Improving global prehospital and emergency medicine, public health, and disaster health care and preparedness
Position Statements

Position Statements

Below are WADEM’s Position Statements as adopted by the Board of Directors.

Disaster Medicine Education in Health Care Profession Training

Disaster medicine is a critical and often neglected component of health care, especially as the incidence of natural and human-induced disasters is increasing globally.1 Since the September 11th attacks in New York City and Washington, DC, there have been numerous proposals and attempts for the standardization and implementation of disaster response and mass casualty education into health care training across many countries.2,3,4

Despite these efforts in the early 2000s, disaster medicine has not been incorporated into many national standards across health care professional training programs.5 The rigor of existing academic requirements and lack of resources have made incorporating disaster medicine into the formal curriculum challenging.6,7 The majority of students and trainees who receive education related to disaster medicine do so as part of optional extracurricular activities that are driven by individual interests.4,8 As such, many practitioners enter professional careers with little exposure to disaster medicine.

The lack of preparedness among health care professionals is concerning because communities turn to their health care providers regularly for guidance, especially during public health emergencies.2,9 Introducing disaster medicine concepts early in health care education will allow students and trainees to feel more comfortable implementing these practices when called upon as future leaders. Disaster medicine education encompasses competencies including leadership, critical thinking, interprofessional collaboration, and communication skills that are necessary for the everyday practice of medicine and will assist in developing well-rounded health care providers.9

As a result, WADEM:

  • Recognizes the need to improve the quality, quantity, and accessibility of disaster medicine education, which may be achieved with a dedicated curriculum at all levels of health care education.
  • Urges for standardizing disaster medicine education across universities and health care training programs.
  • Recommends that disaster medicine education be delivered in a multisession, multimodal format that includes didactic-, simulation-, and interprofessional-based endeavors.
  • Suggests that universities and health care training programs incorporate faculty and community organizations well-versed in disaster medicine preparedness and response to improve existing disaster medicine curricula.
  • Encourages medical education accrediting bodies, education advocacy organizations, and similar stakeholders to prioritize disaster medicine education within their initiatives and standards.
  • Endorses that disaster medicine education activities should be continually evaluated and modified to align with the needs of the local and global communities.
  • Acknowledges the need for further research to better understand disaster medicine education in non-physician health care roles.

Adopted by the Board of Directors on 30 July 2024.

References:

  1. Ecological Threat Register 2020: Understanding Ecological threats, Resilience and Peace - World | ReliefWeb. Published September 9, 2020. Accessed June 29, 2024. https://reliefweb.int/report/world/ecological-threat-register-2020-understanding-ecological-threats-resilience-and-peace.
  2. Training Future Physicians about Weapons of Mass Destruction: Report of the Expert Panel on Bioterrorism Education for Medical Students. Association of American Medical Colleges, 2450 N Street, NW, Washington, DC 20037-1134; 2003. Accessed June 29, 2024. https://eric.ed.gov/?id=ED4823773.
  3. Loke AY, Guo C, Molassiotis A. Development of Disaster Nursing Education and Training Programs in the Past 20 years: A Systematic Review. Nurse Educ Today. 2021;99:104809. doi.org/10.1016/j.nedt.2021.1048094.
  4. Voicescu GT, Valente M, Della Corte F, Becerril M, Ragazzoni L, Caviglia M. Medical Students Education in Disaster Medicine: A Systematic Literature Review of Existing Curricula. Int J Disaster Risk Redu. 2022;77:103090. doi.org/10.1016/j.ijdrr.2022.103090.
  5. Jasper E, Berg K, Reid M, et al. Disaster Preparedness: What Training Do Our Interns Receive During Medical School? Am J Med Qual. 2013;28(5):407-413. doi.org/10.1177/1062860612471843.
  6. Jasper EH, Wanner GK, Berg D, Berg K. Implementing a Disaster Preparedness Curriculum for Medical Students. South Med J. 2017;110(8):523-527. doi.org/10.14423/SMJ.0000000000000681.
  7. Kasselmann N, Willy C, Domres BD, Wunderlich R, Back DA. Implementation of disaster medicine education in German medical schools – a nationwide survey. GMS J Med Educ. 2021;38(4):Doc79. doi.org/10.3205/zma001475.
  8. Jasper E, Berg K, Reid M, et al. Disaster preparedness: what training do our interns receive during medical school? Am J Med Qual. 2013;28(5):407-413. doi.org/10.1177/1062860612471843.
  9. Markenson D, Woolf S, Redlener I, Reilly M. Disaster Medicine and Public Health Preparedness of Health Professions Students: A Multidisciplinary Assessment of Knowledge, Confidence, and Attitudes. Disaster Med Public Health Prep. 2013;7(5):499-506. doi.org/10.1017/dmp.2013.96.

Refugees and Internally Displaced Persons

The crisis in Ukraine has produced dramatic images of people being forcibly displaced. Some five million people, mostly women and children, have fled the country. Another three million are expected to follow. An untold number is internally displaced. Global media outlets vividly depict the pain and suffering of these recent victims of violence.

This tragedy is but the proverbial tip of the iceberg of the humanitarian emergency related to population displacement from conflict. The scale of this emergency remains largely underreported. Less visible are the 84 million forcibly displaced people elsewhere, more than the population of Germany, Turkey. or Thailand. Of these, more than 35 million (42%) are children younger than 18 years of age.

Almost no region is spared this burden. In 2021, the United Nations High Commissioner for Refugees (UNHCR) reported:

Sub-Saharan Africa

  • The East and Horn of Africa, and Great Lakes region hosted nearly 5 million refugees at the end of 2021.
  • The region hosts 67 % of the refugees on the African continent and 20% of the global refugee population.
  • Conflict in the Tigray region in Ethiopia led to the internal displacement of more than 3 million Ethiopians by the end of 2021.

