Relationship between climate change and skin cancer and implications for prevention and management: a scoping review.

OBJECTIVES: This study aimed to explore the published research on the relationship between climate change and skin cancer and the implications for prevention, management and further research. STUDY DESIGN: Scoping review. METHODS: This scoping review following JBI methodology reviewed English articles identified in searches of MEDLINE, Embase, CINAHL, Web of Science and Scopus on 14 April 2023. The screening of articles was completed by two independent reviewers. Data were extracted by a single reviewer and checked by another. A causal pathway diagram was iteratively developed throughout the review and was used to categorise the findings. RESULTS: The search identified 1376 papers, of which 45 were included in the final review. Nine papers reported primary research, and 36 papers were reviews, perspectives, commentaries, editorials, or essays. The papers examined climate change influencing behaviours related to ultraviolet exposure (30 papers), ambient temperature (21 papers) and air pollution (five papers) as possible risk factors; occupational, rural, and contextual factors affecting skin cancer (11 papers); and prevention and access to health care in the context of climate change (seven papers). Most papers were published in journals in subject areas other than health. CONCLUSIONS: This review identified ultraviolet radiation, occupation, rising temperature, individual behaviour and air pollution as possible influences on skin cancer rates. Furthermore, it highlights the complexity and uncertainties in the relationship between climate change and skin cancer and the need for further research on this relationship, including primary epidemiological research and reviews that follow recognised review guidelines and include assessment of health services and social determinants in the causal pathways of this relationship.

Methodological pluralism for better evaluations of complex interventions: lessons from evaluating an innovation platform in Australia.

Complex interventions, such as innovation platforms, pose challenges for evaluators. A variety of methodological approaches are often required to build a more complete and comprehensive understanding of how complex interventions work. In this paper, we outline and critically appraise a methodologically pluralist evaluation of an innovation platform to strengthen primary care for Aboriginal and Torres Strait Islander Australians. In doing so, we aim to identify lessons learned from the approach taken and add to existing literature on implementing evaluations in complex settings, such as innovation platforms. The pluralist design used four evaluation approaches-developmental evaluation, principles-focused evaluation, network analysis, and framework analysis-with differing strengths and challenges. Taken together, the multiple evaluation approaches yielded a detailed description and nuanced understanding of the formation, functioning and outcomes of the innovation platform that would be difficult to achieve with any single evaluation method. While a methodologically pluralist design may place additional pressure on logistical and analytic resources available, it enables a deeper understanding of the mechanisms that underlie complex interventions.

Rationale and methods for a cross-sectional study of mental health and wellbeing following river flooding in rural Australia, using a community-academic partnership approach.

BACKGROUND: Climate change is associated with greater frequency, duration, intensity and unpredictability of certain weather-related events, including floods. Floods harm mental health. There is limited understanding of the mental health and well-being effects from river flooding, particularly over the longer term and in rural contexts. This paper describes the rationale, aims, objectives, study design and socio-demographic characteristics of the sample for a study measuring associations between flood experience and mental health and wellbeing of residents (particularly those most likely to be negatively impacted and hard to reach) in rural NSW Australia 6 months following a devastating flood in 2017. To our knowledge, the study is the first of its kind within Australia in a rural community and is an important initiative given the likelihood of an increasing frequency of severe flooding in Australia given climate change. METHODS: A conceptual framework (The Flood Impact Framework) drawing on social ecological approaches was developed by the research team. It was based on the literature and feedback from the community. The Framework describes putative relationships between flood exposure and mental health and wellbeing outcomes. Within a community-academic partnership approach, a cross-sectional survey was then undertaken to quantify and further explore these relationships. RESULTS: The cross-sectional survey was conducted online (including on mobile phone) and on paper between September and November 2017 and recruited 2530 respondents. Of those, 2180 provided complete demographic data, among whom 69% were women, 91% were aged 25-74, 4% identified as Aboriginal and/or Torres Strait Islander, 9% were farmers and 33% were business owners. CONCLUSIONS: The study recruited a wide range of respondents and the partnership facilitated the community's engagement with the design and implementation of the study. The study will provide a basis for a follow-up study, that will aim to improve the understanding of mental health and wellbeing effects over the longer term. It will provide an important and original contribution to understanding river flooding and mental health in rural Australia, a topic that will grow in importance in the context of human-induced climate change, and identify critical opportunities to strengthen services, emergency planning and resilience to future flooding.

