20

Communities in Crisis:
Disasters, Group Violence,
and Terrorism

Key Terms Learning Objectives

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

● Assault and battery
● Biologic warfare ● Describe a variety of characteristics of disasters, including
● Casualty causation, number of casualties, scope, and intensity.
● Chemical warfare ● Discuss a variety of factors contributing to a community’s potential
● Critical incident stress debriefing for experiencing a disaster.
(CISD)
● Identify the four phases of disaster management.
● Direct victim
● Disaster ● Describe factors involved in disaster planning.
● Disaster planning ● Describe the role of the community health nurse in preventing,
● Displaced person preparing for, responding to, and supporting recovery from
● Gang disasters.
● Genocide
● Compare and contrast the most common types of group violence.
● Homicide
● Indirect victim ● Discuss a variety of factors contributing to a community’s potential
● Intensity for experiencing group violence.
● Looting ● Describe the role of the community health nurse in preventing and
● Lynching responding to group violence.
● Manmade disaster
● Distinguish terrorism from other types of group violence.
● Mass casualty
● Natural disaster ● Use the levels of prevention to describe the role of the community
● Nuclear warfare health nurse in relation to acts of chemical, biologic, or nuclear
● Posttraumatic stress disorder terrorism.
(PTSD)
● Rape
● Refugee
● Riot
● Scope
● Terrorism
● Triage
● Violent crime
446 UNIT 4 Community as Client
W
hat would you do if your local news station broad-
cast an announcement that your community was di-
rectly in the path of a hurricane that earlier in the day
had caused extensive damage and loss of life in a neighbor-
ing state? What would you do if you were shopping at a lo-
cal 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 Sep-
tember 11, 2001, when the world of each American, espe-
cially 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 ter-
rorism are ever-present possibilities, and nurses and other
health care professionals have an obligation to respond ap-
propriately. This chapter will increase your understanding of
the community health nurse’s role in preparing for, respond-
ing 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 commu-
nity-based response is required or even possible. Such a
tragedy may, however, be felt for a lifetime by family mem-
bers 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 in-
juries, 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 earth-
quakes and Florida with hurricanes. Similarly, it is not sur-
prising to hear of drought in Ethiopia or floods in India dur-
ing 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 typ-
ically 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 sam-
pling 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 wild-
fires, 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 acro-
batic maneuver at an air show, killing 83 people, includ-
ing 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 dis-
asters 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-
 CHAPTER 20 Communities in Crisis: Disasters, Group Violence, and Terrorism
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 in-
volved. 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 casu-
alties—often completely overwhelm the resources of even
large cities. Preparedness for mass-casualty incidents is es-
sential for all communities.
The possibility of being prepared is another characteris-
tic 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 fami-
lies 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 com-
munities 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 col-
lapse 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 in-
volvement. 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
447
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 disas-
ter, some direct victims may become displaced persons or
D I S P L A Y 20–1
Direct and Indirect Victims of a Disaster
On September 11, 2001, almost 3000 people died in
the terrorist attacks on the World Trade Center in New
York City. All of the employees and visitors in the two
buildings were direct victims of this disaster, and the
entire population of Manhattan can be considered in-
direct victims.
Hotels, businesses, and apartments for blocks sur-
rounding the Twin Towers suffered structural damage,
blown-out windows, and interiors covered with inches
of powdered cement and other debris. A year after
this disaster, many residents in the surrounding areas
still were unable to return home.
Many rescue workers who were survivors have
lasting psychological effects from their own survival
experiences and from losing close friends and col-
leagues. In addition, many rescuers breathed in the
dust in the air for days and now have respiratory dam-
age. As a result, their status changed from indirect
victim to direct victim.
All people working or visiting Manhattan that day
were affected by the closing of the bridges and tun-
nels and were stranded in New York City until trans-
portation routes opened again, thus becoming indirect
victims.
Other indirect victims included children attending
school and living within sight of the Twin Towers.
They received counseling in school for months, and in
some cases years, after the disaster.
For 1 year after the attack, volunteer construction
workers and rescue workers who lost fellow police of-
ficers, paramedics, or firefighters worked 24 hours a
day. First, the efforts were geared to help look for sur-
vivors. Shortly after, workers knew that they were
looking for the bodies or body parts of victims while
removing thousands of tons of building pieces. Thou-
sands of people who were involved in the recovery ef-
forts can be considered indirect victims.
Family members of the 2833 deceased/or missing
victims, who have been affected for a lifetime, also are
indirect victims. Thousands of children lost a parent,
some parents lost multiple children, and, in some
cases, both spouses were lost because husband and
wife both worked in the World Trade Center. The rip-
ples of tragedy extended beyond the borders of the
United States, because there were hundreds of people
working in the Twin Towers from many different coun-
tries whose family members are now indirect victims.
448 UNIT 4 Community as Client
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 per-
son’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 re-
served for people who are forced to leave their homeland be-
cause 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 exam-
ple, many young people who fled Argentina during the “dis-
appearances” 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, indi-
rect 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 disap-
peared 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 de-
velop 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 com-
pleted, 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, psychologi-
cal factors, and even socioeconomic factors. For instance, el-
derly 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 low-
income 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 Sta-
tion 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 con-
tribute to or mitigate a disaster. Some of the most common
environmental factors are a community’s level of prepared-
ness; the presence of industries that produce harmful chemi-
cals 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 fa-
mous as the Red Cross, the name commonly used when re-
ferring 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 as-
sessment 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 addi-
tion, 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 depart-
ment. As a relatively new department, it is undergoing many
changes related to its scope of service. In June 2002, the Amer-
ican Public Health Association became concerned because
some of the responsibilities of the Centers for Disease Control
and Prevention and the Health Resources and Services Ad-
ministration (such as the cache drugs, medical supplies, and
equipment for emergencies through the National Pharmaceu-
tical Stockpile) were being usurped by the Department of
Homeland Security. Some experts see this department as frag-
 CHAPTER 20 Communities in Crisis: Disasters, Group Violence, and Terrorism
menting the nation’s broad-based public health system, which
may hinder overall responsiveness and compromise the pub-
lic 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 exam-
ple, in March 2000, the governments of South Africa, Eng-
land, Germany, France, and the United States, among other
nations, responded to the floods in Mozambique with heli-
copters, planes, boats, and supplies.
When natural or manmade disasters within the United
States are accompanied by civil disturbance, looting, or vio-
lent 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, pre-
paredness, response, and recovery.
Prevention Phase
During the prevention phase, no disaster is expected or antic-
ipated. The task during this phase is to identify community risk
factors and to develop and implement programs to prevent dis-
asters from occurring. Task forces typically include represen-
tatives from the community’s local government, health care
providers, social services providers, police and fire depart-
ments, major industries, local media, and citizens’ groups.
Programs developed during the prevention phase may also fo-
cus 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 disas-
ter management since September 2001. This can be seen es-
pecially 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 dis-
aster 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.
449
Semiannual disaster drills and tests of the Emergency Broad-
cast System are examples of appropriate activities during the
preparedness phase.
Disaster preparedness activities occur locally, region-
ally, and nationally. A town keeps its warning system work-
ing and tests it each month. Sections of the country coordi-
nate 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 Na-
tional 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 emer-
gency. 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 oc-
curred 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 immedi-
ately, with the goals of saving lives and preventing further in-
jury or damage. Activities during the response phase include
rescue, triage, on-site stabilization, transportation of victims,
and treatment at local hospitals. Response also requires re-
covery, identification, and refrigeration of bodies so that no-
tification of family members is possible and correct, even
weeks after a disaster. This care of the dead is demanding and
time-consuming work that is often overlooked by people un-
familiar 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 re-
pair, rebuild, or relocate damaged homes and businesses and re-
store health and economic vitality to the community. Psycho-
logical recovery must also be addressed. The emotional scars
from witnessing a traumatic event may last a lifetime. Both vic-
tims 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 forma-
tion of a multidisciplinary task force to address disaster pre-
vention and preparedness in the community.
450 UNIT 4 Community as Client
VOICES FROM THE COMMUNITY
“I saw the first plane hit the corner of the World
Trade Center and explode from my kitchen window,
which is 300 feet from the south tower. A blizzard of
gray dust obliterated the bright blue of the sky. Paper
floated through the dust, edges on fire and curling up.
It was beautiful actually, and I couldn’t take my eyes
off of it.
In the aftermath, my life has been completely
turned upside down. I lived in that apartment for 25
years. Until mid-May (2002), it was part of a police
zone; I’ve been back only to clean up. I have thrown
away all my possessions except for a few pho-
tographs and pieces of art. In effect, I’m starting
over. I feel a kinship with the legions of displaced
people in this world, made homeless by events be-
yond their control. They are incredibly strong and re-
silient. I hope that I will be too.”
Kathleen, New York City resident (Cooper & Ianzito,
2002).
Preventing Disasters
Disaster prevention may be considered on three levels: pri-
mary, 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 ob-
viously the most effective level of intervention, both in terms
of promoting clients’ health and containing costs, it is not al-
ways possible. Tornadoes, earthquakes, and other disasters
often strike without warning, despite the use of every avail-
able technologic device for prediction and tracking.
If possible, primary prevention of disasters can be prac-
ticed in all settings: in the workplace and home with pro-
grams to reduce safety hazards, and in the community with
programs to monitor risk factors, reduce pollution, and en-
courage nonviolent conflict resolution. Primary disaster pre-
vention efforts should take into account a community’s phys-
ical, psychosocial, cultural, economic, and spiritual needs.
The community health nurse has a role in each of these ar-
eas. As a teacher, the community health nurse educates peo-
ple 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 vis-
its 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 an-
ticipatory guidance. Disaster drills and other anticipatory ex-
ercises 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 com-
munity 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 tor-
nado, and the local health department’s community health
nurses work with the American Red Cross to provide emer-
gency assistance. Secondary prevention corresponds to im-
mediate and effective response.
Nurses at St. Vincent’s Hospital, the closest Level I
Trauma Center to the World Trade Center, prepared to re-
spond 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, start-
ing the process earlier and routing people for treatment more
effectively. This system was developed after the 1993 ter-
rorist 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 in-
juries 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 crush-
ing injury victims were treated. With organization and pre-
paredness, those needing hospitalization were admitted
within 45 minutes after being triaged and stabilized. Most in-
juries 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 dur-
ing 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 suffer-
ing from symptoms related to fatigue and emotional distress
(Ostrowski, 2001).
Nurses from other hospitals offered to help, and volun-
teers 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 mas-
 CHAPTER 20 Communities in Crisis: Disasters, Group Violence, and Terrorism 451

