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date: 02 June 2020

Healthcare Challenges After Disasters in Lesser Developed Countries

Summary and Keywords

A public health disaster occurs when the adverse health effects of an event such as a natural hazard or threat exceed the coping capacity of the affected human population. The coping capacity of the affected population is hereby dependent on available resources including financial and human resources, health infrastructure, as well as knowledge, planning and organizational capabilities, and social capital. Disasters therefore disproportionally affect lesser resourced regions and countries of the world and pose specific challenges to their health systems as well as to the international humanitarian community in terms of dealing with mortality and injuries, communicable and noncommunicable disease, mental health effects, and long-term disability. Challenges for healthcare delivery in disaster situations in lesser resourced settings include deficiencies in the construction of resilient healthcare facilities, the lack of disaster response plans, shortage of specialized medical personnel, shortcomings regarding training in disaster response, and scarcity of resources such as medicines and portable medical devices and supplies. Other challenges include the absence of appropriate algorithms for the distribution of scarce resources; lack of coordination of medical teams and other volunteers; limited awareness of particular health issues such as mental health problems or disability and rehabilitation; and lack of plans for evacuation, sheltering, and continuation of treatment of those with pre-existing health conditions. Many challenges lesser resourced settings face with regard to healthcare delivery after disasters such as the organization of mortality management, triage and treatment of the injured, or the delivery of rehabilitative and mental health care cannot be reduced to the lack of baseline resources in terms of health infrastructure, technology, and personnel but are related to the absence of proper planning for future disaster scenarios including implementation strategies and simulation exercises. This not only encompasses the formal drafting of disaster preparedness and response plans, contingency planning of hospitals, and the provision of disaster-related training to health personnel but in particular the identification and involvement of the potentially and traditionally affected communities and especially vulnerable groups in all the process of disaster risk reduction.

Keywords: disaster, health systems, low-income countries, middle-income countries, vulnerability, mortality, injury, communicable disease, mental health disability, epidemiology

Introduction: Disasters, Vulnerability, and Lower Resourced Countries

The public health burden caused by disasters can be enormous and encompasses immediate and long-term consequences for mortality, injury, communicable and noncommunicable disease, mental health problems, and disability of the affected population. Disasters occur when a human population is exposed to a threat or hazard in a way that exceeds the coping capacity of that population, so that external assistance is required (Centre for Research on the Epidemiology of Disasters, 2019; Reissman, Schreiber, Shultz, & Ursano, 2009; United Nations Office for Disaster Risk Reduction [UNISDR], 2015). A disaster and its impact on human health are thus a function of the nature and intensity of the hazard, exposure of a human population, and the vulnerability or conversely resilience of the affected community or population. The vulnerability of a community or a particular group of people is herein understood as “lack of capacity to anticipate, cope with, resist, and recover from the impact of a natural hazard” (Wisner, Blaikie, Cannon, & Davis, 2004). Resilience, in turn, means the ability of a community or individual “to resist, absorb, accommodate to and recover from the effects of a hazard in a timely and efficient manner, including through the preservation and restoration of its essential basic structures and functions” (UNISDR, 2015). A wide range of factors that influence the vulnerability and resilience of a population include economic development; population density; development and organization (public vs. private) of the health system, including public health, infrastructure, and construction styles; and public education and awareness, including health literacy of the affected population. Other factors involve the existence of early-warning and alert systems and lines of communication to inform the public in general and vulnerable groups in particular about emerging threats, availability of personnel and infrastructure for emergency response, the existence and state of disaster response plans, as well as cultural traditions and social capital (Reissman et al., 2009; UNISDR, 2015; Wallemacq, 2018).

Lower resourced countries, referred to in this article as low- and middle-income countries (LMICs), are often characterized by shortcomings in almost all of the aspects mentioned in the previous section, which as a result increases their vulnerability to hazards. Disasters thus disproportionately impact lesser developed regions and countries and within a given setting disproportionately affect socially disadvantaged groups, including the poor, the elderly, children, women, and people with existing health conditions. Between 2000 and 2017, for instance, natural disasters killed 130 persons per million population potentially exposed (PPE) in low-income countries as opposed to 18 deaths per million PPE in high-income countries (UNISDR, 2015). In turn, even in high-income countries like Taiwan, the odds of dying in the 1999 earthquake were increased 2.2-fold for people with low incomes as opposed to those with high incomes (Chou et al., 2004). Table 1 provides an example of differences in the health impact of disasters from 2000 to 2015 between a middle-income (China) and a high-income (United States country.