Follow-up cancer care: perspectives of Aboriginal and Torres Strait Islander cancer survivors.

PURPOSE: The purpose of this study was to explore Indigenous Australian cancer survivors' perspectives of follow-up cancer care and management.. METHODS: This is a qualitative study employing individual interviews with 21 Indigenous cancer survivors (13 females, 8 males) recruited from a rural primary health service and large tertiary hospital in Brisbane, Queensland. Yarning methods were used to conduct semi-structured interviews. Yarning is a culturally appropriate, informal conversational process emphasising the importance of storytelling. RESULTS: Findings describe a range of ways in which follow-up cancer care is experienced with four major categories elucidated, namely: links to tertiary health services, links to primary health services, communication between tertiary and primary health services, and lost in transition. Both positive and negative experiences were described; however, the importance of timely and informative discharge information, continuity of care, good communication between tertiary and primary health services, and strong therapeutic relationships were salient issues raised by participants. CONCLUSIONS: These findings highlight the importance of establishing strong therapeutic relationships between patients and tertiary and primary health professionals. Also important for survivorship is provision of discharge summaries or care plans at discharge for survivors and general practitioners as well as access to a range of allied health services. Alternative means for follow-up could be investigated for regional and rural survivors to facilitate convenient and cost-effective follow-up care. Finally, provision of responsive and flexible follow-up care to cater for the diverse range of needs and preferences of cancer survivors is required. A patient navigator available across the cancer continuum could go some way to addressing this.

Tackling the problem of blood culture contamination in the intensive care unit using an educational intervention.

Blood culture contamination (BCC) has been associated with unnecessary antibiotic use, additional laboratory tests and increased length of hospital stay thus incurring significant extra hospital costs. We set out to assess the impact of a staff educational intervention programme on decreasing intensive care unit (ICU) BCC rates to <3% (American Society for Microbiology standard). BCC rates during the pre-intervention period (January 2006-May 2011) were compared with the intervention period (June 2011-December 2012) using run chart and regression analysis. Monthly ICU BCC rates during the intervention period were reduced to a mean of 3.7%, compared to 9.5% during the baseline period (P < 0.001) with an estimated potential annual cost savings of about £250,100. The approach used was simple in design, flexible in delivery and efficient in outcomes, and may encourage its translation into clinical practice in different healthcare settings.

Development of a digital tool for home-based monitoring of skin disease for older adults.

We developed a digital tool for home-based monitoring of skin disease, our digital tool. In the current observational pilot study, we found that DORA is feasible to use in practice, as it has a high patient compliance, retention and satisfaction. Clinicans rated the photos generally good quality or perfect quality. These results show that the digital health tool DORA can easily be used by patients to send photos to their dermatologist, which could reduce unnecessary clinical visits. It may also be used in other settings where digital literacy barriers and unequal access to dermatologists contribute to healthcare disparities.

The Strong Teeth Study; background, rationale and feasibility of fluoridating remote Indigenous communities.

The caries experience of Australian Indigenous children has deteriorated at the same time as that of non-Indigenous children has greatly improved. Fluoridating the water supplies of Indigenous communities emerged as a policy direction at the beginning of the 2000s. However, remote Indigenous communities are small, highly dispersed and isolated. This paper describes the Strong Teeth Study, a series of projects for the fluoridation of remote Indigenous communities in the Northern Territory. The background and rationale for two demonstration fluoridation projects are presented and the feasibility of operating small-scale fluoridation plant and measuring the impact on caries experience described. The demonstration fluoridation projects were commenced, but not sustained. The lessons learnt about environmental enablers and essential service requirements are highlighted. Fluoridation has the potential to improve oral health so as to contribute positively to child development as part of the broader mission of closing the gap in health between Indigenous and non-Indigenous Australians.

A comprehensive approach to health promotion for the reduction of dental caries in remote Indigenous Australian children: a clustered randomised controlled trial.

