rescue efforts.22,23 Other             with open wounds (61%), limb fractures (16%), closed head
impediments included a shortage of necessary, high-tech             injury (9%), and burns (3%).9,24 The majority of chest
equipment from the local rescuers, such as search cameras,          injuries were caused by blunt mechanisms.27 Up to 20% of
retractable rods fitted with lights, and microphones for            the patients hospitalized shortly after the earthquake had
probing rubble. The work of the international teams was             non-trauma-related illnesses, which were caused or exacer-
complicated due to the lack of interpreters and engineers to        bated by the event.24 From the third day following the
determine whether working in and around collapsed build-            earthquake forward, medical diseases became the most
ings was safe.                                                      common causes for hospitalization.9
    International search-and-rescue teams were not able to              The first six hours post-earthquake were critical for
arrive early enough to find a large number of survivors             wound treatment and life-support interventions (intensive
(they managed to find only six people who were alive). The          treatment of hemorrhage, intubation, and defibrillation).
absence of coordination with local authorities reduced the          Chen et al, whose hospital admitted 566 patients during
effectiveness of their work.                                        the three days following the earthquake, noted that no life-
                                                                    support interventions were performed more than seven
Hospitals                                                           hours after the admission.24
There are approximately 700 private and public hospitals                Data concerning the incidence of the crush syndrome
with >120,000 beds used for inpatient care in Taiwan.9 The          caused by the Chi-Chi Earthquake remain unclear. There
areas affected by the Earthquake contained 4,375 health-            is no information on how many people died of crush syn-
care institutions, including 165 hospitals.1 However, these         drome in the prehospital period (immediately after extrica-
medical facilities were not distributed equally around the          tion from the rubble or during evacuation). Data from
territories affected. For example, Nantou County had the            major hospitals in Central Taiwan indicate that 95 patients
least number of medical facilities and the poorest medical          developed crush syndrome due to body compression that
care resources compared to other municipalities. The dis-           occurred during the earthquake. Approximately 30% of
tribution of physicians also differed substantially in the          these patients required hemodialysis support until renal
areas affected by the disaster. For example, Taichung City          function returned.28,29 Thirty-five patients underwent fas-
and Taipei had 23–24 physicians per 10,000 residents                ciotomy for treatment of a compartment syndrome. Six
whereas in Taichung and Nantou Counties this ratio did              cases required amputation of an extremity. Hospital mor-
not exceed 9/10,000.9,24 After the Earthquake, 468 health-          tality in patients with crush syndrome reached 9.5%.28,29
care facilities reported various degrees of structural and          However, Chen et al reported that of 495 patients who
non-structural damage.25 Fortunately, only a few large hos-         were treated in emergency departments during the first two
pitals were damaged severely, but even relatively minor,            days after the earthquake, only 85 required hemodialysis,
non-structural damage such as flooding, the absence of elec-        only three had crush syndrome, and the others had renal
tricity, and fallen objects forced many hospitals to evacuate       insufficiency due to pre-existing chronic diseases.14
patients due to the loss of medical capacity.26 For example,            According to Liang et al, 7,605 injured persons received
the modern, private, 400-bed Shiu-Tuan hospital, the biggest        emergency and/or ambulatory help after the Earthquake.9

May – June 2006                                   http://pdm.medicine.wisc.edu               Prehospital and Disaster Medicine
200                                                                     Disaster Management following Chi-Chi Earthquake

