Abstract
In the aftermath of natural disasters and in the urgency of the deteriorating situation in a “complex emergency”, aid is often provided in a haphazard manner. Organizing appropriate medical help is complicated by differences in the type of disaster, the available infrastructure that remains in place, the status of the country’s wealth, and, occasionally, the outbreak of violence and epidemics. Nevertheless, a sequential order of priorities and changing needs for various types of medical intervention such as (emergency) surgery, rehabilitation, and obstetrics can be made, as for managing medicinal needs, mental health, and communicable diseases. This chapter describes how this medical landscape changes qualitatively and quantitatively and how resources can be adapted dynamically and reflected in the capacity of the emergency medical team (EMT). Recently, disaster-prone countries have seen an expansion in the capacity of national EMTs. For a variety of reasons these are to be preferred over international EMTs, but where the latter are needed it is important that their competencies and capabilities follow both local and general guidelines.
Background
In the urgency of a disaster’s aftermath, the general tendency is to “reinvent the wheel.” As soon as an emergency is declared, health professionals and others, used to working under regular conditions in their home countries, experience the urge to fly over, aiming to provide care to the victims of the disaster. These actors’ heightened state of motivation and excitation related to the disaster often overshadows any doubts they may have about their competence for working in such kind of environment. The typical mistake is to perform medicine “as usual” in a totally disrupted setting. As such, there is frequently confusion between practicing emergency medicine and the specific expertise needed during a disaster’s aftermath. In other words, the relationship between emergency and disaster medicine is not really taken into consideration.
The foreign medical team/emergency medical team (FMT/EMT) initiative has started to elaborate on the minimum standards and provide a classification system in disaster settings[1]. Starting with surgery, it has now been extended to other medical fields such as noncommunicable diseases (NCDs), communicable diseases (CDs), and rehabilitation.
The purpose of this chapter is to provide an overview of this changing approach to addressing the health needs during the different phases of a complex emergency. Such an understanding is essential to improve the planning of the required human and material resources, and to ensure their delivery at the appropriate time and place.
Complex Emergency
From a medical perspective, there are several definitions and approaches for regular emergencies (e.g., a myocardial infarct), mass-casualty incidents (MCIs) (e.g., a train crash), and wide-scale disasters (e.g., a Haiti earthquake)[2–5]. Each of these categories requires a specific health response.
Increasingly, this kind of situation is being categorized as “complex emergencies.” The International Federation of Red Cross and Red Crescent Societies (IFRC) has proposed a definition of complex emergencies, which includes not only a medical but also a sociological perspective[6]. Complex emergencies may be associated not only with the loss of lives, but with widespread violence, displacement of populations, large-scale damage to property and infrastructure, disruptions to societies and economies, hindrance or prevention of humanitarian assistance by political and military constraints, and significant security risks for humanitarian relief workers; all these call for large-scale, multifaceted humanitarian assistance. Moreover, complex emergencies may occur in several different geographical entities (national, international, cross border, and natural contexts) and also have obvious medium-term impacts, not only on the health sector but also on water and food supplies, and may result in economic collapse, social and political instability, and a refugee crisis.
Effect of Natural Disasters
Table 4.1 lists the magnitude of effects that natural disasters have on outcomes such as death, injuries, water and food shortages, and major population movements. Earthquakes cause many deaths, but also injuries, whereas tsunamis, flash floods, and landslides predominantly kill.
| Effect | Earthquakes | Tropical storms | Tsunamis | Slow-onset floods | Landlines | Volcanoes/Lahars |
|---|---|---|---|---|---|---|
| Deaths | +++ | + | +++ | + | +++ | +++ |
| Severe injuries | +++ | ++ | + | + | + | + |
| Risk of communicable diseases | Potential risk following all major disasters (Probably rising with overcrowding and deteriorating sanitation) | |||||
| Damage to health facitlites | +++ Structure/equipment | +++ | +++ Localized | +++ Equipment only | +++ Localized | +++ Structure/equipment |
| Damage to water systems | +++ | + | +++ | + | +++ Localized | +++ |
| Food shortage | Rare (Economic and logistic factors) | Common | Rare | |||
| Major population movement | Rare (Heavily damaged urban areas) | Common (Generally limited) | ||||
In addition, the presence of hazardous materials; chemical, biological, radiological and nuclear (CBRN) substances; and biological or chemical weapons (in armed conflict) will jeopardize the situation. For instance, the nuclear accident in Fukushima that followed the tsunami – itself caused by a heavy, but offshore earthquake – presented significant additional challenges to the aid response.
From a medical perspective, the damage to local health facilities depends on the area that is affected. With a tsunami, the inundated seaboard is relatively narrow. Therefore, the surface that is devastated may not be immense, even though many may have perished. With landslides, the affected surface is again limited due to the geology of the phenomenon. Obviously, different topographies (flat land, hills, mountains; mud or rock streams) result in different areas being affected. Depending on the characteristics of all these complex emergencies, multiple and different specific responses need to be organized.
The Immediate Medical Response in Complex Emergencies
Several factors influence how the immediate medical response to complex emergencies can be optimized. All these parameters should be known and integrated in the decision-making process of EMT deployment.
