Mental health professionals are increasingly becoming aware of the number and variety of catastrophic events affecting the lives of individuals. These sources of Stressors are being generally categorized into man-made (radiation leaks, chemical pollution, terrorism) and natural disasters (earthquakes, tornadoes, volcanoes). The need to plan, develop and offer assistance to the victims of these injurious events is prompting further study into the human health and mental health consequences and sequelae.

I plan to cover several subjects. First I will speak briefly about a definition of law, although I am fairly certain this kind audience understands a good deal about law. I will then indicate my basic thesis. After that I will review some disaster legislation of two states in the United States that addresses legal considerations relevant to events that occur during major disaster situations. Following that I will make some proposals about how some of the concern about the legal issues can be alleviated, particularly on a worldwide basis. Finally, I hope to provide you with a frame of reference for further consideration of legal matters.

I won't pretend that I can summarize everything that has been said here in the past 2½ days or that I can capsulize the most important things that have been said. What I will do is comment on three areas, underlining those that have had an impact on me and, I suggest, are things that we should think about.

I'll divide my comments into three areas: first, a few aphorisms; second, a few issues that have been raised; and third, some recommendations.

Coming from the city in the world which has made the least political progress in the past decade, I hope you will excuse me for starting with a distinction often made in Northern Ireland, and for all I know in other places in relation to the sphere of political activity. We say that such and such a matter is politics with a small p, and such and such is politics with a large P. Let me give you two examples. If I were to say that the contribution of nurses to disaster medicine is ten times as important as the contribution of paramedics, this would not only demonstrate that my death wish is alive and well, it would also be an example of politics with a small p. On the other hand if I were to say that Maggie Thatcher is destroying the National Health Service and somehow we must persuade all non Conservative parties to form a single coalition to get rid of her, that would be an example of politics with a very big P. If you wish to understand the entire scope of political activity, then it is very important that you recognize both politics with a small p and politics with a large P. Politics with a large P is really a subset of politics with a small p, which in its broadest sense embraces the totality of the subject.

The first emergency department in Hungary was established in Hetenyi Geza County Hospital in 1976. It was organized as part of a research program commissioned by the Ministry of Health. Initially, the hospital had 1400 beds which have now increased to 2,000.

The Emergency Department is located on the ground floor of a new building and occupies 1,100 square meters of surface. The operation of the department is divided into three main areas.

Because of its relatively sophisticated infrastructure and the direct and indirect assistance rendered to neighboring states, this paper concentrates on South Africa and those factors which influence the development of Emergency Medical Services on the sub-continent.

Renowned for its scenic beauty, its natural resources, wild life, flora and generally attractive climate, South Africa is a country about two thirds the size of the European Economic Community and approximately one eighth the size of the United States with a population of over 25 million. The current worldwide interest in its internal affairs underlines its mixture of first and third world status and the unique complexity of its society.

The needs of the poorer sections of the community, the usual diseases prevalent among the more affluent, coupled with one of the world's worst road accident records stimulate demands for good Emergency Medical Services.

The object of this paper is to discuss the philosophy of the emergency medical system in Belgium.

In critical situations we should give the best possible treatment as early as possible. As a patient I would like to get the best doctor at the moment I am most in need of him and not when the doctor is badly in need of a patient. The anaesthesiologist is a most suitable practitioner for critical care, trained as he is by the surgeons to protect their patient against all sorts of manmade disasters, very often in distressing conditions.

In Belgium it has been possible to involve anesthesiologists in all aspects of emergency medicine. We are satisfied with this way of handling the problem, and we are not looking for another solution, although we are aware that in other circumstances other solutions may be requested. Nevertheless, we are all well aware that inside our system a further development is needed.

For one hundred years medical and hospital care have developed as telecommunications have been disseminated throughout the industrialized societies.

Telecommunications have a number of important contributions to make in emergency medicine:

1. To permit reporting of all illness or incident to the rescue and medical services.

2. To permit physicians to offer advice and communicate with the patient and/or his rescuers or paramedical attendants.

3. To permit direct observation of the patient's condition by the physician through telemetry of the E.C.G., etc.

4. To permit co-ordination between rescue services and receiving hospitals and between district hospitals and regional centres.

India is one of the most populous nations in the world with over 900 million people living in 21 States. One of these States is Tamil Nadu situated in the Southern tip of India. Madras is the Capital City of Tamil Nadu which has a population of 4 million people. India as a whole is advancing rapidly in the industrial, agricultural and scientific field but rapid modernization also has its disadvantages. An average of 5,000 to 6,000 road trafile accidents occur every year in Madras City alone with at least one fatality per day. About 40% of the accidents involve pedestrians and cyclists who are unprotected by the vehicle shell or by crash helmet.

The Hospital Emergency Response Team concept, as outlined here and in the Multi-Casualty Incident Operational Procedures of the California Fire Chiefs Association, is the result of a consensus effort by all EMS interest groups in Los Angeles. It is an effective way to utilize the skills of emergency medical personnel at the scene of a disaster. The role of the physician is an important one, and this concept was specifically designed to maximize the benefit to be derived from having a physician at the scene. It is important, however, that physicians recognize their limitations; a medical degree does not automatically confer “mystic abilities”in the area of disaster management. The role of the physician should include pre-disaster planning and at-scene patient management responsibilities as a member or leader of a pre-designated hospital-based emergency medical response team.

The Oxfordshire Area Ambulance Service in common with all civilized ambulance services in the western world, has made extensive plans for dealing with major disasters. These plans include the use of specialized vehicles which attend the scene of a disaster in an effort to provide medical expertise and equipment together with some hospital type facilities to commence treatment for the severely injured casualties. In the late '70s, the ambulance service in Oxfordshire purchased a caravan, at ridiculously low cost, from the local regional blood transfusion service which was no longer required. This caravan was converted for use as a three-bedded medical aid unit to be towed and parked near to the scene of the disaster. The unit was superbly equipped, but suffered severely from its size, and also from the need to tow it to its destination. It was a slow and ponderous vehicle but nevertheless it performed a useful service at static displays and exhibitions where the possibility of a major incident was anticipated. It was regularly to be found as a part of the medical presence at the local Royal Air Force establishments during their open days and flying displays. It had many advantages, such as good lighting and ventilation, and was well equipped, but it was very slow to mobilize and move and also because of its size and weight, it was unstable unless properly and carefully parked on a firm surface.

In 1978 an emergency medical system was established to provide extensive, on the spot treatment for medical emergencies and traffic accidents in Münster. It was designed, like other systems (17,21,23,25,31,34) to treat all types of medical emergencies, although it was initially thought that victims of traffic accidents would predominate. The system covers the city of Münster, which is the capital of Westphalia (see Figure 1) and has a population of 270,000 plus its neighboring communities. Thus, the service provides for 300,000 people over a 20 mile circle in diameter. This area has a low percentage of blue collar workers due to a lack of industry, as Münster is mainly an academic, administrative and business center.