Central America and Venezuela

  • In recent years, El Salvador, Guatemala, and Honduras have experienced a dramatic escalation in violence by organized criminal groups, locally called maras.
  • The number of refugees and Venezuelans displaced abroad grew in 2021, reaching over 4 million by the end of the year.
  • Colombia has hosted more than 1.7 million people displaced across borders.
    890,000 people originating from El Salvador, Guatemala, and Honduras remain forcibly displaced.

Europe

  • Turkey continues to be the world's largest refugee-hosting country, home to 3.7 million refugees.
  • In 2021, more than 114,000 people risked their lives trying to reach Europe by sea; over 3,200 of them are dead or missing.
  • Europe granted international protection to more than a quarter of a million people within the region.

Iraq

  • Nearly 1.2 million Iraqis continue to be internally displaced in 2021, and the country hosts over 250,000 refugees from other countries.
  • Although Iraqi Internally Displaced Persons (IDP) returnees consistently outnumber those who are internally displaced, many struggle to reintegrate and still require humanitarian assistance.

South Sudan

  • By the end of 2021, there were more than 2.1 million South Sudanese refugees.
  • 95% of South Sudanese refugees are hosted in Uganda, Sudan, Ethiopia, and Kenya.
  • 45,900 South Sudanese refugees returned to their country by mid-year 2021.

Syria

  • Conflict in Syria reached its 11th year in 2021.
  • There are 13.5 million displaced Syrians, representing more than half of Syria's total population.
  • 6.8 million Syrian refugees are hosted in 128 countries.
  • 80% of all Syrian refugees are in neighboring countries, with Turkey hosting more than half (3.6 million).

Rohingya Refugee Emergency

  • The Rohingya are a stateless Muslim minority in Myanmar. The vast majority of Rohingya refugees are women and children, including newborn babies. Many others are elderly, requiring additional aid and protection.
  • 1.1 million stateless Rohingya refugees have fled Myanmar since the start of violence in 2017.
  • 90% of Rohingya refugees live in Bangladesh and Malaysia.

Yemen

  • Fighting in Yemen, already one of the poorest countries in the Middle East, severely compounds suffering arising from long years of poverty and insecurity.
  • In 2021, the internally displaced population in Yemen reached 4 million, with displaced families constantly facing acute risk of acute and chronic famine.
  • Natural disasters have exacerbated conflict in Yemen, forcing Yemenis to flee multiple times.

The massive numbers bespeak the breadth of the crisis, but not the depth. Host nations are often ill-equipped to support the influx of refugees. Low/Middle income and Developing countries host 85% of the world’s refugees, with the least developed countries providing asylum to 27% of the total. Refugee camps lack civic infrastructure; electricity, running water, sewer and waste disposal, schooling and education, commerce, law enforcement, healthcare, and representation are aspirational at best. Tentage and shanty-like structures constitute the built environment, often placed in natural hazard areas. Crowded and highly flammable, these settings are often afflicted with fire, destroying meager belongings at best and lives at worst. Close quarters offer an ideal breeding ground for communicable diseases, a concern that eclipses the current focus on COVID-19. The population of seven camps -- in Kenya, Jordan, South Sudan, and Tanzania – each approximates that of a small city, ranging between 66,000 and 185,000 inhabitants. Therein lies a cruel irony: existing within a large crowd but being culturally, nationally, financially, and emotionally alone.

Nor is the issue transitory. While many forcibly displaced situations have been resolved – post-1945 European refugees, Indo-Chinese boat people, and South African political exiles, for example – others are perniciously persistent. There are more than 170 protracted refugee camps across Africa and more than two million registered refugees in Gaza and the West Bank. The consequences of prolonged encampment include material deprivation, psychosocial problems, violence, sexual exploitation, exploitative employment, and resort to negative coping mechanisms. This begets intergenerational crises.

Some refugee communities have self-organized to a certain extent. The 80,000 people in Jordan’s Za’atari camp created an internal community with its own economic system. Families living in the camp started bakeries, barbershops, and even a pizza delivery service. Inspiring as this is, it is a poor substitute for the normalcy of home. So too are the burdens of the internally displaced. Of the nearly 89 million forcibly displaced persons worldwide, two-thirds are internally displaced, strangers and guests in their own nation. Risk of disease, poor nutrition, minimal to no educational opportunities, and crowded isolation not only impact refugees and IDPs today but – perhaps more ominously – for generations to come. Trauma has been shown to be intergenerational; so too is the trauma of being a refugee or IDP. Genetic science has identified that influences on a mother can be passed through an unborn child to that child’s offspring. Even if every displaced person could miraculously return home today, the effects of dislocation will persist for years to come.

The World Association for Disaster and Emergency Medicine (WADEM) advances the position that the issue of forcibly displaced persons is a major disaster hiding in plain sight. The plight of the displaced is a wicked problem: intractable in its complexity, intensely dynamic, and impervious to simple solutions. Absent greater international coordination and collaboration, innovative interventions, and a truly global approach to resettlement – establishing resilient societal, cultural, and economic communities consistent with the Sustainable Development Goals – forcible displacement will continue to challenge a just and equitable world, at a significant cost and harm to those affected. Failure to address this crisis will saddle future generations with an incalculable global health burden among the currently displaced and across all of society.

Adopted by the Board of Directors on 28 May 2022.

References:

COVID-19: Impact on Children, Pediatric-Focused Response, and Mitigation

COVID-19 as a Disaster
The World Health Organization declared COVID-19 a pandemic on 11 March 2020. As the pandemic spread, the challenges for health systems and the need to balance the protection of lives and livelihood around the world became evident. As of 31 December 2021, there have been over 275 million cases of COVID-19 worldwide and over five million deaths. Health care systems and resources have been stretched and many health care providers have become overwhelmed. Economically, the pandemic response, mitigation, and recovery efforts have added approximately 24 trillion dollars to the global debt. The insecurity, recurrent shutdowns, sequential isolation of lockdown, and prolonged school closures produced detrimental effects on children's physical, mental, and social well-being.1 Public health has never had a challenge of this magnitude in the modern era, highlighting the importance of leadership and strategies in partnering with the public.