A total of 7% (164 patients) of the total of 2,347 victims       2.8%, and 7.9%, respectively.30 The rate of psychiatric mor-
who perished as result of the earthquake died in hospitals.      bidity (defined as >4% according to the Chinese Health
Assuming that the majority of the injured victims who            Questionnaire) was as high as 24.5%.31 Females more fre-
received emergency and or ambulatory help were hospital-         quently were affected by mental disorders than males.30
ized, the hospital mortality rate was 3% (164 of 7,605).         Rescue workers also were found to suffer from post-trau-
However, this seems to be an underestimation because some        matic stress disorders.32 The level of stress experienced was
victims did not receive traditional methods of treatment and     significantly higher in non-professional rescuers than in
were not hospitalized. A major cause of hospital deaths was      professional rescuers. The high level of stress caused by the
complications from sepsis. No database that contained evi-       earthquake seemed related to an increased rate of myocar-
dence for the results of treatment of the earthquake victims     dial infarctions compared to the same period in the previous
could be found.                                                  year.33 More frequent myocardial infarctions, however, did
   Physicians faced the greatest difficulties during the first   not cause an increase in post-earthquake mortality from
hours after the event, which were also the most crucial for      cardiovascular diseases, and did not differ between disaster
emergency patient care. The experience of one of the largest     and non-disaster areas.34
hospitals in Taiwan (1,290-bed university teaching hospital          The disaster seemingly influenced the suicide rate in
located in Taichung City, 10 km away from the Chelungpu          affected areas as the suicide mortality rate in disaster areas
fault and 40 km from the earthquake epicenter) showed that       was higher in 1999.34 During the 2–15 months following
only 18% of all on-staff physicians assisted in emergency        the Earthquake, victims (defined as those who were
patient treatment during the first hours after the earth-        injured, lost a family member, or experienced major prop-
quake.24 This resulted in a major overload on the working        erty loss) were 1.46 times more likely to commit suicide
physicians. The number of wound treatments, as well as the       than non-victims.35 Special mental health protection pro-
number of advanced life support interventions per physician      grams should target victims of the earthquake specifically,
increased significantly compared to the pre-earthquake peri-     rather than simply targeting all of the individuals residing
od. However, there is no information that indicates how the      in the affected area.
lack of staff influenced the waiting time for a medical proce-
dure. Those physicians who did not assist in emergency pro-      Conclusion
cedures did so mainly because they: (1) were taking care of      The most important question that should be addressed is
their own families (20%); (2) lost communication with the        whether it was possible to reduce the number of casualties.
hospital and/or had transportation difficulties (22%); or (3)    There were several objective factors that made the 1999
believed that they could be of no help (14%).                    earthquake in Taiwan particularly devastating. First, the
   Significant damage to local medical facilities reduced the    epicenter was located close to the surface of the earth, caus-
number of hospitals able to provide necessary medical assis-     ing the main shock to be severe, and was followed by several
tance to the victims soon after the Earthquake. The shortage     strong aftershocks. Also, in the mountain areas, the tropical
of manpower during the first hours following the event cre-      climate promoted massive landslides that caused additional
ated additional difficulties for effective medical assistance.   casualties. It remains questionable whether the death toll
                                                                 would have been lower if the event had occurred during the
Subacute Phase Prolonged Effects                                 day when the majority of people were not inside apartment
Information concerning the morbidity and mortality of            buildings but in offices, schools, stores, or on the highways.
patients admitted to hospitals after the first day following     There is no doubt, however, that the occurrence of this
the Earthquake is limited. Wang et al have shown that            event at nighttime made the initial rescue procedures more
among the 1,724 patients hospitalized from the second to         challenging, especially in the conditions of a blackout.
seventh day after the earthquake, only 39 were in unstable       Many dreadful consequences of the earthquake could have
condition and required emergency care.3 Primary diagnoses        been prevented:
included: (1) minor injuries; (2) upper airway infection; (3)        1. The design of many buildings in Taiwan, especially
hypertension; (4) dermatitis; and (5) gastroenteritis.                  those structures built before the 1980s, did not cor-
Teaching hospitals played an important role in providing                respond to modern seismic guidelines, or these
medical assistance during the subacute phase. Five days                 guidelines were ignored during construction;
after the earthquake, the major teaching hospitals parti-            2. The national emergency plan designed for different
tioned the affected area into 26 medical supporting units               disasters also showed significant limitations. The EOC
and provided continuous medical help to local institutions              failed to provide coordination of rescue procedures and
on-site, as well as referring patients to back-up hospitals.3           medical assistance to the victims. It was unable to
During the month following the earthquake, 250–300                      gather necessary information from the affected sites
patients were treated per day. The most common diagnoses                during the initial phase of the disaster due to the dys-
of newly admitted patients were chronic medical illnesses               function of traditional telephone communication. As a
and psychiatric disorders.                                              result, the mobilization of central help, such as armed
   During the 4–6 months following the earthquake, an                   forces, was insufficient and delayed;
increased rate of psychiatric disorders was detected. The            3. Local rescuers, who courageously acted on-scene
rate of active major depression, past major depressive                  from the first hours after the Earthquake, did not
episodes, and post-traumatic stress disorder was 9.5%,                  have the necessary equipment or sufficient training to

