Abstract
Providing humanitarian relief to affected populations is a top priority following a major sudden onset disaster (SOD). The main form of medical relief to affected areas is the emergency medical teams (EMTs). These are groups of health professionals and support staff operating locally or outside their country of origin by providing healthcare to disaster-affected populations. Despite best intentions, for decades EMTs were disorganized and followed no clear standards. In the aftermath of the 2010 Haiti earthquake, the EMT Working Group of the World Health Organization‘s global health cluster initiated a global effort to standardize the EMTs system. This new system was put to the test in 2013 with the deployment of medical aid to the Philippines following Typhon Haiyan, and later on during the Ebola outbreak in West Africa and the earthquake in Nepal in 2015. This chapter reviews the history of medical aid to disaster affected areas, the process of coordinating and standardizing EMTs and the latest implementation of the new EMT coordination system.
Introduction
Providing humanitarian relief to affected populations is a top priority following a major sudden-onset disaster (SOD). These global-scale disasters can generate huge numbers of casualties and extensive damage to local infrastructure, including medical facilities. In many cases, the need to handle the surge in demand for immediate lifesaving procedures, as well as long-term public health management, surpasses the ability of the local health-care system. This is especially true if medical facilities sustain damages, and/or if health-care personnel are affected. Consequently, and as is often the case, the affected population is in dire need of medical aid to support the overloaded and crumbling local health-care system. The international aid during the initial life-saving phase usually takes the form of urban search and rescue (USAR) teams and emergency medical teams (EMTs) sent by donating countries and nongovernmental organizations (NGOs) not affected by the disaster. This chapter focuses on the latter.
Most destructive natural disasters and associated casualties take place in specific regions and in a small number of countries. Asia sees the most disasters, fatalities, and affected populations. Africa has the highest death rate[1]. According to the UN University’s World Risk Report from 2016, the global hotspots for a high disaster risk are in Oceania, Southeast Asia, Central America, and the southern Sahel region in Africa. The countries most gravely affected typically belong to the low-income or developing categories. This means that they already face sanitation problems, limited access to suitable drinking water, and limited public awareness of threat reduction and mitigation measures[2]. Consequently, major disasters striking these regions often result in a high number of casualties and a need for external assistance[1]. Major changes are occurring within regions with a growing number of middle income countries in historically disaster prone regions are becoming more resilient with national response teams and the rise in regional entities such as ASEAN (Association of Southeast Asian Nations) offering support between countries in their region.
The main form of medical relief to affected areas is the EMTs, formerly known as foreign medical teams (FMTs) (the term was changed to expand the definition so as to include local medical entities in the affected country). These are groups of health professionals and support staff operating locally or outside their country of origin by providing health care to disaster-affected populations. These health professional groups of physicians, nurses, paramedics, and other health professionals comprise a significant element of the global health workforce, and play an important role in saving lives and supporting the health-care provisions to people affected by an emergency or disaster[3].
In most countries, medical professions are highly regulated, and exercising medical practice is subject to vigorous regulation, accreditation, licensing, and quality control. However, up until very recently, regulations concerning the medical practice in disaster-stricken areas were almost never enforced. In the chaos following the crisis, suboptimal medical care was often encountered. Inevitably, this had hindering effects on achievement of the main goal of saving as many lives as possible and reducing the suffering of the affected population.
The need for increased accountability of humanitarian response, specifically the medical one, has been confirmed from evaluations of many disasters in the past, in particular the Indian Ocean tsunami in 2004 and the 2010 earthquake in Haiti. Usually, under the circumstances of these and similar disasters, the ministry of health (MoH) of the affected country faces a no-win situation: they require urgent medical care, which should be not only be speedy but also effective and professional, but end up with many teams pouring in, some without advance notice or proper registration[4,5].
