TERNOPIL STATE MEDICAL UNIVERSITY

INSTITUTE OF NURSING

INTERNATIONAL NURSING SCHOOL

 

Communities in Crisis: Disasters, Group Violence, and Terrorism

Upon mastery of this chapter, you should be able to:

Describe a variety of characteristics of disasters, including causation, number of casualties, scope, and intensity.

Discuss a variety of factors contributing to a community’s potential for experiencing a disaster.

Identify the four phases of disaster management.

Describe factors involved in disaster planning.

Describe the role of the community health nurse in preventing, preparing for, responding to, and supporting recovery from disasters.

Compare and contrast the most common types of group violence.

Discuss a variety of factors contributing to a community’s potential for experiencing group violence.

Describe the role of the community health nurse in preventing and responding to group violence.

Distinguish terrorism from other types of group violence.

Use the levels of prevention to describe the role of the community health nurse in relation to acts of chemical, biologic, or nuclear terrorism.

 

What would you do if your local news station broadcast an announcement that your community was directly in the path of a hurricane that earlier in the day had caused extensive damage and loss of life in a neighboring state? What would you do if you were shopping at a local mall, suddenly heard an explosive noise followed by shouts and cries for help, then noticed that a pungent odor was filling the air? What DID you do on the morning of September 11, 2001, when the world of each American, especially those in New York City, in Washington, D.C., and on a plane over rural Pennsylvania, changed forever? What did you do when you heard of multiple terrorist attacks on the United States? As distant as some of these scenarios might seem from your own life, disasters, group violence, and terrorism are ever-present possibilities, and nurses and other health care professionals have an obligation to respond appropriately. This chapter will increase your understanding of the community health nurse’s role in preparing for, responding to, and recovering from disasters, group violence, and terrorism.

DISASTERS

A disaster is any natural or manmade event that causes a level of destruction or emotional trauma exceeding the abilities of those affected to respond without community assistance. The crash of a private plane over the Pacific Ocean in which no bodies are recovered and no environmental impact is felt is not a disaster by this definition, because no specific community-based response is required or even possible. Such a tragedy may, however, be felt for a lifetime by family members and friends, who need emotional support and possibly long-term financial assistance. If a plane with 150 passengers crashes over land, destroying several homes in its path, the community affected is unable to cope with the resulting injuries, deaths, and property destruction without assistance; by the definition used here, this constitutes a disaster.

The geographic distribution of disasters varies because certain types of disasters are more common in some parts of the world. For example, California is associated with earthquakes and Florida with hurricanes. Similarly, it is not surprising to hear of drought in Ethiopia or floods in India during the monsoon season. When certain types of disasters are anticipated, communities are usually better prepared for them. For instance, California has strict building codes to prevent destruction of structures in the event of earthquakes, but most California homes lack the basements and insulation that characterize homes in regions often visited by tornados or winter storms. Similarly, residents of Germany, Austria, and Russia are better prepared for blizzards than for heavy rain, which probably explains in part the devastation caused in some communities by floods there in 2002. Because the local media in the United States do not typically report on disasters unless there are mass casualties, one may be unaware of the frequency and variety of both natural and technologic disasters worldwide.

Here is a brief sampling of major disasters that occurred in 2002-2003:

• January 2002, Ipiales, Columbia—a Boeing 727 crashes into a mountain, resulting in 92 fatalities

• January 2002, Democratic Republic of Congo—a volcano engulfs the city of Goma; 300,000 to 500,000 people are displaced

• February 2002, Ayyat, Egypt—a fire engulfs a crowded passenger train and 361 people are killed

• March 2002, Afghanistan—a series of earthquakes leaves 1000 dead and 7000 homeless

• May 2002, Andhra Pradesh State, India—a brutal heat wave causes 600 deaths nationwide

• May 2002, Bangladesh—an overloaded ferry capsizes in a storm; 300 are drowned

• June 2002, Western United States—several major wildfires, including the worst fire in Colorado’s history, with 137,760 acres and 600 structures consumed. In Arizona, another fire burns 468,638 acres and destroys 400 structures.

• June 2002, China—a coal mine gas explosion kills 111

• June 2002, Russia—the worst flooding in a decade leaves 93 dead and 87,000 homeless

• July 2002, Ukraine—a jet fighter crashes during an acrobatic maneuver at an air show, killing 83 people, including 23 children; it becomes the worst air show disaster in history

• September 2002, Dakar, Senegal—in one of Africa’s deadliest ferry accidents, a vessel capsizes in heavy winds, resulting in the loss of almost 1000 lives

• October 2002, Moscow—gas kills 115 hostages in a raid on a theater

• December 2002, Mexico—New Year fireworks explosion kills 28

• February 2003, Daegu, South Korea—an arson attack on the subway system kills 182 people

• February 2003, Iran—a military plane crash kills 302

• May 2003, Algeria—a 6.7 earthquake kills more than 2000 people

• August 2003, France—a prolonged heat wave kills 10,000 people, mostly elderly

• September 2003, U.S.—Hurricane Isabel knocks out power to 2 million people

• December 2003, Bam, Iran—an earthquake kills 28,000 people and injures 30,000

Characteristics of Disasters

Disasters are often characterized by their cause. Natural disasters are caused by natural events, such as the floods in western Europe or the earthquakes in Afghanistan in 2002. Manmade disasters are caused by human activity, such as the bombing of the World Trade Center in New York City in 2001, the displacement of thousands of Kosovars during their war with Serbia in 1999, or the riots in Los Angeles in the early 1990s. Other manmade disasters include nuclear re actor meltdowns, industrial accidents, oil spills, construction accidents, and air, train, bus, and subway crashes.

A casualty is a human being who is injured or killed by or as a direct result of an incident. Although major disasters sometimes occur without any injury or loss of life, disasters are commonly characterized by the number of casualties involved. If casualties number more than 2 people but fewer than 100, the disaster is characterized as a multiple-casualty incident. Although multiple-casualty incidents may strain the health care systems of small or mid-sized communities, mass-casualty incidents—those involving 100 or more casualties— often completely overwhelm the resources of even large cities. Preparedness for mass-casualty incidents is essential for all communities.

