In light of the recent blog by the US Centers for Disease Control and Prevention (CDC) that focused on household emergency preparedness for the zombie apocalypse and other disasters like hurricanes, I began to ask myself whether health systems can prepare for similarly complex disasters (1). In order to contemplate this issue fully, I read Pride and Prejudice and Zombies and The Zombie Survival Guide as well as watched six terrifying episodes of The Walking Dead amid the backdrop of researching a section on complex disaster prevention for an upcoming issue of Infectious Disease Clinics of North America (2,3,4,5).

What we do know is that natural disasters know no boundaries and any nation or population can be subject to a catastrophic disaster at any time. However, some nations and populations are more at risk of disasters than others due to geographic location, poverty and several socio-political factors. This issue of disaster risk reduction (DRR) rose to global prominence in the aftermath of the tsunami in the Indian Ocean in December, 2004.

After a disaster, some populations suffer more acutely than others. It is worth considering the complex issues of how societies organise themselves in terms of risk and actual prevention and care, for access to clean water and sanitation, and how they communicate and initiate behavioural change among the displaced or fragile populations. At the forefront of most discussions when planning post-disaster management and action is the priority placed on certain elements of disaster relief, such as the building of embankments, the distance to clean water, or the time from incident to response. It is hard to imagine how such conventional prevention techniques would apply to the spread of zombie-ism which is generally considered viral.

However, among recent nature disasters rather than mythical ones, we see examples of varying responses and outcomes as in the two cyclones in South Asia. There was a relative success in Bangladesh in terms of lives saved and response co-ordination after Cyclone Sidr in November, 2007, compared with the devastating loss of more than 100,000 lives after Cyclone Nargis in Myanmar in May, 2008 not to mention the loss of draught animals and dykes, and the flooding of fields during planting season [6]. Bangladesh reverted to its well-developed programme for disaster risk reduction that includes national level co-ordination, whereas in Myanmar there was no national platform for disaster preparedness and delays occurred in the coordination of international response to the disaster. In addition to the immediate and obvious impact of natural disasters, conditions often worsen in poorly coordinated settings as evidenced in 2010 when Vibrio cholerae emerged in post-flood Pakistan, and for the first time since the 1960s in post-earthquake Haiti [6].

In general, there are seven factors that can turn any disaster into a complex disaster regardless of the severity or magnitude of the initiating event such as a hurricane, earthquake, or tsunami. According to the United Nations Department of Humanitarian Affairs, the seven factors are: poverty, ungoverned population growth, rapid urbanisation and migration, transitional cultural practices, environmental degradation, lack of awareness and information, and war and civil strife [7].

Poverty is by far the single greatest factor that contributes to the vulnerability of a population to complex disasters. In addition to lacking financial resources to prepare for or recover from a disaster, impoverished people are also more likely to have low levels of education and low amounts of political influence to properly deal with a disaster situation. In addition to increases in birth rates, rapid population growth can be the consequence of urbanisation or migration. Population growth without limits produces a population that is more likely to settle in areas that are unsuitable or at risk for natural disasters. This means that more people are at risk of disease and most importantly, more likely to undergo civil strife while competing for scarce resources. Of course, this means that there is an inherent equity issue as the poor are more likely to suffer during any disaster. We can assume that there would be no exception in the case of the zombie apocalypse and the poor would most likely to be the most profoundly affected.

Clearly, ensuring populations are informed about what to do to prepare in advance of a natural disaster such as a hurricane, and also to be able to fend for themselves following the event is of upmost importance. A lack of awareness and the dissemination of accurate information is a major factor turning one disaster into a multiple or complex disaster such as subsequent outbreaks of cholera, malnutrition, physical injury, and perhaps even zombie-ism.
War and civil strife are extreme events that can both produce disasters or be caused by disasters normally as a result of the preceding six factors [8]. The phrase for disasters that specifically strike war-torn populations is complex humanitarian emergencies [9].

Prompted by the devastation that followed the tsunami on 26 December 2004, there was widespread acceptance that an early warning system should be installed and other actions taken to prevent loss of life where possible. The World Conference on Disaster Reduction was held in Japan in January, 2005 and resulted in the creation of the Hyogo Framework for Action 2005-2015 (HFA), which was endorsed by 168 UN member states and urges all countries to make major efforts to reduce their disaster risk by 2015. The HFA outlines the need to increase awareness and understanding about disaster risk reduction (DRR), the importance of knowing the real and potential risks, and taking action against them. Specific recommendations included the need to create or enhance early warning systems, build DRR into education, and reduce risk factors such as deforestation, unstable housing, and the location of communities in risk-prone areas.

Types of activities that can feature in a national or regional DRR programme can include establishing early warning systems; using local knowledge of events; building an awareness of risk and risk preparedness through community activities; building flood resistant buildings and safe homes; developing contingency plans; helping communities and individuals develop alternative sources of income; and establishing insurance or micro-finance programmes to help transfer the risk of loss and provide additional resources to the community [10].

Fortunately the zombie apocalypse falls squarely into the realm of fiction, but thinking about preparedness for any large scale disaster is certainly good practice.

TLPK wishes to express her sincere gratitude to the CDC for sparking such lively discussion about the undead and to her son David (age 12) for research support and expert consultation on issues related to zombie-ism.

(1) http://www.bt.cdc.gov/socialmedia/zombies_blog.asp
(2) Austen J, Grahame-Smith S. Pride and Prejudice and Zombies. Quirk Productions: Canada, 2009.
(3) Brooks M. The Zombie Survival Guide: Complete Protection from the Living Dead . Three Rivers Press: New York, New York, 2003.
(4) http://www.amctv.com/shows/the-walking-dead
(5) http://www.id.theclinics.com/
(6) BBC News 2010. Burma death toll jumps to 78,000. http://news.bbc.co.uk/1/hi/world/asia-pacific/7405260.stm (accessed 4 November 2010).
(7) Rottman S 2010. Haiti cholera outbreak causes not clear, experts say. http://www.bbc.co.uk/news/world-latin-america-11618352 (accessed 25 October 2010).
(8) United Nations, Department of Humanitarian Affairs [UN-DHA] The use of military and civil defence assests in relief operations. MCDA Reference Manual. 1995. Accessed 1 Dec 2010 at www. Reliefweb.int
(9) Burkholder B, Toole M Evolution of complex disasters. Lancet 1995; 346:1012-1015.
(10) Development Research Network. Disaster Risk Management and Climate Change Adaptation in South Asia. Portfolion. Issue 3. December 2010.

Tracey Koehlmoos is programme head for health and family planning systems at ICDDR,B and adjunct professor at the James P. Grant School of Public Health, BRAC University, Dhaka, Bangladesh.