experts views by a review of some books!

Advice from experts: Surviving a disaster: Controlling our fears ? a review of book ?unthinkable by Dr. G. Balakrishnan for the benefit of readers
Q&A with Amanda Ripley, author of The Unthinkable: Who Survives When Disaster Strikes ? and Why
As we go about our day-to-day lives, disasters are far from the minds of most people. But 90 percent of Americans live and work in places where there are significant risks for earthquakes, tornadoes, floods, hurricanes, terrorism or other natural and human-made disasters. When a life-or-death situation occurs, some people do better than others. In the midst of a disaster, many people panic, while others assume leadership roles. Some people emerge as heroes while others simply freeze.
APHA?s Get Ready campaign recently interviewed award-winning Time magazine writer Amanda Ripley, who has criss-crossed the globe to cover some of the most devastating disasters of our time. In her recent book, The Unthinkable: Who Survives When Disaster Strikes ? and Why, Ripley offers insight into how our brains work during disasters and tells us how we can increase our odds of surviving. ? TDJ
What happens to us in the midst of a disaster and why do some of us do better than others?

We literally use different parts of our brains instantly in a disaster. Everything changes. As one Sept. 11 survivor said to me, ?You don?t ever want to have to think in a disaster.? He knew that because he had experienced the complete change that occurs when you are in a life or death situation. So literally you lose peripheral vision, your heart rate increases, your blood pressure goes up, you get an injection of stress hormones which help you perform physically, but actually make it much harder to perform cognitively, so you have a lot of trouble making decisions ? even simple decisions ? or processing new information. So the reason some of us often do better than others in a disaster usually has to do with what was in our brains before everything went wrong, because you won?t be able to really progress much from where you were once things go bad. So it really depends on what you had in your head as far as what to do, how to do it, when to do it, before everything went wrong.
How can we overcome weaknesses and boost our odds of surviving in a disaster?

The more familiarity you have beforehand with any of your major risks and how to get out of them, the better you will do. For example, if you know that you live in place that is at high risk for flooding, which is true of many millions of Americans, then the more thinking you have done about what you would take with you, how you would evacuate, when you would evacuate, how you would deal with your elderly mother ? all of those things are not going to go very well if you wait until you are under stress ? you are not going to make great decisions. So the more you can feed your brain with plans and thoughts and even execute some of those plans in advance, the better you are going to do.
In general, we have certain weaknesses when it comes to assessing risk and performing well under stress. We also have a lot of strength, but if we can understand what the weaknesses are in advance, then we can do a lot better. One of the biggest weaknesses is that we tend to move very slowly under extreme duress, and the more we have done in advance the more quickly we will push through that phase and perform appropriately.
Why do so many of us shut down or freeze in the midst of a disaster?

This is so common, so pervasive across every kind of high-stress event. I have talked to firefighters who have many tales of people freezing up, all the way to stockbrokers who have seen it on the trading floor during a stock market crash. You see it across all kinds of contexts, and you actually see it in every animal that has ever been tested in a laboratory setting. This tendency to shut down or freeze is, in my mind, an evolved defense mechanism. It is so powerful and so common that I don?t think we would have evolved to this state unless it served a purpose. In many particularly ancient kinds of threats, shutting down in a life or death situation, where your body goes numb, you stop moving, you look like you?re dead, could be an appropriate response if you?re getting attacked by a saber-toothed tiger, for example. But in more modern situations, it is not as appropriate. We need to understand this better because it?s the kind of thing you can overcome, and it?s very, very dangerous in events like fires or plane crashes. We?ve seen this many times, we know that this is a bigger risk than almost any other behavior ? certainly much more likely than panic ? so we should start planning for it in advance.
In your book you talk about the ?survival arc? that we all must travel to get from danger to safety. Can you explain a bit about that?
Across all different kinds of disasters, from sinking ships to burning buildings, people tend to go through three phases. The first phase is a powerful kind of denial, where your brain works quite aggressively to normalize what is happening, to downplay the threat and make sense of what?s happened based on everything that your brain has seen before. It is a perfectly normal response, but it can take up precious time. The second phase after denial is deliberation. Most people become extremely social in disasters. They look to each other for cues and advice and information, and that is also a really important phase, but again, it can take up a lot of time if you don?t push through that phase efficiently. The third phase is the decisive moment, where people take action based directly on what?s happened in the denial and deliberation phases. Sometimes it?s the appropriate action and sometimes it?s not, but often we only know that in retrospect.
Are there any specific traits that might predict how well we will do in a disaster?