AIM: To evaluate the effect of a community-oriented primary health care (CPHC) intervention on oral health behaviours of Indigenous preschool children living in remote communities of Australia's Northern Territory. METHODS: The study was a community-clustered randomised controlled trial over two years, set in 30 remote Indigenous communities in the Northern Territory of Australia. Children aged 18-47 months at baseline were enrolled in the study. The intervention included fluoride varnish applications, training of primary care workers, and health promotion for oral health at an individual, family and community level. Intervention communities received six-monthly visits over two years and control communities were visited at baseline and two years later with no contact in the intervening period. The outcome measures reported in this paper are the impact of the intervention on two secondary endpoints: oral health promotion activities in the community and personal oral health practice of children. RESULTS: The intervention did not produce any significant change in oral health behaviours, clinical measures of oral hygiene, or community programmes promoting oral health. Dental caries can be reduced but will continue to be a problem among young remote Indigenous children while they experience major social disadvantage.

Hospital infection society prevalence survey of Healthcare Associated Infection 2006: comparison of results between Northern Ireland and the Republic of Ireland.

As part of the Third Healthcare Associated Infection (HCAI) Prevalence Survey of the United Kingdom and Ireland, HCAI point prevalence surveys were carried out in Northern Ireland (NI) and the Republic of Ireland (RoI). Here we explore the potential benefits of comparing results from two countries with different healthcare systems, which employed similar methodologies and identical HCAI definitions. Forty-four acute adult hospitals in the RoI and 15 in NI participated with a total of 11 185 patients surveyed (NI 3644 patients and RoI 7541). The overall HCAI prevalence was 5.4 and 4.9 in NI and the RoI, respectively. There was no significant difference in prevalence rates of HCAI, device-related HCAI or HCAI associated with bloodstream infection but there was a difference in meticillin-resistant Staphylococcus aureus-related HCAI (P = 0.02) between the two countries. There were significantly more urinary tract infections and Clostridium difficile infections recorded in NI (P = 0.002 and P < 0.001). HCAIs were more prevalent in patients aged >65 years and in the intensive care unit in both countries. HCAIs were also more prevalent if patients were mechanically ventilated, had had recent non-implant surgery (RoI) or had more recorded HCAI risk factors. This is the first time that HCAI prevalence rates have been directly compared between NI and the RoI. By closely examining similarities and differences between HCAI prevalence rates in both countries it is hoped that this will influence healthcare planning and at the same time reassure the public that HCAI is important and that measures are being taken to combat it.

Feasibility of a novel participatory multi-sector continuous improvement approach to enhance food security in remote Indigenous Australian communities.

BACKGROUND: Food insecurity underlies and compounds many of the development issues faced by remote Indigenous communities in Australia. Multi-sector approaches offer promise to improve food security. We assessed the feasibility of a novel multi-sector approach to enhance community food security in remote Indigenous Australia. METHOD: A longitudinal comparative multi-site case study, the Good Food Systems Good Food for All Project, was conducted (2009-2013) with four Aboriginal communities. Continuous improvement meetings were held in each community. Data from project documents and store sales were used to assess feasibility according to engagement, uptake and sustainability of action, and impact on community diet, as well as identifying conditions facilitating or hindering these. RESULTS: Engagement was established where: the community perceived a need for the approach; where trust was developed between the community and facilitators; where there was community stability; and where flexibility was applied in the timing of meetings. The approach enabled stakeholders in each community to collectively appraise the community food system and plan action. Actions that could be directly implemented within available resources resulted from developing collaborative capacity. Actions requiring advocacy, multi-sectoral involvement, commitment or further resources were less frequently used. Positive shifts in community diet were associated with key areas where actions were implemented. CONCLUSION: A multi-sector participatory approach seeking continuous improvement engaged committed Aboriginal and non-Aboriginal stakeholders and was shown to have potential to shift community diet. Provision of clear mechanisms to link this approach with higher level policy and decision-making structures, clarity of roles and responsibilities, and processes to prioritise and communicate actions across sectors should further strengthen capacity for food security improvement. Integrating this approach enabling local decision-making into community governance structures with adequate resourcing is an imperative.

Challenges for improving surveillance for pesticide poisoning: policy implications for developing countries.