LEVELS OF PREVENTION MATRIX

SITUATION: A natural disaster—tornado.

GOAL: Using the three levels of prevention, negative health conditions are avoided, or promptly diagnosed and treated,
and the fullest possible potential is restored.

PRIMARY PREVENTION SECONDARY PREVENTION TERTIARY PREVENTION

Health Promotion Primary

and Education Health Protection Early Diagnosis Prompt Treatment Rehabilitation Prevention

Health
Promotion
and Health
Education Protection

• Increase community • Community members • Remain in your • Rescue individuals • Remain safe • Educate • Keep
awareness know what to do and position of safety promptly and get during the community recom-
• Increase community where to go, whether until a community appropriate care for immediate members mended
preparation through at home, work, school, all-clear warning those injured as soon recovery period about the immuniza-
education or elsewhere in the signal is sounded as possible • Accept help from need to tions
• Each person is as community or until rescued • The infrastructure of others—friends, enhance current
prepared as possible • Get to safety before • Leave a damaged the community family, and planning • Community
both physically and the impact—southwest building cautiously, becomes/remains community against physical
emotionally corner of a home’s if able and not intact, keeping services damage structures
basement or an seriously injured, community members • Rebuild family from future need
interior room away and do not return safe from hazards lives through natural rebuilding,
from windows and until it is declared such as live wires, counseling and disasters, with infra-
under heavy furniture safe broken gas lines, and other services to based on structure
fallen debris restabilize life experiences planning
physically, with the and sup-
emotionally, current ports that
spiritually, and disaster improve
financially ability to
withstand
natural
disasters

