Although acute physical injuries are the leading cause of human mortality and morbidity in natural disasters, a significant proportion of deaths are a result of poor hygiene and sanitation, inadequate nutrition as well as insufficient health care services due to the destruction of healthcare structure and resources to cope with the diseases prevalent in the affected area. Whilst the provision of basic care following disasters usually focuses on the treatment of acute conditions like injuries, diarrhoea and respiratory infections, as well as more recently on psychosocial and mental health services, the provision of care for chronic diseases is rarely seen as a priority. For the twenty-first century, the aging of most populations around the world, in combination with an increase of non-communicable, often chronic, diseases, calls for a rethink (E. Y. Y. Chan and E. Sondorp, Medical Interventions Following Natural Disasters: Missing Out on Chronic Medical Needs, Asia Pacific Journal of Public Health, 2007).
The burden of chronic disease
Table 1 highlights the burden of chronic disease in selected countries frequently affected by natural disasters. The absence or disruption of treatment for chronic diseases (like diabetes, high blood pressure, mental illness and HIV/AIDS) is not only life-threatening for vulnerable groups, but may also give rise to complications (e.g. diabetes retinopathy, stroke) resulting in a reduction in quality of life and potentially impaired livelihoods, due to the costs of complication treatments and avoidable deaths.
To act or not to act
Typically, a natural disaster emergency health response would include treatment for injuries, basic care for common diseases, surveillance and emergency preparedness for disease outbreaks. Management of non-communicable chronic disease is usually left out. There are a number of questions that need to be considered when deciding to provide medical services for chronic diseases in developing countries during medical relief after natural disasters. Table 2 outlines some of these issues.
Gaps in responses
There are virtually no guidelines regarding the management of chronic medical conditions after natural disasters. The Sphere Minimum Standards highlight the issue of chronic medical condition management, but guidelines in terms of deciding which conditions to manage, indicators for monitoring or guidelines on treatments to adopt in emergency settings are absent. The key gap at the field level seems to be the lack of mandate and awareness among relief agencies and health workers of the need to manage chronic diseases during emergency relief operations. After the Sichuan earthquake in May 2008, frontline medical teams found that up to 38% of survivors needed clinical management of their pre-existing chronic medical conditions before further surgical interventions could be performed for their physical trauma (E. Y. Y. Chan, The Untold Stories of the Sichuan Earthquake, The Lancet, August 2008). Only a handful of relief groups had identified chronic disease management as a priority during emergency medical relief work. Even when surgeons and appropriate drug supplies were available, many older patients with orthopaedic trauma were not surgically treated because of their poor clinical condition (for instance unstable glucose control for diabetes). In addition, immediately after the initial acute phase, the patient profile changes as there will be an increasing number of patients seeking care for non-disaster health needs, such as unstable hypertension and minor stroke as a result of a lack of medication.
The major field debate regarding chronic disease management post-disasters concerns whether medical care should be provided for chronically ill people living in areas where pre-disaster health services do not exist. To help decision-making on whether or not to include care for chronic diseases after a natural disaster, we present a conceptual model in Figure 1.
It is important to understand the pre-existing circumstances in the disaster-affected location before making decisions. Population beliefs and receptivity, pre-disaster service availability, local technical capacity, resource availability in terms of finances and materials, the commitment and duration of involvement of the intervening agency and possible partnerships should all be considered. During the assessment, the timing of the intervention (in terms of the stage of the disaster), its goals, where operations are set up, the availability of a referral system and the technical capacity of relief agencies all have to be examined.
Regardless of the decision, it is important to highlight that management of chronic conditions involves a spectrum of services ranging from disease prevention/protection to health promotion, diagnosis, treatment, rehabilitation (tertiary prevention) and palliative care. Some of these services, such as health advice, would incur no cost but have, potentially, long-term implications for disease prevention. For instance, not only can smoking cessation advice prevent potential adverse clinical outcomes such as heart diseases, stroke and cancer, but health advice may also reduce spending on cigarette consumption. Even if it is decided not to provide chronic disease treatment, there are still ways to provide support. For example, agencies could try to identify referral options, where relevant services and clinical management support are provided, and facilitate referral. At the very least, they might consider documenting the key chronic disease burdens among the disaster-affected population so as to highlight health gaps that need to be addressed.
In the decades to come, non-communicable chronic medical conditions will become too significant a burden to ignore during emergency medical field operations. It is important that emergency medical missions do not substitute for local systems, and issues of sustainability of treatment should be carefully assessed. Nevertheless, refusing to manage chronic medical conditions during emergency operations may result in the very mortality and morbidity which the relief operation intends to minimise.
Emily Y. Y. Chan (email@example.com) works in the School of Public Health, Faculty of Medicine, The Chinese University of Hong Kong. Egbert Sondorpis a member of the Health Policy Unit at the London School of Hygiene of Tropical Medicine.