A disaster is an event or situation that causes great damage, destruction, and human suffering; overwhelms local capacity; and can necessitate requests for national or international assistance. In its 2019 Global Assessment Report, the Head of the United Nations (UN) Office for Disaster Risk Reduction states that “the human race has never before faced such large and complex threats.” With the launch of the Global Humanitarian Overview 2021, the UN Secretary-General has quoted:
Conflict, climate change and COVID-19 have created the greatest humanitarian challenge since the Second World War… together, we must mobilize resources and stand in solidarity with people in their darkest hour of need.
Climate change directly impacts health through the injuries, displacements, and deaths associated with floods, storms, wildfires, and heat-related illnesses. Occurrences of extreme weather events have doubled since the year 2000, with disasters associated with natural hazards having affected 60 million people in 2018 alone. Between 1998 and 2017, 2 billion people were affected by floods and 125 million by earthquakes. Not limited to natural and environmental events, disasters in the context of human activity, war, terrorism, industrial catastrophe, and pandemics, for instance, demand large-scale coordinated response efforts and attention. In the 21st century, conflicts are increasingly affecting civilian populations; since 2010 the world has reached the highest number of internally displaced persons (IDPs) ever with 51 million IDPs and doubling to 20 million refugees. The global COVID-19 pandemic is reported to have set back decades of development progress, with extreme poverty increasing for the first time since 1990.
Reducing the risks and minimizing negative impacts of disasters is approached through comprehensive emergency management. Generally, comprehensive emergency management involves a cycle of four phases: preparedness, response, recovery, and mitigation ( Fig. 26.1 ). During the preparedness phase, planning, training exercises, and resource management activities are conducted. Response in a disaster focuses on saving lives and reducing damage and covers warnings, evacuations, emergency response, medical care, and relief efforts. Evolving to the recovery phase, service restoration, reconstruction, and longer-term care and support are implemented. Mitigation strategies can include evaluation of previous response outcomes, vulnerability identification and awareness, and public education.
Large-scale disasters such as sudden-onset emergencies necessitating international response are typically managed under the auspices of the UN Office for Disaster Risk Reduction, which covers preparedness, response, and recovery measures. Coordination of responses is operationalized through a cluster approach, which groups disaster response into clusters covering each of the main areas of action, including health, shelter, sanitation and water, logistics, and emergency telecommunications. Various humanitarian organizations including UN agencies (such as UNICEF, the United Nations Children’s Fund) and nonprofit organizations (International Federation of Red Cross and Red Crescent Societies) are designated by the Inter-Agency Standing Committee (IASC) as lead(s) responsible for each cluster’s activities. The IASC was created by the UN in 1991 and is the highest-level humanitarian coordination forum of the UN. The Health Cluster is led by the World Health Organization (WHO), and the Emergency Telecommunications by the World Food Program. The UN response is coordinated with the national authorities, and humanitarian actors should actively engage with and support the national and local authorities to lead or progressively take over the response.
Disasters and Disability
The field of disaster medicine has made important advances in the past 25 years, with formalization of training, education, and clinical competencies. While surgical and acute care are traditionally the focus of emergency medical responses, there is increasing recognition of the critical role of rehabilitation in disaster management. Articles 11, 25, and 26 of the UN Convention on the Rights of Persons With Disabilities clearly support as a human right the access to rehabilitation for persons with disabilities, including during emergencies and natural disasters. Unfortunately, in many areas affected by disasters, rehabilitation resources and infrastructure are often poorly developed, particularly in low and low-middle income countries. Relative to general populations, persons with disabilities endure higher risks in disaster and emergency situations, including conflicts. Physical and societal barriers include inaccessible transport and shelters, loss of specialized equipment such as wheelchairs and communication aids, deprioritization for emergency services, and absence of disability-specific planning. Hurricane Katrina in the United States exposed such vulnerabilities, with disproportionate death rates for persons with disability.
Notwithstanding the higher risk and vulnerability of persons with disability in disasters, improvement in disaster responses, in general, has resulted in increased numbers of persons surviving severe trauma events, with high numbers of injured survivors relative to mortality. Injuries more commonly occurring in disasters include complex fractures and peripheral nerve injuries, spinal cord and brain injuries, and amputations. Earthquakes result in lower-extremity trauma with amputations, compound fractures, soft tissue, nerve, and spinal cord injuries. Cyclones cause more upper body trauma, with head injuries most common. Wars, conflicts, and terrorist attacks result in blast injuries and gunshot wounds; a report from a hospital in Turkey treating refugees from the Syrian war described firearm injuries as the major cause of injuries needing emergency surgery, with a survival rate of 24% for neurosurgical cases. Between 150 and 750 new spinal cord injuries were estimated to have occurred in each of the earthquakes in Iran (2003), Pakistan (2005), and Haiti (2010).