For these and other reasons, there has been a growing debate over the efficacy of the health-care system based on the medical teams arriving in disaster areas to provide medical treatment to the affected population. The main problems have less to do with the professionality of the teams, rather with the lack of organization, coordination, and integration of these teams into a single and effective health-care system. Experience has shown that, in many cases, the deployment of EMTs is not based on assessed needs. In some cases, teams arrive in affected areas on their own merits regardless of actual necessity. Such teams are often unfamiliar with the international emergency response systems and standards, and may not integrate smoothly into the usual coordination mechanisms[6].
The purpose of this chapter is to describe the development process of the international system for EMT organization and coordination, which was set forth by the World Health Organization (WHO) and other global leaders in an effort to generate a better, more reliable, efficient, and standardized coordination system for medical relief to affected areas.
The Medical Requirements in Disaster-stricken Areas
Before we account the drawbacks of the medical relief system until its recent regulation by WHO, we should first describe the medical needs often present in disaster-stricken areas. Providing medical aid to affected areas comprises several efforts. The first is immediate lifesaving procedures performed on casualties resulting directly from the adverse event. These efforts include emergency and disaster medicine procedures, such as resuscitation, hemodynamic stabilization, lifesaving surgery, amputations, and so on. Providing immediate, lifesaving medical care efficiently and rapidly is of utmost importance to saving as many lives as possible.
It is important to note that in most cases, especially following a devastating natural disaster such as a large earthquake, the local medical system is strongly impacted. Many of its facilities might be deemed inappropriate to provide medical care due to danger from after-shocks or loss of critical infra-structure, power and access to safe water required for medical care. In addition, a substantial number of the workforce is expected to be absent, be it because they were personally harmed or because they choose to firstly attend to their personal and familial needs before reporting for their duties. The weak and unstable local health-care system is in dire need of substitutes, and these are usually provided in the form of EMTs responding from within and outside the affected region.
However, it is important to understand that, even in events with major trauma impact such as earthquakes, the acute phase of medical care is temporary. Even in events with major trauma impact such as earthquakes, the acute phase is relatively short and, 7 to 10 days after the event, there will be a significant decrease in trauma patients and a rise in patients seeking care due to nontrauma-related complaints and routine medical problems. (see Figure 9.1). These include patients in need of treatment for illnesses or other medical conditions that preceded the disaster, for example, diabetes, pregnancy care or communicable disease such as dengue. Consequently, a very different set of medical skills and resources is required to accommodate the shifting needs of the affected population.
Figure 9.1 Conceptual model for the variation over time of needs/use of hospital resources for nontrauma emergencies, trauma complications and elective surgery before and following a sudden-impact disaster (SID)[8]
Another important aspect of medical relief to affected areas is public health. It is commonly thought that disasters bring about public health emergencies While outbreaks are sometimes seen following a major disaster, it is not the disaster itself that causes them; rather it is the lack of access to suitable drinking water and food supplies, lack of shelter or increase exposure to mosquitoes after floods that give rise to different outbreaks, including diarrhea, respiratory illness or vector borne disease. For example, the contamination of water following the devastating earthquake in Haiti (2010) led to the worst cholera outbreak in the history of the country, affecting ~700 000 and killing about ~9000[7]. However, this need not be the case. If efforts are made (as soon as the response phase is initiated) to secure the affected population with alternative sources of drinkable water and food supply, access to shelter and bed nets outbreaks can be avoided, especially if coupled with public health messages on issues like food hygiene and hand washing. EMT response is now seen as part of a wider public health approach with prevention as important as direct medical care, including public health messaging by the EMTs to the local population.
Other aspects of medical relief in emergencies include restoration of critical services, rehabilitation of the injured, and mental health. [6] and these services are provided both by general EMTs and by “specialist care teams.” Historically neglected by EMTs these aspects are important to consider even in the first days. Providing affected populations with proper health recovery plans and supporting their mental wellbeing are of crucial importance in the stabilization and rehabilitation of the population.