sages. 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 indi-
rect victims themselves (Ostrowski, 2001).
Tertiary Prevention. Tertiary disaster prevention in-
volves reducing the amount and degree of disability or dam-
age resulting from the disaster. Although it involves rehabil-
itative work, it can help a community recover and reduce the
risk of further disasters. In this sense, it becomes a preven-
tive 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 dif-
ficult to assist her patients with their needs because of her
own insecurities and fears. She and a peer responded to a re-
quest from the Logan Airport Employee Assistance Program
(EAP) asking for help with crisis counseling for United Air-
lines 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 tur-
moil, and their ability to function was affected. “The terror-
ists had taken away their colleagues, friends and sense of se-
curity” (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 essen-
tial, for healthy grieving. Some employees needed to talk
about good times, others were quiet and sad, and others ex-
pressed a fear of flying again but did so with the support of
family and friends. All demonstrated courage and an ability
452 UNIT 4 Community as Client
to continue their lives with a sense of strength and hope.
Working with these employees enabled the nurse to recap-
ture 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 dis-
cussed in this and the following section. See Display 20–2
for a summary of these elements.
Personal Preparation. Before we discuss the prepara-
tion of a disaster plan for a community, we should consider
the need for all nurses to address their own personal pre-
paredness to respond in a disaster. Display 20–3 describes
the tragic outcome of one nurse’s lack of preparation when
she attempted to provide nursing care at the scene of the Ok-
lahoma City bombing. 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 dis-
aster 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 li-
cense, durable clothing, and basic equipment such as stetho-
scopes, 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.
D I S P L A Y 20–2
Elements of a Disaster Plan
A disaster plan should address all of the following:
Chain of authority
Lines of communication
Routes and modes of transport
Mobilization
Warning
Evacuation
Rescue and recovery
Triage
Treatment
Support of victims and families
Care of dead bodies
Disaster worker rehabilitation
D I S P L A Y 20–3
Nurses at Disaster Sites: Help or Hindrance?
On April 19, 1995, 37-year-old Rebecca Anderson, a
registered nurse working in Oklahoma City, after
hearing a televised report of the bombing of the Fed-
eral Building, went to the site wearing jeans and a
sweatshirt. Along with firefighters and other rescue
workers in hardhats and other protective gear, she
was allowed to enter the scene. Within a short time,
Rebecca was struck on the back of the head by a
concrete slab that fell from the building’s wreckage.
She died 5 days later of massive cerebral edema.
Nurses can learn the following lessons from this
tragedy:
• Never enter a disaster scene unless you are di-
rected to do so by an emergency medical techni-
cian, fire, or law enforcement official.
• Contact local hospitals and clinics to offer your
help; your medical expertise is more useful in the
clinical environment.
• Take courses in first aid and emergency care. Con-
tact your local Red Cross for a list of courses.
• Contact your local health department to learn more
about your community’s disaster plan and how you
can contribute in the event of a disaster in your
area.
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 peo-
ple warned in time? Did evacuation efforts remove all peo-
ple in danger? What were the community’s on-site re-
sponses, and how effective were they? What programs were
put in place to rehabilitate the community?
Establishing Authority, Communication, and Trans-
portation. 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. Usu-
ally, the chain is hierarchical, with, for example, the com-
munity’s governmental head (eg, mayor) initiating the plan,
alerting the media to broadcast warnings, authorizing the po-
lice to begin evacuations, and so on. Within each level of the
organization, the hierarchy continues. For example, at the lo-
cal 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-in-
command must have equal knowledge of the community’s
disaster plan and be able to step in without delay.
 CHAPTER 20
Effective communication is often a point of breakdown
for communities attempting to cope with major disasters. Af-
ter the terrorist attacks in Oklahoma City and New York City,
phone lines were damaged and cellular sites were over-
whelmed, making communication difficult. Communication
was possible only through handheld radios or by way of
couriers on foot. At times of heightened chaos and stress, as
well as after physical damage to communication facilities and
equipment, misinformation and misinterpretation can flour-
ish, leading to delayed treatment and increased loss of life.
Again, clarity and flexibility are the watchwords for es-
tablishing lines of communication. How will warnings be
communicated? What backups are available if the normal
communication systems are destroyed in the disaster? How
will communication between relief workers at the disaster
site, hospital personnel, police, and governmental authorities
be maintained? What role will local media play, both in keep-
ing information flowing to the outside world and in broad-
casting needs for assistance and supplies? Finally, how will
friends and family members of victims be informed of the
whereabouts or health status of their loved ones? The char-
acteristics of effective communication during disasters are
summarized in Display 20–4.
Closed or inefficient routes of transportation can also in-
crease injury and loss of life. For example, if a single, narrow
mountainous road is the only means of transporting firefight-
D I S P L A Y 20–4
Effective Communication During Disasters
To be effective, communication during disasters must
elicit action. Communication that elicits action pro-
vides information that is
• Believable
• Current
• Unambiguous
• Authoritative
• Predictive of the probability of future events (what
is going to happen next?)
Effective communication is
• Interactive—it allows for and addresses questions
• Conclusive—it eliminates room for speculation and
catastrophizing
• Urgent—conveys seriousness without resorting to
fear tactics
• Clear, simple, and repetitive
• Characterized by solutions and suggestions for
success
• Personal—it uses people’s names if possible and
addresses their real and perceived needs
Finally, because rumors can hinder effective action or
provoke premature action, effective communication
includes rumor control. It provides suggestions for
constructive activity, reducing time and energy spent
on rumor generation and perpetuation.
Communities in Crisis: Disasters, Group Violence, and Terrorism 453
ers to or evacuating residents from the scene of a forest fire,
then disaster planners should propose widening the road or
clearing a second road. Disaster planners must also consider
what routes emergency vehicles will take when transporting
disaster victims to local and outlying hospitals or health care
workers to the disaster site. What if the chosen routes are in-
accessible because of floodwaters, advancing fires, mountain
slides, or building rubble? Are alternative routes designated?
Mobilizing, Warning, and Evacuating. In many nat-
ural disasters, local weather service personnel, public works
officials, police officers, or firefighters have the earliest infor-
mation indicating an increasing potential for a disaster. These
officials typically have a plan in place for providing commu-
nity 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 as-
sume 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 commu-
nicating warnings, but alternative strategies, such as police
or volunteers canvassing neighborhoods with loudspeakers,
should also be in place. In multilingual communities, mes-
sages 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 to-
tal disaster plan. The plan should cover notification of the po-
lice, 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 exam-
ple, 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 re-
lief 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
454 UNIT 4 Community as Client

dogs trained to locate dead bodies may be brought in (Fig. ber of casualties exceeds immediate treatment resources. The
20–1). Usually, the immediate disaster site is not the best goal of triage is to effect the greatest amount of good for the
place for the disaster nurse, who can be far more effective in greatest number of people. Figure 20–2 shows the four basic
triage and treatment of victims. One of the lessons of the categories of the international triage system, as well as a
World Trade Center bombing was that the greatest need for triage tag.
medical professionals was at the local hospitals, not at the Prioritization of treatment may be very different in a
disaster site. mass-casualty event as opposed to an average day in a hos-
Rescue workers face the logistically and psychologi- pital emergency department. Under normal circumstances, a
cally difficult task of determining when to cease rescue ef- person presenting to a hospital emergency department with a
forts. Some factors to consider include increasing danger to myocardial infarction and showing no pulse or respirations
rescue workers, diminishing numbers of survivors, and di- would receive immediate treatment and have a chance of re-
minishing possibilities for survival. For example, after a covery. At a disaster site, a victim without a pulse or respi-
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 num-

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 un-
conscious 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 pre-
senting 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 mat-
ter showing). Life-saving heroics on this group of victims will
only delay medical care on more viable victims.

