Typhoon Haiyan (known locally as Yolanda) made landfall in the Philippines on 8 November 2013. Just over a year on, this article reflects on what the World Health Organisation (WHO) the co-lead for the health cluster alongside the Philippines Department of Health (DoH) has learnt, how these lessons have influenced the response over time and what this means for responses to health emergencies in the future. The article is based on internal information from WHOs own work, though it is hoped that the main findings will also be useful to other agencies.
Responding to multiple disasters
The first lesson is that national agencies and the international community need to be ready to respond to multiple natural disasters each year in the Philippines. The country is one of the worlds most disaster-prone. Typhoon Haiyan was the third crisis to hit the country in two months, following conflict in Zamboanga and an earthquake in Bohol, which combined displaced 750,000 people. This meant that response services including national and international agencies and the Philippine army were already stretched.
WHO Philippines has been working with the DoH to set up Emergency Operations Centres in vulnerable areas of the country, and to establish a gold, silver and bronze command system+The colours signify different levels of control within a hierarchical framework: gold for strategic, silver for tactical and bronze for operational. to direct disaster responses. The agency has also been restocking and pre-positioning medical supplies and equipment in anticipation of more natural disasters, and is developing toolkits with the DoH for emergency preparedness. These toolkits will provide guidance on procedures and practices to ensure a quick response in the aftermath of an emergency. Both national and local governments are working to ensure that health structures are disaster resilient.
A second lesson is that, in any emergency response, aid agencies need to be prepared for the situation on the ground. Foreign medical teams need to bring enough food, water, shelter, fuel and communications equipment to be self-sufficient, particularly in areas that are physi-cally cut off and where communications are poor or non-existent. They also need to factor into their pre-arrival planning sufficient health supplies and capacity to deal with the health priorities and ground realities in the Philippines. Some teams came ready to treat the injured but had not considered the immediate demand for services for pregnant mothers or the need to replace daily medications. The country has a triple burden of disease: communicable and non-communicable diseases plus the impact of natural disasters on an already stretched health service. The Philippines also has the highest fertility rate in Asia: for some military medical teams accustomed to treating injuries it was a surprise to find they had to dust off their skills at delivering babies too. Some teams needed additional drug supplies from WHO Philippines to treat chronic heart disease and hypertension.
For efficient use of the medical personnel, facilities and medication brought in by foreign medical teams, it is essential to systematise the procedure for their deployment. WHO Philippines instigated a registration and briefing system to make sure foreign teams were prepared before they were deployed to areas needing support. WHO helped the DoH to coordinate over 150 foreign medical teams during the response. They held over 193,000 consultations, performed over 5,000 surgeries and assisted in over 1,200 deliveries.
Anticipate likely needs
A third lesson concerns anticipating what the needs will be during different phases of the response. In the first wave, the initial days and weeks are focused on treating the injured, providing equipment to newly disabled people and attending to pregnant women. A second wave of activity involves the prevention of disease outbreaks through the restarting of surveillance activities to track any potential outbreaks and an immunisation campaign across the whole affected area to protect children against measles, rubella and polio. This is coordinated by the national government, but UN agencies and foreign medical teams provide important support on disease surveillance and often participate in the delivery of immunisation campaigns. Measles is circulating constantly in the Philippines, and after a disaster children living in crowded conditions are particularly vulnerable to developing complications and even dying of the disease. In addition to poor living conditions, there can be large-scale migrations in the aftermath of a major disaster, which are likely to have an impact on immunisation needs.
In the first wave of immunisations conducted in the typhoon-affected area, almost 110,000 children were vaccinated against measles, and an expanded catch-up campaign in the National Capital Region in JanuaryFebruary 2014 saw an additional 1.7 million children immunised. In addition, there is an urgent need to get those living with TB and multi-drug resistant TB (MDR-TB) back on treatment to prevent the spread of the disease and increased drug resistance. The typhoon-affected area had an estimated 26,249 TB cases with 356 cases of MDR-TB. By mid-December almost all TB patients were back in treatment services. There is also a need to prevent other communicable diseases such as dengue, which spreads quickly where mosquitos are able to breed among debris.