Table 1. Health Impact of Natural Disasters from 2000 to 2015: China Versus United States


United States

Occurrence of disasters












Deaths/1 million population



Injured/1 million population



Deaths/1 million population by event



Injured/1 million population by event



Source: Author’s creation with data for number of deaths and number of injured extracted from EM-DAT, calculated with 1.4 billion population for China and 327 million for the United States.

At the center of the increased risk of an adverse health impact of disasters in LMICs are undeveloped and weak health systems, which involve “the resources, organizations and institutions devoted to producing interdependent actions aimed principally at improving, maintaining or restoring health” (Bayntun, Rockenschaub, & Murray, 2012). In a disaster context, the health system is essential in ensuring and organizing search and rescue operations; management of fatalities; treatment of the injured; prevention of communicable and noncommunicable diseases; food safety; management of medical donations, water, sanitation, and hygiene; vaccinations; and reproductive and mental health (Auf der Heide & Scanlon, 2007; Reissman et al., 2009). However, although moderate progress has been recently reported in the development of health systems of some LMICs (such as China, Vietnam, India, Colombia, Mexico, Thailand, and Kenya) (Han, 2012), in many LMICs health systems still suffer from inadequate financing. This is witnessed not only in cutbacks of health budgets but also in inadequate and poor health infrastructure and logistics, which thus impact effective access and delivery of healthcare services even in nonemergency situations.

Those already weak healthcare systems are further strained by disaster, for instance due to the destruction of healthcare facilities or death, injury, and displacement of health professionals. The replacement of both dead and injured health workers alone poses a serious challenge in LMICs, which grapple with limited numbers of well-trained personnel as it is. At the same time, the health system must deal with increased time-sensitive demands including, among others, bed capacity, clinical specialists, and medical equipment on the one hand and the need to uphold predisaster levels of supply for those with chronic and critical conditions on the other (Zhong, Clark, Hou, Zang, & Fitzgerald, 2014).

Respective challenges for healthcare delivery in disaster situations include deficiencies in the construction of resilient healthcare facilities, the lack of disaster response plans, shortage of specialized medical personnel, shortcomings regarding training in disaster response, and scarcity of resources such as medicines and portable medical devices and supplies. Other challenges include the absence of appropriate algorithms for the distribution of scarce resources; lack of coordination of medical teams and other volunteers; limited awareness of particular health issues such as mental health problems or disability and rehabilitation; and lack of plans for evacuation, sheltering, and continuation of treatment of those with pre-existing health conditions (Han, 2012; Kobusingye et al., 2005; Swanson et al., 2015; Zhong et al., 2014).

In the following sections, challenges that disasters pose to healthcare delivery in LMICs along different lines are outlined: impact on vulnerable populations, including people with existing health conditions; mortality management; triage and treatment of injuries; communicable diseases; mental health; and disability and rehabilitation. The article further discusses challenges related to building back the health system in the recovery phase as well as issues related to epidemiological research on the health impact of disasters and related healthcare delivery.

Vulnerable Populations

When a disaster strikes, certain groups of people within the disaster-affected setting are more vulnerable to its adverse direct and indirect effects, including death, injury, malnutrition, communicable disease, and exacerbation of pre-existing noncommunicable diseases such as diabetes or hypertension. Vulnerable populations include people with existing health conditions such as those with disabilities, pregnant women, children, elderly persons, ethnic minorities, and those with poor education and poor economic status (Reissman et al., 2009; Wallemacq, 2018).

The special needs of vulnerable populations are often less considered and prioritized in the aftermath of disasters in LMICs due to omissions in existing disaster legislations and response plans, concentration of the medical response to mortality management and new injuries, diversion of healthcare workers and resources, and lack of pre-existing vulnerability analyses and lists of vulnerable people and their location. These factors and others make it hard to both reach and direct the necessary resources to vulnerable people.

Particular challenges regarding tailoring the disaster health response to the needs of vulnerable populations include the following:

  • Some vulnerable groups have special evacuation needs that are often not considered in disaster response plans and that are not made known to personnel responsible for search and rescue as well as evacuation. People with mobility impairments, for example, will face transportation issues during evacuation and may not be able to travel by conventional means and instead may need specialized vehicles with accessible features. On the other hand, people with hearing, vision, speech, cognitive, or intellectual limitations may not be able to comprehend critical information like verbal announcements and directional signs, explain their needs to the rescue team, or understand how to obtain assistance. (American Medical Response Office of Emergency Management, 2013; World Health Organization [WHO], 2016).