FIGURE 20–2. Victim triage tag recom-

FIGURE 20–1. Hazardous ma- mended by the California Fire Chiefs Association. There are four
terials suit used by the military and most fire depart- basic categories that are all applied when a medical system is over-
ments. (Photo by Cynthia Tait.) whelmed with victims. (Photo by Cynthia Tait.)
 CHAPTER 20
rations would most likely be placed in the nonsalvageable
category.
Mass casualties refers to a number of victims that is
greater than that which can be managed safely with the re-
sources 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 com-
munity 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 pro-
curement, distribution, and replenishment of all supplies.
Disposable items might be in short supply, requiring resteril-
ization procedures that may be unfamiliar to a nurse not ac-
customed to field work. These procedures may pose a chal-
lenge even to an experienced nurse because of the field
environment. The nurse may also manage provision or distri-
bution 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 spiri-
tual 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 anxi-
ety 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; how-
ever, such victims must be assessed for head trauma and in-
ternal 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. Identifi-
cation and transport of the dead to a morgue or holding fa-
cility 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 avail-
able to assist families awaiting news of missing loved ones.
Communities in Crisis: Disasters, Group Violence, and Terrorism 455
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.
Supporting Recovery From Disasters
Disasters do not suddenly end when the rubble is cleared and
the victims’ wounds are healed. Rather, recovery is a long,
complex process that often includes long-term medical treat-
ment, physical rehabilitation, financial restitution, and psy-
chological and spiritual support.
Long-Term Treatment. Long-term treatment may be
required for many victims of disasters, straining the local re-
habilitative-care facilities and resources. Children who were
victims may have to deal with lifelong disabilities or scars
from their ordeal, and families may be without adequate fi-
nancial support for their child’s medical care. Elderly citi-
zens who may formerly have been in excellent health but
who sustained serious injuries in the disaster might suddenly
find that they can no longer live independently and must
move to a long-term care facility. After floods, landslides,
fires, or earthquakes, extensive property damage may cause
some residents or businesses to relocate rather than rebuild
on land they now deem to be disaster-prone. A disaster that
creates numerous victims in a small community may alter the
entire social fabric of that community permanently.
Long-Term Support. Victims of disasters may need
funding to repair or rebuild their homes or to reopen busi-
nesses, such as stores, restaurants, and other services needed
by the community. Insurance settlements, FEMA funding,
and private donations may assist in financing community re-
habilitation. Health care workers may be required to assist
victims in filling out necessary paperwork. Immediately af-
ter a disaster, some victims may be unable to concentrate on
anything beyond fulfilling their immediate needs and those
of their family.
Psychological support is often required after a disaster,
both for victims and for relief workers. Some individuals
may experience posttraumatic stress disorder (PTSD), a
syndrome that may be marked by flashbacks, nightmares,
disinterest in daily affairs, hypervigilance, survivor’s guilt,
or decreased concentration. The “traumatic event” criterion
for PTSD, as set forth in the current edition of the Diagnos-
tic and Statistical Manual of Mental Disorders, was un-
doubtedly met by the coordinated attacks on New York City,
the Pentagon, and Flight 93 on September 11, 2001. Less dra-
matically, many victims, especially elderly persons dis-
placed from their homes, may quietly lose their will to live
and drift into apathy and malaise. Individuals whose belief in
God was unshakable before the incident may now wonder
456 UNIT 4 Community as Client
how God could have let this happen, especially if they have
lost a loved one. These victims often require not only em-
pathic listening but also long-term skilled spiritual counsel-
ing before they can begin to regain their former faith. In as-
sessing a community’s citizens for counseling needs after a
disaster, the nurse should not forget to include children. Of-
ten, children do not have words to express their feelings or
fears and may act out in ways adults find difficult to under-
stand, unless age-appropriate psychological intervention is
provided.
Many studies were generated out of the unprecedented
exposure to trauma in the United States on September 11,
2001. Some researchers examined mental health needs in
New York State and the public costs of mental health re-
sponse after the attacks (Jack & Glied, 2002; Herman, Fel-
ton, & Susser, 2002). Others studied immediate psychologi-
cal reactions and reactions up to 6 months after the attacks.
(Schlenger et al., 2002; Silver et al., 2002) (see Research:
Bridge to Practice I).
RESEARCH: BRIDGE TO PRACTICE I
Silver, R.C., Holman, E.A., McIntosh, D.N., Poulin, M.,
& Gil-Rivas, V. (2002). Nationwide longitudinal study
of psychological responses to September 11. JAMA,
288(10), 1235–1244.
On September 11, 2001 the United States experienced
the most deadly terrorist attacks ever to occur on home
soil. The traumatic events affected many people directly
and the entire nation indirectly. Researchers found this
to be a unique opportunity to examine longitudinally the
process of adjustment.
A national probability sample of 3496 adults received
a Web-based survey. The questionnaire focused on stress-
related symptoms and behaviors that represent adjust-
ment or maladjustment; respondents were polled initially
and at 2 and 6 months after the event. Seventy-eight per-
cent (2729 individuals) completed the survey within 23
days of the terrorist attacks; 1069 of the participants who
resided outside New York City were selected from the
first wave of respondents. The main outcome measures
were September 11–related symptoms of acute stress,
posttraumatic stress, and global distress. Seventeen per-
cent of the U. S. population surveyed outside of New
York City reported symptoms of September 11–related
posttraumatic stress 2 months after the attacks, and 5.8%
reported them at 6 months. High levels of posttraumatic
stress symptoms were associated with
• Being female
• Marital separation
• Pre–September 11 physician-diagnosed depression or
anxiety disorder or physical illness
Need for Self-Care. Self-care, including stress educa-
tion for all relief workers after a disaster, helps to lower anx-
iety and put the situation into proper perspective. Critical in-
cident stress debriefing (CISD) provides victims with
professional debriefing in small groups or individually and
becomes a mechanism for emotional reconciliation. The
ideal time for CISD is between 24 and 72 hours after the dis-
aster event. Positive effects of CISD include
• Accelerating the healing process
• Equipping participants with positive coping mechanisms
• Clearing up misconceptions and misunderstandings