The possibility of being prepared is another characteristic that varies with different types of disasters. For instance, the path and time of landfall of a hurricane can be tracked so that residents in the storm’s path can be evacuated and families and businesses can be protected. Communities can also minimize devastation from flooding by building reservoirs or refusing to grant building permits in flood-prone areas, and sandbagging can be used during rainy weather. In fire-prone areas, communities can post notices to heighten awareness of fire danger and enforce regulations to cut back vegetation near structures in forested areas. On the other hand, some disasters strike without warning. For example, the terrorist attacks in New York City caught thousands of civilians unaware. They were trapped in buildings with limited escape routes and very little time to retreat to safety. For employees in the Pentagon on 9/11, survival depended on being in the right place at the right time. The number of fires in the western United States in 2002 was unanticipated and uncharacteristically large, and control was hindered by heat and high winds. Residents were stranded in rural areas or barred from re-entering their communities for weeks, without any knowledge of whether they would have homes when they were allowed to return.

The scope of a disaster is the range of its effect, either geographically or in terms of the number of victims. The collapse of a 500-unit high-rise apartment building has a greater scope than does the collapse of a bridge that occurs while only two cars are crossing.

The intensity of a disaster is the level of destruction and devastation it causes. For instance, an earthquake centered in a large metropolitan area and one centered in a desert may have the same numeric rating on the Richter scale, yet have very different intensities in terms of the destruction they cause.

Victims of Disasters

Because disasters are so variable, there is no typical victim in a disaster. Nor can anyone predict whether he or she will ever become a victim of a disaster. However, once disaster strikes, victims may be characterized by their level of involvement.

Direct victims are the people who experience the event, whether fire, volcanic eruption, war, or bomb. They are the dead and the survivors, and even if they are without physical injuries, they are likely to have health effects from their experience. Some may be without shelter or food, and many experience serious psychological stress long after the event is over (Display 20-1).

Depending on the cause and characteristics of the disaster, some direct victims may become displaced persons or refugees. Displaced persons are forced to leave their homes to escape the effects of a disaster. Usually, displacement is a temporary condition and involves movement within the person’s own country. A common example is relocation of residents of flooded areas to schools, churches, and other shelters on higher ground. Typically, the term refugee is reserved for people who are forced to leave their homeland because of war or persecution. For example, in early 2000, thousands of refugees fled Chechnya to escape advancing Russian troops opposed to the republic’s separatist attempts.

Often, the displacement of refugees is permanent. For example, many young people who fled Argentina during the “disappearances” between 1976 and 1982 did not return when a democratic government regained power in 1983. Thousands of young men and women who protested against the regime in power at the time simply disappeared.

Indirect victims are the relatives and friends of direct victims. Although these people do not experience the stress of the event itself, they often undergo extreme anguish from trying to locate loved ones or accommodate their emergency needs. If bodies cannot be found or are unidentifiable, indirect victims experience even greater anguish and may not be able to accept that their loved one has died. For example, many of the mothers of young Argentineans who disappeared in the 1970s still march daily in downtown Buenos Aires, demanding public acknowledgment of the murders of their daughters and sons. Family members of victims from 9/11 in New York City have worked with architects to develop a complex of buildings and a memorial that meets the expectations of most of the indirect victims and honors their loved ones. This is a long and arduous task that, once completed, will help with the long healing process.

Factors Contributing to Disasters

It is useful to apply the host, agent, and environment model to understand the factors contributing to disasters, because manipulation of these factors can be instrumental in planning strategies to prevent or prepare for disasters.

Host Factors

The host is the human being who experiences the disaster. Host factors that contribute to the likelihood of experiencing a disaster include age, general health, mobility, psychological factors, and even socioeconomic factors. For instance, elderly residents of a mobile home community may be unable to evacuate independently in response to a tornado warning if they no longer can drive. Impoverished residents of a lowincome apartment complex in a large city may notice that their building is not compliant with city fire codes but may avoid alerting authorities for fear of being forced to move to more expensive housing.

Agent Factors

The agent is the natural or technologic element that causes the disaster. For example, the high winds of a hurricane and the lava of an erupting volcano are agents, as are radiation, industrial chemicals, biologic agents, and bombs. The Station Nightclub fire and the apartment deck collapse in Chicago demonstrated that irresponsibility of contractors and inspectors and failure to adhere to safety policies can act as agents of disaster, resulting in death and destruction.

Environmental Factors

Environmental factors are those that could potentially contribute to or mitigate a disaster. Some of the most common environmental factors are a community’s level of preparedness; the presence of industries that produce harmful chemicals or radiation; the presence of flood-prone rivers, lakes, or streams; average amount of rainfall or snowfall; average high and low temperatures; proximity to fault lines, coastal waters, or volcanoes; level of compliance with local building codes; and presence or absence of political unrest.

Agencies and Organizations for Disaster Management

Among disaster-relief organizations, perhaps none is as famous as the Red Cross, the name commonly used when referring to the American Red Cross, the Federation of Red Cross and Red Crescent Societies, and the International Committee of the Red Cross. The American Red Cross was founded in 1881 by Clara Barton and was chartered by the U. S. Congress in 1905. It is authorized to provide disaster assistance free of charge across the country through its more than 1 million volunteers.

The Federal Emergency Management Agency (FEMA), established in 1979, is the federal agency responsible for assessment of and response to disaster events in the United States. It also provides training and guidance in all phases of disaster management. The World Health Organization’s Emergency Relief Operations provide disaster assistance internationally, and the Pan American Health Organization works to coordinate relief efforts in Latin America and the Caribbean. In addition, various international nongovernmental organizations (such as Doctors Without Borders, the International Medical Corps, and Operation Blessing), religious groups, and other volunteer agencies provide needed emergency care. The newest safety-related agency in the United States is the Department of Homeland Security. Organized in 2002, it incorporates many of the nation’s security, protection, and emergency response activities into a single federal department.

As a relatively new department, it is undergoing many changes related to its scope of service. In June 2002, the American Public Health Association became concerned because some of the responsibilities of the Centers for Disease Control and Prevention and the Health Resources and Services Administration (such as the cache drugs, medical supplies, and equipment for emergencies through the National Pharmaceutical Stockpile) were being usurped by the Department of Homeland Security. Some experts see this department as fragmenting the nation’s broad-based public health system, which may hinder overall responsiveness and compromise the public health system (Late, 2002). It is hoped that such serious concerns will be addressed as this department evolves.

Governments often send their military personnel and equipment in response to international disasters. For example, in March 2000, the governments of South Africa, England, Germany, France, and the United States, among other nations, responded to the floods in Mozambique with helicopters, planes, boats, and supplies. When natural or manmade disasters within the United States are accompanied by civil disturbance, looting, or violent crime, the resources of local police departments may be overwhelmed. In such cases, the National Guard is often called in to restore order.

Phases of Disaster Management

In developing strategies to address the problem of disasters, it is helpful for the community health nurse to consider each of the four phases of disaster management: prevention, preparedness, response, and recovery.