Among the many survivors I have talked to, the people who have military training or even Boy Scouts training tend to perform a little better in a lot of situations. But more important is not the training but the culture, the whole outlook on life. Research shows that if you have what?s called an ?internal locus of control,? so you believe that you influence your destiny, then you tend to do better and recover more fully in a lot of situations. If on the other hand you feel like you are kind of at the mercy of fate and are in a more passive victim role in your day to day life, then that could be problematic because you?ll be less likely to take action and can have trouble recovering. It?s not 100 percent for every situation, but those trends tend to play into it. So the more you feel like you?re in control of your destiny and the more confidence you have in your ability to affect change, the better you actually do. It?s very much a self-fulfilling prophecy.
Are there any simple ways that we can train our fears and thoughts to help us survive in a disaster?
There are simple things you can do that are taught to first responders and elite military units, and they basically are not that different from yoga. Anything you can do to ramp down that fear response so that it doesn?t overwhelm your ability to think will help. We know that the most effective way to influence your subconscious brain is through breathing. With controlled breathing, for example, you breathe in for four counts, hold for four counts, release for four counts, hold for four counts and you repeat, over and over and over again whenever you are under stress. It could be mild stress, but it?s something I practice all the time, in traffic and so forth. This is the kind of thing that is actually taught to swat teams and Navy Seals. It is extremely effective in helping you control the physiological response to stress.
In your book you mention who the real first responders in a disaster are. Who are they?
Talk to anyone who has actually survived a disaster and they will instantly tell you that they were the first responders. Since Sept. 11 we have become very reliant upon first responders. We spend a lot of money equipping firefighters, police and so forth and that is all well and good, but the reality is that in major disasters, those people are not there, they just can?t be everywhere at once. In big disasters, regular people do the majority of life saving, so the people you work and live with are the first responders and I really think that this is probably the most important lesson I have learned in covering disasters over the last decade. If we continue to focus on the experts and not the public, we are not going to get any better at this. We really have to focus our energy on the people who are always first at the scene in every disaster and that?s regular people, so continuing to pour billions of dollars into equipping first responders, and not equipping and training the public is, I think, a mistake.
When it comes to hurricanes and other weather-related risks, we often overestimate ourselves. Can you explain how?
The three major risks that I consider the most under-appreciated but significant risks that most Americans face are fire, floods and lightning. Those are things that, because of the way we are wired, we don?t spend a lot of time worrying about in advance. We don?t really stress about them. We stress about things that are less likely to happen, for example our kids getting kidnapped, or terrorism attacks or shark attacks. But these are things that are extremely unlikely for most people. There is only so much attention we all have to spend in preparedness, so it is important to really prioritize. What are my biggest risks? It obviously depends on where you live and how you live but certainly we know that disasters are getting more frequent and more expensive in this country, largely because of wind and water events. We live in these dense, vertical cities near water, so we really have to try to focus our minds on things like floods, and also fire, which generally kills more people every year than all other disasters combined.
In your book you talk about ?group think? and you note that our best chances of survival are usually improved by sticking together. Why is that?

It seems to be an evolved reality because you see it in mammals as well. Chimpanzees, for example, when they are under a threat, will form groups and show each other affection. They also become very hierarchical and pay even more attention to the leader than normal, and this is also true of humans. The reality is that in disasters, we don?t turn into the kinds of hysterical mobs that we see in movies. We tend to actually show each other great courtesy when things are going very bad and that should be enormously reassuring to people. I can?t tell you how many times I?ve heard this from survivors ? people who have been in terrorist attacks, people who have been in enormous fires ? they always marvel at how well most people behaved. In general, the crowd does not really like panic, does not like people who are screaming and out of control, and the crowd will snuff that out pretty quickly, either by helping that person or minority of people or by aggressively telling them to stop. So generally, people form groups and that is helpful because you need information more than almost anything else in most disasters. Ten brains and 20 hands are better than one brain and two hands.
What is the biggest mistake made by the people in charge of protecting us?
Again and again, the people in charge of protecting us tend to underestimate the ability of the public. They think that people will panic if they are given frightening or potentially frightening information. They think people will loot or misbehave and I can?t tell you how many times this has come up. Even in my conversations with high-level emergency preparedness officials, there is among every group of experts a belief that they know better. I think this is just part of human nature, but it is very dangerous when it comes to preparedness. The reality is, usually you may know better but you?re not going to be there. The tendency to think that regular people will not perform well is often misguided. Regular people perform much better on average than we expect. So we really need to enroll regular people, engage them creatively, listen to them in advance and have them literally at the table when we are making decisions about emergency evacuation drills, about how to prepare for biological threats. They literally need to be at the table or else a natural bias will warp our planning and we will end up with emergency plans that are written for emergency responders.
? Q&A conducted, edited and condensed by Teddi Dineley Johnson, The Nation's Health, APHA
For more information on Ripley or on The Unthinkable: Who Survives When Disaster Strikes ? and Why, visit www.theunthinkable.com.
March 2009