Globally, the COVID pandemic has also highlighted deep inequities and the fragility of global supply chains. In addition, global vaccine hesitancy due to varying performance and reports about different vaccines has led to under-vaccination in some of the communities with the highest risk factors, even those that have access to vaccines and testing. The inequity of access to vaccines approved for pediatrics is even more stark. Currently, many nations in Africa, the Caribbean, Latin America, and the Asian Steppe have no access to pediatric vaccines and must rely on vaccination of adults when available and public health measures to protect children.

COVID-19 and Children
Understanding the impact of COVID on children and that of children on the pandemic are critical to pandemic preparedness for and response to the health and welfare of children and more broadly on society. Now more than ever, children are playing an important role in the transmission of SARS-CoV-2 infection and outbreak dynamics, with record numbers of children currently hospitalized with COVID-19.2 Children can contract COVID-193-6 and even those who are asymptomatic can transmit the virus.7 Presently, the Omicron variant has led to the most significant surge in US pediatric COVID cases of the pandemic with a 25% increase in the cumulative number of pediatric cases since the beginning of the pandemic during the first months of 2022.2 A study from seven countries (France, Germany, Italy, Spain, South Korea, the United Kingdom, and the United States) reported that the COVID-19-related death rate among children (age 0 to 19 years) was 0.17 per 100,000 as of February 2021.8 According to the government of Brazil, there were 2,057 known cases of severe acute respiratory syndrome (SARS) due to COVID-19 in children younger than 19 by Feb 2021 and in children less than nine years old at least 852 deaths.2

The presentation of COVID-19 in children is diverse. While respiratory symptoms including fever, chills, or cough are the most commonly reported in adults,9-10 children are more likely than adults to have gastrointestinal symptoms most commonly including nausea, vomiting, diarrhea, and abdominal pain as their initial symptoms or only symptoms.11-14 Children with underlying medical conditions are at even greater risk for severe disease as a consequence of COVID-19 infection.15-17

Furthermore, COVID-19 is associated with an increased risk of myocarditis in children compared to adults, but the absolute risk is low (<0.15 percent)18 and the condition is usually transient.7 Not only can acute COVID-19 cause morbidity and mortality but, following a primary infection with SARS-CoV-2, children may suffer from long-term complications including conditions unique to children, most notably the multisystem inflammatory syndrome in children (MIS-C).19 In the United States, more than 6,000 children have met the case definition for MIS-C.2 The psychosocial impact of the COVID-19 pandemic on children has created a mental health pandemic as well as adversely affected children’s academic, social and emotional development, the total impact of which we have yet to see.20,21

Pandemic Mitigation
Mitigation measures during the COVID-19 pandemic have had profound medical, psychosocial, and economic impacts on individuals, families, and society. Children should wear masks in public as much as can be tolerated and continue the proven practices of good hand hygiene common to all respiratory viruses. WADEM also advocates for isolation when a child has tested positive even if they are asymptomatic, as they can still transmit COVID to others. Those children who are required to be isolated should be given every educational and social resource to keep them engaged in their schooling and community so that they can easily re-engage on their return to normal classroom and play settings. See Appendix 1 for proposed action items.

COVID-19 Vaccinations for Children
Vaccines have a long-standing history of safety and efficacy in protecting individuals and populations against infectious diseases. We strongly advocate that those vaccines approved for use in children be made available worldwide. WADEM supports the recommendation to vaccinate children and adolescents against SARS-CoV-2. Appendix 2 depicts several international health organizations’ recommendations for vaccinating children.

Vaccine Hesitancy
Vaccine hesitancy has become more common worldwide and was cited by the World Health Organization (WHO) as a top 10 global health threat in 2019. The accelerated development of the COVID-19 vaccines has led to perceptions that corners are being cut regarding safety assessments. A younger age (e.g. <60 years old), lower levels of education, lower household income, rural residence, and lack of health insurance have been associated with COVID-19 vaccine hesitancy.22-25

WADEM urges caregivers to check with their pediatricians and community health care providers on how to get their eligible children vaccinated. WADEM wishes to emphasize that the safest way to protect your children is to have every eligible person in your family vaccinated against COVID-19.

Appendix 1: WADEM PedsDM SIG Action items

  • Evaluate the impact of mitigation initiatives on COVID-19 on children and society regarding treatment and use of health care resources, particularly hospitals that best accommodate the numbers and needs of adult and pediatric patients.
  • Understand public knowledge, attitudes, practices, and factors driving acceptance and hesitancy regarding mitigation strategies and initiatives.
  • Provide a repository of information for health care providers, parents and children, and nonmedical providers regarding challenges in the initiation and adoption of effective mitigation strategies.
  • Learn from and educate stakeholders including health care providers, legislators, community entities/members that engage with children including schools, daycares, after-school programs, religious organizations, personnel, parents, and children regarding mitigation.
  • Generate pediatric-focused mitigation strategies and initiatives at local, regional, and global levels.
  • Promote and support ongoing research funding and infrastructure and engage, develop, and study the impact of mitigation including diagnostic criteria, treatment, and vaccines.

Appendix 2: International Pediatric Organizations Recommendations:

Adopted by the Board of Directors on 25 February 2022.

