Background

Historically, there has been significant variation in the motivation, type, and quality of international medical teams and field hospitals deployed to natural disasters worldwide. A multiplicity of nations and agencies being involved in a disaster response, each with their own mandate, standards, work habits, and modes of operation, invites inefficiencies and wasteful duplication of work effort. Additionally, shortages of competency-based training for responders may lead to underperformance and medical error[1]. Experiences from the earthquakes in Haiti in 2010 and Pakistan in 2005 propelled an effort from the World Health Organization (WHO) and partners to strive for minimum standards for emergency medical teams (EMTs) responding to disasters, applicable to both domestic and foreign governments/militaries, intergovernmental organizations, and nongovernmental organizations (NGOs). Additionally, these standards are a useful reference for the governments of recipient countries, as well as in-country health providers responding domestically[2]. In this effort, a decision was made to consider field hospitals and the medical personnel staffing them according to the services they provide rather than the physical structure. Thus, the term (foreign) field hospital has been dropped in favor of a system that captures different levels of care. Three levels of foreign medical team (FMT) (types 1–3) were defined in 2013, but in 2015 the term “foreign” was replaced by “emergency” (EMT) to allow a classification system that include both national (N-EMT) and international (I-EMT) categories[3]. Below is a more detailed definition of the type of services each level should include. To register and become a WHO-verified EMT, providers are required to go through a verification process. I-EMTs must adhere to certain minimum standards and modes of operation, according to type of EMT, in order to optimize quality of care, streamline interteam cooperation and ensure accountability[2]. This is an ongoing effort and, following each new disaster, new aspects are added to ensure the standards are updated and fit to context. The reader is encouraged to refer to the WHO website for the latest version of the standards. EMTs are a surge-capacity function, which may be used to manage excess caseloads of injured and other extra medical care needs during a limited time period. In recent conflicts, this system has been useful to set up care and referral systems close to the frontline. Updated guidance notes for EMTs in conflicts are available from the WHO’s website.

Types of EMTs

The classifications of EMTs are based on capability, capacity, and types and level of health-care services offered. Groups of providers that wish to respond to a natural disaster must maintain, or preferably exceed, the minimum standards outlined below. Alternatively, if the team is unable to do so, they should merge with a group providing the required standard in order to deploy. In the coming years, it is likely that only teams verified by WHO will be allowed to enter and practice in affected countries. It is the receiver of the EMTs that define whether EMTs are needed and will be accepted, not the sender. This chapter will focus on I-EMTs and their scope in natural disasters. For deployment to man-made disasters, the same type and levels of standards apply while the operating environment and mandates of the agencies remain very different[4].

Modes of Deployment

The mode of deployment of I-EMTs is dependent on a wide variety of factors. Comparative studies between disaster areas, as well as analysis of the logistical performance in varying disaster environments, demonstrate that a combination of the predisaster state and vulnerability of the affected area, and the nature of the hazard will heavily influence its postdisaster operations[5–7]. A country with a robust health system and developed infrastructure is likely, due to its inherent lower vulnerability, to be less severely affected, as well as to be in a better position to effectively utilize and integrate international assistance if needed. The challenges faced in the deployment of I-EMTs can be divided into administrative, logistical, and operational. Administrative challenges relate to the host country’s ability to effectively receive I-EMTs; this includes issues such as licensing, visas, and permits. Logistical challenges include delivery of deployable structures, medicines, and health-care materials, which is dependent on functional runways and ports, which may be disrupted due to the disaster. Additionally, different agencies may compete with each other for access to these, as was the case during the 2010 Haiti earthquake[8]. In terms of EMT type and location, the choice of whether to rely on existing structures or deploy temporary ones is affected by quality, location, and integrity of buildings; for example, following an earthquake, structures may remain hazardous[9]. Choices of location are primarily directed by local authorities, but are influenced by the context, accessibility, and security, as well as the nature of the disaster. During the 2015 flood in Freetown, Sierra Leone, which occurred during the Ebola outbreak, a population of 4800 internally displaced persons were housed in camp areas set up in two soccer stadiums. The I-EMTs were located within stadium grounds, which enabled effective Ebola screening practices and the possibility to immediately isolate suspected cases, in addition to providing care to the displaced population[10].