BACKGROUND: Surveillance is a critical public health tool for the control of pesticide poisoning. However, surveillance activities in developing countries are bedevilled by multiple problems, and inferences made from review of flawed data may lead to mistaken policy decisions. METHODS: Results of intensified surveillance from an intervention project in the Western Cape Province of South Africa were compared to the pattern of poisonings reported in routine notifications to the health authorities for a control farming district and in the study district over a 5-year period preceding the study. Intensified surveillance data results were also contrasted with policy approaches based on routine notifications and on Regional Poison Centre reports. RESULTS: Poisoning rates reported in the study area increased almost 10-fold during the intervention period. Compared to intensified surveillance, hospital and health authority sources greatly underestimate the proportion of cases due to occupational poisoning, and overestimate suicide as a proportional cause. In addition, the risks for women appear underestimated from routine notifications. Assumptions that a lack of awareness is responsible for most poisonings are not borne out by the empirical data when reporting is intensified. CONCLUSIONS: Current policy assumptions are faulty, may result in inappropriate blame being attributed to victims and, by relying on information as the main element of education, may shift responsibility onto the individual. Improvements in the surveillance system should aim to restructure the types of data collected, and facilitate intra-governmental and inter-sector collaboration. The culture of monitoring based on report writing must change to one of surveillance that leads to intervention.

Surveillance for equity in cervical cytology screening.

BACKGROUND: The opportunistic basis on which screening has been conducted in South Africa has resulted in multiple rescreening of a small proportion of the population (which excludes most women at high risk) and low population coverage. There has consequently been a failure of screening to impact on the incidence of cervical cancer in most of the population. AIM: To propose the use of the ratio of smears showing cervical intra-epithelial neoplasia (CIN)III: smears showing signs of malignancy as an indicator for the surveillance of equity in cervical cytology screening, and to apply this indicator to an area of the Western Cape of South Africa. RESULTS: Marked inequity in screening is demonstrated between metropolitan and non-metropolitan area, and between different non-metropolitan districts. Inequity in screening between different age groups of women is also found, and this is associated with an inappropriately young age distribution of screening activity. CONCLUSIONS: The application of this indicator in the routine surveillance of screening activity may be useful in monitoring progress towards the implementation of more equitable screening programmes, and the validity of the indicator should be tested in other settings.

Cervical cancer mortality in Australia: contrasting risk by Aboriginality, age and rurality.

BACKGROUND: The poor health status of Australia's indigenous population is reflected in relatively high mortality rates from almost all causes, including preventable causes such as cervical cancer, where the rate is six to eight times that of non-Aboriginal women. However, there is little information on the geographical distribution of risk, an important issue for service deployment. This study examined the risk of death from cervical cancer in relation to Indigenous status, age and rurality. METHODS: Data from death registers from Australian states and territories who have identified Aboriginal people were examined for 1986-1997 to obtain a list of all deaths where the primary cause was cancer of the cervix. The data categorized females by 5-year age group, by metropolitan, rural or remote category and by Indigenous status. Mean age at death and standardized mortality ratios for deaths from cervical cancer were calculated for Aboriginal compared with non-Aboriginal women in metropolitan, rural and remote areas. RESULTS: The risk of death from cervical cancer for Aboriginal women compared with non-Aboriginal women increased by 4.3-fold for metropolitan areas, 9.7-fold for rural areas and 18.3-fold for remote areas. CONCLUSIONS: Aboriginal women in rural and remote areas of Australia are at significantly higher risk of death from cancer of the cervix than either Aboriginal women in metropolitan areas or non-Aboriginal women in any area. This result raises questions about access to services for prevention and early diagnosis and other factors that might impact on the incidence and natural history of the disease.

Trends in cervical cancer mortality in South Africa.

BACKGROUND: Cervical cancer is an important cause of death throughout the world, especially in less developed countries. Reports of trends in cervical cancer mortality from less developed countries have been limited by poor data quality and inaccurate population estimates. This paper examines trends in cervical cancer mortality in South Africa from 1949 to 1990 and discusses the impact of cytology screening on these trends. METHODS: Analysis of national mortality statistics and reconstructed population data. RESULTS: The age-standardized mortality rates for Whites declined after the mid 1960s, while that for Coloureds rose, particularly before the 1970s. These trends were affected predominantly by trends among women in the 35-64 age range. CONCLUSIONS: The pattern of mortality in successive birth cohorts for Whites is consistent with a reduction in age-specific mortality following the advent of cytological screening. The same pattern is not evident in trends for Coloureds, among whom screening has apparently had a minor impact if any at all. The apparent lack of impact of screening in those groups of women most at risk of cervical cancer lends weight to demands for the implementation of equitable and rational screening programmes for cervical cancer in South Africa and internationally.