References:

  1. Tan W. School closures were over-weighted against the mitigation of COVID-19 transmission: A literature review on the impact of school closures in the United States. Medicine (Baltimore) 2021;100:e26709. doi:10.1097/MD.0000000000026709
  2. Pediatric AA of. Children and COVID-19: State Data Report 4 February 2021. Child Hosp Assoc 2021;:1–26.
  3. Coronavirus Disease 2019 in Children - United States, February 12-April 2, 2020. MMWR Morb Mortal Wkly Rep 2020;69:422–6. doi:10.15585/mmwr.mm6914e4
  4. Lu X, Zhang L, Du H, et al. SARS-CoV-2 Infection in Children. N Engl J Med 2020;382:1663–5. doi:10.1056/NEJMc2005073
  5. Dong Y, Mo X, Hu Y, et al. Epidemiology of COVID-19 Among Children in China. Pediatrics 2020;145. doi:10.1542/peds.2020-0702
  6. Irfan O, Muttalib F, Tang K, et al. Clinical characteristics, treatment and outcomes of paediatric COVID-19: a systematic review and meta-analysis. Arch Dis Child 2021;106:440–8. doi:10.1136/archdischild-2020-321385
  7. Kelvin AA, Halperin S. COVID-19 in children: the link in the transmission chain. Lancet Infect Dis 2020;20:633–4. doi:10.1016/S1473-3099(20)30236-X
  8. Liguoro I, Pilotto C, Bonanni M, et al. SARS-COV-2 infection in children and newborns: a systematic review. Eur J Pediatr 2020;179:1029–46. doi:10.1007/s00431-020-03684-7
  9. Zimmerman KO, Akinboyo IC, Brookhart MA, et al. Incidence and Secondary Transmission of SARS-CoV-2 Infections in Schools. Pediatrics 2021;147. doi:10.1542/peds.2020-048090
  10. Stokes EK, Zambrano LD, Anderson KN, et al. Coronavirus Disease 2019 Case Surveillance - United States, January 22-May 30, 2020. MMWR Morb Mortal Wkly Rep 2020;69:759–65. doi:10.15585/mmwr.mm6924e2
  11. Wang D, Ju XL, Xie F, et al. [Clinical analysis of 31 cases of 2019 novel coronavirus infection in children from six provinces (autonomous region) of northern China]. Zhonghua er ke za zhi = Chinese J Pediatr 2020;58:269–74. doi:10.3760/cma.j.cn112140-20200225-00138
  12. Moradveisi B, Ataee P, Ghaffarieh A, et al. Diarrhea as a Presenting Symptom of Coronavirus Disease 2019 in Children. Adv Biomed Res 2020;9:35. doi:10.4103/abr.abr_90_20
  13. Tian Y, Rong L, Nian W, et al. Review article: gastrointestinal features in COVID-19 and the possibility of faecal transmission. Aliment Pharmacol Ther 2020;51:843–51. doi:10.1111/apt.15731
  14. Xia W, Shao J, Guo Y, et al. Clinical and CT features in pediatric patients with COVID-19 infection: Different points from adults. Pediatr Pulmonol 2020;55:1169–74. doi:10.1002/ppul.24718
  15. Parri N, Magistà AM, Marchetti F, et al. Characteristic of COVID-19 infection in pediatric patients: early findings from two Italian Pediatric Research Networks. Eur J Pediatr 2020;179:1315–23. doi:10.1007/s00431-020-03683-8
  16. McCormick DW, Richardson LC, Young PR, et al. Deaths in Children and Adolescents Associated With COVID-19 and MIS-C in the United States. Pediatrics 2021;148. doi:10.1542/peds.2021-052273
  17. González-Dambrauskas S, Vásquez-Hoyos P, Camporesi A, et al. Pediatric Critical Care and COVID-19. Pediatrics 2020;146. doi:10.1542/peds.2020-1766
  18. Boehmer TK, Kompaniyets L, Lavery AM, et al. Association Between COVID-19 and Myocarditis Using Hospital-Based Administrative Data - United States, March 2020-January 2021. MMWR Morb Mortal Wkly Rep 2021;70:1228–32. doi:10.15585/mmwr.mm7035e5
  19. Tsabouri S, Makis A, Kosmeri C, et al. Risk Factors for Severity in Children with Coronavirus Disease 2019: A Comprehensive Literature Review. Pediatr Clin North Am 2021;68:321–38. doi:10.1016/j.pcl.2020.07.014
  20. López-Bueno R, López-Sánchez GF, Casajús JA, et al. Potential health-related behaviors for pre-school and school-aged children during COVID-19 lockdown: A narrative review. Prev Med (Baltimore) 2021;143:106349. doi:10.1016/j.ypmed.2020.106349
  21. McKune SL, Acosta D, Diaz N, et al. Psychosocial health of school-aged children during the initial COVID-19 safer-at-home school mandates in Florida: a cross-sectional study. BMC Public Health 2021;21:603. doi:10.1186/s12889-021-10540-2
  22. Nguyen KH, Srivastav A, Razzaghi H, et al. COVID-19 Vaccination Intent, Perceptions, and Reasons for Not Vaccinating Among Groups Prioritized for Early Vaccination - United States, September and December 2020. MMWR Morb Mortal Wkly Rep 2021;70:217–22. doi:10.15585/mmwr.mm7006e3
  23. El-Mohandes A, White TM, Wyka K, et al. COVID-19 vaccine acceptance among adults in four major US metropolitan areas and nationwide. Sci Rep 2021;11:21844. doi:10.1038/s41598-021-00794-6
  24. Fisher KA, Bloomstone SJ, Walder J, et al. Attitudes Toward a Potential SARS-CoV-2 Vaccine : A Survey of U.S. Adults. Ann. Intern. Med. 2020;173:964–73. doi:10.7326/M20-3569
  25. Daly M, Jones A, Robinson E. Public Trust and Willingness to Vaccinate Against COVID-19 in the US From October 14, 2020, to March 29, 2021. JAMA 2021;325:2397–9. doi:10.1001/jama.2021.8246

Role of Primary Care in Disasters

Strong health care systems are founded on a strong primary healthcare sector of local community-based healthcare providers.1,2 This can be attributed to the central role primary care plays in integrating care within health systems.3,4 Health care systems with an effective primary care sector demonstrate greater effectiveness and efficiency and are more equitable.5 Importantly, the effective integration of the primary care sector into the health care system can reduce the high health costs and health services’ utilization associated with chronic disease management.6

While the World Health Organization acknowledges primary health care as an “essential foundation for health emergency and risk management, and for building community and country resilience within health systems,”7 primary care is often underrepresented in discussions related to disaster and emergency situations.

