Jenny Dengler, PA-C, MedTreks Assistant Faculty
Global disaster medicine and humanitarian medical aid is an emerging area of medicine.
With the increase in global transportation and ever-present need for medical providers, the world of medicine is becoming more accessible. Throughout 2017 there has been extreme weather and sudden onset disasters (SOD) including, but not limited to; Hurricane Irma, Hurricane Harvey, Hurricane Maria, earthquakes in Mexico, Iraq, and Iran, and severe global flooding. Millions of individuals have been impacted by SODs in the last year alone and when considering the impacts over the last ten years the numbers reach into the billions impacted. Natural disasters have led to exorbitant economic losses as well as spikes in morbidity and mortality for the impacted nations.
Over the last year developed nations have been impacted drastically from SODs, however, it
pales in comparison to developing nations who will take years to recover from the recent
disasters. In general, the most disaster-prone regions are also the low and middle-income nations that already have significant health disparities. As the demand for international relief and medical support increases it is important to consider when humanitarian aid can cause harm. How do organizations ensure that there is standardized care that can be continued in the host nation after volunteers leave the country?
What happens to patients post-disaster? What if the system is unable to maintain those needing follow up care? Ultimately who is medically accountable to these patients? There are likely more questions than answers when considering the impacts of disaster medicine and this discussion will aim to address some of the concerns in humanitarian medicine but is in no means comprehensive.
Disasters response teams, humanitarian groups, medical relief organizations, and
numerous non-government organizations support missions providing medical care to patients in developing nations and to those impacted by disasters. Teams of volunteers will land in a country days after the disaster with great intentions of providing world-class medical care to those in critical need. However, most of those responding to disasters or on humanitarian missions have minimal experience in this setting and many use these scenarios to “practice” skills they may not otherwise have access to within their scope of practice in their own country of origin. Numerous nurses, EMTs/Paramedics, and Providers (Physicians, Physician Assistants, and Nurse Practitioners) will arrive to provide the care sans medications or supplies with the anticipation that these supplies will be available in the country. Little consideration is placed on the health care management and administration needs of these organizations/teams to ensure proper operations and logistics to reduce the impact the team will make on the host nation.
The concerns surrounding medical disaster relief and humanitarian missions have also sparked an interest in the medical anthropology community. A recent paper by Abramowitz, Marten, and Panter-Brick entitled Medical Humanitarianism: Anthropologists Speak Out on Policy and Practice, brings to light the questions that arise outside of the medical sector (Abramowitz, Marten, & Panter-Brick, 2014). Respondents of this study highlighted numerous concerns. Of particular interest, the anthropologists noted that humanitarian aid and research can cause unintended harm among the vulnerable populations and that organizations responding to the needs of these vulnerable groups do not address the underlying concerns such as oppression and injustices (Abramowitz, Marten, & Panter-Brick, 2014). What benefit arises if providers come in the country to provide “band-aid” care to patients, yet do not address the cause of poor health care access? What assets can be procured to improve access, follow up care, and meet the sustainable development goals as well as the goals of the host nation? Organizations providing care to developing nations need to begin to branch into the politics of global health and provide more than basic medical care to these nations. There will never be a shortage of providers who want to make an impact. Now that there is an ease of access to the developing nations it is time to expand in humanitarian and disaster medicine to include topics in health care disparities, sustainability, continuity of care, marginalized groups, and other areas in medicine that lead to oppression of patients in developing nations. To provide the best care to these populations one cannot be blind to the roots of the problem.