Prevention Phase

During the prevention phase, no disaster is expected or anticipated. The task during this phase is to identify community risk factors and to develop and implement programs to prevent disasters from occurring. Task forces typically include representatives from the community’s local government, health care providers, social services providers, police and fire departments, major industries, local media, and citizens’ groups. Programs developed during the prevention phase may also focus on strategies to mitigate the effects of disasters that cannot be prevented, such as earthquakes, hurricanes, and tornadoes.

The United States has strengthened this phase of disaster management since September 2001. This can be seen especially at airports, where airline passengers must now go through a more rigorous security screening before boarding the plane. Nonpassengers cannot go beyond the security area. Photographic identification is required at two or more points before boarding. Random searches of hand-carried luggage occur, and passengers are screened with wands that detect metal. In some states, luggage is tested for radioactive material, police officials with trained dogs patrol the airport, or people are asked to take their shoes off for examination as part of the screening process. All of these measures have been initiated to prevent a disaster.

Preparedness Phase

Disaster preparedness involves improving community and individual reaction and responses so that the effects of a disaster are minimized. Disaster preparedness saves lives and minimizes injury and property damage. It includes plans for communication, evacuation, rescue, and victim care. Any plan must also address acquisition of equipment, supplies, medicine, and even food, clean water, blankets, and shelter. Semiannual disaster drills and tests of the Emergency Broadcast System are examples of appropriate activities during the preparedness phase. Disaster preparedness activities occur locally, regionally, and nationally. A town keeps its warning system working and tests it each month. Sections of the country coordinate larger warning systems to notify communities in the path of a tornado or hurricane, and the country has a plan to stockpile smallpox vaccine for mass immunization. The National Institute of Allergy and Infectious Diseases has tried diluting a few of the existing 86 million doses of vaccine and has tested the diluted dosage on 100 volunteers to see whether it still works. The results showed that this cache alone contained enough to vaccinate everyone in an emergency. Laboratories have been contracted to make more than 200 million doses in the event that biologic warfare becomes a threat. The last case of smallpox in the United States occurred in 1949, and routine immunization was halted in 1972, although many doctors refused to use the vaccine even before that date. With a largely unvaccinated population, most people in the nation would need the vaccine. Having the vaccine ready is a demonstration of disaster preparedness.

Response Phase

The response phase begins immediately after the onset of the disastrous event. Preparedness plans take effect immediately, with the goals of saving lives and preventing further injury or damage. Activities during the response phase include rescue, triage, on-site stabilization, transportation of victims, and treatment at local hospitals. Response also requires recovery, identification, and refrigeration of bodies so that notification of family members is possible and correct, even weeks after   disaster. This care of the dead is demanding and time-consuming work that is often overlooked by people unfamiliar with disaster response. Supportive care, including food, water, and shelter for victims and relief workers is also an essential element of the total disaster response.

Recovery Phase

During the recovery phase, the community takes actions to repair, rebuild, or relocate damaged homes and businesses and restore health and economic vitality to the community. Psychological recovery must also be addressed. The emotional scars from witnessing a traumatic event may last a lifetime. Both victims and relief workers should be offered mental health services to support their recovery (see Voices from the Community).

Role of the Community Health Nurse

The community health nurse has a pivotal role in preventing, preparing for, responding to, and supporting recovery from a disaster. After a thorough community assessment for risk factors, the community health nurse may initiate the formation of a multidisciplinary task force to address disaster prevention and preparedness in the community.

Preventing Disasters

Disaster prevention may be considered on three levels: primary, secondary, and tertiary. These are applied to a natural disaster in the Levels of Prevention Matrix.

Primary Prevention. Primary prevention of a disaster means keeping the disaster from ever happening by taking actions that completely eliminate its occurrence. This is the first aspect of primary disaster prevention. Although it is obviously the most effective level of intervention, both in terms of promoting clients’ health and containing costs, it is not always possible. Tornadoes, earthquakes, and other disasters often strike without warning, despite the use of every available technologic device for prediction and tracking.

If possible, primary prevention of disasters can be practiced in all settings: in the workplace and home with programs to reduce safety hazards, and in the community with programs to monitor risk factors, reduce pollution, and encourage nonviolent conflict resolution. Primary disaster prevention efforts should take into account a community’s physical, psychosocial, cultural, economic, and spiritual needs. The community health nurse has a role in each of these areas. As a teacher, the community health nurse educates people at home, at work, at school, or in a faith community about safety and security focused on preventing a disaster. The community health nurse can teach community members how to protect themselves from the effects of a natural disaster.  The nurse can be a part of a safety team, if working as a school nurse or occupational health nurse. If working for a health department, the nurse can determine during home visits whether a family has a personal disaster plan and help them develop one if none exists. There are many actions the nurse can initiate.

The second aspect of primary disaster prevention is anticipatory guidance. Disaster drills and other anticipatory exercises help relief workers experience some of the feelings of chaos and stress associated with a disaster before one occurs. It is much easier to do this when energy and intellectual processes are at a high level of functioning. Anticipatory work can dissipate the impact of a disastrous event. The community health nurse has a role in these disaster drills through committee membership, organization of drills at the place of employment, or activism at the grassroots level to assist in holding community-wide disaster drills on a regular basis.

Secondary Prevention. Secondary disaster prevention focuses on the earliest possible detection and treatment. For example, a mobile home community is devastated by a tornado, and the local health department’s community health nurses work with the American Red Cross to provide emergency assistance. Secondary prevention corresponds to immediate and effective response.

Nurses at St. Vincent’s Hospital, the closest Level I Trauma Center to the World Trade Center, prepared to respond to the victims of September 11, 2001, in New York City. They were expecting major trauma cases, but this area was quieter than usual. Triage was conducted both on the streets outside of the emergency department and inside, starting the process earlier and routing people for treatment more effectively. This system was developed after the 1993 terrorist attack on the World Trade Center. Because of the total devastation of the 2001 disaster, those who did survive emerged relatively uninjured and became rescuers of those they could free from the debris. Both rescuers and survivors suffered injuries from falling and flying debris outside of the buildings, but most of the survivors received less serious injuries than emergency personnel were expecting. There were many minor injuries, such as smoke inhalation, eye injuries, and fractures. In another area, heart attack, burn, and crushing injury victims were treated. With organization and preparedness, those needing hospitalization were admitted within 45 minutes after being triaged and stabilized. Most injuries occurred among rescuers, although a few civilians were also hurt. In the first 4 to 6 hours, 264 victims were seen.

On a typical day, that number would have been 40 to 45 during the same time period. In the days after the disaster, some rescuers found body parts and had to transport them to the morgue. Rescuers came to the emergency department suffering from symptoms related to fatigue and emotional distress (Ostrowski, 2001).