As such, WADEM recognizes primary care as an essential element of disaster health care and supports a holistic whole-of-health approach to disaster management inclusive of all levels of healthcare within the entire disaster cycle of prevention, preparedness, response, and recovery. WADEM strongly endorses the inclusion and integration of the primary health care workforce in emergency preparedness and planning, with the goal of optimizing their contributions to emergency health response and recovery.

Building local health care professional capability and capacity is key to enhancing local community resilience, a key strategy alluded to in Australia’s National Strategy for Disaster Resilience by the Council of Australian Governments.8 A resilient health system, as described by Fitzgerald, Capon, and Aitken, is “a system that integrates all aspects of health care [which] is essential for facing future challenges”.9 Greater emphasis on building community health care prevention and preparedness has the potential to foster efficient utilization of local response and associated resources and reduce the need for an external response when catastrophes do occur. This enables effective response to the significant increase in primary health care burden highlighted by the research, in particular the needs of those with chronic health conditions.10,11 It will also improve health care access within the community to trusted known local health care professionals who are naturally attuned, through daily practice, to the status of health at the community level (pers comm S.Burkle), as well as reinforce post-disaster continuity of care, recovery, and continuing viability of the health care sector.

The Sendai Framework for Disaster Risk Reduction (2015-2030)12 recommends:

  • Increasing resilience of critical infrastructure and reducing the impact to basic services including healthcare;
  • Including all aspects of healthcare especially for “people with life-threatening and chronic disease” and ensuring they continue to have access to life-saving services throughout the response and recovery from a disaster; and
  • Advocating for resilient health services to remain operational, safe, and effective during and following disasters.

In accordance with the Sendai Framework, current knowledge of the epidemiology of the comprehensive health effects of disasters provides an opportunity for risk reduction and improvement in community health outcomes following disasters. A 2011 scoping review on primary care in disasters stated “primary health care is very important for effective health emergency management during response and recovery, but also for risk reduction, including preparedness” 13 and calls for clarification of terminology inclusive of the entire disaster cycle, and increasing primary care disaster research.

Primary health care inherently provides such emphasis on prevention and risk reduction on a daily basis through the provision of:

  • Foundational knowledge of extant community health conditions and challenges;
  • Healthcare focused on primary, secondary, and tertiary prevention;
  • Health literacy and wellness promotion;
  • Early surveillance for emerging disease outbreaks;
  • Early intervention in the management of chronic conditions;
  • Comprehensive team approach for holistic ongoing management of biopsychosocial health;
  • Easily accessible care within the community; and
  • Delivery from local known and trusted health care professionals who will remain long after the media and other emergency responders have left.

Therefore, this WADEM position statement adopts the following:

  • Recognizes primary healthcare as inclusive of family physicians, pharmacists, nurses, social workers, psychologists, and any health worker who usually works as the first point of contact for a person within the local community health system;
  • Supports the evidence that primary health care has been shown to provide a strong foundation for healthcare (e.g. decreasing infant mortality, reducing morbidity and mortality rates, increasing life expectancy);
  • Strives for the inclusion of the primary health care workforce as part of an interprofessional approach to disaster health management throughout the entire disaster cycle – prevention, preparedness, response, rehabilitation, and recovery;
  • Strongly recommends the involvement of primary health care providers in educational and disaster risk reduction activities, as well as advocating for their greater integration in disaster healthcare, with crucial roles to contribute during all stages of the disaster cycle; and
  • Endorses an inclusive resilient health care system that can flexibly adapt to impacts from disasters.

Adopted by the Board of Directors on 31 August 2021.

References:

  1. Starfield B, Shi L, Macinko J. Contributions of primary Care to health systems and health. Milbank Q. 2005;83(3):457-502. doi: 10.1111/j.1468-0009.2005.00409.x.
  2. Van Weel, C. & Kidd, M. R. 2018. Why strengthening primary health care is essential to achieving universal health coverage. CMAJ. 2018 Apr 16; 190(15): E463–E466. doi: 10.1503/cmaj.170784
  3. Valentijn PP, Schepman SM, Opheij W, et al. Understanding integrated care: A comprehensive conceptual framework based on the integrative functions of primary care. Int J Integr Care. 2013 Mar 22;13:e010. doi: 10.5334/ijic.886
  4. Maarsingh OR, Henry Y, Van de Ven PM & Deeg DJ. Continuity of care in primary care and association with survival in older people: a 17-year prospective cohort study. Br J Gen Pract. 2016 Aug;66(649):e531-9. doi: 10.3399/bjgp16X686101.
  5. Starfield B. Primary care: an increasingly important contributor to effectiveness, equity, and efficiency of health services. SESPAS report 2012. Gac Sanit. 2012 Mar;26 Suppl 1:20-6. doi: 10.1016/j.gaceta.2011.10.009.
  6. Lawn S, Zabeen S, Smith D, et al. Managing chronic conditions care across primary care and hospital systems: lessons from an Australian Hospital Avoidance Risk Program using the Flinders Chronic Condition Management Program. Aust Health Rev. 2018 Sep;42(5):542-549. doi: 10.1071/AH17099
  7. Primary health care and health emergencies. In: Technical Series on Primary Health Care: World Health Organization; 2018.
  8. Council of Australian Governments. National Strategy for Disaster Resilience. Barton, ACT: Commonwealth of Australia; 2011.
  9. FitzGerald GJ, Capon A, Aitken P. Resilient health systems: preparing for climate disasters and other emergencies. Med J Aust. 2019 Apr;210(7):304-305. doi: 10.5694/mja2.50115
  10. Greenough PG, Lappi MD, Hsu EB, Fink S, Hsieh YH, Vu A, Heaton C & Kirsch TD. 2008. Burden of disease and health status among Hurricane Katrina-displaced persons in shelters: a population-based cluster sample. Ann Emerg Med. 2008 Apr;51(4):426-32. doi: 10.1016/j.annemergmed.2007.04.004.
  11. Miller AC & Arquilla B. 2008. Chronic diseases and natural hazards: impact of disasters on diabetic, renal, and cardiac patients. Prehosp Disaster Med. Mar-Apr 2008;23(2):185-94. doi: 10.1017/s1049023x00005835.
  12. The United Nations Office for Disaster Risk Reduction (UNISDR). Sendai Framework for Disaster Risk Reduction 2015-2030. Geneva, Switzerland: United Nations Office for Disaster Risk Reduction (UNISDR); 2015.
  13. Redwood-Campbell L, Abrahams J. Primary health care and disasters—the current state of the literature: what we know, gaps and next steps. Prehosp Disaster Med. 2011 Jun;26(3):184-91. doi: 10.1017/S1049023X11006388.

