Below are WADEM’s Position Statements as adopted by the Board of Directors.
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:
Central America and Venezuela
Rohingya Refugee Emergency
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.
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
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 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
Appendix 2: International Pediatric Organizations Recommendations:
Adopted by the Board of Directors on 25 February 2022.
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:
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:
Therefore, this WADEM position statement adopts the following:
Adopted by the Board of Directors on 31 August 2021.
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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:
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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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:
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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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 every1,000 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:
Adopted by the Board of Directors on 4 February 2019.
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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:
Adopted by the Board of Directors on 8 December 2017.
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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:
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:
Adopted by the Board of Directors on 24 April 2017.
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