Nurses from other hospitals offered to help, and volunteers brought food; the owners of a restaurant and coffee shop near the hospital closed their doors to the public and provided free food and beverages for hospital staff. Massage therapists came to the hospital and volunteered to give massages. The nurses received tremendous support from strangers and peers across the country. This helped them keep up their spirits as they dealt with the direct victims, while being indirect victims themselves (Ostrowski, 2001).

Tertiary Prevention. Tertiary disaster prevention involves reducing the amount and degree of disability or damage resulting from the disaster. Although it involves rehabilitative work, it can help a community recover and reduce the risk of further disasters. In this sense, it becomes a preventive measure.

Another example from September 11, 2001, comes from a nurse living in the Boston area who, after that date, began to lose a sense of hope for her future. She often found it difficult to assist her patients with their needs because of her own insecurities and fears. She and a peer responded to a request from the Logan Airport Employee Assistance Program (EAP) asking for help with crisis counseling for United Airlines survivors of 9/11. The planes used in the attacks were from American and United Airlines, and the community of employees felt like survivors because they lived while fellow employees were lost in the disaster. Employees were in turmoil, and their ability to function was affected. “The terrorists had taken away their colleagues, friends and sense of security” (DiVitto, 2002, p. 21).

The most important interventions the nurses provided were a listening ear and validation that what the employees were feeling and experiencing was normal, and often essential, for healthy grieving. Some employees needed to talk about good times, others were quiet and sad, and others expressed a fear of flying again but did so with the support of family and friends. All demonstrated courage and an ability to continue their lives with a sense of strength and hope. Working with these employees enabled the nurse to recapture the essence and true meaning of her life (DiVitto, 2002).

Preparing for Disasters

Disaster planning is essential for a community, business, or hospital. It involves thinking about details of preparation and management by all involved, including community leaders, health and safety professionals, and lay people. A disaster plan need not be lengthy. Two weeks after the April 1995 Oklahoma City bombing of the Murrah Federal Building by two American citizens, one hospital distilled its 44-page manual into a 5-page disaster response guide. Such a concise plan should still contain information on the elements discussed in this and the following section. See Display 20–2 for a summary of these elements.

Personal Preparation. Before we discuss the preparation of a disaster plan for a community, we should consider the need for all nurses to address their own personal preparedness to respond in a disaster. Personal preparedness means that the nurse has read and understood workplace and community disaster plans and has developed a disaster plan for her or his own family. The prepared nurse also has participated in disaster drills and knows cardiopulmonary resuscitation and first aid. Finally, nurses preparing to work in disaster areas should bring copies of their nursing license and driver’s license, durable clothing, and basic equipment such as stethoscopes, flashlights, and cellular phones.

Assessment for Risk Factors and Disaster History.

As noted earlier in the chapter, the community health nurse is uniquely qualified to perform a community assessment for risk factors that may contribute to disasters. In addition, the nurse should review the disaster history of the community. Have earthquakes, tornadoes, hurricanes, floods, blizzards, riots, or other disasters occurred in the past? If so, what (if any) were the warning signs? Were they heeded? Were people warned in time? Did evacuation efforts remove all people in danger? What were the community’s on-site responses, and how effective were they? What programs were put in place to rehabilitate the community?

Establishing Authority, Communication, and Transportation.

In addition to assessing for preparedness, the effective disaster plan establishes a clear chain of authority, develops lines of communication, and delineates routes of transport. Establishing a clear and flexible chain of authority is critical for successful implementation of a disaster plan. Usually, the chain is hierarchical, with, for example, the community’s governmental head (eg, mayor) initiating the plan, alerting the media to broadcast warnings, authorizing the police to begin evacuations, and so on. Within each level of the organization, the hierarchy continues. For example, at the local hospital, the hospital administrator may be responsible for alerting nurse managers to call in additional personnel. Flexibility is essential, because key authority figures may themselves be victims of the disaster. If the home of the chief of police is destroyed in an earthquake, his or her second-incommand must have equal knowledge of the community’s disaster plan and be able to step in without delay.

Mobilizing, Warning, and Evacuating. In many natural disasters, local weather service personnel, public works officials, police officers, or firefighters have the earliest information indicating an increasing potential for a disaster. These officials typically have a plan in place for providing community authorities with specific data indicating increased risk.

They may also advise the mayor’s office or other community leaders of their recommendations for warning or evacuating the public. Additionally, they may recommend actions the community can take to mitigate damage, such as spraying rooftops in the path of fires, sandbagging the banks of rising rivers, or imposing a curfew in times of civil unrest. Disaster plans must specify the means of communicating warnings to the public, as well as the precise information that should be included in warnings. Planners should never assume that all citizens can be reached by radio or television or that broadcast systems will be unaffected by the disaster. Broadcast media may indeed be a primary means of communicating warnings, but alternative strategies, such as police or volunteers canvassing neighborhoods with loudspeakers, should also be in place. In multilingual communities, messages should be broadcast in multiple languages. Not only homes but also businesses must be informed. Information that should be communicated includes the nature of the disaster; the exact geographic region affected, including street names if appropriate, and the actions citizens should take to protect themselves and their property.

An evacuation plan is an essential component of the total disaster plan. The plan should cover notification of the police, local military personnel, or voluntary citizens’ groups of the need to evacuate people, as well as methods of notifying and transporting the evacuees. A plan should also be made for responding to citizens who refuse to evacuate. For example, will police authorities forcibly remove an elderly citizen from his home to a shelter? Will evacuation plans include household pets? If farms or ranches are in the path of fires or floods, will animals be evacuated?

Responding to Disasters

At the disaster site, police, firefighters, nurses, and other relief workers develop a coordinated response to rescue, triage, and treat disaster victims.

Rescue. One of the first obligations of relief workers is to remove victims from danger. This job typically falls to firefighters and personnel with special training in search and rescue. Depending on the disaster agent, protective gear, heavy equipment, and special vehicles may be needed, and dogs trained to locate dead bodies may be brought in. Usually, the immediate disaster site is not the best place for the disaster nurse, who can be far more effective in triage and treatment of victims. One of the lessons of the World Trade Center bombing was that the greatest need for medical professionals was at the local hospitals, not at the disaster site.

Rescue workers face the logistically and psychologically difficult task of determining when to cease rescue efforts. Some factors to consider include increasing danger to rescue workers, diminishing numbers of survivors, and diminishing possibilities for survival. For example, after a plane crash on a snowy mountain, rescue efforts may cease if it is deemed that anyone who might have survived the crash would subsequently have died from exposure.