Science and Evaluations in Disasters

WADEM endorses the need to improve the evidence-base of disaster health interventions; improve the quality and accountability of preparedness, response and recovery in this domain; and systematically structure and advance the science of disaster health. Evaluation has a strategic role to play in informing interventions designed to reduce the impact of disasters upon individuals and communities. The aim of such evaluation is to improve science related to the understanding of impacts of disasters and ensure relevance, efficiency, and effectiveness of interventions.

Evidence-based evaluation typologies, frameworks, and methodologies are required to guide users on the application of tools that effectively measure the impact of an intervention and allow for comparison of outcomes to inform current and future practitioners and enhance policymaking. This important development is aimed at facilitating the availability of evidence relevant to disaster evaluation standards and guide robust technical evaluation capacity development. Achievement of this will provide evidence as the basis for change in policies, programs, or projects. As a result, WADEM:

  • Recognizes the need to improve the quality, quantity, and accessibility of evaluation, as well as specific assessment tools in this domain;
  • Strives to standardize the evaluation methodologies in the field of emergency and disaster medicine and management;
  • Supports the use of evaluation in disasters in achieving indicators related to the Sendai Framework for Disaster Risk Reduction 2015-2030; 1
  • Urges education of disaster evaluation methodology and typologies;
  • Recommends engaging the advice or involvement of professionals with evaluation expertise to improve understanding of evaluation in all stages of disaster prevention, planning, response, and recovery;
  • Endorses "Health Disaster Management: Guidelines for Evaluation and Research in the Utstein Style" and subsequent frameworks; 2, 3, 4, 5
  • Endorses "Disaster Metrics: A Comprehensive Framework for Disaster Evaluation Typologies;" 6
  • Endorses the development and use of standardized tools for the evaluation of disasters.

The relevance to the WADEM mission is that, through evaluating and understanding the impacts of disasters, communities can prevent, prepare, respond and recover more effectively.

Adopted by the Board of Directors on 9 April 2020.

References:

  1. Assembly, U.G., 2015. The Sendai Framework for Disaster Risk Reduction 2015–2030. Resolution A/Res/69/283, see https://www.unisdr.org/files/resolutions/N1516716.pdf.
  2. Sundnes, K. (1999). Health Disaster Management: Guidelines for Evaluation and Research in the Utstein Style: Executive Summary. Prehospital and Disaster Medicine, 14(2), 11-20. doi:10.1017/S1049023X0002728X.
  3. Birnbaum, M., Daily, E., & O’Rourke, A. (2015). Research and Evaluations of the Health Aspects of Disasters, Part III: Framework for the Temporal Phases of Disasters. Prehospital and Disaster Medicine, 30(6), 628-632. doi:10.1017/S1049023X15005336.
  4. Birnbaum, M., Daily, E., & O’Rourke, A. (2015). Research and Evaluations of the Health Aspects of Disasters, Part IV: Framework for Societal Structures: The Societal Systems. Prehospital and Disaster Medicine, 30(6), 633-647. doi:10.1017/S1049023X15005348.
  5. Birnbaum, M., Daily, E., & O’Rourke, A. (2015). Research and Evaluations of the Health Aspects of Disasters, Part V: Epidemiological Disaster Research. Prehospital and Disaster Medicine, 30(6), 648-656. doi:10.1017/S1049023X1500535X.
  6. Wong, D., Spencer, C., Boyd, L., Burkle, F., & Archer, F. (2017). Disaster Metrics: A Comprehensive Framework for Disaster Evaluation Typologies. Prehospital and Disaster Medicine, 32(5), 501-514. doi:10.1017/S1049023X17006471.

Gender and Disasters

Gendered expectations shape our risk, ability, and legacy. Internationally, mortality in most disasters is higher for women and children than men. More women than men inhabit risk-prone localities in inadequate housing, and through poverty, have fewer resources for adaptation to climate or escape in catastrophic disasters.

Most societies are patriarchal, where gender is the central organizing framework as evidenced by structural discrimination of men against women, for example, during pregnancy and the postnatal period including breastfeeding, in childcare arrangements, women’s lower status and income, the objectification of women, and violence against women. Those with diverse gender and sexual identities, too, are frequently ignored, excluded, and vilified.

The constraints and expectations of socially-constructed binary gender roles harm people with women expected to nurture others and sacrifice their own safety and wellbeing, and men expected to be protectors and providers, stoic and courageous. Such narrow gender roles and gendered power dynamics lead to damaging effects on mental and physical health and reluctance to seek help for all.