Advice From APHA Experts: How to create a healthy emergency stockpile
Q&A with Capt. Laura A. McNally, MPH, RD, FADA, a dietitian with the U.S. Public Health Service
Much has been written in the media lately about the threat of pandemic flu. The flu virus that causes a pandemic can spread easily from person to person and may cause large numbers of people to become ill and die. In the event of pandemic flu or other natural disaster, your local officials might advise you to shelter in place, which is a precaution that aims to keep you and your family safe in your home. To prepare for such an emergency, you?ll need to have created ? in advance ? an emergency stockpile of healthy foods.
To help you make the healthiest choices when planning what will go into your stockpile, the American Public Health Association recently sought advice from Capt. Laura A. McNally, MPH, RD, FADA. McNally is a dietitian officer in the U.S. Public Health Service and chair of the Emergency Preparedness Task Force for the American Dietetic Association.


When it comes to stockpiling, many of the obvious foods that come to mind, such as canned soups and vegetables, are high in sodium. How can we pack foods that are healthy?
There are many options available today. The low-sodium, low-fat canned foods that are available are ideal for stockpiling. Things such as canned soups ? Healthy Choice makes one option or Campbell?s makes another low-sodium option ? these are good choices. Other good choices for canned foods are those foods that are packed in their own juices, such as canned fruits. You can buy vegetables that are low in sodium, and those also would make very good options. So when you are looking for low-sodium foods, there are many options now available in canned products.
How about crackers and chips?
Crackers and chips tend to have more sodium. Given that you potentially would have a limited water supply or juice supply, you will want to stay away from salty items such as crackers, nuts and chips, although we recognize that those are comfort foods and may be the kinds of foods that many, children in particular, will want to have. You don?t have to avoid them totally but you can buy non-salted nuts, you can buy low-sodium crackers and you can also buy low-sodium or no-salt chips, so it?s not impossible to have those in your stockpile.
How much water should we plan on including in our emergency stockpile?
The recommendation for water is that we have one gallon of water per person per day. This is for food, drinking and personal use, such as brushing your teeth. You can possibly have water supply in your home at that time, but you do want to make sure that you also have an extra stockpile. So at very minimum the one gallon of water per person per day is recommended, for at least a three-day supply, and for pandemic flu it may be much longer.
How often should you rotate your water supply?
Your water supply does need to be rotated because bacteria will build up in it. Water is stamped with a date on it, and what I recommend is that you actually (use) stickers. Whether it is for water or other foods in your emergency supply kit, take a sticker and put the date on it that you put it in there and then if you use a regular rotation schedule, you will be able to look at the date that it went in, and make sure that at six months you look at the expiration date that?s been stamped on it. And also with canned goods, inspect for any signs of bulging or anything like that on the lids, to be sure that the product has not gone bad on you. But it is important that you rotate your water on a regular schedule.
How often should foods be rotated?
It is a good recommendation, just as you would change the batteries in your smoke alarms every six months along with (changing your clocks, to rotate) your emergency food supply ? your foods and your water. It?s a good idea to put that as part of your practice?that way you would have a trigger point and you would be able to remember to rotate these foods and if you put the sticker on it with the date that you put in it, you know how long it?s been in your kit, and you might even put a trigger in there, ?Needs to be removed at six months,? or ?Okay for one year.? But many of our food products now have expiration dates on them, and that will help us make sure that we?re not storing foods that go bad on us. Peanut butter is one that can go rancid, so it is important to rotate your foods.
For storing your stockpile, what kinds of containers work best?
There is no particular container that we are recommending, however I do think it?s a good idea to store your food in maybe a big, plastic bin that has a lid that is secure, because you want to make sure if you?re storing it, particularly in the basement or in the garage or in a location where there is potential for rodents or bugs to get into it, that the lid is sealed tight and will prevent anything from getting in there. The other thing you want to do is make sure that you store it in a place where the temperature is pretty stable, and that you don?t have extremes of hot or cold, which may impact the quality of your food.
What are some of the healthy foods we should include in our stockpile?
We recommend things that require no refrigeration, little or no preparation, no cooking and that require little or no water added to them, because you don?t want to take your water supply and use it with your foods. Many chicken, tuna (products), things like that, come in these vacuum-packed sealed containers, which are much easier to store than canned products. But for proteins I usually recommend canned meats or chicken, canned tuna, salmon -- those kinds of things. Canned beans make an excellent source of protein. They generally are low in sodium and require no cooking and can be added to many things, so I always recommend various kinds of canned beans, as well as your canned fruits packed in water and vegetables with no added salt. Along with this I would recommend protein and fruit bars. These are especially important for children because it gives them something sweet to eat, but make sure you are buying ones that have some nutritional value, not just (those with) chocolate and other added things that don?t give it as much value. Other things would include dry cereals?granola ? that is something that is important for your kids. Peanut butter is always a very good staple, and dried fruits or trail mix. Nuts, as long as you buy the unsalted variety, are good for snacking as well as a protein source. (Also) low-sodium crackers, your canned juices, and you always want to make sure that you have some kind of non-perishable pasteurized milk or dried powdered milk available. And vitamins, because your nutrients in your foods will not be necessarily what you would get if you were on a regular diet.
How about infants and children? Any special considerations for them?
If you have infants or very young children, you need to make sure that you include the infant formula as well as extra water for reconstitution, or better yet, cans that are already constituted. And for young children, foods that they are interested in eating, (such as) finger foods, your canned fruits, vegetables?Vienna sausage even may be more appealing to a young child. And then last of all, your comfort and stress snack foods, because we?re going to need those. Those are a little harder to plan. You don?t want to put chocolate in there if there is a potential for it to melt. But make sure that you do put comfort foods, especially for pandemic flu, because you may be confined to your home for longer than a three-day period and you?ll want to make sure that you have foods that your family will be able to eat during periods of high stress.
How about a can opener?
Fortunately the sealed packages don?t require a can opener and many of our cans do have pop lids, but absolutely a can opener is an essential element to have.
When creating our stockpile, for how many days should we plan?
The recommendation is a three-day supply, however, as I said, with pandemic flu and having to shelter in place, it may be that you need to realistically plan to have food for at least a week. If (officials) do recommend sheltering in place, the schools will be closed, day care will be closed, after-school programs will be closed and you may find yourself with your family at home for a much longer period of time.
Any special concerns for people with special health issues such as diabetes or high blood pressure?
The main thing to consider with those kinds of health issues is that they have adequate supplies of their medications, whether it be insulin or pills, and that they have any other health supplies that they need for their particular condition. Obviously, the kinds of foods that they would stockpile would be those that they can eat, in other words low-sodium kinds of items. With diabetes they want to make sure that the protein and fruit bars that they choose are not those that are high in sugar ? there are many that are made for diabetics. Dried fruit or trail mix may not be a high option for them, whereas nuts might be fine. So I think the diet that they eat on a regular basis is the same kind of recommendation that they?ll need for stockpiling.