With any organized medical team, the team is led by the physician and is supported by
physician assistants, nurse practitioners, nurses, and medical assistants/paramedics/EMTs. Little research is available on the proper supportive team needed to respond to disasters to ensure there are sufficient medical providers and support staff to meet the influx of patients. Furthermore, minimal research is available on the skills needed by all levels of the team and most importantly the medical providers. A study conducted by Wong et al. in 2015 assessed the core surgical competencies needed in disaster response (Wong et al., 2015). Surgeons in 22 countries were surveyed (n=147) with over 50% having experience in humanitarian response. Amongst the responding surgeons, it was agreed that formal training, experience with humanitarian aid, and global health experience were fundamental to provide adequate preparation for future medical responses. Furthermore, this study could identify critical procedures that should be in the armamentarium of the surgeon if they are to respond to disasters. Regarding generalized medical care, a cross-sectional survey by Noguchi et al. in 2016 assessed the skills necessary for medical providers in disasters (Noguchi et al., 2016). This survey was answered by 52 physicians with experience in disaster response. Through this survey, it was determined that with the mix of providers and various disaster settings that there is a core of 23 skills noted by the Japanese team that is generally performed in austere environments regardless of the location or disaster. A select group of skills noted in the study and the previous are identified in table 1. Furthermore, the results of these studies in conjunction with current humanitarian needs will allow for curriculum development to ensure that medical response teams are credentialed and meeting minimal standards of care. This allows teams and host nations to trust that those who are responding have met or exceeded expectations in humanitarian care, ensuring that the best care is provided to the patient in austere conditions.
The following is a list of skill set for disaster response:
1. History taking and physical exam
2. Pharmacology management
3. Intubation and surgical airway
4. Clean water supply
5. Chronic disease management
7. Conscious sedation
8. Hygiene and sanitation
9. Health management of the team
10. Pediatrics including nutrition
11. Abdomen packing and hemorrhage control
12. Medical waste management
13. Infectious disease
14. Mass casualty triage
15. Orthopedics: fracture, amputations, fasciotomy
16. Storage of equipment and secure pharmaceuticals
17. Mental health (psychological first aid)
18. Splinting and casting
19. Foreign body removal
20. Healthcare administration
21. Wound irrigation, Incision and drainage
22. Civil affairs and media
Management of Chronic Conditions
Noncommunicable disease (NCD) is the leading cause of death globally accounting for
40 million deaths or 70% of the global mortality (WHO, 2017). The leading causes of NCD are; cardiovascular disease, cancer, respiratory disease, and diabetes. Globally there are 15 million deaths due to NCDs in the age range of 30-69 and of these premature deaths 80% come from low and middle-income countries (WHO, 2017). These statistics are critical as the majority of disasters and humanitarian relief efforts are focused in developing nations where these statistics are the highest. This means that disaster relief providers should be vested in having a knowledge base in chronic disease management. The medical care provided will be even more complex given the high acuity of trauma and infectious disease, but also the implications of comorbid conditions impacting their overall healing process. Furthermore, these patients may have undiagnosed, longstanding health conditions and the front-line provider may have to treat these conditions as well as the acute injuries and diseases. Current guidelines set by the World Health Organization Foreign Medical Teams (FMT) delivering care during disasters is limited on the management of NCDs in disaster medicine. Historically, the goals of disaster medicine and humanitarian relief is to assess and correct the immediate need with the anticipation that the local health care will recover efficiently and be able to provide ongoing care. However, most of the developing nations have a failing or inadequate health system that may take years to recover from a disaster or is unable to meet the expectations of patients who have been treated by relief groups who lack adequate follow-up care. Given the increasing rate of NCD and majority of patients with one or more NCDs who are living in disaster-prone areas, it may be appropriate to shift the focus to include chronic disease management in the acute phase of relief and long-term recovery. McDermott et al. present a study on the management of diabetic patients in a deployed field hospital. This study gave great examples of scenarios presented to the AusMAT disaster team during Typhoon Haiyan. This paper creates a table addressing a model for acute non-communicable disease care post sudden onset disaster which should be utilized in curriculum development (McDermott, Hardstaff, Alpen, Read, & Coatsworth, 2017). The challenges faced and overcome by the AusMAT team during Typhoon Haiyan allowed recommendations to be made in regard to increased preparedness for NCDs, operational guidelines, and patient follow up. The author of this review agrees with McDermott et al. in that medical teams presenting to the host nation should be strongly integrated with the host nation’s Ministry of Health Services. With proper integration, there can be improved medical record keeping, discharge summaries, and follow up care.