The Medical Relief System in the Mirror of Time
The establishment of the UN in 1945 marked a turning point in the globalization of the humanitarian system. The main beneficiaries of humanitarian aid shifted from Europeans to other populations in need, worldwide. The decolonization process had a profound impact on the emergence of NGOs. In parallel, it also gave rise to a growing number of nonaligned, third-world countries, which continue to express their rights to sovereignty from major power blocs [9,10].
The expanding humanitarian sector entered the 1950s with many elements recognizable in today’s system already in place: governance mechanisms, specialized task forces and agencies, and NGOs, all engaged in conflicts, natural disasters, disease outbreaks, and food and nutrition crises, such as the Nigerian Civil War (1967–1970) (see Figure 9.2)[9].
Figure 9.2 Nigerian Civil War, 1967–1970; Umuosu, September to October 1968: food distribution in a feeding center
One critical incident took place in the beginning of the 1970s. In November 1970, a severe cyclone and storm surge hit the coastal areas of the Ganges Delta, in what was then East Pakistan, killing an estimated 300 000 people. By the end of 1971, an estimated 10 million refugees sought safety[11]. The East Pakistan crisis, as it was subsequently called, was an extensive refugee crisis that encouraged the UN to take affirmative actions to promote global humanitarian efforts[9]. Arguably, this incident marked the new era of humanitarian and medical relief to affected areas, which led to the current architecture of this system.
The 1970s were a time of rapid evolvement of the humanitarian system. A devastating famine crisis struck countries in the Ethiopia and Sahel region of Africa (Chad, Gambia, Mali, Mauritania, Niger, Senegal, and Upper Volta/Burkina Faso), leading to a global effort to assist the affected population with resource mobilization. However, there is general agreement that these efforts were poorly coordinated within the system and between the system and local governments[9].
Additional crises and disaster situations span across the 1980s and 1990s, including natural disasters (e.g., Ethiopian famine [1984–1985], Armenian earthquake [1988], Somali famine [1991–1992], and Hurricane Mitch [1998]), and armed conflicts (e.g., Bosnia [1991–1995], Somali civil war [1991–1993], First Gulf War [1991], Bosnian War [1992–1995] [see Figure 9.3], Rwandan genocide [1994] [see Figure 9.4], and Kosovo [1999])[9]. These incidents all displayed elements of poor coordination of medical relief operations.
In 1991, the Inter-Agency Standing Committee (IASC) was established by the UN as a platform for coordination between UN agencies on the global level. These efforts were made in light of the understanding that coordination of external relief to affected areas is fundamental for effective humanitarian action[16].
Despite the good intentions, the 6.5-magnitude earthquake that hit Bam, Iran, on December 26, 2003 was another example of the difficulty of medical relief coordination. The devastating earthquake left the local health-care system dramatically impaired and international aid was evidently required. Even though the international community dispatched sufficient quantities of resources, the coordination of these resources was substantially lacking. In fact, Abolghasemi and colleagues[17] claim:
An important lesson learned from the Bam earthquake experience is that the assumption that receiving greater amounts of relief items results in a more effective response, is false. As encountered in the Bam earthquake, extensive international assistance could be burdensome on the management and coordination of the activities, transport, storage, and distribution of relief items.
This incident highlighted the importance of developing a robust mechanism of organization and coordination of medical relief to affected areas[17–19].
The literature provides an elaborate account of other cases demonstrating the multitude of difficulties and deficiencies of the medical relief system up until recently. For example, studies have shown that medical teams focused primarily on trauma care and neglected other aspects of health care such as primary and public health, essential obstetrical care, and pediatrics[20–22]. In addition, medical teams were also criticized for poor medical records keeping[23], administration of technically improper surgical procedures[4], and deficiencies in the fields of training and education, leadership, coordination and management, integration between different teams, organization, and standardization[8,24].
Up until the late 2000s, humanitarian aid missions were often arriving on scenes of affected areas with little to no coordination, as well as insufficient understanding of the situation on the ground, the needs it entails, and inadequate awareness of other teams and delegations operating in the area. As a result, a suboptimal health-care system was operating in the field, one in which the benefit of each medical team was often lost[4,6,8,19,24–28].
