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

Position Statements

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

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.

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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.

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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 centres. 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.

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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 2014-2015, 44 out of every 1,000 Australian paramedics suffered some form of assault.1 The Centers for Disease Control and Prevention in the United States of America 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.2 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.3

The World Health Organization (WHO) issues a quarterly Attacks on Health Care4 dashboard with 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, and 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.5

WADEM supports the WHO Attacks on Health Care Project 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.

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References:

  1. https://www.nwas.nhs.uk/media/865201/reported-physical-assaults-2014-15.pdf accessed 2 October 2018
  2. https://www.usfa.fema.gov/current_events/083117.html accessed 2 October 2018
  3. Workplace Violence in Healthcare. https://www.osha.gov/Publications/OSHA3826.pdf accessed 4 November 2018
  4. Attacks on Health Care. https://www.who.int/emergencies/attacks-on-health-care/en/ accessed 4 November 2018
  5. https://www.who.int/hac/techguidance/attacks_on_health_care_q_a/en/ accessed 4 November 2018

Accurate Reporting of Public Health Information

The mission of WADEM is the global improvement of prehospital and emergency health care, public health, and disaster health and preparedness. 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.

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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 recognises the need for implementation of disaster risk reduction programmes.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.

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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.