What is an emergency?
An emergency is a sudden and usually unforeseen event that calls for immediate measures to minimize its adverse consequences. Emergencies include natural disasters, such as earthquakes and severe meteorological events, but also “complex emergencies” resulting from armed conflict and its consequences, such as civil disruption and refugee crises (1).
Why are people with noncommunicables diseases more vulnerable to the health impact of emergencies?
Common characteristics of noncommunicable diseases explain why individuals with noncommunicable diseases are more vulnerable to the health impact of emergencies.
Noncommunicable diseases are chronic conditions:
- that require the provision of continuous care over an extended period (often lifelong);
- that often create a dependence in relation to a medicine, a medical technology or an appliance;
- whose evolution can be punctuated by acute complications that require specialized medical care, incur health costs and may limit function, affect daily activities and reduce life expectancy;
- that necessitate coordination of care provision and integration between different providers and settings, with regular medical follow-up.
The elderly, children with noncommunicable diseases and people in need of palliative care are particularly vulnerable.
What are the challenges in treating and managing noncommunicable diseases in emergencies?
Noncommunicable diseases require ongoing management for optimal outcomes, which is challenging in emergency settings. In addition, natural disasters or conflicts can increase the risk of acute noncommunicable disease exacerbations and decrease the ability of health systems to respond. Finally, complex emergencies may compromise prevention and control of these diseases over a prolonged period; result in lack of access to timely treatment and poor outcomes on patients; and increase costs of managing complications for humanitarian agencies.
There are multiple potential mechanisms by which emergencies may increase the burden or interfere with the management of noncommunicable diseases.
Physical injuries
The interaction between noncommunicable diseases and physical injuries sustained during emergencies can result in life-threatening complications. For example, after the Sichuan earthquake in May 2008, frontline medical teams found that up to 38% of survivors needed acute management of a pre-existing disease before surgery required for an earthquake-related injury (2).
Degradation of living conditions
Loss of shelter, shortage of water and food, lack of food that is suitable for disease-related dietary restrictions, lack of storage for medications, forced displacement, unemployment and the need for physical security (i.e. from combatants) may all reduce the ability of affected people to appropriately manage their condition.
Interruption of treatment
Destruction of key health infrastructure and the medical supply chain; shortage of health providers (who may have been injured or killed), and lack of access to safe health care facilities may all preclude appropriate management of noncommunicable diseases in emergency settings. Even when health infrastructure is undamaged and accessible, lack of consistent access to power or water can mean that life-sustaining treatments, like haemodialysis, are unavailable.
In general, the capacity and sophistication of the pre-emergency health system will determine the likelihood of care in the post-emergency setting. Systemic weaknesses, such as an incomplete or absent national strategy for noncommunicable diseases, fragmented medical services and limited human resources, as often observed in many low- and middle-income countries, are magnified by an emergency. In many fragile states, capacity for disease management may remain much lower than pre-emergency levels long after the acute phase has resolved.
What should be the focus for noncommunicable disease management during emergencies?
Humanitarian response in emergencies can be divided into three phases: preparation/mitigation, emergency response, and post-emergency/reconstruction.
Effectively managing noncommunicable diseases in emergencies will require inclusion of care for noncommunicable diseases into standard operating procedures, ideally integrated with other aspects of relief efforts.
The focus of the health sector response for the management of noncommunicable diseases during these various phases of emergencies should be to prevent and reduce excess disease, death and suffering from noncommunicable diseases.
In the acute phase of emergencies or in rapid onset emergencies, for individuals living with a chronic condition prior to the crisis, maintaining access to pre-emergency treatments should be the mainstay of the response. Minimum standards for disease management in emergencies revolve around four priority actions. First, to identify individuals with diagnosed noncommunicable diseases and to determine whether they have continued access to the treatments they were receiving before the emergency. Second, to identify treatment options for people with life-threatening acute exacerbations (e.g. heart attacks) or those for who interruption of treatment could be life-threatening or cause significant avoidable suffering (e.g. diabetes patients requiring insulin, patients requiring kidney dialysis treatment or transplant patients). Third, in situations where treatments for noncommunicable diseases are unavailable, it is important to create effective and practicable standard operating procedures for referral. Lastly, to assess and facilitate the availability of essential medication, diagnostic equipment and core laboratory tests for the routine ongoing management of noncommunicable diseases, through the primary health care system, based on the WHO model list of essential medicines.
Cancer care, in particular, requires a complex diagnostic and service delivery setup. In many low- and middle-income countries, cancer care capacity may already be limited before an emergency. Efforts should therefore be made by humanitarian actors and the ministry of health in each country to integrate care for noncommunicable diseases into its emergency preparedness and response planning for the health sector, in order to identify and resolve ethical dilemmas related to limited resources, competing priorities and distributive justice.
During the recovery phase after emergencies or during protracted emergencies, such as long-term settlements of displaced populations, the management of noncommunicable diseases should expand to include management of sub-acute and chronic presentations of previously identified noncommunicable diseases, as well as ongoing care, i.e. lifestyle-related disease prevention and palliative care.
The post-emergency phase could also offer opportunities to improve care from the baseline, including deliberate integration of management of noncommunicable diseases into the primary health care system and a concerted public health response to control risk factors at the population level. The WHO package of essential noncommunicable disease interventions for primary health care in low-resource settings provides a set of protocols, medicines and equipment for managing the four common noncommunicable diseases (3). These interventions can be used as a guide and adapted to the local context.