Women and people of diverse gender and sexual identity are at increased risk of violence in disasters through the reinforcement of traditional gender roles, exacerbated power inequality and exposure in evacuation sites and recovery centers. There is a greater willingness to excuse men’s violence when they present as suffering as a result of the disaster or have been cast as “heroes” in it. Disaster also disrupts services previously offered by housing, refuge, and domestic violence organizations. The limited targeted support for women and Lesbian, Gay, Bisexual, Trans, and Intersex (LGBTI) people experiencing domestic violence is exacerbated in the context of an emergency.

The lack of attention to violence against women and people of diverse gender and sexual identities in disasters and their aftermath must be addressed through first understanding the problem. Sex/gender-disaggregated data (with options for indeterminate/intersex/unspecified) will provide an informed basis on which to improve required services.

Male privilege brings costs for men as well as women. Gender norms encourage men and boys to be risk-takers, which can expose them to danger. Men are frequently reluctant to seek help after a disaster and can be isolated from support services and social networks due to culturally embedded notions of masculine stamina. It is common for men to self-medicate with drugs or alcohol as a coping mechanism after a trauma. As a result, WADEM:

  • Recognizes that disasters have differential effects on women, men, and people of diverse gender and sexual identities due to a range of factors that include discrimination, socially-constructed gender roles and expectations, and unequal access to wealth and power. Women and people of diverse gender and sexual identities are under-represented in decision making and their perspectives are under-utilized in disaster contexts.
  • Supports the Sendai Framework for Disaster Risk Reduction 2015-2030 in its statement that a gender perspective should be integrated into all disaster policies and practices, and that women’s leadership should be promoted and facilitated. Ideally, this would be extended to include LGBTI people.
  • Urges education of disaster personnel in recognizing and acting upon gender or cultural practices which may discriminate against or endanger women and people of diverse gender and sexual identities in times of disaster.
  • Recommends engaging the advice or involvement of professionals with gender expertise to improve understanding of the way gender compounds disaster experience, e.g. through women’s health services, organizations to promote the wellbeing of LGBTI people, or from gender units in universities. Importantly, WADEM urges the inclusion of specialist domestic violence services in all stages of disaster planning, recovery, and reconstruction.

The relevance to the WADEM mission is that through acknowledging and understanding the gendered impacts of disaster in emergency management and response, communities can prepare and rebuild more effectively, reduce violence, and ultimately save lives.

Adopted by the Board of Directors on 14 August 2019.

References:

  1. The Sendai Framework for Disaster Risk Reduction 2015-2030
  2. Sustainable Development Goals (5: Achieve gender equality and empower all women and girls)
  3. UN Convention on the Elimination of All Forms of Discrimination against Women - https://www.ohchr.org/en/professionalinterest/pages/cedaw.aspx
  4. The GEM Guidelines Literature Review provides the evidence base. (Available: UN Prevention Web or AIDR Knowledge Hub)
  5. www.genderanddisaster.com.au
  6. www.gdnonline.org

Protection of Health Care Workers in all Environments

WADEM believes that all health care workers have the right to work in safety. For emergency responders to provide the best possible care to the community they need a safe, non-threatening environment that is respected by the community, family members, and bystanders. WADEM encourages the protection of health care workers against all threats or acts of violence in the workplace.

Attacks on health care include any act of verbal or physical violence, or obstruction, or threat of violence that interferes with the availability, access, and delivery of curative and/or preventive health services in any environment. These attacks endanger health care providers while depriving patients of their right to health care. These attacks may not only affect the clinical outcomes of patients, but, also, may affect their ability to care for themselves and their families, to participate in gainful employment, and to achieve their highest level of productivity.

Incidents of work-related violence have occurred worldwide. From 2014-15, 44 out of every 1,000 paramedics in the United Kingdom suffered some form of assault.1 The Centers for Disease Control and Prevention in the United States estimates that 2,600 EMS workers received hospital treatment in 2014 for injuries resulting from work-related violence. A recent study reviewing the impact of violence against paramedics across 13 countries, reported that 65% of responders had been assaulted.3 The US Occupational Safety and Health Administration (OSHA) reports that from 2002 to 2013, the incidents of serious workplace violence (those requiring days off for the injured worker to recuperate) were four times more common in health care than in private industry on average.4

The World Health Organization (WHO) Attacks on Health Care5 dashboard includes statistics of injuries and deaths in complex humanitarian emergencies. These data include out-of-hospital and in-hospital attacks reported through information that is publicly available, and from relevant WHO country offices. In 2017, there were reports of 322 health care attacks in 20 countries including 65 in the prehospital setting, 154 in a health care facility, 93 of the reported attacks were on health care providers, and 10 were on patients.

One direct effect of work-related violence is the strain placed on health care delivery. Affected workers may be unavailable to work due to recuperative needs following an attack, and some workers may elect to abandon their health care career after years of education and experience. There is also a flow-on effect in terms of adverse mental health outcomes for emergency responders, with heightened rates of suicide and self-harm compared to the general population. The loss of dedicated, highly trained and educated health care providers in either of these ways is unacceptable. Furthermore, on-the-job assaults and threats may complicate the recruitment retention of future health care workers.

WADEM supports the WHO Attacks on Health Care initiative in all environments, in the developed and developing world, as well in complex humanitarian emergencies (CHE) to:

  • Develop a body of evidence to better understand the extent and nature of the problem and its consequences to health care delivery;
  • Develop a strong advocacy campaign to:
    • end attacks on health care;
    • promote the sanctity of health care in all circumstances;
    • deliver health care unhindered by violence; and
    • promote the application of International Humanitarian Law; and
  • Develop and promote the implementation of best practices for the prevention of attacks, and the mitigation of their consequences to the health service delivery in all environments.

Adopted by the Board of Directors on 4 February 2019.