Triage. Whereas emergency nurses daily determine which clients require priority care, the community health nurse may be at a loss as to where to start when faced with multiple victims of a disaster. Knowing the principles and practice of triage allows the nurse to offer her or his nursing skills most effectively.

Triage is the process of sorting multiple casualties in the event of a war or major disaster. It is required when the number of casualties exceeds immediate treatment resources. The goal of triage is to effect the greatest amount of good for the greatest number of people. Figure 20–2 shows the four basic categories of the international triage system, as well as a triage tag.

Prioritization of treatment may be very different in a mass-casualty event as opposed to an average day in a hospital emergency department. Under normal circumstances, a person presenting to a hospital emergency department with a myocardial infarction and showing no pulse or respirations would receive immediate treatment and have a chance of recovery. At a disaster site, a victim without a pulse or respi rations would most likely be placed in the nonsalvageable category.

 

Victim triage tag. There are four basic categories that are all applied when a medical system is overwhelmed with victims.

1. Red: Urgent/Critical

Victims in this category have injuries or medical problems that will likely lead to death if not treated immediately (e.g., an unconscious

victim with signs of internal bleeding).

2. Yellow: Delayed

Victims in this category have injuries that will require medical attention; however, time to medical treatment is not yet critical

(e.g., a conscious victim with a fractured femur).

3. Green: Minor/Walking Wounded

Victims in this category have sustained minor injury or are presenting with minimal signs of illness. Prolonged delay in care

most likely will not adversely effect their long-term outcome (e.g., a conscious victim with superficial cuts, scrapes, and

bruises).

4. Black: Dead/Non-salvageable

Victims in this category are obviously dead or have suffered mortal wounds because of which death is imminent (e.g., an

unconscious victim with an open skull fracture with brain matter showing). Life-saving heroics on this group of victims will

only delay medical care on more viable victims.

 

Mass casualties refers to a number of victims that is greater than that which can be managed safely with the resources the community has to offer, such as rescue vehicles and emergency facilities available to serve disaster victims while also meeting the needs of the rest of the community. Frequently in mass casualty occurrences, the broader community needs to become involved, which necessitates calling in rescue vehicles, firefighters, and police officers from neighboring towns, or the use of neighboring hospitals. This adds another layer of disaster management coordination that must be considered.

Immediate Treatment and Support. Disaster nurses provide treatment on-site at emergency treatment stations, in shelters, or at local hospitals and clinics. In addition to direct nursing care, on-site interventions might include arranging for transport once victims are stabilized and managing the procurement, distribution, and replenishment of all supplies.

Disposable items might be in short supply, requiring resterilization procedures that may be unfamiliar to a nurse not accustomed to field work. These procedures may pose a challenge even to an experienced nurse because of the field environment. The nurse may also manage provision or distribution of food and beverages, including infant formulas and rehydration fluids, and arrange for adequate, accessible, and safe sanitation facilities, either on-site or in a shelter. Finally, the nurse often must also arrange for psychological and spiritual care of victims of disasters.

Some victims who seem physically uninjured may, in fact, be suffering from major injuries but be unable to relate their symptoms to a relief worker because of shock or anxiety about injured, dead, or missing loved ones. For instance, a father pulling debris away from his collapsed house after a tornado may be so worried about a missing child that he does not realize that he has a broken arm.

Other victims may be so emotionally traumatized by a disaster that they act out, disrupting efforts to assist them and other victims and even engaging in dangerous activities. This may cause relief workers to focus on emotional care; however, such victims must be assessed for head trauma and internal injuries, because their behavior may have a physical cause. If they are physically able, such victims may be given a simple, repetitive task to perform, which serves as both a distraction and a means to restore, to a small extent, their sense of control over their environment.

Care of Bodies and Notification of Families. Identification and transport of the dead to a morgue or holding facility are crucial, especially if contagion is feared. Toe tags make documentation visible and accessible. Records of deaths must be made and maintained, and family members should be notified of their loved ones’ deaths as quickly and compassionately as possible. If feasible, a representative from each of the area’s faith communities should be available to assist families awaiting news of missing loved ones. As stated earlier, a family’s recovery from their loss is often delayed when notification of relatives (indirect victims) is not possible because the victims’ bodies are badly damaged or not found. This was a major problem of the World Trade Center disaster, in which few of the victims were found. In some cases, only minute pieces of tissue were available for DNA processing. In other situations, just a piece of jewelry or clothing remained. And for some victims, no remains were found.

 

GROUP VIOLENCE

The rates of group violence and violent crime decreased in many U. S. cities at the end of the 1990s. The actual number of violent crimes peaked in 1993 at almost 4.2 million annually. By 1998, that number had dropped to less than 2.8 million (U. S. Department of Justice, 1999). The U. S. Department of Justice’s National Crime Victimization Survey (NCVS) for 2000–2001 indicated that violent crime had decreased another 10%, making its incidence the lowest in NCVS history (since 1973) (U. S. Department of Justice, 2002). According to the Federal Bureau of Investigation’s Uniform Crime Reports, the crime index rate fell for the 10th straight year in 2000, declining 3.3% from 1999, 18.8% from 1996, and 30.1% from 1991 (U. S. Department of Justice, 2002). However, violent crime is still an emotional and powerful public issue, often influencing our votes, our choices of where to live, work, shop, and vacation, and our decisions about where and how to educate our children. Indeed, the American Public Health Association (APHA) has worked for many years to turn the spotlight on violence as a public health issue. Gun violence in particular both a public health emergency and a grave threat to an entire generation of young adults (USDHHS, 2000).

Types of Group Violence

The problem of family violence is discussed in more detail in Chapter 25, school and adolescent violence in Chapter 28, and workplace violence in Chapter 29. This chapter presents an overview of group violence and how it affects communities.

Gang Violence

The California Attorney General defines a gang as a looseknit organization of individuals between the ages of 14 and 24 years that has a name, is usually territorial or claims a certain territory as being under its exclusive influence, and is involved in criminal acts. Its members associate together and commit crimes against other gangs or against the general population. Gangs are most commonly involved in drug distribution, aggravated assault, robbery, burglary, and motor vehicle theft (Huff, 2002). Some gangs focus on stealing, whereas others focus on fighting. Large cities are the most likely to have gang problems, and rural counties are the least likely.