Health care management in a disaster is often an overlooked skill. The reality is that
disasters are in great need of managerial volunteers who can assist in the organization of medical teams responding to disasters, ensuring teams meet minimum requirements to practice medicine in the host nation, that supplies are available, and to coordinate care between teams and host facilities. Eleven themes in health care management were noted in a qualitative study of 30 disaster management experts in 2015 (Pourhosseini, Ardalan, & Mehrolhassani, 2015). Human resource management is critical to ensure low impact on the host nation, that groups arriving meet the present needs and will not create more chaos in an already chaotic environment with skills that cannot be utilized, and that personnel are accounted for in the host nation. The above study noted that experts in the field would note that many medical and nursing students would
arrive to disasters and be of little use as they are not able to function and create a bigger strain on the system as well as lack of organization and responsibility (Pourhosseini, Ardalan, &
Mehrolhassani, 2015). Not only does management need to be aware of the skills and resources
that the team is bringing to the disaster, but also what is available in the country. Most disasters will experience electrical outages, impacts on water sanitation, impacts on travel due to the destruction of roads, rails, and airports, and of course; shortage of medications, reduced hospital staff, and destruction of hospitals. During these shortages, foreign countries and volunteers will send supplies to the host nations, however, these supplies can be out of date or unfamiliar to the local medical personnel and are wasted. Wasted supplies and unnecessary goods tend to be sent to disaster areas by outreach organizations in other nations with good intentions, however, many who send supplies are not familiar with the needs and inadvertently increase the burden of the disaster. As an experience of the author, during Hurricane Harvey in Texas a small, historically impoverished town of Wharton received piles of snowsuits which created a burden on the local services as they try to manage the influx of donations. This creates a strain physically on the system but also impacts the volunteers emotionally who have witnessed so much destruction and need to decide to waste these products as they are not needed. Waste management during a disaster is another topic on its own, but critical for providers to be aware of as months can go by without sanitation removal which increases the rodent population and subsequent infectious disease. Due to the increased burden on sanitation services, it is critical that teams have the ability to manage their own medical and personal waste to ensure this does not impact the local environment and sanitation services post-recovery. Also, teams need to be able to acquire their own clean water as local systems will be overburdened and local citizens may not have this access and will be relying on the medical teams arriving in the country to provide clean water.
In the review of recent literature, it has been noted that is there is a lacking accrediting body
or overseer of the medical teams and organizations responding to the disaster. The author of this
review by no means believes a costly accreditation process needs to occur as that would likely
break an organization financially. Instead, there should be accountability within the recognized
organizations to work together post-disaster to evaluate the records and care provided by teams. Having a third-party review to ensure compliance measures and standards of care are met within the country will hold teams accountable to the care they provide. Furthermore, it is important to assess the cultural impact and views of the care provided by those patients and host country who received care to improve practices in disaster medicine. Medical providers are held accountable to their patients in developed nations and this should transfer to developing nations as well. It would be unethical to view the disaster and those in developing nations as a means of increasing skills and scope of practice for one’s medical practice. The author once heard a nurse mention she wants to travel to a disaster to practice her suturing skills as this is not in her scope in America. Given that this is a mindset of a portion of those traveling to disasters it is critical that there is a means to ensure that those who
are responding to disasters are practicing within their licensed scope. Through holding, teams
accountable to ensuring their volunteers are fully licensed, credentialed, and capable of the
necessary skills required for humanitarian missions will allow accountability to the team, the
volunteers, and will create a standard that needs to be met or exceeded in order to be considered for deployment. This ensures that the team is aware of medicolegal considerations for deployment and that the team has the necessary skills to reduce the already high risk of negligence given the austere environment and lack of health care infrastructure in the host nation. This accountability will also reduce the influx of teams that come into the nation as teams should not be considered deployable unless standards are met. With only the necessary teams in country it will improve the coordination of care and improve the follow up care needed for these patients as teams will be required to have documentation that can be transferred to the Ministry of Health and with the patient to help the host nation be able to meet the following care needed post-recovery and will allow teams coming in for later assistance to follow the care of the patient. It is critical as disaster and humanitarian teams grow and more missions are accomplished in developing nations that there is a paper trail to be followed to ensure that patients are receiving appropriate management of their health care needs. Beyond the legal considerations for the patients and ensuring that the medical needs of the patients have appropriate follow through, it is imperative that the volunteer team members have the appropriate standard of care as well. Teams responding to disaster need to take all the steps necessary to ensure that they have adequate supplies to ensure hygiene and sanitation, clean water, and appropriate medical supplies for the team members as well. It would be a significant burden on the host country and the team to have to prepare an emergency flight for an injured or ill volunteer. These logistics on how to handle medical emergencies for the volunteers is also critical and needs to be in the action plan for a disaster team. The World Health Organization has created a document on Foreign Medical Teams and minimum standards that must be met by teams in SODs (WHO, 2013).