New disabling or potentially disabling injuries require dedicated, targeted, and timely rehabilitation interventions to reduce impairment and optimize outcomes for the injured, the family, and community. Evidence supports that rehabilitation in disasters improves patient and community outcomes in both the short and long term, reduced disability and complications, improved participation, and quality of life. In Pakistan, rehabilitation professionals and trainees in the military program were able to provide more specialized care for one cohort of spinal cord survivors, which demonstrated improved outcomes relative to those who did not receive specialized rehabilitation care. Following the 2010 earthquake in Haiti, persons with new spinal cord injuries were denied admission to some field hospitals, and one center reported “…we believed it would be incorrect to use our limited resources to treat patients with such a minimal chance of ultimate rehabilitation.” While many persons with spinal cord injury did ultimately get treated in Haiti — in fact Haiti was represented at the 2012 Paralympics in London, UK by one such individual — the oft-overlooked yet vital role of rehabilitation in disasters was evident. The aftermaths of the Haitian earthquake, coupled with other relatively recent disasters including the Pakistan earthquake, Sichuan, China earthquake 2008, and Hurricane Katrina 2005, have mobilized efforts of international aid organizations, the WHO, and disability advocates and professions to promote, strengthen, and regulate disaster management in the context of persons with disabilities ( Table 26.1 ). Guidance notes, training resources, and rehabilitation recommendations have been developed, further supporting a more structured approach across the disaster life cycle. Core rehabilitation-specific activities during a disaster response have been proposed, with refinement informed by experience and research ( Fig. 26.2 ). In the United States, a “functional-needs approach” has been adopted by the Federal Emergency Management Agency since 2010 in identifying disability-related needs in a disaster. Five areas are considered: communication, medical health, functional independence, supervision, and transportation (C-MIST), recognizing that persons with disabilities as well as other vulnerable groups (children, elderly) may need additional assistance.
|Organization||Activities/Mission||Resource Examples a||Website|
|World Health Organization (WHO)||WHO works worldwide to promote health, keep the world safe, and serve the vulnerable; including goal to protect a billion more people from health emergencies||who.int/health-topics/disability|
|Humanity and Inclusion (HI)||International aid organization working in situations of poverty and exclusion, conflict, and disaster. Works alongside people with disabilities and vulnerable populations|
|International Committee of the Red Cross (ICRC)||Independent neutral organization ensuring humanitarian protection and assistance for victims of armed conflict and other situations of violence||icrc.org|
|United Nations Office for the Coordination of Humanitarian Affairs (OCHA)||OCHA contributes to principled and effective humanitarian response through coordination, advocacy, policy, information management, and humanitarian financing tools and services||Relief Web—global online site for timely and accessible resources||reliefweb.int/|
|Médecins Sans Frontières||Nonprofit, member-based organization, provides medical assistance to people affected by conflict, epidemics, disasters, or exclusion from health care||Medical Guidelines: Essential drugs||msf.org|
|International Society of Physical and Rehabilitation Medicine||Professional organization of physicians and researchers in physical and rehabilitation; Disaster Rehabilitation Committee advocates for physical and rehabilitation medicine perspective in minimizing disability, optimizing functioning, and health-related quality of life in persons who sustain traumatic injury, and those with preexisting disability during natural or man-made disasters||Multiple publications on rehabilitation in disasters||isprm.org|
|International Spinal Cord Society||Professional organization of spinal cord injury clinicians and scientists; endeavors to foster education, research, and clinical excellence|
|International Society for Prosthetics and Orthotics||Professional organization aiming to improve the quality of life for persons who may benefit from prosthetic, orthotic, mobility, and assistive devices||Implementing prosthetic and orthotic services in low-income settings||ispoint.org|
a Many of these publications are collaborative efforts of multiple organizations.
Telerehabilitation in Disasters
The goals of rehabilitation in a disaster are not unlike any rehabilitation setting; manage the injury/trauma, prevent secondary complications, apply a holistic approach to functional restoration and recovery, and facilitate community reintegration.
Telehealth strategies have been used effectively in disaster situations for several decades, including human-caused disasters and natural disasters. In 1988 the National Aeronautics and Space Administration agency deployed a spacebridge to facilitate telerehabilitation support for the earthquake victims in Armenia, and the US armed forces has a long history of employing telerehabilitation support in military humanitarian action. In a review of telerehabilitation and disasters published in 2014, the authors concluded that telerehabilitation systems should be established in disaster-risk areas as a preparedness strategy.