  • Disasters may further lead to the breakdown of the support chain of vulnerable groups due to displacements of their family members, friends, and medical professionals; loss of medications and medical devices; or interruption of outpatient or community-based services (WHO, 2016). For example, due to their level of cognitive ability, emotional vulnerability, susceptibility to injury and disease, and dependence upon the support of family members, children require extra attention and supervision and thus respective capacity planning (Hoffman, 2009).

  • While temporary shelters are designed to meet the immediate needs of the majority population, they are often not suited to meet the needs of vulnerable groups. People with existing health conditions, the elderly, and children as well as pregnant women and lactating mothers, for instance, need more water, special nutrition, nutritional supplements or medications, and possibly regular medical check-ups to maintain their health. People with disabilities in turn may have difficulties accessing shelters or facilities within shelters such as latrines (WHO, 2016).

  • Medical facilities including field hospitals need to plan for and provide surge capacity for not only those newly injured but also those with existing health conditions whose condition may worsen in the wake of a disaster. Disasters, for example, increase the risk of miscarriages, preterm births, and low birth weight and thus increase the volume of maternal and neonatal patients, necessitating additional capacity for gynecological and obstetric care delivery (American College of Obstetricians and Gynecologists, 2017).

Dealing With Fatalities

Large-scale natural disasters such as earthquakes, tsunamis, and hurricanes can cause hundreds or thousands of deaths; deaths are mainly due to being hit by debris, high and low falls, drowning, and burns. Consequently, this requires well-organized mass mortality management, which basically involves the handling of dead bodies, including those of animals (carcasses) in a dignified manner (Cordner, Coninx, Kim, Van Alphen, & Tidball-Binz, 2016). This can overwhelm existing resources within the health system. The international standards outlined in the Sphere Project Handbook call for measures that ensure the dignity of the deceased and their families in accordance with their religion, customs, or cultural beliefs (Inter Agency Standing Committee, 2018). Appropriate mortality management includes search for and recovery of dead bodies; victim identification using fingerprints, dental records, DNA records, and photo identification depending on the local resources and baseline identification records; documentation; postmortem or forensic analysis; and treatment, transportation, storage, disposal, and burial of corpses as well as the provision of any support that may be required by the bereaved families (Cordner et al., 2016; Morgan et al., 2006; Reissman et al., 2009). However, ensuring these standards requires predisaster planning, effective coordination, and well-organized healthcare systems that cannot be guaranteed in many LMICs. Particular challenges include the following:

  • National or local mass fatality management plans that require activation during disasters are absent in many LMICs. In Haiti, for instance, following the 2010 earthquake, the Pan American Health Organization (PAHO) reported that due to poor coordination, many dead bodies piled up outside morgues and hospitals, while thousands were buried unidentified in mass graves (de Ville de Goyet, Sarmiento, & Grünewald, 2011). After the 2004 South Asian tsunami that ravaged Indonesia, Sri Lanka, and Thailand, proper management of dead bodies, estimated at 165,708, 35,399, and 8,345, respectively, was one of the most significant challenges (Morgan et al., 2006). This was due to inadequate refrigeration facilities for preserving human remains (apart from Thailand, which managed to mobilize some facilities), insufficient forensic capacity, and disruption of the provision of medical services. Morgan et al. (2006) reported that these challenges were inevitable, simply because none of these three countries had in place a single organization in charge of coordinating the management of dead bodies. Similarly, the PAHO report on lessons learned from the 2010 Haiti earthquake concludes by noting that “There are no Non-Government Organizations (NGOs) and very few bilateral teams with skills and resources for the identification and respectful management of dead bodies. It is thus a humanitarian niche that has not yet been filled” (Cordner et al., 2016).