Type of Disaster
As mentioned previously, different disasters require different types of health (and other) care. For example, surgical support is more important after an earthquake than in a tsunami setting (e.g., the Haiti earthquake in 2010 versus the Indian Ocean tsunami in 2004). Slow-onset floods require support for health facilities and water supply rather than surgical assistance (for instance, Hurricane Harvey in Houston, USA, in 2017).
Phases of a Disaster
Following an earthquake, the first priority is search and rescue, followed by emergency relief, early recovery, medium- to long-term recovery, and finally, the community development (Figure 4.1)[8]. Similar outlines can be made for other types of disaster, but beyond broad classification, each is a unique event, which requires careful assessment for how, when, and what help is required. In practice, the stages of recovery do not always follow a neatly defined course or timing.
Figure 4.1 Timing of disaster responses following an earthquake
Geographical, Sociological, and Demographic Characteristics
Obviously, the outcomes of similar natural disasters are vastly different when they strike places such as Port-au-Prince (Haiti), Kathmandu (Nepal), or Fukushima (Japan). The geography, building codes and how they are enforced, economic prosperity (and being part of a larger state that provides support), demographics of the affected area, and many other factors are key determinants to anticipate the health needs.
General information, such as a country’s health profile[9], can be found on the World Health Organization (WHO) website. These list life expectancy, the under-5 mortality rate, the proportion younger than 15, the maternal mortality rate, and the population over 60, which are all important and extremely relevant indicators.
As an example, Table 4.2 lists basic health data for four countries that were hit by a complex emergency: Haiti (earthquake), Liberia (Ebola outbreak), Indonesia (earthquake), and Japan (earthquake, tsunami, and nuclear incident). The case of the Ebola outbreak is unusual. This was a pandemic with a slow onset compared to the others, which were sudden-onset disasters (SODs).
Table 4.2 Baseline comparison between four different countries affected by complex emergencies
| Country | Haiti (2010) | Liberia (2014–2015) | Indonesia (2013) | Japan (2013) |
|---|---|---|---|---|
| General population (thousands) | 10 317 | 4294 | 249 866 | 127 144 |
| Population under 15 years (%) | 35 | 43 | 29 | 13 |
| Population over 60 years (%) | 7 | 5 | 8 | 32 |
| Life expectancy (years) | 62 (2012) | 62 (2012) | 71 (2012) | 84 (2012) |
| Under-5 mortality (per 1000 live births) | 73 (2012) | 71 (2012) | 29 (2012) | 3 (2012) |
| Maternal mortality (per 100 000 live births) | 380 (2012) | 640 (2012) | 190 (2012) | 6 (2012) |
| Total fertility rate (no. of children per woman) | 3.1 | 4.8 | 2.3 | 1.4 |
| Five leading causes of death (among the top 10 causes) |
|
|
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| World Bank income classification | Low | Low | Low-middle | High |
In addition, countries can be classified by their economic development using the World Bank criteria (fiscal year 2018)[10]:
Low-income country: defined as countries whose gross national income (GNI) per capita is less than USD 1025.
Lower middle-income economies: countries with a per capita GNI between USD 1026 and USD 3995.
Upper middle-income economies: countries with a per capita GNI between USD 3996 and USD 12 375.
High-income economies: countries with a per capita GNI above USD 12 376.
The data thus gathered on the characteristics of the affected population will help the EMT to anticipate the needs (pediatric versus adult or both, surgery versus medical approach, pediatrics and obstetrics needs, and risks for CDs and NCDs).
Again, this needs to be done on a case-by-case basis; for instance, Dumont and colleagues[11] argued that, during the acute phase of the earthquake in Nepal, the need to treat anemia with transfusion was probably overestimated, since the background prevalence of anemia was high[12].
Safety and Security
Even if violence and insecurity worsen in the aftermath of a catastrophe, it remains essential to make a clear distinction between armed conflict and other types of violence that may hamper aid in complex emergencies.
During a complex emergency, desperate victims may resort to violence simply in an effort to survive. Looting of supermarkets or houses is the most commonly encountered situation. Fights and riots are frequent in the case of distribution of food, water, nonfood items, and other support.
During an armed conflict, security becomes a major concern of aid workers. Bombing, shelling, landmines, and terrorist attacks can all present risks for EMT staff members; at the very least, they severely enhance stress levels. Encounters with regular troops, rebels, or child soldiers carrying weapons are all situations that require appropriate behavior from EMT staff members. Support and training from security officers can decrease the risk of major security incidents.
To some extent, armed conflicts are complex emergencies, whereas the reverse is usually not the case. In short: every armed conflict is a complex emergency, but not every complex emergency is an armed conflict!
Every EMT that is to be deployed in an armed conflict zone must attend to its safety and undergo security training. Importantly, these precautions must be adapted to each specific kind of environment.
Such competences must be acquired and require time to reach adapted standards to ensure the safety and security of the victims, as well as EMT staff members (whether they operate in a national or international context).
Related posts:
Chapter 6 – Training and Accreditation
Chapter 3 – Definitions, Needs, Scenarios, Functional Concept, and Modes of Deployment
Chapter 7 – Personnel
Chapter 15 – Pediatrics in a Field Hospital
Chapter 18 – Orthopedics in a Field Hospital
Chapter 25 – Infectious Diseases and Public Health in a Field Hospital
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