The humanitarian reform of 2005, followed by the perceived failure of the humanitarian aid to respond effectively to the Darfur (Sudan) crisis in 2004, introduced new elements to improve capacity, predictability, accountability, leadership, and partnership. The most notable aspect of the reform was the creation of the cluster approach[16]. According to the UN disaster assessment and coordination (UNDAC), which is part of the UN’s Office for the Coordination of Humanitarian Affairs (OCHA):
Clusters are groups of humanitarian organizations (UN and non-UN) working in the main sectors of humanitarian action, e.g. shelter and health. They are created when clear humanitarian needs exist within a sector, when there are numerous actors within sectors and when national authorities need coordination support[29].
The cluster approach was first utilized in the humanitarian response to the 2005 Pakistan earthquake. Arjun Katoch, who was then the deputy head of UNDAC, recalls:
The UNDAC team led by Gerhard Putman Cramer (of which I was the Deputy Team Leader) used [the cluster approach] as a basis for organizing and writing the Flash Appeal for the Pakistan earthquake. This was approved by Jan Vandermootele, who was the UN Resident Coordinator in Islamabad then (subsequently also the UN Humanitarian Coordinator). There was no conscious decision by either OCHA or the IASC to “deploy” the cluster system. We just decided to use it based on the reform report, as it was a logical continuation of the “sectors” used earlier in natural disaster coordination in the field. These clusters included a health cluster. That was the first use of a health cluster[30].
Additional attempts were made to promote better humanitarian response. For example, efforts were made to share knowledge, experiences, and lessons between members of the humanitarian action community. However, these were often ineffective. Following each disaster incident, practitioners would publish their insights into the humanitarian aid extended, but these were highly specific, cultural-biased, and non-representative. Consequently, generalization of findings was difficult, and there was no practical way to derive overarching conclusions and comprehensive guidelines.
In an effort to achieve better organization and management of medical teams responding to provide humanitarian aid to affected populations, WHO appointed local health officials working on its behalf to assume responsibilities for medical relief coordination during emergencies. Despite good intentions, the expectations for better coordination of medical aid were short lived. The appointed officials, normally tasked with day-to-day health-care issues in the developing countries they were stationed in, were holding insufficient knowledge and expertise in emergency management. Subsequently, coordination of medical aid remained lagging.
An outrage over this suboptimal mechanism was gradually heard, culminating with the 2010 earthquake in Haiti, which is widely agreed as the pivotal point of change in recent years[8,15,18,19,24,28,31]. The 2010 Haiti earthquake was pivotal in the sense that it brought the need of enhancing the EMT system to center stage. Perhaps most prominently, it brought a renewed and strengthened interest toward the accountability of EMTs. Today, it is recognized that there needs to be greater accountability, more stringent oversight, and better coordination of the work of EMTs[3]. It is now widely agreed that standardizing the capabilities of EMTs, their resources, and inter-operational guidelines will further improve resource utilization and will facilitate a better mechanism of saving lives[6,8,19,24,25,28]. Yet, to date, there is no single accepted definition of accountability in the humanitarian context[32].
In the aftermath of the Haiti earthquake, WHO recognized the necessity of change in the EMTs system:
Serious questions have been raised about the clinical competence and practices of some EMTs deployed in recent years. It is now recognized that there needs to be greater accountability, more stringent oversight and better coordination of their work[3].
Related posts:
Chapter 6 – Training and Accreditation
Chapter 3 – Definitions, Needs, Scenarios, Functional Concept, and Modes of Deployment
Chapter 11 – Auxiliary Medical Services in a Field Hospital
Chapter 7 – Personnel
Chapter 18 – Orthopedics in a Field Hospital
Chapter 25 – Infectious Diseases and Public Health in a Field Hospital
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