Prehospital and Disaster Medicine                    http://pdm.medicine.wisc.edu                                  Vol. 21, No. 3
Chan, Alagappan, Ghandi, et al                                                                                                                                 201

       extricate people from the ruins of collapsed buildings;                       7. The absence of a concrete scheme of physician
    4. In the absence of a centralized dispatch mechanism,                              mobilization led to a lack of medical personnel
       the majority of emergency medical assistance teams                               working in hospital emergency departments during
       did not arrive at the scene during the first six hours                           the first hours after the earthquake. No data are
       after the Earthquake when the probability of saving                              available to show the waiting time for different
       lives was significantly higher. Long travel distances                            emergency procedures (including surgeries) during
       also prevented international teams from arriving in                              this period. An increased number of advanced life
       Taiwan on the first day after the Earthquake. The                                support interventions per physician could have
       lack of coordination with the Command Center and                                 increased the waiting time for this procedure, and
       local authorities further delayed their arrival to the                           could have influenced the outcome of treatment neg-
       affected areas;                                                                  atively. Medical assistance during the subacute phase
    5. The distribution of casualties among local and back-up                           of the disaster was organized better, which it made
       hospitals was not organized properly. As a result, many                          possible to avoid high hospital mortality and any
       local hospitals were overcrowded. The emergency plan                             outbreaks of dangerous infectious diseases. A med-
       did not fully take into consideration the reduced                                ical follow-up program of earthquake victims should
       capacity of local hospitals due to structural and non-                           be considered in the future.
       structural damage sustained during the Earthquake;                            The experience of the Taiwan Chi-Chi Earthquake
    6. The evacuation times were extended because of dam-                         demonstrates that precise disaster planning, the establish-
       aged roads. Insufficient use of air transportation further                 ment of one, designated central command, improved coop-
       contributed to the delay in emergency patient care; and                    eration between central and local authorities, modern rescue
                                                                                  equipment available to trained disaster specialists, rapid
                                                                                  prehospital care, and medical personnel availability, as well
                                                                                  earthquake-tolerant buildings and infrastructure, all are
                                                                                  necessary in order to improve disaster responses.