Should antibiotics be included in your emergency stockpile?
Antibiotics are a prescription item. You don?t really want to stockpile an antibiotic because you don?t know which antibiotic you are going to need for a particular condition. If you are already on an antibiotic, then by all means you should make sure that you take that with you (if you are told to evacuate), but as a general rule, no, antibiotics are not an item that should be in your emergency stockpile because you don?t know which one you need for any particular condition.

What kinds of foods should pregnant mothers have in their stockpile?
The kinds of foods that pregnant mothers would want would be the same as the general population. They have no special requirements other than an increased caloric requirement. That?s making sure that they have adequate kinds of proteins, adequate fluids. They may want to ensure that they have a higher load of fruit juices and water in their stockpile to ensure that they have adequate hydration.
Any tips for making it fun for kids to get involved in creating a stockpile?
There is a wonderful Web site called Ready.gov, and there is a children?s portion that helps children learn what they need to do to create their family?s emergency stockpile, which includes, of course, things beyond food and water?also clothing and those kinds of items. I recommend that all families take a look at that. But in addition to that, they can also prepare their own perhaps small side stockpile with some of the kinds of foods that they like, so that they know that in the event that something occurs, they have the kinds of foods that are important to them, and they may have their own utensils that make them feel better?children-size utensils?and you need to make sure that when you are packing your stockpile that you do include not only that can opener but knives and forks and spoons and paper plates and paper bowls. Paper is probably better because you will not have the ability to do dishwashing. And so with your kids you want to pack things that are familiar to them, and again, the fruit bars and maybe the Vienna sausage?it depends on what stage that child is at as to the kinds of foods that are going to be their favorites.
Is there anything else you?d like to add?
When we are looking at fluids, probably our better choice, of course, is water, and there are a number of small one-serving things where you change water to lemonade or you can change it to iced tea, or things like that. But I would really recommend that you not stockpile soda. Soda contains no nutrients and all it contains is sugar and calories, and that?s not going to be a good option when you are trying to shelter in place or in an emergency stockpile because there is no value added to having any kind of soda. You really want to stick with your water and your juice, which is going to add for your hydration, and avoid those foods that are going to also make you very thirsty.
? Q&A conducted and condensed by Teddi Dineley Johnson, The Nation's Health
APHA wishes to thank the Food and Nutrition Section for helping to make this feature possible.