• Restoring or reinforcing group cohesiveness
• Promoting a healthy, supportive work atmosphere
• Identifying individuals who require more extensive psy-
chological assistance
CISD addresses all components of the human response to
trauma, including physiologic effects, emotions, and cognition.
Studies have shown that CISD allows individuals to regain a
sense of normalcy much sooner than those not receiving CISD.
• Severity of exposure to the attacks
• Early disengagement from coping efforts
• Denial
Global distress was associated with severity of loss
due to the attacks, early coping strategies and giving up,
which decreased with active coping.
Conclusions were that the psychological effects of a
major national traumatic event are not limited to those
who experience it directly. In addition, the degree of
traumatic response is not predicted simply by exposure
to or loss from the trauma. “Instead, use of specific cop-
ing strategies [seeking social support, active coping, de-
nial, behavioral disengagement] shortly after an event is
associated with symptoms over time. In particular, dis-
engaging from coping efforts can signal the likelihood
of psychological difficulties up to 6 months after a
trauma” (p. 1235).
This study suggests that even individuals who are not
directly exposed to a trauma may demonstrate poten-
tially disturbing levels of trauma-related symptoms.
Symptoms that appear in a large number of indirectly af-
fected people may represent a normal response to an ab-
normal event. The study suggests that the use of coping
strategies enhances recovery. A community health nurse
needs to be cognizant of this relationship and prepared
to enhance it in clients who experience a traumatic
event. Rituals and activities that provide comfort—such
as participation in faith community rituals, sharing fears
and concerns with family and friends, and talking about
feelings with others, lay and professional—are examples
of healthy coping strategies.
 CHAPTER 20 Communities in Crisis: Disasters, Group Violence, and Terrorism
Self-care comes in many forms and is part of a prescrip-
tion for emotional healing after a traumatic event. Self-care
is not just for rescue workers but for everyone touched by
trauma. Keep in mind the following self-care points (Peeke,
2002):
• Give yourself time to heal. You need time to adjust. Even
though you want the pain to be over immediately, it is
healthier to realize that this is a long-term recovery
process.
• Ask for emotional support. Talk with family and friends
around the country. It feels good to be connected with oth-
ers. You listen and support one another as you share your
feelings.
• Take care of yourself; it will improve your ability to deal
with stress. Eat regularly, avoid alcohol, maintain sleep
patterns, follow your exercise routine, and embrace each
day as a gift.
• Reestablish daily routines. Getting back to your regular
routine is important and gives you a sense of security and
normalcy.
• Use your time wisely. A significant traumatic event gives
you an opportunity to reprioritize how you spend your
time each day. Are you living your dreams and passions?
Traumatic events remind us of our fragile nature and that
each moment should be savored and enjoyed.
• Give something back. Your life goes on. Demonstrate
your gratefulness by becoming part of a global healing
process. Donate to charities and give time to causes you
have ignored. Seek ways to reach out to those who are in
need of help.
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 annu-
ally. By 1998, that number had dropped to less than 2.8 mil-
lion (U. S. Department of Justice, 1999). The U. S. Depart-
ment of Justice’s National Crime Victimization Survey
(NCVS) for 2000–2001 indicated that violent crime had de-
creased 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 pow-
erful 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 emer-
gency and a grave threat to an entire generation of young
adults (USDHHS, 2000).
457
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 loose-
knit organization of individuals between the ages of 14 and
24 years that has a name, is usually territorial or claims a cer-
tain territory as being under its exclusive influence, and is in-
volved 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 dis-
tribution, 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 indi-
vidual 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 iden-
tify 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 emo-
tional 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); ar-
son (the deliberate burning of buildings); lynching (execu-
tion by hanging without due process of law); or physical at-
tacks on a perceived enemy or on law enforcement officers.
Riots often erupt during times of war, political instabil-
ity, 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
458 UNIT 4 Community as Client
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 com-
mon after announcements of legal decisions that are per-
ceived 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. Internation-
ally, riots often erupt over sporting events, especially if the
fans are close to the action. Fans storm the field, assault offi-
cials, and attack the opposing team after a bad play or deci-
sion 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 pre-
cipitate a riot. In 1999, for example, there were widespread
riots in India in protest of the inflated price and limited avail-
ability 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, re-
gardless 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 dis-
cussed in Chapter 25.
One type of group assault that is becoming more preva-
lent 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 ele-
ments include some form of sexual contact and a lack of con-
sent. 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 his-
tory of childhood sexual abuse among rapists, a patriarchal
value system in which men are expected to prove their mas-
culinity by dominating or “conquering” women, and an en-
vironment in which violence is explicitly or implicitly ac-
cepted or encouraged.
Homicide. Homicide is the killing of one person by an-
other. 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 Ger-
many (U.S. Department of Health and Human Services,
2000). Studies have shown that factors identified with vio-
lence include, but are not limited to “complex interactions
between poverty, racism, excess consumption of alcohol,
the plethora of illegal drugs, dysfunctional familial rela-
tions, abuse of children by adults, scarcity of viable em-
ployment and resources, lack of effective hand gun regula-
tion, inadequate services from schools and other social
agencies, stereotyping between peer groups and between
adults and children, and a general erosion of respect for in-
dividual 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, uni-
versities, restaurants, and workplaces. For example, on
March 1, 2000, a gunman in Pennsylvania went on a shoot-
ing 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 in-
jured 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 mil-
lions of Jews, Catholics, gypsies, homosexuals, intellectuals,
and other “undesirables” by the Nazis before and during
World War II. Tragically, genocide continues today. Recent
 CHAPTER 20 Communities in Crisis: Disasters, Group Violence, and Terrorism 459