PIP: A review of cervical cancer mortality statistics from South Africa for the period 1949-90 suggested that screening has disproportionately benefited White women--the population group at lowest risk of this form of cancer. For Whites, the annual number of deaths from cervical cancer peaked in the late 1960s at 133, then began a steady decline, reaching 102 in 1986-90. Among Coloreds, however, there was a steady increase in annual deaths throughout the entire period under review--from 55 in 1949-55 to 219 in 1986-90. Most of this increase occurred among Colored women over 34 years of age. A similar increase, from 8 to 25 deaths/year, was recorded among Asian women in the period under review. (Deficiencies in mortality data precluded calculation of mortality rates for South African Blacks; however, cervical cancer mortality is known to be highest among this population group.) The decline in cervical cancer mortality among White women coincided with the introduction of cytologic screening in the mid-1960s. More widespread use of screening in the public sector is urged to reduce the disparities in cervical cancer rates between racial groups.

Outreach and improved access to specialist services for indigenous people in remote Australia: the requirements for sustainability.

STUDY OBJECTIVE: To examine the role of specialist outreach in supporting primary health care and overcoming the barriers to health care faced by the indigenous population in remote areas of Australia, and to examine issues affecting its sustainability. DESIGN: A process evaluation of a specialist outreach service, using health service utilisation data and interviews with health professionals and patients. SETTING: The Top End of Australia's Northern Territory, where Darwin is the capital city and the major base for hospital and specialist services. In the rural and remote areas outside Darwin there are many small, predominantly indigenous communities, which are greatly disadvantaged by a severe burden of disease and limited access to medical care. PARTICIPANTS: Seventeen remote health practitioners, five specialists undertaking outreach, five regional health administrators, and three patients from remote communities. MAIN RESULTS: The barriers faced by many remote indigenous people in accessing specialist and hospital care are substantial. Outreach delivery of specialist services has overcome some of the barriers relating to distance, communication, and cultural inappropriateness of services and has enabled an over fourfold increase in the number of consultations with people from remote communities. Key issues affecting sustainability include: an adequate specialist base; an unmet demand from primary care; integration with, accountability to and capacity building for a multidisciplinary framework centred in primary care; good communication; visits that are regular and predictable; funding and coordination that recognises responsibilities to both hospitals and the primary care sector; and regular evaluation. CONCLUSIONS: In a setting where there is a disadvantaged population with inadequate access to medical care, specialist outreach from a regional centre can provide a more equitable means of service delivery than hospital based services alone. A sustainable outreach service that is organised appropriately, responsive to local community needs, and has an adequate regional specialist base can effectively integrate with and support primary health care processes. Poorly planned and conducted outreach, however, can draw resources away and detract from primary health care.

Specialist outreach clinics in primary care and rural hospital settings.

BACKGROUND: Specialist medical practitioners have conducted clinics in primary care and rural hospital settings for a variety of reasons in many different countries. Such clinics have been regarded as an important policy option for increasing the accessibility and effectiveness of specialist services and their integration with primary care services. OBJECTIVES: To undertake a descriptive overview of studies of specialist outreach clinics and to assess the effectiveness of specialist outreach clinics on access, quality, health outcomes, patient satisfaction, use of services, and costs. SEARCH STRATEGY: We searched the Cochrane Effective Practice and Organisation of Care (EPOC) specialised register (March 2002), the Cochrane Controlled Trials Register (CCTR) (Cochrane Library Issue 1, 2002), MEDLINE (including HealthStar) (1966 to May 2002), EMBASE (1988 to March 2002), CINAHL (1982 to March 2002), the Primary-Secondary Care Database previously maintained by the Centre for Primary Care Research in the Department of General Practice at the University of Manchester, a collection of studies from the UK collated in "Specialist Outreach Clinics in General Practice" (Roland 1998), and the reference lists of all retrieved articles. SELECTION CRITERIA: Randomised trials, controlled before and after studies and interrupted time series analyses of visiting specialist outreach clinics in primary care or rural hospital settings, either providing simple consultations or as part of complex multifaceted interventions. The participants were patients, specialists, and primary care providers. The outcomes included objective measures of access, quality, health outcomes, satisfaction, service use, and cost. DATA COLLECTION AND ANALYSIS: Four reviewers working in pairs independently extracted data and assessed study quality. MAIN RESULTS: 73 outreach interventions were identified covering many specialties, countries and settings. Nine studies met the inclusion criteria. Most comparative studies came from urban non-disadvantaged populations in developed countries. Simple 'shifted outpatients' styles of specialist outreach were shown to improve access, but there was no evidence of impact on health outcomes. Specialist outreach as part of more complex multifaceted interventions involving collaboration with primary care, education or other services was associated with improved health outcomes, more efficient and guideline-consistent care, and less use of inpatient services. The additional costs of outreach may be balanced by improved health outcomes. REVIEWER'S CONCLUSIONS: This review supports the hypothesis that specialist outreach can improve access, outcomes and service use, especially when delivered as part of a multifaceted intervention. The benefits of simple outreach models in urban non-disadvantaged settings seem small. There is a need for good comparative studies of outreach in rural and disadvantaged settings where outreach may confer most benefit to access and health outcomes.