The merits of telerehabilitation approaches have been reported for conditions such as stroke, musculoskeletal and neuromuscular disorders, and are well described in this textbook. However, there is a paucity of literature specific to telerehabilitation in the context of disasters. Drawing on disaster rehabilitation evidence and extrapolating telerehabilitation principles from the general non-disaster field can inform current telerehabilitation approaches across the disaster cycle and identify further research needs. In a special report published in the Journal of Rehabilitation Medicine , authors call on the need to develop innovative models of rehabilitation during disasters, including telerehabilitation in order to optimize delivery of timely, cost-efficient, and patient-centered services as needed.
One of the key benefits of telerehabilitation initiatives is the increased ability for persons with disability to access essential health services when physical attendance at a hospital or clinic is not possible or represents a significant burden. A disaster situation presents extreme obstacles to health care access, which telerehabilitation can potentially rectify. Benefits of telerehabilitation during disasters can include:
Remote consultations with rehabilitation specialists not available in the field, facilitating earlier assessment and initiation of appropriate interventions, and thus earlier discharge to community,
Earlier and informed triage to allow for appropriate transfers, referrals, or evacuations as needed,
Peer-to-peer support for patient assessment and management,
Avoiding the need patients to be transported through dangerous or unstable territory,
Assessment and management direct to consumer reducing burden to overwhelmed health facilities,
Training and mentoring of local health providers in more specialized care needs, and providing longer-term capacity and skills development, and
Technical evaluations facilitating specialized rehabilitation interventions, for example, three-dimensional scanning of residual limbs to generate a custom prosthesis offsite.
Another consideration is that telerehabilitation services could reduce strain on a medical system burdened due to ongoing disaster, where a patient could receive ongoing rehabilitation services from home, freeing up hospital beds potentially in need for emergency circumstances. In pandemics, as the world has recently experienced, telerehabilitation can:
Allow for patients and families to maintain “lockdown” practices while still accessing health services,
Reduce burdens and risks to health facilities and personnel by reducing in-person contacts,
Be used for triage assessment to determine if in-person visit is required.
Through the disaster continuum ( Fig. 26.1 ), rehabilitation-specific roles have been described. Considering such activities in the context of telerehabilitation allows for identification of strategies across all four phases of disaster management.
Effective planning is based on awareness of how a disaster will affect health and anticipating the tasks and resources that will be required. Telehealth information technology and mobile communication technology should be adapted for disaster preparedness and training purposes; it should be tested in advance with appropriate training of users. Rehabilitation professionals should look to their professional organizations for vetted and/or accredited training resources specific to disaster management and response.
Preparedness activities that are intended to address needs of persons with existing disability, and those with new injuries and rehabilitation needs include:
Identify population needs; evaluate telerehabilitation capacities among persons with disability in disaster-risk areas.
At health systems levels, establish mechanisms to secure electronic health records that can be accessible in an emergency or disaster.
Train rehabilitation providers and persons with disability on use of telecommunication technologies and applications; identify and test options for use in disaster situations.
Establish procedures for protection of patient information and confidentiality in a telerehabilitation encounter.
Train and credential rehabilitation providers in disaster medicine and rehabilitation.
Incorporate telerehabilitation strategies into disaster response planning and simulation exercises.
Identify local, regional, national, and international resources for telerehabilitation provision that can take a lead coordinating role in disaster response.
At local and regional levels, establish mechanisms to register and contact persons with disability in the event of a disaster.
Develop and disseminate accessible modules for injury-specific telerehabilitation interventions, in keeping with diagnoses likely to be encountered.
Foremost in a disaster situation, the responding health care provider must be approved and working collaboratively with the local or national health services or designated Health Cluster agencies; credentials should be appropriately vetted and approved by the disaster coordinating body. While telehealth improves access to much-needed rehabilitation services that are often in very short supply, if available at all in disaster situations, it is of paramount importance that such access does not circumvent the coordination and delivery efforts of the national response services and official coordinating centers. The WHO, with guidance and leadership from international aid organizations, has created recommendations for rehabilitation in disaster, as well as minimum technical standards for rehabilitation teams in disasters.
A disaster situation does not allow for reduced considerations of and adherence to proper informed consent and confidentiality, and as such the security and protection of all beneficiaries must be upheld in all response efforts. Further, telerehabilitation providers should be aware of the realities “on the ground” such that recommendations and interventions are feasible, safe, and culturally and socially appropriate.
Recognizing that communications services may be damaged, interrupted, or unreliable, providers must be prepared for contingencies, including options for asynchronous store and forward platforms, simple mobile application–based interfaces, or basic mobile telecommunication. Sharing and storing of electronic health information, including biometric data or imaging, must strive to meet security standards.
Telerehabilitation response activities can include:
Peer-to-peer support for triage of potentially disabling injuries
Peer-to-peer support for guidance in specialized rehabilitation assessment and management, including therapy, equipment, referrals, care transitions, for example, in diagnoses such as burns, amputation, spinal cord injuries, and brain injuries ( Fig. 26.3 )