Needs Assessment

For a successful response, it is vital for the I-EMT to understand the needs of the population affected. Is a deployment necessary? What capacities are available? What health-care needs can be expected based on the type of event? What other conditions can be expected that are context-specific and not necessarily a result of the disaster? An effective needs assessment can mitigate discrepancies between needs on the ground and availability of equipment and medicines brought by the I-EMT unit, and is characterized by intense intelligence gathering within the first hours or days post-event. These so-called “remote magnitude assumptions” can, within a few hours, provide sufficient information to guide deployment. Vulnerability of the affected, in combination with the type and severity of the hazard, will provide information about the type and magnitude of assistance that may be needed (see below). However, it should be emphasized that an I-EMT cannot deploy only based on needs. Any I-EMT must ensure that their service is wanted and requested by the affected country. Permission by the host country is needed before deployment. Ideally, this is done by rapidly communicating type, size, and length of deployment of the I-EMT through WHO’s EMTCC or other channels such as the virtual onsite operations coordination center (OSOCC).

Once on ground, more detailed information is needed to target and tailor the assistance, and ensure that it is integrated into the existing health system. There is no fixed formula by which to perform a needs assessment, and the method will vary with context. The chief objectives are to determine whether international assistance is required, provide information to direct donor priorities, and to determine a baseline understanding of the disaster by which to compare subsequent outcomes[11]. A variety of methods and sources can be utilized, including local media, liaising with local rescue services who are often first on scene, interviews with key individuals such as community leaders, structured interviews with groups, needs surveys, and structured observation of events[11].

Needs assessments can be challenging in the very early stages of disasters, especially so when communications are affected and local media outlets compromised. Lessons learned from the performance of the Israel Defense Forces (IDF) forward disaster scout teams during 15 overseas responses reveal that the deployment of small teams of highly experienced individuals within a few hours of the disaster has a significant impact on the performance of the subsequent medical response[9]. These teams consist of a logistician, a medical officer[12], communications officer, and an information specialist, and they are tasked with rapid, focused intelligence gathering. In cases of the disaster-affected area being under the authority of a functional government, the team will liaise with local authorities. When this is not the case, such as during the 2010 Haiti earthquake, the team will gather information en route, from other agencies, NGOs, WHO, and local media outlets[9]. Once on ground, they will liaise with national authorities and the UN system. Thanks to the EMT process, a significant number of governments in disaster-prone areas now have the capacity to assess the need for an I-EMT and, if needed, request and coordinate incoming EMTs. The era of self-deploying teams should be over.

Health Needs in Disasters

The well-established epidemiological model of morbidity and mortality being determined by the agent, host, and environment is applicable to disasters as well. Thus, the health needs that I-EMTs are likely to encounter vary with type of disaster, the socioeconomic and material vulnerability of the affected area, and geographical region[13].

Understanding the likely epidemiology of the days, weeks, and months following different types of disasters is key to planning for appropriate health-care provision. For example, during the IDF I-EMTs’ response to the Nepal earthquake, where the country’s infrastructure had largely been spared, there was a fairly high burden of nontrauma cases early in the aftermath, which went on to outnumber trauma cases during weeks 4–11 post-event.