There are theories on how gangs form. Hirschi’s (2004) social bond theory proposed that criminal behavior results from the weakening (in youth) of the ties that bind the individual to society. He believed that the strong subcultural bonds insulate the individual from conventional behavior. Gangs often require members to display symbols of their allegiance to one another. These symbols also serve to identify them to other gangs. They may include certain colors, special caps or coats, tattoos, handshakes or other signs, and terminology unique to the gang. Gangs may also require members to participate in rites of passage or “hazing” to test their loyalty, events that often involve committing a crime. Gang members usually share the same ethnicity or at least the same belief system. Many gangs today have sophisticated Web sites and are capable of equally sophisticated crimes (Huff, 2002; Miller, Maxson, & Klein, 2001).

Gang members consider themselves family and turn to each other for support. Often, members are searching for emotional intimacy in the gang as a substitute for a dysfunctional family that is unwilling or unable to provide that intimacy. Gangs also provide discipline and a structured environment to young people who, because of absent or unresponsive parents, may have a strong desire for an external locus of authority and a set of predictable rules and regulations.

Riots

A riot is a violent disturbance created by a large number of people assembled for a common purpose. It may or may not involve criminal activities, such as willful destruction of cars, stores, and other property; looting (stealing goods); arson (the deliberate burning of buildings); lynching (execution by hanging without due process of law); or physical attacks on a perceived enemy or on law enforcement officers. Riots often erupt during times of war, political instability, racial inequity, and economic injustice.

For example, in the United States, the decades of the 1960s and 1970s were marked by frequent demonstrations against the Vietnam War, which occasionally escalated from peaceful marches and protests to full-scale riots. Riots have also been sparked during protests of racial inequities and are especially common after announcements of legal decisions that are perceived as racist. For example, when the officers accused of assaulting Rodney King in Los Angeles were acquitted in April 1992, violent riots caused 53 deaths, 2000 arrests, and more than 1 billion dollars in property damage. Internationally, riots often erupt over sporting events, especially if the fans are close to the action. Fans storm the field, assault officials, and attack the opposing team after a bad play or decision that negatively affects the outcome for their team. Such riots have caused multiple injuries and deaths. Inflated food prices or inequitable distribution of food or supplies can precipitate a  riot. In 1999, for example, there were widespread riots in India in protest of the inflated price and limited availability of onions, a staple in the Indian diet.

Violent Crimes by Specific Groups of Perpetrators

Violent crimes are those involving physical or psychological injury or death, or the threat of injury or death. These crimes are often accompanied by destruction to or loss of property.  For example, armed robbery is considered a violent crime, regardless of whether anyone is injured during the crime.

Assault and Battery. Legally, assault and battery refers to the threat to use force against another person, and the accomplishment of that threat. More loosely, assault can be used to refer to any violent attack such as assault with a deadly weapon or sexual assault. Domestic assault is discussed in Chapter 25.

One type of group assault that is becoming more prevalent is assault on the homeless. These assaults are usually perpetrated on individual homeless men, often by groups of three or more young men who beat the victim severely and sometimes fatally, sometimes for no other reason than that he asked them for money. Alcohol and drugs are often factors. In addition, abuse of the homeless is considered to be a new and underestimated hate crime (Bacque, 2000).

Rape. Legal definitions of rape vary, but the key elements include some form of sexual contact and a lack of consent. Consent is considered lacking under conditions of force, deception, or coercion, or when the victim is a minor or is drugged, unconscious, mentally retarded, or physically restrained.

Different categories of rape are commonly described. One of the most common is date rape, in which the assailant and victim meet by mutual consent but the assailant forces the victim to engage in a sexual act against the victim’s will. Stranger rape is sudden and usually violent, involving the use of a knife, gun, or violent physical force. Statutory rape refers to sexual intercourse with a female who has not reached the statutory age of consent; in many states, this age is 14 years. Rape may also be perpetrated by a group, as when a group of college men drug and then rape a female student or when a youth gang assaults and rapes a woman jogging on its “turf” after dark. Both agent and environmental factors can contribute to rape. Some of the more common factors are an increased history of childhood sexual abuse among rapists, a patriarchal value system in which men are expected to prove their masculinity by dominating or “conquering” women, and an environment in which violence is explicitly or implicitly accepted or encouraged.

Homicide. Homicide is the killing of one person by another. Like the rates for group violence overall, the homicide rate is declining. In 1980, there were 10.2 homicides for every 100,000 people in the United States; by 1998, this rate had fallen to 6.2 per 100,000 (U.S. Department of Health and Human Services, 2000). However, homicide is still the leading cause of death for African-American youth aged 15 to 24 years. Their murder rate is an alarming 25.2 per 100,000 people (compared with 4.3 per 100,000 for white youths and 9.9 per 100,000 for Hispanic youths). Even though homicide rates in the United States have improved,

the rate among males aged 15 to 24 years in the United States is 10 times higher than in Canada, 15 times higher than in Australia, and 28 times higher than in France or Germany (U.S. Department of Health and Human Services, 2000). Studies have shown that factors identified with violence include, but are not limited to “complex interactions between poverty, racism, excess consumption of alcohol, the plethora of illegal drugs, dysfunctional familial relations, abuse of children by adults, scarcity of viable employment and resources, lack of effective hand gun regulation, inadequate services from schools and other social agencies, stereotyping between peer groups and between adults and children, and a general erosion of respect for individual rights of freedom, security, and responsibility” (Benda & Turney, 2002, p. 7).

In addition, the 21st century has already been marred by numerous instances of multiple homicides in schools, universities, restaurants, and workplaces. For example, on March 1, 2000, a gunman in Pennsylvania went on a shooting spree at his apartment complex and at two fast-food restaurants, killing two people and critically wounding three.

In the summer of 2002, a 10-year-old girl in the Bronx, New York, was fatally struck by a stray bullet after gang members looking for free food and beer crashed a baby’s christening party at a church. In the fall of 2002, the areas around Silver Spring, Maryland; Washington, D.C.; and northern Virginia were terrorized by two snipers who randomly killed or injured 13 people engaged in everyday activities (see What Do You Think? I).

Genocide. The most notorious historical example of genocide, the killing of a group of people because of their racial, political, or cultural differences, was the murder of millions of Jews, Catholics, gypsies, homosexuals, intellectuals, and other “undesirables” by the Nazis before and during World War II. Tragically, genocide continues today. Recent examples include the mass “ethnic cleansings” in Bosnia, Rwanda, and Kosovo in the last decade of the 20th century.