MedTreks RN, Lynn teachers HopeCore healthcare workers on appropriate splinting techniques
Where do we go from here?
Evidence and research surrounding medical care by foreign volunteers in developing
nations is beginning to emerge. There are still more questions than answers surrounding the
ethics of care and how providers can reduce harm when providing care in austere environments. Through continued research it will be important to address; technology and creating translatable medical records that can be utilized with satellite technology, telemedicine to assist with chronic disease management and care during the recovery phase, creating disaster and humanitarian medical curriculums, accreditation for teams, and evaluation of care provided by the teams. The World Health Organization is on the front lines of creating a standardized protocol for foreign medical teams. This is a step in the right direction to ensure that developing nations and the citizens are not harmed by the care provided by international teams. Every country will have different standards of care and it is critical that providers and teams give the minimum standard of care for the host nation and ensure that follow up care is available for the citizens. If organizational structure is going to change and more people are going to be aided during these missions, teams must ensure that they are invited to the host nation through the Ministry of Health (MoH) to ensure coordination of supplies and tracking of personnel. Through a top-down approach medical teams can focus on medical care of the citizens and helping rebuild the medical infrastructure within the host nation instead of sweeping into the nation for one to two
weeks and leaving hundreds of patients behind without any continued care or resources.
The Ministry of Health, especially in developing nations, needs to have the proper
training to know what medical resources are available globally in the event of a SOD or for
general medical assistance. Having a global network of medical resources will allow host
nations to select the teams that can best serve the needs of the nation and allow the non-government organization to be in direct communication with the government to assist with care transfer. If the World Health Organization can train the Ministry of Health on needs assessment and create the standards for Foreign Medical Team it will ensure that the NGOs responding have met or exceeded the regulations for disaster and humanitarian relief. Furthermore, teams self- deploying to host nations without the logistical support or proper organization should be held financially accountable to the host nation due to the risk of harmful impact to the infrastructure, citizens, and volunteers. Foreign medical teams need to be held accountable to their volunteers and be able to protect them in the event of a medical emergency and also need to ensure that the team members have the appropriate level of training prior to deployment. It is critical to ensure all team
members are licensed and credentialed and have a basic understanding of disaster medicine. In order to create teams that meet the standard requirements of the WHO FMT, there needs to be evidence-based curriculum development and accreditation of teams. Post-deployment evaluations from an unbiased third party as well as within the organizations from the team perspective need to occur as well. It is critical that teams grow from their errors and if they are not willing to make the necessary changes to ensure no harm is caused to the host nation they need a period of remediation before being able to redeploy. Furthermore, it would be greatly beneficial to teams to have the ability to consult with a medical anthropologist in order to create the lowest impact on the current culture and determine how the team can give more than just medical care. It is certain this paper likely made more question arise in the mind of those joining or being a part of medical disaster and humanitarian teams. Hopefully, this paper also addressed some concerns you can take back to your teams to create the most sustainable, low-impact, and medically competent team that is responding to the needs of those in developing nations.
Through collaboration, accountability, and standardized protocols more people can have the
access to the care they need before, during, and after the crisis and as providers we can continue to first do no harm.