The type of disaster has a substantial effect both on mortality and on the medical needs that a deploying I-EMT needs to prepare for. Adverse health events can be divided into those that occur as a direct consequence of the disaster, and those occurring indirectly. Direct consequences occur as a result of environmental forces – such as tremors, wind, or rain – or as a result of the consequences of these forces, such as structural collapse and flying debris[14]. By contrast, indirect consequences can occur as a result of the disaster, leading to disruption of usual societal functions, such as transportation, environmental protection, medical care, health programs, and police, fire, and rescue services. Furthermore, indirect consequences also include displacement, damage to property, and personal loss[14]. The epidemiological community makes a chief distinction between earthquakes and nonearthquakes, such as floods, droughts, and storms[15]. In the case of earthquakes, trauma cases predominate in the immediate aftermath and may then be replaced by nontrauma orthopedic and medical needs[13,16,17]. Data from the Brussels-based Center for Research on the Epidemiology of Disasters suggest that the ratio of injured to dead in an earthquake is about 4:1, while in tsunamis the corresponding figure is 1:9. Thus, the need for trauma surgeons after a tsunami is very limited[18]. In the event of nonearthquake disasters, I-EMTs can expect to manage more medical cases. For example, while the direct consequences of a flood potentially cause significant loss of life, flooding events rarely account for a substantial burden of nonlethal injury. However, the indirect consequences that occur as a result of disrupted infrastructure and displacement may result in substantial increases in medical needs[15]. Droughts by nature are not disasters that disrupt infrastructure through environmental kinetic force and thus do not produce trauma casualties. Instead, direct consequences of drought events account for an increased burden of malnutrition and dehydration. Additionally, the indirect effects of droughts may in the longer term produce increases in infectious disease outbreaks, and outbreaks of sexually transmitted diseases, as well as interpersonal violence as large populations are forced to migrate and live in camps[19,20]. Some disasters are in themselves unique and can have knock-on effects on the health system of the affected region. An example is the 2014–2015 Ebola epidemic in West Africa. While constituting an infectious disease outbreak, the magnitude of this event in terms of mortality, morbidity, geographical expanse, and societal consequences certainly mirrors the consequences of more common disasters, with a presence of I-EMTs assisting in managing cases and performing contact tracing and isolation of suspected cases. The three countries chiefly affected by the Ebola outbreak – Guinea, Sierra Leone, and Liberia – had fragile health systems pre-event with substantial unmet health needs. The resource demands posed by the Ebola outbreak thus created substantial strain on staff, hospital beds, lab capacity, ambulance services, and pharmaceuticals. As a consequence, the provision of preventive measures and health care for non-Ebola conditions was negatively affected, such as a significant drop in provision of surgery and maternal health services, as well as other essential health services[21,22]. The 2014–2015 and 2018 Ebola outbreaks in Africa have also been unique in terms of the demands they placed on length of engagement. The international response to the crisis needed to last years rather than the weeks-to-months commitment that is commonplace for more conventional disasters. The temporal scale of the outbreak created its own unique health phenomena; as schools were closed to contain the outbreak, more young people came to stay at home in their villages, which led to increases in children born. Additionally, due to reports of doctors, nurses, and patients being infected with Ebola, individuals refrained from seeking health care in hospitals out of concern of being infected.

Apart from managing the new health needs of the population post-event, I-EMTs must also be prepared to manage baseline conditions prevalent in the affected area pre-event. The level of economic development plays a substantial role in determining these health needs as this affects the overall health status of the predisaster population[23]. The far-reaching consequences of disasters – including disruption of health systems, infrastructure, loss of livelihood, homelessness, disruption to ecosystems, social dislocation, and economic consequences – disproportionally affect developing nations[15]. Thus, in contexts such as low-income countries with rudimentary health systems being affected by a disaster, apart from the burden of trauma patients seen initially, I-EMTs will also need to prepare for managing infectious diseases as there will be a high baseline prevalence of these affecting the population. In addition, the burden of noncommunicable diseases (NCDs) must be addressed. As the world moves toward greater economic development, baseline rates of NCDs such as diabetes and heart failure increase, chiefly so in middle-income countries[24,25]. Following a disaster and subsequent disruption of the health infrastructure, these chronic health needs may be unmet and thus need to be anticipated by a deploying I-EMT.