Factors Contributing to Group Violence

Violence among specific groups of perpetrators and violence directed toward selected groups of people often has its roots in the childhood or youth of the perpetrators. These forms of violence can be traced to many causes. The U. S. Department of Justice has identified a number of host causes or correlates of delinquency, including feelings of alienation or rebelliousness and lack of societal bonding (Wilson & Howell, 1993). Environmental factors include

• Parental conflict, lack of supervision, child abuse, or inconsistent parenting

• Negative school experiences, including early academic failure and lack of commitment to school

• Negative peer influence, including peers who engage in criminal activity

• Socioeconomic factors, such as high rates of substance abuse in the community, living in a high-crime neighborhood, and economic deprivation

The roots of youth gang problems are multifactorial. They may be related to lack of social opportunities, social disorganization, institutional racism, cultural maladaptation, deficiencies in social policy, and availability of criminal opportunities.

Additionally, frequent exposure to violence in the news, at sporting events, on television programs, in movies, on the Internet, in video games, and in violent pornography has been linked to an increase in aggression. Children seem to be especially vulnerable, and the link seems to be particularly strong if the subject matter glorifies violence as the ideal and appropriate solution to personal problems (Goode, 2000). For example, Dr. James Garbarino, author of Lost Boys: Why Our Sons Turn Violent and How We Can Save Them (1999), observes that children “have ample opportunities to see on television and in the movies how you threaten people, what it means to shoot someone, and ample opportunities to learn about revenge and how desirable it is in this society. For the nation to be shocked and appalled . . . is either a kind of denial or hypocrisy.” Simple access to weapons cannot be discounted as a factor in criminal activity. The United States imposes fewer restrictions on the manufacture, sale, and licensure of guns than any other industrialized nation and, as a correlate, is faced with higher rates of gun-related injuries and murders. Many of the youths involved in school shootings in the United States in the 1990s had easy access to guns that belonged to parents, other relatives, or neighbors. Weapons such as simple bombs can be made from instructions found on the Internet. Increasingly, rifles and assault weapons, rather than handguns, are being used in acts of group violence. These weapons allow for more rapid firing of more bullets and tend to cause significantly higher numbers of casualties. The murders of 12 students and 1 teacher in the 1999 assault on Columbine High School in Colorado, for example, were made possible by the easy acquisition and use of these more sophisticated weapons (see Research: Bridge to Practice II).

Role of the Community Health Nurse

Community health nurses can play a key role in reducing group violence by interacting with students, parents, churches, law enforcement officials, local politicians, and community organizers.

Preventing Group Violence

The typical model for preventing or reducing group violence includes activities such as assessing the problem, developing policy based on established objectives, conducting research, procuring funding, and promoting offender accountability. For example, an increase in rapes on one university campus might prompt the nursing department to facilitate a university-wide open forum to discuss the issue, identify possible factors, initiate research, and develop solutions. Programs might include outreach to all students currently enrolled at the university through dormitory teaching sessions, church-group activities, involvement of team coaches for university sports, and even participation by teachers and student advisors. Violence can be reduced in elementary and secondary schools by increasing supervision and surveillance.

Community health nurses can influence the reduction of school violence by establishing strong cooperative relationships between adults and students, recognizing (and helping others, such as parents and teachers, to recognize) behaviors that could signal a problem, and identifying situations that may predispose teens to violence. The “Six Vs” can be used to help identify teens who may need evaluation, especially if the frequency or intensity of these behaviors increases (Steger, 2000):

• Venting—angry outbursts inappropriate for the child’s age, frequent mood swings, and other behaviors indicating poor control of emotions

• Vocalizing—threats by a teen to harm self or others, or use of inappropriate language or profanity

• Vandalizing—intentional damage of property or a history of vandalism, even targeting his or her own property

• Victimizing—teens who see themselves as victims, whether true or not, become just as prone to violence as those who have actually been abused; they blame others for their problems and do not take responsibility for their actions

• Vying (for attention)—being involved in gangs or fringe groups, acting out in class, bringing weapons or other contraband to school to show others, wearing outlandish or banned clothing, or purposefully getting suspended or expelled.

• Viewing—like actual victims of abuse, young people who witness the abuse of others are likely to display violent tendencies themselves.

TERRORISM

At the start of the 21st century, the world is a global community. This is particularly evident in the increased incidence and sophistication of terrorist threats and acts around the world. Incidents occurring on U.S. soil such as the bombing of the World Trade Center in 1993 and its destruction on September, 11, 2001, along with the other terrorist attacks that day, have alerted us to our vulnerability and dramatically emphasized the need for increased preparedness within our communities. The anthrax scares after September 11 confirmed that our vulnerability exists in many areas; biologic, chemical, and nuclear terrorist threats are possible.

The U. S. Federal Bureau of Investigation defines terrorism as “the unlawful use of force and violence against persons or property to intimidate or coerce a government, the civilian population, or any segment thereof, in furtherance of political or social objectives” (Evans et al, 2002).

A terrorist is overzealous and obsessed with an idea. Terrorism and terrorist acts are not new; although the term terrorism can be traced back to 1798, the use of terrorist tactics precedes this date. A highly organized religious sect called the sicarii attacked crowds of people with knives during holiday celebrations in Palestine at about the time of Christ. During the French and Indian War of 1763, British forces gave smallpox-contaminated blankets to Native Americans. During World War I, the German bioweapons program developed anthrax, glanders, cholera, and wheat fungus as weapons targeting cavalry animals. In World War II, the Japanese tested biologic weapons on Chinese prisoners.

Three major countries operated offensive bioweapons programs in recent years: the United Kingdom until 1957, the United States until 1969, and the former Soviet Union until 1990. Iraq started its bioweapons program in 1985 and continued to develop weapons until 2003. At least 17 other nations are currently suspected of operating offensive bioweapons programs (Evans et al., 2002). Bioweapons include such things as mustard gas, materials to create sarin and VX gas, and anthrax. Terrorists typically use nuclear, biologic, or chemical (NBC) agents and explosives or incendiary devices to deliver the agents to their targets.

Nuclear warfare involves the use of nuclear devices as weapons and can take several forms. Terrorists who gain access to nuclear power plants could cause a chain of events that lead to a meltdown of the nuclear core, thereby releasing radioactive particles for hundreds of miles around the site. Nuclear accidents have occurred, but no known terrorist attacks have yet involved the use of nuclear power plants as weapons. A terrorist attack using nuclear weapons or destruction of a nuclear plant would cause multiple and prolonged deaths with extensive damage and negative effects for decades.

Chemical warfare involves the use of chemicals such as explosives, nerve agents, blister agents, choking agents, and incapacitating or riot-control agents to cause confusion, debilitation, death, and destruction (Yergler, 2002). Terrorists in the Middle East, willing to sacrifice their own lives, strap bombs to themselves and detonate the explosives in or near targets. Others crash vehicles loaded with explosives into crowds of people or into a building. Many such incidents have occurred during the war in Iraq in 2003–2004.