Dr. James Garbarino, author of Lost Boys: Why Our Sons Turn
WHAT DO YOU THINK? I Violent and How We Can Save Them (1999), observes that chil-
dren “have ample opportunities to see on television and in the
movies how you threaten people, what it means to shoot some-
One of the reasons our national homicide rates are
one, and ample opportunities to learn about revenge and how
going down may be the improvements in emergency
desirable it is in this society. For the nation to be shocked and
care achieved over the past 30 years. Medical tech-
appalled . . . is either a kind of denial or hypocrisy.”
nology has helped to lower the death rate among as-
Simple access to weapons cannot be discounted as a fac-
sault victims by almost 70%, in the process
tor in criminal activity. The United States imposes fewer re-
decreasing the national murder rate. People who
strictions on the manufacture, sale, and licensure of guns than
would have ended up in morgues 20 years ago are
any other industrialized nation and, as a correlate, is faced
now simply treated and released by a hospital, often
with higher rates of gun-related injuries and murders. Many
in a matter of a few days. As good as this news is, it
of the youths involved in school shootings in the United States
artificially improves homicide statistics. Violence is
in the 1990s had easy access to guns that belonged to parents,
still being committed, but the victims survive and do
other relatives, or neighbors. Weapons such as simple bombs
not become homicide statistics.
can be made from instructions found on the Internet. Increas-
ingly, rifles and assault weapons, rather than handguns, are
Associated Press. (2002, August 12). Medical ad-
being used in acts of group violence. These weapons allow for
vances, drop in death rate linked. The Fresno Bee, A5.
more rapid firing of more bullets and tend to cause signifi-
cantly higher numbers of casualties. The murders of 12 stu-
dents and 1 teacher in the 1999 assault on Columbine High
examples include the mass “ethnic cleansings” in Bosnia, School in Colorado, for example, were made possible by the
Rwanda, and Kosovo in the last decade of the 20th century. easy acquisition and use of these more sophisticated weapons
(see Research: Bridge to Practice II).
Factors Contributing to Group
Healthy People 2010 Goals for
Violence
Reducing Group Violence
Violence among specific groups of perpetrators and violence
The Healthy People 2010 document (U.S. Department of
directed toward selected groups of people often has its roots
Health and Human Services, 2000) lists a number of goals for
in the childhood or youth of the perpetrators. These forms of
reducing youth violence, including the following:
violence can be traced to many causes. The U. S. Department
• Reduce physical assaults among people aged 12 years and
of Justice has identified a number of host causes or correlates
older to less than 25.5 per 1000 persons from a baseline in
of delinquency, including feelings of alienation or rebel-
1998 of 31.1 per 1000 persons.
liousness and lack of societal bonding (Wilson & Howell,
• Reduce to 33.3% the prevalence of physical fighting
1993). Environmental factors include
among adolescents in grades 9 through 12, from a base-
• Parental conflict, lack of supervision, child abuse, or in-
line in 1997 of 36.6%.
consistent parenting
• Reduce to less than 6% the prevalence of weapon carry-
• Negative school experiences, including early academic
ing by adolescents in grades 9 through 12, from a baseline
failure and lack of commitment to school
in 1997 of 8.5%.
• Negative peer influence, including peers who engage in
In addition, Healthy People 2010 calls for a reduction in
criminal activity
work-related homicides to no more than 0.4 per 100,000 work-
• Socioeconomic factors, such as high rates of substance
ers, from a baseline in 1998 of 0.5 per 100,000. It also calls for
abuse in the community, living in a high-crime neighbor-
a reduction in workplace assault to no more than 0.6 per 100
hood, and economic deprivation
workers, from a baseline in 1987–1992 of 0.85 per 100.
The roots of youth gang problems are multifactorial.
They may be related to lack of social opportunities, social
disorganization, institutional racism, cultural maladaptation,
Role of the Community Health
deficiencies in social policy, and availability of criminal
Nurse
opportunities. Community health nurses can play a key role in reducing
Additionally, frequent exposure to violence in the news, at group violence by interacting with students, parents, churches,
sporting events, on television programs, in movies, on the In- law enforcement officials, local politicians, and community
ternet, in video games, and in violent pornography has been organizers.
linked to an increase in aggression. Children seem to be espe-
cially vulnerable, and the link seems to be particularly strong if Preventing Group Violence
the subject matter glorifies violence as the ideal and appropri- The typical model for preventing or reducing group violence
ate solution to personal problems (Goode, 2000). For example, includes activities such as assessing the problem, developing
460 UNIT 4 Community as Client
RESEARCH BRIDGE TO PRACTICE II
Schuster, M.A., Franke, T.M., Bastian, A.M., Sor, S., &
Halfon, N. (2000). Firearm storage patterns in US
homes with children. American Journal of Public
Health, 90(4), 588–594.
SAFETY AND HOME FIREARM STORAGE
PATTERNS
The researchers involved with this study used data
from the 1994 National Health Interview Survey
(NHIS) and the Year 2000 Objectives supplement to
study the presence of firearms in the home and firearm
storage patterns among families with children. The
NHIS is an annual survey covering demographics,
health, health care utilization, and insurance. One sec-
tion of the Year 2000 supplement covers firearms.
Respondents from the 6990 sample homes with chil-
dren younger than 18 years of age (representing more
than 22 million children in more than 11 million homes)
reported that they had at least one firearm (69% re-
ported having more than one firearm), with 43% keep-
ing at least one unlocked firearm. Overall, 4% kept
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 univer-
sity-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. Exam-
ples of successful actions some schools have taken are listed
in Display 20–5.
Community health nurses can influence the reduction of
school violence by establishing strong cooperative relation-
ships 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 (Ste-
ger, 2000):
• Venting—angry outbursts inappropriate for the child’s
age, frequent mood swings, and other behaviors indicat-
ing poor control of emotions
firearms unlocked, unloaded, and stored with ammuni-
tion, and 9% kept firearms unlocked and loaded. There-
fore, a total of 13%—some 1.4 million homes with 2.6
million children—store firearms in a manner accessible
to children.
The percentage of children living in homes with
firearms increases with the child’s age, from 28% for
children younger than 1 year of age to 38% for chil-
dren aged 13 to 17 years. The types of firearms in-
cluded handguns (53%), shotguns (61%), rifles (65%),
and other types (2%). With the accessibility of firearms
increasing in households as children age, loading of
firearms by older children is a possibility.
Community health nurses, of course, do not control
what goes on in the homes of families with children.
Ultimately, families decide what they believe is best.
We can, however, make sure that when families make
these decisions, they are informed about the risks asso-
ciated with firearms and how to reduce those risks.
Special efforts may be warranted to address firearm
safety issues directly with adolescents.
D I S P L A Y 20–5
Actions Schools Can Take to Reduce
Violence
Schools can take the following actions to reduce their
risk for violence:
• Improve environmental design
• Install surveillance cameras, metal detectors, and
pay phones or dial-free access connections to
emergency services
• Increase security personnel
• Decrease access by outsiders to campus
• Institute school-wide safety plans, drills, and codes
• Train administrators and teachers to identify poten-
tially violent or psychologically impaired students
• Identify students who are associated with gangs
• Expel students who are caught with weapons on
campus
• Suspend or expel students for threatened or real
acts of violence
• Institute a policy that allows for searching students
and lockers
• Hold parents accountable for students’ actions and
make them financially responsible for any damages
incurred
 CHAPTER 20 Communities in Crisis: Disasters, Group Violence, and Terrorism
• 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 con-
traband 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.
Community health nurses can become involved through
the following actions:
• Speaking about school violence at middle and high school
assemblies, PTA meetings, parenting meetings, neighbor-
hood watch meetings, and church meetings
• Encouraging parents to involve their children in youth
group programs such as the Boy or Girl Scouts, Big
Brothers/Big Sisters, faith community youth groups, and
4-H; donating time to these groups; or, if they do not ex-
ist in the community, working to establish them
• Participating in local and national crime-prevention
councils
• Joining professional nursing organizations that engage in
campaigns to reduce violence
• Writing, producing, or promoting public service an-
nouncements that aim to reduce violence
• Promoting the inclusion of articles about group violence
in local newspapers, community newsletters, and faith-
based community bulletins
• Offering ongoing anger management and conflict resolu-
tion courses
To reduce gang membership and associated violence,
positive social development starting from infancy and an in-
tensive focus on interactions within the school system are
crucial. The school nurse or community health nurse work-
ing in education can sponsor programs to nurture social val-
ues and ethics and to help students dissociate from delin-
quent peers and role models. After-school programs in which
youths have an opportunity to play sports; volunteer with the
poor, the sick, or the elderly; or challenge their learning in
math clubs and on debate teams can improve self-esteem and
reduce the seduction of gang membership.
The community health nurse can also provide proactive
leadership in preventing gang activity. Community mobi-
lization and local organization are key components. Addi-
tionally, understanding of both the roots of specific gang is-
sues and the community conditions that contribute to the
problem is necessary for finding solutions and alternatives to