1. Lee GC, Loh C: Preliminary report from MCEER-NCREE workshop on                 15. Ko PC, Ma MH, Shih FY, Lin FY: Urban prehospital emergency medical
    the 921 Taiwan earthquake. Available at http://mceer.buffalo.edu/research/        transportation in Taipei following the Taiwan earthquake. Prehosp Disast Med
    Reconnaissance/taiwan9-21-99/99-SP03.pdf. Accessed 22 November 2005.              2000;15(3):s45(Abstract).
2. Earthquake Engineering Research Institute: EERI special earthquake report,     16. Ishii N, Nakayama S, Matsuda H, et al: A comparative study of emergency
    December 1999. Learning from earthquakes. The Chi-Chi, Taiwan earth-              medical response in Hanshin-Awaji and Taiwan earthquake: Lessons learned
    quake of September 21, 1999. Available at http://www.eeri.org/lfe/pdf/tai-        from rapid medical response in Taiwan earthquake. Prehosp Disast Med
    wan_chi_chi_eeri_preliminary_report.pdf. Accessed 22 November 2005.               2000;15(3):s45 (Abstract).
3. Wang LM, Chih PS, Chern CH, et al: The role of the teaching hospitals in       17. Safar P: Resuscitation potentials in mass disasters. Prehosp Disast Med
    the subacute phase of 921 earthquake in Taiwan. Prehosp Disast Med                1986;2:34–47.
    2000;15(3):s91(Abstract).                                                     18. Pretto EA, Ricci E, Llain M, et al: Disaster reniamatology potentials: a struc-
4. Chen KT, Chen WJ, Malilay J, Twu SJ: The public health response to the Chi-        tured interview study in Armenia. III. Results, conclusions, and recommenda-
    Chi earthquake in Taiwan, 1999. Public Health Reports 2003;118:493–499.           tions. Prehosp Disast Med 1992;7:327–337.
5. Liao YH, Hwang LC, Chang CC, et al: Building collapse and human deaths         19. Pretto EA, Angus DC, Abrams JI, et al: An analysis of prehospital mortality
    resulting from the Chi-Chi earthquake in Taiwan, September 1999. Arch             in an earthquake. Prehosp Disast Med 1994;9(2):107–117.
    Environ Health 2003;58:572–578.                                               20. Thiel CC, Schneider JE, Hiatt D, Durkin ME: 911 EMS process in the Loma
6. Chou YJ, Huang N, Lee CH, et al: Who is at risk of death in an earthquake?         Prieta earthquake. Prehosp Disast Med 1992,7:348–358.
    Amer J Epidemiol 2004;160:688–695.                                            21. Schultz CH, Koenig KL, Noji EK: A medical disaster response to reduce
7. Hays WW, Chaker AA, Hunt CS: Learning from disaster. Civil Engineering             immediate mortality after an earthquake. New Engl J Med 1996;334:438–444.
    Magazine December 1999. Available at http://www.pubs.asce.org/ceon-           22. Chiu WT, Arnold J, Shin YT, et al: A survey of international urban-and-res-
    line/1299feat.html. Accessed 21 November 2005.                                    cue teams following the Ji Ji earthquake. Disasters 2002;26:85–94.
8. Chiu WT, Arnold J, Huang W, et al: Survey of international search and rescue   23. Koido Y, Kondo H, Tada A, et al: JDR medical team’s relief activities following
    teams after the Ji Ji earthquake in Taiwan. Ann Emerg Med 2001;37:733–734.        the earthquake disaster in Taiwan. Prehosp Disast Med 2000;15(3):s46(Abstract).
9. Liang NJ, Shin YT, Shin FY, et al: Disaster epidemiology and medical           24. Chen WK, Cheng YC, Ng KC, et al: Were there enough physicians in an
    response in the Chi-Chi earthquake in Taiwan. Ann Emerg Med                       emergency department in the affected area after a major earthquake? An analy-
    2001;38:549–555.                                                                  sis of the Taiwan Chi-Chi earthquake in 1999. Ann Emerg Med
10. Chan CC, Lin YP, Chen HH, et al: A population-based study on the imme-            2001;38:556–561.
    diate and prolong effects of the 1999 Taiwan earthquake on mortality. Ann     25. Mingi CL: Taiwan’s problems of disaster management from the point of view
    Epidemiol 2003;13:502–508.                                                        of a 500-bed hospital hit hard by an earthquake. Prehosp Disast Med
11. Hsu EB, Ma M, Lin FY, et al: Emergency assistance team response following         2000;15(3):s102 (Abstract).
    Taiwan Chi-Chi earthquake. Prehosp Disast Med 2002;17:17–22.                  26. Chuang CC, Yao GC, Chi CH et al: The operational and functional compo-
12. Ma MH, Hsu E, Choo MKF, et al: Assessment of emergency medical relief             nents of hospital buildings—The experience in the Taiwan Ji-Ji earthquake.
    services following the Taiwan earthquake. Prehosp Disast Med                      Prehosp Disast Med 2000;15(3):92(Abstract).
    2000;15(3):45(Abstract).                                                      27. Yi-Szu W, Chung-Ping H, Tzu-Chieh L, et al: Chest injuries transferred to
13. Ko PC, Ma MH, Shih FY, Lin FY: The effects of the Taiwan earthquake on            trauma centers after the 1999 Taiwan earthquake. Amer J Emerg Med
    the urban emergency health care system. Prehosp Disast Med                        2000;18:825–827.
    2000;15(3):s101(Abstract).                                                    28. Huang KC, Lee TS, Lin YM, Shu KH: Clinical features and outcome of crush
14. Chen HC, Tsai CK, Tsai J: An overview of the patients needing hemodialysis        syndrome caused by Chi-Chi earthquake. J Formos Med Assoc 2002;101:249–256.
    in the Taiwan 921 earthquake. Prehosp Disast Med 2000;15(3):s90 (Abstract).   29. Hwang SJ, Shu KH, Lain JD, Yang WC: Renal replacement therapy at the
                                                                                      time of the Taiwan Chi-Chi earthquake. Nephrol Dial Transplant
                                                                                      2001;16(Suppl 5):78–82.