The aircraft used on September 11, 2001, were huge chemical weapons because they were carrying thousands of tons of jet fuel. The success of the mission depended on the surprise of the attack, severe damage to recognizable buildings, and the deaths of many people. The collapse of the buildings was unplanned. If the planes had been low on fuel, the damage would not have been as severe. The liquid fuel burned at such a high temperature that the internal structure of the buildings was weakened.

Biologic warfare involves using biologic agents to cause multiple illnesses and deaths. Typical biologic agents are anthrax, botulinum, bubonic plague, Ebola, and smallpox. These agents could be used to contaminate food, water, or air. Deliberate food and water contamination remains the easiest way to distribute biologic agents for the purpose of terrorism (Khan, Swerdlow, & Juranek, 2001). In addition, the U. S. Office of Technology Assessment has speculated that the release of 220 pounds of anthrax spores from a crop-duster over the Washington, D.C., area on a calm, clear night could kill between 1 and 3 million people (U. S. Army Chemical and Biological Defense Command, 1998) (see Chapter 9). The United States is very concerned about the possibility of biologic warfare or bioterrorism, as nations should be.

The anthrax infections and deaths that occurred after September 11, 2001, have added to these concerns. However, it has not been confirmed that these incidents were committed by an organized foreign or domestic terrorist group. They could have been carried out by a single disturbed citizen, who would be a terrorist nevertheless, because the outcomes would be the same: fear, death, and destruction. Factors Contributing to Terrorism Political factors are the most common contributors to terrorism. Anti-American sentiment runs high in many foreign countries, especially those that perceive the United States as a threat to their military, economic, social, or religious selfdetermination. Terrorist acts against American military installations abroad, in airports, in airplanes, at American embassies, and even on American soil have occurred frequently in the last decade as an expression of political unrest. The war in Iraq in 2003–2004 was based on information about suspected bioterrorism weapons and reports that Iraq was harboring anti-Western terrorists; these two pieces of information resulted in the toppling of the Saddam Hussein political regime. However, hundreds of military lives were lost, and no weapons of mass destruction were found.

Within the United States, violence-prone members of militia movements, violent antiabortion activists, racial desegregation advocates, and other radical groups have performed terrorist acts, such as the bombing of health clinics offering abortions. In 1984, members of a religious cult, the Rajneeshees, lived in Wasco County, Oregon, and followed a self-proclaimed guru exiled from India. In an attempt to reduce voter turnout in an upcoming county election, they sprinkled  Salmonella bacteria over items on salad bars in local restaurants and in the produce sections of grocery stores. They hoped that, with a reduced voter turnout, representatives friendlier to their group would win the election. Their attack failed to affect the election and killed no one; however, 751 people became sick. The media underreported this event because domestic terrorism was not a topic of concern at that time in U. S. history.

Role of the Community Health Nurse

Community health nurses need to be prepared for the possibility of terrorist activity. They have a role in primary, secondary, and tertiary prevention.

SUMMARY

A disaster is any event that causes a level of destruction that exceeds the abilities of the affected community to respond without assistance. Disasters may be caused by natural or manmade/technologic events and may be classified as multiple- casualty incidents or mass-casualty incidents.

The scope of a disaster is its range of effect, and the intensity is the level of destruction it causes. Victims of disasters include direct victims, those injured or killed, and indirect victims, the loved ones of direct victims. Displaced persons are those who are forced to flee their homes because of the disaster, and refugees are those who are forced to leave their homelands, usually in response to war or political persecution.

Host factors that contribute to the likelihood of experiencing a disaster include age, general health, mobility, psychological factors, and socioeconomic factors. The disaster agent is the fire, flood, bomb, or other cause. Environmental factors are those that could potentially contribute to or mitigate a disaster. In developing strategies to address the problem of disasters, it is helpful for the community health nurse to consider each of the four phases of disaster management: prevention, preparedness, response, and recovery.

Primary prevention of disasters means keeping the disaster from ever happening by taking actions to eliminate the possibility of its occurrence. Secondary prevention focuses on earliest possible detection and treatment. Tertiary prevention involves reducing the amount and degree of disability or damage resulting from the disaster.

In addition to assessing for preparedness, an effective disaster plan establishes a clear chain of authority, develops lines of communication, and delineates routes and modes of transport. Plans for mobilizing, warning, and evacuating people are also critical elements of the disaster plan. At the disaster site, police, firefighters, nurses, and other relief workers develop a coordinated response to rescue victims from further injury, triage victims by seriousness of injury, and treat victims on-site and in local hospitals. Care and transport of dead bodies must also be managed, as well as support for the loved ones of the injured, dead, or missing.

Long-term support includes both financial assistance and physical and emotional rehabilitation.

Self-care, including stress education for all relief workers after a disaster, helps to lower anxiety and put the situation into proper perspective. CISD provides victims with a mechanism for emotional reconciliation and healing.

Problems of group violence include school violence, gangs, riots, and violent crimes. A gang is an organization of youths that has a name, is usually territorial or claims a certain territory as being under its exclusive influence, and is involved in criminal acts.

The roots of group violence are multifactorial and include inadequate parenting; socioeconomic and racial injustices; exposure to violence in media, cartoons, and pornography; and easy access to weapons.

The goals of Healthy People 2010 for reducing violence include reductions in physical assaults and weapon carrying by schoolchildren and reduction of work-related assaults and homicides.

The role of the community health nurse in preventing and reducing group violence includes effective community organization and program development, as well as policy making to address the family and environmental factors that contribute to increased risk of group violence.

Terrorism is the unlawful use of force or violence against persons or property to intimidate or coerce a government or civilian population in the furtherance of political or social objectives. Terrorism may be nuclear, biologic, or chemical, including nerve agents and explosive devices. The community health nurse should be alert to signs of possible terrorist activity and prepared to address the secondary or tertiary effects of such attacks. Preparation includes knowledge of the effects of specific biologic or chemical agents and how to help people cope with the terror they personally feel.

 

Internet Resources

Action Committee Against Violence: http://www.acav.org

Almanac of Disasters: http://www.disasterium.com

Bioterrorism: http://bioterrorism.straws.com

Bioterrorism Resources: www.acponlone.org/bioterro/index.html

Center for the Study and Prevention of Violence: http://www.colorado.edu/cspv/

Citizen Corps: www.citizencorps.gov

Men Against Domestic Violence (MADV)—Domestic Violence Resources: http://www.silicom.com/~paladin/madv/

National Coalition Against Domestic Violence (NCADVE): http://www.healthtouch.com