References:

  1. https://www.nwas.nhs.uk/media/865201/reported-physical-assaults-2014-15.pdf accessed 2 October 2018
  2. National Institute for Occupational Safety and Health. Medical Services Workers - Injury Data. https://www.cdc.gov/niosh/topics/ems/data.html. accessed 2 October 2018.
  3. Maguire BJ, Browne M, O’Neill BJ, Dealy MT, Clare D, O’Meara P. International Survey of Violence Against EMS Personnel: Physical Violence Report. Prehosp Disaster Med. 2018;33(5):526–531.
  4. Occupational Safety and Health Administration. Workplace Violence in Healthcare. https://www.osha.gov/sites/default/files/OSHA3826.pdf. accessed 4 November 2018.
  5. World Health Organization. Surveillance System for Attacks on Health Care. https://extranet.who.int/ssa/LeftMenu/Index.aspx. accessed 4 November 2018.

Accurate Reporting of Public Health Information

Accurate and transparent release of public health information is necessary to inform response and recovery activities associated with disasters. The resolution to adopt the international health regulations in 2005 recognized the World Health Organization's leadership in monitoring and responding to public health emergencies.1 Preservation of global health security is reliant upon timely reporting of emergencies and health threats to enable appropriate preparedness and response.2

Withholding, suppression, delayed, or deliberate inaccurate reporting public health information presents a risk to potential health threats to populations. The restriction of epidemiological health information hampers efforts to respond to events3 The transparent and timely release of public health information is logical, ethical, and required to maintain and improve global health. As such, WADEM endorses that:

  • Global health security is reliant upon timely reporting of emergencies and threats to enable appropriate preparedness and response.
  • Withholding, suppression, delayed or deliberate inaccurate reporting public health information presents a risk of potential health threats to populations.
  • That Customary International Humanitarian law recognizes the prohibition of attacks on, destruction of or render useless any public health infrastructure indispensable to the survival of the civilian population; that the Geneva Convention (Article 55 & 56) requires that an occupying power must restore the public health infrastructure and protections afforded to the civilian population to mitigate and prevent mortality and morbidity after any conflict or war. This applies equally to post sudden-onset-disasters or public health emergencies of international concern necessary to protect global health.
  • The accurate, transparent and timely release of official public health information is necessary to identify risks, provide health alerts, and promote and protect global health.

Adopted by the Board of Directors on 8 December 2017.

References:

  1. Organization WH. International Health Regulations (2005): World Health Organization; 2008.
  2. DOC I. Global health security-epidemic alert and response. 2001.
  3. Burkle FM. Global health security demands a strong international health regulations treaty and leadership from a highly resourced World Health Organization. Disaster Medicine and Public Health Preparedness. 2015;9(5):568-80.

Climate Change

Climate change is affecting disaster risk and disaster impact. WADEM recognizes climate change as an issue of global concern. It is WADEM’s responsibility to support the capacity of emergency management, humanitarian, and health professionals to address the disaster impacts of climate change.

WADEM supports health improvement activities, with emphasis on health promotion during and following a disaster to reduce the effects of climate change, achieved by cooperation among and between multidisciplinary professions involved in research, education, management, and practice in prehospital, emergency, public health, and disaster health care.

The United Nations General Assembly has encouraged the Intergovernmental Panel on Climate Change to continue to assess the adverse effects of climate change upon communities and recognizes the need for implementation of disaster risk reduction programs.1 The Special Report on Managing the Risks of Extreme Events and Disasters to Advance Climate Change Adaptation2 and the Fifth Assessment Report produced by the Intergovernmental Panel on Climate Change3 provide an updated review of scientific knowledge relevant to climate change and reported consensus on emerging risks associated with climate change; as such it represents an emerging threat to the health status of communities. Impact categories identified by these reports relative to disaster risk include:

  • Increased morbidity and mortality due to extreme heat waves, fire, and other extreme weather events;
  • Biodiversity changes leading to infectious disease spread and duration due to alterations in weather and vector distribution;
  • Reduced food yields due to drought;
  • Increased displacement of populations; and
  • Increased risk of conflict, poverty, and economic shock.

The Lancet Countdown on tracking progress on health and climate change is an international, multidisciplinary research collaboration which aims to track the health impacts of climate hazards, health resilience and adaptation, health co-benefits of climate change, and calls for mitigation and broader political engagement.4

The Sendai Framework for Disaster Risk Reduction (2015-2030), a 2015 UN landmark agreement, outlines priorities for action while identifying climate change as both a driver of disaster risk and as an influencing factor of disaster impact and sustainable development.5 As a result, WADEM:

  • Recognizes the importance of climate change due to its influence on frequency and severity of natural hazards, and on disasters of natural, public health-related, and conflict causes; and
  • Recommends all disaster and emergency professionals and organizations adopt a risk-based approach to emergency planning that prepares for and enhances resilience to climate change effects and recommends linking this to the implementation of the Sendai Framework for Disaster Risk Reduction (2015-2030).

Adopted by the Board of Directors on 24 April 2017.

References:

  1. United Nations General Assembly resolutions on natural disasters and vulnerability (59/233 and 58/215).
  2. IPCC. Managing the Risks of Extreme Events and Disasters to Advance Climate Change Adaptation. Intergovernmental Panel on Climate Change [Core Writing Team: Field CB, Barros V, Stocker TF, et al]. IPCC; Geneva, Switzerland; 2012:582pp.
  3. IPCC. Climate Change 2014: Synthesis Report. Contribution of Working Groups I, II, and III to the Fifth Assessment Report of the Intergovernmental Panel on Climate Change [Core Writing Team: Pachauri RK and Meyer LA (eds.)]. IPCC; Geneva, Switzerland; 2014:151pp.
  4. Watts N, et al. The Lancet Countdown: Tracking Progress on Health and Climate Change. Lancet. 2017;389(10074):1151–1164.
  5. United Nations General Assembly. Sendai Framework for Disaster Risk Reduction 2015-2030. A/RES/69/283: 2015.

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