  • While dead bodies may pose a health risk when deaths result from a highly contagious disease such as Ebola, cholera, or Lassa fever or when a natural disaster occurs in an area where such disease is endemic, outbreaks of epidemics attributed to dead bodies in natural disasters are usually minimal (Cordner et al., 2016). This is because most of the victims in disasters die of trauma, drowning, or fire, not communicable diseases (Cordner et al., 2016; Morgan, 2004). Moreover, most infectious microorganisms do not survive for more than 48 hours (with the exceptions of HIV and Ebola) (WHO, 2006). While precautions should be taken by those handling corpses, risks arising from dead bodies after natural disasters for the general public are largely a myth—however, unfortunately a persistent one continuously fueled by the mass media (Watson, Gayer, & Connolly, 2007). Rather than directly arising from dead bodies, major health risks may arise from drinking water contaminated by fecal materials released from dead bodies; diversion of responders from treatment of survivors based on the assumption that the hasty disposal of dead bodies is a public health concern; psychological distress for surviving families, which is exacerbated if bodies are not handled with dignity and in a culturally appropriate manner; and injuries sustained while recovering dead bodies (Cordner et al., 2016). To avoid the risk of disease outbreaks and transmissions associated with dead bodies in disasters, it may also be important to have separate morgues in place to help to prevent cross-contamination between dead bodies of disaster victims and those who died of other causes (Reissman et al., 2009). Based on these factors, campaigns directed at providing the general public with realistic information about public health risks arising from dead bodies are an essential component of disaster health response. According to Morgan et al. (2006), the improper management of dead bodies can affect both the general public and those who are more intimately involved in handling them. In this case, training of local people in communities who typically arrive first at the scenes of disasters in rescue missions deserves considerable attention in resource-constrained settings.

  • Another seldom-discussed concern related to mortality due to natural disasters is connected to an overfocus on mortality figures in news coverage. National and international donators are oftentimes more interested in mortality figures than rather than the number of survivors in need. This may lead to an exaggeration of disaster-related mortality by responsible governmental authorities and thus to the diversion of attention from the actual needs of the public in terms of healthcare delivery (de Ville de Goyet et al., 2011).

Triage and Treatment of Injuries

Disasters that cause fatalities usually also cause injuries with similar etiology (i.e., blunt trauma, near drowning, and burns). Likely because of increased survival due to earlier and better emergency response as well as better reporting and recording due to increased availability of medical services and documentation, the odds of being injured as opposed to dying in natural disasters have increased (Reinhardt et al., 2011). Figure 1 shows the trend in the number of fatalities and injuries due to earthquakes and storms between 1980 and 2015.

Healthcare Challenges After Disasters in Lesser Developed Countries

Figure 1. Number of fatalities and injuries due to earthquakes and storms from 1980 to 2015 and exponential smoothing trend.

Source: Author’s creation based on data extracted from EM-DAT.

Lacerations and musculoskeletal injuries, including fractures, are the most common injuries in disasters. Severe injuries such as spinal fractures, traumatic brain injuries, and crush injuries may occur, particularly in earthquakes, storms, and landslides. Immediate surgical treatment may be needed to reduce the risk of associated deaths as well as avoid further complications.

Emergency care is a vital and integral component of health systems, particularly in resource-constrained countries (Balikuddembe, Ardalan, Khorasani-Zavareh, Nejati, & Raza, 2017). Such care focuses on the provision of urgent and rapid medical attention to patients at the scene of an incident, during transfer or transportation, and on arrival to the nearest receiving healthcare facility to stabilize the patient’s life-threatening conditions and minimize mortality, trauma, and disability. A number of activities are administered as emergency care. Among others, these include scene management, extrication, triage, bleeding control, lifting, fracture immobilization and wound dressing, airway management and ambulance transfer, referral, and hospital deposition (Kobusingye et al., 2005).

In an ideal world, all injuries would receive the best available treatment as quickly as possible. Due to the sudden incidence of large numbers of injuries in disasters, this is, however, often impossible. Limitations in available medical personnel, equipment and medicines, transportation means, and hospital facilities typical for LMICs necessitate decisions on who to treat first and with which resources on the field and after possible referral to a hospital facility. Decision-making under such conditions of scarce resources is called triage. According to Iserson and Moskop (2007, p. 275), it involves the “sorting of patients for treatment priority in emergency departments, and in multi-casualty incidents, disasters, and battlefield settings.” In a proper triage system, a healthcare worker assesses each patient’s needs (as a basis for micro-allocation). Then a triage officer who does not assess or treat individual patients makes decisions upon treatment and/or referral priority based on predefined criteria. In this, the triage officer takes into account the whole population of patients in order to save the greatest number, based on available medical personnel, medicines, and medical equipment, transportation means and times as well of state of roads and the state and type of referral health facilities (Iserson & Moskop, 2007). Against this background, the triage and treatment of people injured in a disaster is identified as another significant challenge to healthcare systems in LMICs.