May – June 2006                                              http://pdm.medicine.wisc.edu                           Prehospital and Disaster Medicine
202                                                                                          Disaster Management following Chi-Chi Earthquake

30. Chou FH, Su TT, Chou P, et al: Survey of psychiatric disorders in a Taiwanese   33. Tsai CH, Lung FW, Wang SY: The 1999 Ji-Ji (Taiwan) earthquake as a trig-
    village population six months after a major earthquake. J Formos Med Assoc          ger for acute myocardial infarction. Psychosomatics 2004;45:477–482.
    2005;104:308–317.                                                               34. Kuo HW, Wu SJ, Chiu MC: Disease-specific mortality associated with earth-
31. Yang YK, Yeh TL, Chen CC: Psychiatric morbidity and posttraumatic symp-             quake in Taiwan. Mid Taiwan J Med 2003;8:157–164.
    toms among earthquake victims in primary care clinics. General Hosp Psych       35. Chou YJ, Huang N, Lee CH, et al: Suicides after the 1999 Taiwan earthquake.
    2003;25:253–261.                                                                    Intern J Epidemiol 2003;32:1007–1014.
32. Guo YJ, Chen CH, Lu ML, et al: Post-traumatic stress disorder among pro-
    fessional and non-professional rescuers involved in an earthquake in Taiwan.
    Psych Res 2004;127:35–41.

Prehospital and Disaster Medicine                                    http://pdm.medicine.wisc.edu                                                 Vol. 21, No. 3
                        BE PART OF THE SOLUTION!

                Your esteemed colleagues throughout the world
              are working together to forge a new direction for this,
            the most exciting and humanitarian branch of medicine.
                   (Founded in 1976 as The Club of Mainz)

The Club of Mainz was founded on 02 October 1976 with the goal of improving
the worldwide delivery of prehospital and emergency care during everyday and
mass disaster emergencies. The founding members were renowned
researchers, practitioners, and teachers of acute care medicine who joined
together to focus their energies on the scientific, educational, and clinical
aspects of immediate care.
  Following the constant development of its scope and extension worldwide,
and to better reflect its nature, the organization’s name was changed to The
World Association for Disaster and Emergency Medicine (WADEM).
  While WADEM has grown over the years, the founding principles have
remained the same. Our members continue to work actively to solve scientific,
technical, and political problems surrounding the management of emergency
incidents. Through their dedication, and with your help, if you will join us, we can
better provide pioneering solutions and meaningful change in our disaster-rid-
den world.


                 To join the WADEM, please visit our website or
                  mail the pull-out card located in this Journal.

To top