Disasters such as Typhoon Haiyan magnify the threat from non-communicable diseases (NCDs) because they disrupt access to and delivery of essential interventions, including medicines. This constitutes a third wave of activity. NCDs are among the top killers in the Philippines, accounting for more than 70% of the deaths recorded in the country annually. Within weeks of the typhoon there was a rise in the number of patients requiring treatment for NCDs, and as the months went on the risk of heart attacks and strokes grew significantly due to the stress of the situation combined with long-term health problems. In the first three months after the disaster, 14,000 consultations were reported for hypertension alone. Another 1,770 consultations were reported for diabetes. The need to address NCDs proactively before a natural disaster and to ensure sufficient care in the aftermath was a key lesson from the response to Haiyan. WHO provided additional supplies for NCD treatment to the foreign medical teams that came to assist in the response as many had not anticipated the level of demand.
Within three to four months after a disaster there is a transition from an emergency response to an early recovery phase. Emergency response activities such as supplementary feeding programmes close down and free health care dries up as foreign medical teams leave. This transition can lead to further health challenges that have to be planned for and managed. For example, in many of the typhoon-affected areas malnutrition was already a problem. The concern was that this would be exacerbated when feeding programmes finished. WHO has been promoting breastfeeding of newborns and infants as a way to improve child health, and has trained health workers to treat severe acute malnutrition in particular. Meanwhile, as public water supply systems are restored, they need to be tested for water quality. Results of water quality testing done in priority areas of region 8 revealed the presence of bacteriological contamination in a third of the samples collected. There was a clear need for training and skills enhancement of water safety engineers to ensure safe water supplies. WHO has trained 340 sanitary inspectors on water quality management and distributed test kits to nine provinces and two cities.
Mental health needs
In the first few weeks after a disaster it is essential to provide psychosocial first aid, particularly to people who have lost family, homes or livelihoods. However, mental health impacts begin to really show after around six months, when the initial adrenalin rush dies away and morale and energy dip. Responding to mental health needs requires a fourth wave of activity. WHO estimates that, in humanitarian emergencies, the percentage of people suffering from depression or anxiety disorders can double from a baseline of 10% to about 20%, while the percentage of people with severe mental disorders can increase by up to 50%.
A baby boom
Finally, there is typically a baby boom following a disaster. More women become pregnant than previously expected, leading to greater demand for prenatal care and for food and vaccines for children following their birth. This puts additional pressure on health services just as many aid agencies are pulling out. This fifth wave of health needs requires a scaling up of services and a longer-term plan to serve the needs of a growing population.
Strengthen long-term resilience
Given these multiple waves of health needs it is important that health teams do not all rush in at once, but that assistance is staggered to make sure that peoples needs are met for months not just weeks after the disaster. This is a question of coordination and requires the support of donors and aid agency managers. WHO Philippines was particularly grateful to those teams that held back and took over once the initial rush had subsided and others had pulled out. It is important to recognise the work that was done after the TV cameras had gone. Considerable health needs remain more than a year after the typhoon, with implications for the management and funding of the health aspects of the response given that most funding tends to finish within 12 months. Ultimately, there has to be a sixth wave of activity: the transition from recovery to development, with a multi-year plan in place to ensure the full restoration of health services to all those in the affected areas. This requires investment in health planning, information management and capacity-building at all levels.
A final lesson therefore concerns how to strengthen resilience for the future, particularly given the frequency and severity of natural disasters in the Philippines. We know that the health facilities that best withstood the typhoon were often originally built and supported by the community. It is at the level of communities that this resilience has to be forged. To build resilience at local level requires improving the skills of community health workers. First aid training can help ensure that communities are able to assist the injured before national and international teams have reached them. Resilience also needs to be built into the construction and management of health facilities, and WHO has included building plans, design parameters and guidelines for rebuilding health facilities in two photobooks published by the DoH, entitled Rising Anew: Health at the Heart of Healing. These health facilities require a predictable supply of clean water and electricity services that are sadly lacking even in areas not hit by the typhoon. To improve this situation, local officials need to understand where these services are absent and take charge of rectifying this. WHO Philippines has worked hard with the DoH to map the status of health infrastructure and health services. This process is ongoing and will guide recovery operations.
The Philippines faces multiple natural disasters each year, and to respond to them we need to have the right emergency services and systems in place. The structure created to deal with disasters has to be able to handle multiple waves of health needs over months and, in the case of a disaster on the scale of Haiyan, for years after the event. This requires investment in health planning, information management and capacity-building at all levels. WHO Philippines continues to work with the national government and international partners to ensure the full restoration of health services to all those in typhoon-affected areas.
Dr Julie Hall MBE is the WHO Representative to the Philippines.