youth gang involvement.
461
An effective school gang-suppression strategy should
include the following:
• Development of guidelines for appropriate teacher and staff
responses to a variety of gang behaviors and delinquency
• Application and enforcement of rules and regulations
that support positive relationships and communication
among school personnel, parents, students, and commu-
nity agencies
• Development of parenting and gang-awareness classes
• Establishment of training programs for increasing knowl-
edge about gangs and the community resources available
for assistance
Finally, although community health nurses cannot pre-
vent riots, they can be familiar persons in their neighbor-
hoods, encouraging the sharing of feelings of anger or hostil-
ity or the exchange of information about criminal activities.
Also, the nurse is usually familiar with the normal environ-
ment in the neighborhood—the flow of people, the degree of
friendliness of neighbors and business owners, and the usual
activities. The nurse can use this familiarity to detect when
something feels “unusual.” Part of continuous community as-
sessment includes gathering such subconscious impressions
or intuitions. If cues from the community indicate increased
tensions or exaggerated negative feelings toward particular
persons or groups, the nurse can share this information with
the proper authorities. Many neighborhoods are served by
community centers where there are social workers, educators,
neighborhood-watch groups, probation officers, and other
community service workers, all excellent resources with
whom the nurse can share perceptions.
Assessing a Community’s Level or
Potential for Violence
School nurses are in an ideal position to identify behaviors
that indicate an increased potential for youth violence and to
initiate age-appropriate therapies. It is crucial to identify
these behaviors early and to teach others to watch for them
(National Crime Prevention Council, 2002). The following
indicators can be used to identify potentially violent youths:
• Depression or mood swings
• Obsession with violent or pornographic games, Internet
sites, television shows, or movies
• Absence of age-appropriate anger-management skills
• Artwork, writing, or language that displays violence, pro-
fanity, anger, association with gangs, or social isolation
• Evidence of cruelty to animals
• History of bullying or fighting
• Self-perception as a victim
• Obsession with violence or weapons
All riots begin with an altercation between two or more
people that accelerates out of control. In assessing a commu-
nity’s potential for a riot, the nurse needs to be keenly and
continually aware of interactions among individuals and
small groups within the community. In some sharply divided
communities, even disagreements at a school board or town
council meeting can escalate into localized riots. In commu-
462 UNIT 4 Community as Client
nities where drug dealing is common, riots between gangs
can occur when drug deals “go bad” or police conduct large
“sting” operations. Communities that are fraught with
poverty, high levels of unemployment or ethnic or racial di-
visions also experience a high level of tension that can erupt
into violence over seemingly minor events, such as a routine
arrest of individuals in a barroom brawl. Even the number
and quality of constructive after-school activities for older
children and teens can be a predictor of group violence, be-
cause restless teens who roam neighborhood streets, drink-
ing alcohol and “looking for fun,” often end up engaged in
violent fights and group crimes. The community health nurse
has an obligation to assess the potential for group violence in
all of these areas.
Responding to Group Violence
Community models for addressing the problem of group vi-
olence should involve as many community members as pos-
sible. Not only key legislators and law enforcement officials,
but also former criminals, current gang members, and youth
and adult offenders should be included. Community reli-
gious leaders, educators, members of social and cultural or-
ganizations, and criminologists can contribute significantly
to the development of effective plans for action that the en-
tire community can endorse. The community health nurse
also should be integrally involved in these community ac-
tions to reduce group violence.
Supporting Recovery From Group
Violence
Although the community health nurse should leave investi-
gation and suppression of violent crime to law enforcement
officials, an effective interface for community rehabilitation
may involve education, community mobilization, and out-
reach. Comprehensive case management is paramount. Mul-
tiagency cooperation is required to provide needed services
for mental health, drug treatment, family counseling, job
training and placement, reentry to school or the workforce,
formation of more positive social alliances, and expanded
economic opportunities.
Counseling is the primary rehabilitative intervention for
victims of rape. It may be necessary not only immediately af-
ter the attack but months or even years later, as new re-
sponses and reactions arise. In addition, options for preg-
nancy prevention and the prevention of sexually transmitted
disease need to be discussed. Possible exposure to human im-
munodeficiency virus (HIV) is another harrowing aspect of
rape with which women need medical and psychological
support to cope.
TERRORISM
At the start of the 21st century, the world is a global com-
munity. This is particularly evident in the increased inci-
dence and sophistication of terrorist threats and acts around
the world. Incidents occurring on U.S. soil such as the bomb-
ing 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 con-
firmed that our vulnerability exists in many areas; biologic,
chemical, and nuclear terrorist threats are possible.
The U. S. Federal Bureau of Investigation defines ter-
rorism 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 further-
ance of political or social objectives” (Evans et al, 2002).
A terrorist is overzealous and obsessed with an idea. Ter-
rorism and terrorist acts are not new; although the term ter-
rorism can be traced back to 1798, the use of terrorist tac-
tics 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 Na-
tive 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 con-
tinued 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 ac-
cess 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 at-
tacks have yet involved the use of nuclear power plants as
weapons. A terrorist attack using nuclear weapons or de-
struction of a nuclear plant would cause multiple and pro-
longed 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). Terror-
ists 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
 CHAPTER 20 Communities in Crisis: Disasters, Group Violence, and Terrorism
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 build-
ings, 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 an-
thrax, 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. Of-
fice 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 be-
tween 1 and 3 million people (U. S. Army Chemical and Bi-
ological Defense Command, 1998) (see Chapter 9).
The United States is very concerned about the possibil-
ity of biologic warfare or bioterrorism, as nations should be.
The anthrax infections and deaths that occurred after Sep-
tember 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 terror-
ism. 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 self-
determination. Terrorist acts against American military in-
stallations abroad, in airports, in airplanes, at American em-
bassies, 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 sus-
pected bioterrorism weapons and reports that Iraq was har-
boring anti-Western terrorists; these two pieces of informa-
tion 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 de-
segregation advocates, and other radical groups have per-
formed 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 re-
463
duce voter turnout in an upcoming county election, they
sprinkled Salmonella bacteria over items on salad bars in lo-
cal restaurants and in the produce sections of grocery stores.
They hoped that, with a reduced voter turnout, representa-
tives 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 possi-
bility of terrorist activity. They have a role in primary, sec-
ondary, and tertiary prevention.
Primary Prevention
Community health nurses are in ideal situations within
communities to participate in surveillance. They must look
and listen within their communities for anti-group senti-
ments, which might reflect anti-religion, anti-gay, or anti-
ethnic feelings. The nurse should report any untoward ac-
tivities accordingly.
Nurses should be alert to signs of possible terrorist ac-
tivity. Specific indicators of possible chemical or biologic
terrorism include unusual numbers of dead or dying animals;
unexplained serious illnesses or deaths; an unusual liquid,
spray, vapor, or odor; and low-lying clouds or fog unrelated
to weather. Unusual swarms of insects might also indicate
the use of biologic agents for terrorism. “Many nurses cur-
rently employed have little knowledge regarding the poten-
tial pathogens that could be released, or how to respond to a
chemical or biological attack” (Veenema, 2002, p. 63). Less
subtle forms of terrorism include bombings, mass shootings,
and hijackings, which are more difficult to uncover in time to
prevent injury or death (see Clinical Corner).
Secondary and Tertiary Prevention
Although prevention of terrorist incidents is primarily the re-
sponsibility of the Department of Defense, the Department of
Homeland Security, and public health and law enforcement
agencies, community health nurses must be ready to handle
the secondary and tertiary effects of such attacks. Knowing
the lethal and incapacitating chemical weapons that may be
used by terrorists is important. Many of the communicable
disease organisms that could be used by terrorists are dis-
cussed in Chapter 9 (see What Do You Think? II).
Realizing that terrorist attacks may result in large num-
bers of casualties, the community health nurse must be pre-
pared to act safely, access information rapidly, and use re-
sources effectively. Specifically, the community health nurse
may be called on to provide direct care to victims, to volunteer
as a hospital-community liaison, to set up and administer mass
immunizations, to make home visits to affected families, or
to serve on committees responding to terrorist acts. Formu-
464 UNIT 4 Community as Client
C L I N I C A L C O R N E R
A 1999 shooting at Columbine High School in Colorado
left 15 people dead. National attention was focused on