Data for diagnosis, monitoring and treatment in indigenous health: the case of cervical cancer.

Deficiencies in the availability and quality of data on the health status of indigenous Australians have long been recognised. For cervical cancer, data demonstrate a 2-5 fold greater incidence rate and an 8-10 fold greater mortality rate for Indigenous women compared to non-Indigenous Australians. However, incidence and mortality data are only available for some states and there is little or no information available on the geographic or social distribution of risk, or the reasons for risk differentials. There are also little or no data on the utilisation of, or preferences for, screening services. Thus, while there is clearly a need for a cervical cancer control program specifically to target Indigenous women, current data are inadequate to inform planning and implementation, and current systems are inadequate to monitor effectiveness. This situation is the result of insufficient research and inadequate attention to recording of Indigenous status in routine data systems and applies to a greater or lesser extent across the spectrum of health of Indigenous Australians. Health workers across the spectrum in mainstream and Indigenous medical services have a shared responsibility for improving the availability and quality of data and ensuring the appropriate use of information necessary to achieve and monitor improvements in service delivery and health status of Indigenous people.

Women's attitudes to cervical smear testing.

This study examined women's attitudes and motivations towards cervical screening. The sample consisted of 680 women attending three general practices in two New Zealand towns. Subjects completed a questionnaire relating to their knowledge of the cervical smear test and their current cervical smear status. The questionnaire also assessed what influenced their decision to have an up to date smear test or what reasons subjects gave for not having a current test. Women's preference for the smear taker was also investigated. Most women in the sample (92%) indicated they knew what a cervical screening test was. Current smears were proportionately less common in the at risk groups. The most frequently reported motivation for women to have a current smear was that their doctor had recommended it (30.6%), followed by the response that it was an established part of their personal health routine (20.2%). Most women who didn't have current smear tests gave the reason that they had not got around to having a test (39.4%), with the next reported reason being that the test was embarrassing (17.8%) and their doctor didn't suggest it (14.7%). The majority of women in the sample (59.7%) preferred their own doctor to do the test. The findings of this study highlight the importance of the women's general practitioner in influencing women in high risk groups to have smear tests. They also suggest significant improvements in increasing the number of women screened could be made using existing services.

General practitioners' perceptions regarding coordinated care.

OBJECTIVE: To explore the attitudes of general practitioners to the changing roles in the coordination of complex patient care. METHOD: A questionnaire survey was distributed with Australian Doctor. RESULTS: GPs were found to fall into four broad groups in relation to care coordination: those who do not want to expand their role in coordination of care (30%); those who would like to expand their role in coordination of care, but do not want to take costs into account when making decisions about patient care (34%); those who would like to expand their role in coordination of care, do think costs should be taken into account, but do not wish to be involved in budget management (21%); and those who would like to expand their role in coordination of care and be involved in budget management (22%). CONCLUSION: In the context of the introduction of managed care in Australia, this survey highlights the potential for GPs to take on a range of roles and responsibilities under these arrangements.

Operation Nightingale: the role of BMH Dharan following the 1988. Nepal earthquake, and some observations on Third World earthquake disaster relief missions.

Following a large earthquake in Nepal, the experience of a small hospital in dealing with the resulting mass casualties is described. The value of pre-planning and effective triage of the injured is stressed, and aspects of surgical and medical care specific to earthquake victims discussed. Clinical and administrative challenges encountered in mounting a major relief exercise in a Third World setting are also described. frequent exercising of military hospitals and personnel in handling mass casualties is an applicable to civilian natural catastrophies as to battlefield medical support.