Mass Gatherings as Rallies in Taipei: Incident Reporting and Literature Review

 

 

From the Department of Emergency Medicine (Wang TL, Ma HP, Chang LP, Yang YJ), Shin-Kong Wu Ho-Su Memorial Hospital

Correspondence to Dr. Tzogn-Luen Wang, Department of Emergency Medicine, Shin-Kong Wu Ho-Su Memorial Hospital, 95 Wen Chang Road, Taipei, Taiwan. E-mail M002183@ms.skh.org.tw

A crowd of ‘pan-blue' supporters estimated more than 100,000 yesterday amassed outside the Presidential Office on April 10, 2004. This was once again an extreme mass gathering during president election period in Taiwan. This report is not intended to give comments on political issues. However, public health response may be the essential part of emergency medicine or even of disaster medicine in such an incident. Although preparation for mass gathering has been recognized as a means of training in disaster medicine, there are still no uniform methods or guidelines in such preparation and training. We'd like to summarize this incident and thus review the preparation process of previous mass gatherings such as Olympic games in Europe as a reference for future considerations in the response preparation for such mass gatherings.

More than 300,000 people launched a massive protest rally outside the office compound of the president since March 21, 2004, demanding a thorough investigation into the 319 shooting case that is widely believed to have important impacts on the election. The protest was initiated by the ally of two political parties. The people gathered since 2:00 p.m. that day and the speeches of the leaders of both party began at 4:00 p.m.. The police have deployed layers of wire to stop the protesters, some of whom even raged into collision with the police. At the same time, there were more than twenty students that protested the alleged illegal election and held a hunger strike.

Top Abstract Introduction Incident Report Preparation Casualties Discussion Conclusion References

Bureau of Health, Taipei City Government has held an emergency meeting to prepare extensively and monitor health events immediately. The consultants included all of chiefs of emergency response hospitals in Taipei. The consultant conference has drawn the following conclusion.
First, the response time should be taken into consideration because of the possible factors such as the distance between the strike point to the receiving hospitals and the number of the gathering people.
Second, the types of hunger strike should be categorized as those who ate and drank nothing (totally hunger strike) and those who drank water only (partial hunger strike). The former would suffer from immediate physical insult after 24 hour's starvation whereas the latter did not have immediate danger. Force protection should be considered for the former group.
Third, the duration of hunger strike should also be taken into account. In general, the victim might have ketoacidosis after 3 day's total starvation and become comatous or devastating after 7 days.
Fourth, the medical aid and humanitarian assistance should be done professionally under the neutral attitude of politics.
The response strategies have thus decided to take actions according to three stages:
Stage 1 (Day 0 to Day 3): emergency response system not activated
Stage 2 (Day 4 to Day 7): active medical understanding
Stage 3 (Day 8 and later): activate emergency response system; implement incident command post and primary medical aid post
If there was any persons who underwent totally hunger strike for more than 24 hours, Stage 3 action should be begun right away. The related flow chart, records and standard operations plan would be organized by Taipei Veterans General Hospital. All of the medical centers in Taipei have attended the program of medical aids.

Mass gathering is believed to provide a good chance to examine the validity of incident command system and response plan at each level of response system. Public health should be the first priority. The primary objectives of the public health response system were as follows:¹ (1) to detect and respond rapidly to disease outbreaks or unusual increases in health conditions; (2) to prevent weather-related illness; (3) to prevent foodborne and waterborne infectious diseases; (4) to assure that medical response to individual emergencies and possible mass casualties would be timely and of high quality; and (5) to take advantage of the activity as an opportunity to promote healthy lifestyle choices and other prevention messages.² A complete public health strategy should be developed under three stages of designing: assessment, policy development, and assurance. Assessment includes surveillance and environmental health services monitoring. The former includes enrolling data from the hospitals concerning each patient, including demographics, type of injury, and final disposition on leaving the emergency department, whereas the latter includes standardized, daily reports from field environmental health staff for the purpose of monitoring type, intensity, and location of environmental health staff activities.
Besides, the policy for mass gathering health should consider several aspects such as environmental health regulations, special food service, water supply, solid waste, special on- site sewage disposal, emergency medical services planning, and medical disaster planning. Public Health Service regional health administrator should be responsible for coordinating mass casualty preparedness including (1) propositioning of medical teams with expertise in responding to chemical and biological incidents; (2) placement of pharmaceutical agents in hospitals to manage mass chemical exposures; (3) training of hospital and emergency response personnel in decontamination and treatment for victims of mass casualties; and (4) development of a tabletop exercise in mass casualty response for community, local health, and emergency response officials.^2,3 Assurance should also be overemphasized. Weather related illness should be prevented by providing necessary materials for daily living. Besides, public education and information can be provided by well-trained persons in the nearby. In our reported incident, the response plan is focused upon emergency medical service. Food and water supply were supplied by the attending people themselves or the supporting parties. Environmental issue seemed to be overlooked. It is also necessary to plan for the potential public health and medical consequences of a disaster,³ including unexpected number of deaths, injuries, or illnesses in the affected community, exceeding the capacities of local health services and requiring external assistance; adverse environmental effects, with increased risk for communicable diseases and environmental hazards; disruption of local health infrastructures; and large population movements. In our reported incident, the public health system was modeled on the emergency operations center used in disaster management and included on-site partners. Public health staff was an integral part of this planning and execution and served as members of City Law Enforcement Command staff. Engagement of key partners and early planning were important for the establishment of a workable emergency response capability.

Public health activities should include the development and use of an augmented surveillance system to monitor health conditions and detect disease outbreaks; creation and implementation of environmental health regulations; establishment of a central Public Health Command Center and response teams to coordinate response to public health emergencies; planning for potential mass casualties and the provision of emergency medical services; implementation of strategies for the prevention of heat-related illness; and distribution of health promotion and disease prevention information. Public health agencies should take the lead in organizing and implementing a system for preventing and managing public health issues at future mass gathering.

Kilbourne EM, Choi K, Jones TS, Thacker SB, and the Field Investigation Team. Risk for heatstroke: a case-control study. JAMA 1982;247:3332-6

Noji E. The nature of disaster: general characteristics and public health effects. In: Noji E, ed. The Public Health Consequences of Disasters. New York, NY: Oxford University Press; 1997:3-20