the issue of violence among teens. The public and the
media looked to public health experts for answers to the
problem of increasing violence in this population. Com-
munity health nurses are among those whose aim is to
assess and address the problems surrounding individual
and group violence in their communities.
Imagine that, as a community health nurse, you have
just been named the head of a multidisciplinary task
force whose objective is to prevent teen violence within
your community. Your project has been funded for 3
years. Having worked in other nursing roles in your
community over the past 10 years, you have developed
excellent partnerships with resource persons within your
community. After reading the information about your
community, respond to the questions that follow.
COMMUNITY INFORMATION
You are in a desert suburban community of 40,000 indi-
viduals, who primarily commute to high-tech jobs in a
nearby city. The average household income is $56,000
per year. The divorce rate in the community is 63%. The
number of teens whose primary caregiver returns home
WHAT DO YOU THINK? II
THE AMERICAN RED CROSS—AMERICAN’S
DISASTER RELIEF AGENCY
The American Red Cross (ARC) has responded to dis-
asters of every shape and size for more than 100 years.
In the 14 months after September 11, 2001, ARC
chapters provided shelter or financial assistance for
67,000 separate disasters across the country. More than
2100 licensed mental health professionals are available
for ARC assignments. In New York City, as a result of
the September 11, 2001, terrorist attack, the ARC
• Opened 49,999 cases
• Served 13,171,855 meals/snacks
• Made 183,732 mental health contacts
• Opened 14 shelters
• Provided 41,898 relief workers for the disaster
• Opened 31 service delivery sites
• Received $933.2 million dollars in donations
through June 2002.
The ARC has spent funds on a family gift program,
aid for displaced workers or residents, immediate re-
lief, and direct support, and for other purposes.
after 5:30 PM is 78%. Ethnicity is as follows: 52% Anglo,
30% Asian, 12% Hispanic, 4% Black, and 2% other.
Identified problems among teens include racial divi-
sion, gang violence, a high school dropout rate of 17%,
and a high incidence of methamphetamine use. The inci-
dence of violent crimes in this community is 28% higher
than in neighboring communities. Besides organized
sports, there are very few extracurricular activities avail-
able through the school or within the community.
QUESTIONS
1. Faced with this daunting task, where will you begin
your efforts?
2. With what agencies and individuals will you need to
develop partnerships to maximize the efficacy of the
task force?
3. Brainstorm about possible ways to capitalize on the
use of technology in your efforts to reduce the risk of
violence in the community.
4. How will you disseminate the information you obtain
to advance the cause of globalization of public
health?
5. What ethical issues will you anticipate as you begin
your efforts?
lating, updating, and following a disaster plan is one of the
most effective community-based strategies to minimize in-
jury and mortality from terrorism.
Most community health nurses will not be on the front
line of uncovering or immediately responding to terrorist ac-
tivities, but their skills will be needed with groups, families,
or individuals who experience a terrorist-related event. Some
of the activities listed earlier in this chapter to help people
deal with the aftermath of a disaster would also be appropri-
ate if terrorism is the cause of the disaster. In addition, com-
munity health nurses may work with people who need help
coping or who want to do something to help.
After experiencing a traumatic event such as a terrorist
attack, people do not know how to cope. We are warned to
expect more attacks. We are told to be vigilant. The terror we
are fighting is often our own. This is a new experience for
most people, and assistance from the community health
nurse can help them cope effectively. The following 10 tips
were gathered from experts in many fields by Foley (2002)
and are common-sense approaches to fight anxiety:
• Be a little afraid—a certain level of fear is healthy if you
learn to use it as positive energy. Use your pinch of anxi-
ety to be more vigilant about your safety and that of your
family, especially when you travel, and in taking care of
your health.
• Keep a courage journal—fear immobilizes, and courage
 CHAPTER 20 Communities in Crisis: Disasters, Group Violence, and Terrorism
takes action. Every time you take action, you are getting
past fear. Even small steps are an opportunity to build
more courage. Every time you take a courageous step—
getting on a plane, opening your mail—write it down.
• Reassure your children. In the act of reassuring your chil-
dren, you will reassure yourself.
• Hang out with children. Do things with your children—
most young people carry a charge of positive energy that
is infectious. If you do not have young children, volunteer
at a school or read to children at a nearby day care center.
• Cook something hearty, healthy, and large, and invite lots
of people in to eat it. The process of cooking is good for
the soul. The aromas are good for the soul. And the chop-
ping and dicing make you feel that you are doing some-
thing useful and concrete.
• Give kindness to others. We all need each other now.
Make a point of chatting with the woman at the checkout
counter or letting a pedestrian cross the street when you
are driving. Wave hello to strangers. You will be amazed
how much it is true that in giving, we receive.
• Get spiritual. Reach out and participate in your faith com-
munity or get involved in one, if so inclined. Believing in
a power greater than yourself can be comforting.
• Laugh. Laughter is the best medicine for fear. Spend
evenings in good company—group laughter is better than
laughing alone.
• Get back to nature. Spending interactive time with nature
is a remedy for just about any soul sickness. Go to the
park, take a walk, work in your garden.
• Find reasons to believe the sky is not falling. All the un-
pleasant facts and figures get our “anxiety juices” flowing.
Seek out positive people, and read literature that encour-
ages positive thinking. Do not feed the “dark side.” Turn off
the news and opt for a funny movie or an inspirational story.
Community health nurses can make major differences in
grassroots efforts to bring about change, but on a day-to-day
basis the little things they say and do with peers and clients
can make just as big a difference.
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 multi-
ple-casualty incidents or mass-casualty incidents.
The scope of a disaster is its range of effect, and the in-
tensity is the level of destruction it causes. Victims of disasters
include direct victims, those injured or killed, and indirect vic-
tims, the loved ones of direct victims. Displaced persons are
those who are forced to flee their homes because of the disas-
ter, and refugees are those who are forced to leave their home-
lands, usually in response to war or political persecution.
Host factors that contribute to the likelihood of experienc-
ing a disaster include age, general health, mobility, psycholog-
ical factors, and socioeconomic factors. The disaster agent is
465
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 dis-
asters, it is helpful for the community health nurse to con-
sider each of the four phases of disaster management: pre-
vention, preparedness, response, and recovery.
Primary prevention of disasters means keeping the dis-
aster from ever happening by taking actions to eliminate the
possibility of its occurrence. Secondary prevention focuses
on earliest possible detection and treatment. Tertiary preven-
tion 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 work-
ers after a disaster, helps to lower anxiety and put the situa-
tion 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 cer-
tain territory as being under its exclusive influence, and is in-
volved in criminal acts.
The roots of group violence are multifactorial and in-
clude inadequate parenting; socioeconomic and racial injus-
tices; exposure to violence in media, cartoons, and pornog-
raphy; 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 govern-
ment 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 ter-
tiary 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.
466 UNIT 4 Community as Client
ACTIVITIES TO PROMOTE
CRITICAL THINKING
1. Think about your own community and its resi-
dents. What are some host factors that might
increase its risk of experiencing a disaster?
What environmental factors might be signifi-
cant? In each case, identify the likely agent.
What interventions could be included in a dis-
aster plan to reduce these risk factors?
2. The nightly news shows that at least 200 peo-
ple have been injured in an explosion in a
neighboring community. At the disaster site,
victims are still being recovered from the
wreckage, and local hospitals are over-
whelmed with patients who have fractures,
lacerations, and burns. You want to offer your
assistance as a registered nurse. How should
you go about volunteering your services?
3. Your local high school is complaining of an
increasing gang presence. Members have
been recruiting and intimidating students,
and fights with knives have broken out re-
peatedly in the past month. A random search
of lockers revealed two guns and eight
knives, and as many as 25% of students are
staying out of school because of parents’
fears of violence. Describe one possible re-
sponse of a community health nurse to ad-
dress the problem of gang violence in this
situation.
4. Access one or more of the Internet sites listed
in this chapter. Report on the change in sta-
tistics for disasters, group violence, or terror-
ism since the year 2003. Have rates
increased or decreased? What factors might
be involved in this change?
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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/
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http://www.healthtouch.com
National Crime Prevention Council: http://www.ncpc.org
National School Board Association:
http://www.keepschoolssafe.org
National School Safety Center: http://www.nssc1.org
National Youth Gang Center: http://www.iir.com/nygc/
Nursing World: Bioterrorism and Disaster Response:
www.NursingWorld.org/news/disaster
Partnerships Against Violence Network (PAVNET):
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Teens, Crime, and the Community: http://www.nationaltcc.org
United Nations Declaration of Human Rights—“A Life Free of
Violence”: http://www.undp.org/rblac/gender/
Youth Crime Watch of America: http://www.ycwa.org