Health Care at Mass Gatherings

As the number of spectators attending the Olympic Games has steadily increased, the scope of Olympic medicine has expanded beyond just caring for athletes. In this issue of JAMA, 2 articles focus on the measures taken to ensure the health of the estimated 2.2 million athletes, staff, and spectators who attended the 1996 Centennial Olympic Games in Atlanta, Ga. The article by Meehan et al¹ describes the planning and implementation of a public health surveillance and response system. The article by Wetterhall et al² examines the 10715 physician-patient encounters recorded during the 17 days of the Olympic Games. These articles provide valuable information for planning future Olympic Games, and present useful lessons that can be applied to medical care for other mass gatherings and special events.

Application of a scientific approach to the planning and analysis of medical care for special events is a relatively new occurrence. Until recently, little more than individual subjective reports have appeared in the medical literature, reflecting a haphazard approach.³ However, increasing attention is being focused on the unique issues involved in providing care during large gatherings. Although the phrase mass gathering medical care frequently is used to describe these activities, this phrase also can apply to the care of temporarily displaced populations, including disaster victims and refugees, whose care requires distinct resources and a vastly different approach. To avoid confusion, mass gathering medical care should have more inclusive usage, whereas special event medical care should be reserved as a more specific phrase, characterized by Baker et al⁴ as "the provision of preventive, or definitive primary medical care or hospital referral to well persons attending or participating in major sports, recreational, or political events."

As this ambiguous terminology illustrates, the lack of standardized definitions, indicators, and methods represents the greatest barrier to advancement of this field. Among 3 published reports from recent Olympic Games held in North America, meaningful comparison or trend analysis is difficult because of differing definitions of medical facility usage rates and approaches to analysis.^{1 ,4 - 5} Wetterhall and colleagues² are the first to use accreditation status (eg, athletes, staff, spectators) to evaluate medical usage patterns, but do not make use of patient acuity measures. Such a measure was developed and recommended following the 1988 Calgary Winter Games.⁴ This lack of longitudinal standardization in analysis of Olympic medical care may be an inevitable result of the decentralized nature of Olympic planning, but it precludes a better understanding of future special event medical care needs.

Even with a more standardized approach, there remains considerable variation in the nature of these events and in the populations attending them. Patterns of system use are affected by many variables, often in ways that are not intuitive. For example, a complex relationship exists between crowd size and medical service use, with variables such as event location, duration, and logistics frequently overshadowing the effect of population size. Spectators attending longer-duration outdoor events, especially those that allow spectator ambulation (ie, canoeing and kayaking) may be considerably more likely to require medical care compared with persons attending much larger, seated stadium events (eg, basketball). Environmental factors,⁶ population demographics, and the baseline health status of participants also may have a dramatic effect on usage patterns of medical care.⁷ A better understanding of the effects and interaction of these variables is needed to develop models capable of predicting future resource needs.

Meehan and colleagues¹ describe a systematic, coordinated process in planning Atlanta's public health response. Several points deserve emphasis. Public health officials must be involved from the time of initial proposal development. Adequate funding for public health components must be allocated. Prediction of resource requirements should be based on a comprehensive evaluation of anticipated medical care usage rates and assessment of public health risks. This analysis should then guide development of specific prevention strategies, monitoring systems, and contingency planning. The value of legislation and policy modification to reduce identifiable public health risks has been reported in previous Olympics⁸ and is now underscored. Meehan et al¹ also demonstrate the need for health officials to remain aggressive and for vocal advocates to guard against compromises to the health of the public from potential political and commercial conflicts (such as attempts to limit potable water access to encourage beverage sales). Public health risks related to commercial food vendors have been documented not only in Atlanta, but also at the 1984 Los Angeles Games⁸ and the 1982 Knoxville World's Fair.⁹ The importance of centralized control and communication, continuous indicator surveillance, and rapid response capability is illustrated by a successful response to early reports of poor food-handling practices and the prompt relocation of human and material resources because of unanticipated crowd patterns. Further, the importance of contingency planning and coordination with other public safety agencies was demonstrated by the unified response to the Centennial Olympic Park bombing.

Meehan et al¹ also discuss the costs of public health services, and Wellerhall et al² discuss costs related to medical service delivery. Although some important details are missing and many costs remain unallocated, this is, to our knowledge, the first time that the costs of either medical services or public health measures for special events or the Olympic Games have been reported. How these substantial health resources are best apportioned is an important concern for which much more information is needed. Although much of the equipment and a large proportion of the professional services at major events such as the Olympics are donated, it is only through the careful accounting for all resources, both purchased and donated, that the true costs of protecting and treating participants can be calculated. With these financial data available, various cost efficiencies for both treatment and preventive services could be determined and would provide information that health planners and managers would find indispensable.

With economic growth, citizens of many less-developed countries have become more mobile, often crossing national borders to attend sporting events such as regional or international soccer matches. Tens of thousands of spectators, representing many nations, now regularly attend events such as the Central American and Caribbean Games or the Africa Cup.¹⁰ With the increases in mobility and crowd size come increased health risks, especially in parts of the world where communicable disease outbreaks are common. Providing the planning, surveillance, and treatment capabilities that have been achieved in Atlanta and in other more developed countries is beyond the reach of many governments that have fewer resources and lower budgets for health. Further, in some developing countries, public health personnel do not participate in event planning and the surveillance needed to prevent or control communicable disease outbreaks may be neglected. Carefully documenting the results of health measures for mass gatherings in developed countries would help identify those activities of greatest benefit. Such information would help poorer countries set evidence-based priorities for the use of their limited health resources.

The potential for major health emergencies at mass gatherings and special events is a real threat. Careful documentation and detailed analyses are essential to continue to learn and refine strategies for how to best provide protection to participants and spectators of future events. Standardization of definitions, indicators, and methods is an important next step.