First responders are often not medical professionals but lay responders, neighbors, or military personnel, particularly in remote and rural areas. These individuals may have limited knowledge about proper techniques for extrication and immobilization and lack even basic skills for the delivery of first aid, which may lead to avoidable deaths as well as additional injuries surrounding extrication and transportation (Kobusingye et al., 2005). The plausible solution, to provide community-based trainings for those likely first responders in disaster-prone areas, is unfortunately rarely realized in many LMICs.

Standardized triage procedures and respective guidelines are still lacking in LMICs, as are sufficient emergency medical personnel with appropriate triage skills. In this regard, during the 2008 Wenchuan earthquake in China, Zhong et al. (2014) reported that

Medical students [who formed a significant proportion of the volunteers responding to the disaster] also failed to receive appropriate disaster training. They acquire their training and skills in the inpatient wards of large tertiary care hospitals in urban areas where the emphasis is on making the right diagnosis rather than on the principles of triage and emergency management. (p. 4)

While some triage systems such as the Simple Triage and Rapid Treatment (START) system may be easy to use and apply in low-resource settings, they have serious limitations as they do not take into account available resources, time needed for treatments, or injuries (i.e., of the walking wounded), which may become life threatening after a period of time if not treated immediately, such as crush injuries, and thus probably lead to over-triage (Iserson & Moskop, 2007; Kobusingye et al., 2005).

Triage, treatment, referral, and transportation of the injured may be further complicated by a huge influx of lay volunteers and uncoordinated NGOs, a problem that came to prominence and Van Hoving, Wallis, Docrat, and De Vries (2010) described as “medical tourism” following the 2010 Haiti earthquake. Pourhosseini, Ardalan, and Mehrolhassani (2015) remark for Iran:

Interviewees [Iranian disaster experts and managers] stated that in many past disasters, various groups including medical and nursing students, the public and organizational forces came to the region with charitable purposes to provide assistance. The presence of these groups in effected region did not have any consequences except that it made a chaos in the region as this presence was without coordination and without considering the actual needs of the region. (p. 113)

Most importantly, some emergency care interventions that are vital for the survival of injured people in disasters may either be inadequate or fail to be delivered. This may be attributed to the absence of a unified command and control system to properly direct existing personnel and resources, few and poorly equipped transportation facilities (ambulances) and communication equipment, and poor road infrastructure that can cause unnecessary delays (Balikuddembe et al., 2017; Kobusingye et al., 2005; Razzak & Kellermann, 2002). Proper transportable equipment for field diagnosis and treatment may further be unavailable.

(Zhong et al., 2014)

Surgical interventions are limited due to lack of a sterile environment, and urgent surgery is often performed in less than ideal environments and by unskilled personnel that pose a high-risk for the patient. A review of 62 studies about challenges for wound care in disaster settings emphasized high rates of wound infection and the lack of trained personnel to deliver anesthesia and surgery, particularly in rural areas, and recommended emphasizing not primarily closing wounds but “cleaning, debridement, and dressing wounds in preparation for delayed primary closure” (Merchant et al., 2015). Difficulties in adhering to protocols due to lack of equipment, lack of space, patient and caregiver behavior, deviations from hygiene routines, deviations from antibiotic prescriptions, and high turnover of expatriate surgeons have been identified as major challenges in a qualitative study on war wound management (Älgå et al., 2018). Shelton, Hamm, Olatosi, and Johnson (2018) reported difficulties in sterile processing of surgical equipment due to flood water contamination in the 2015 Columbia, South Carolina, flood.

Eventually, the surge capacity of hospitals receiving injured victims for treatment is often not sufficient (Zhong et al., 2014). This is further complicated by the fact that many healthcare facilities have been destroyed while rehabilitative or other tertiary care units for transferring stabilized patients are not available. For example, after the 2003 Bam earthquake in Iran, almost all of the health facilities were destroyed along with 50% of the local health staff in the affected areas being displaced, injured, or killed. In Nepal following the 2015 earthquake, approximately 90% of the health facilities included in Giri et al.’s (2018) prospective hospital-based study were reported to have been destroyed or severely damaged.

Communicable Disease Control

The outbreak of communicable (i.e., infectious) disease is another daunting threat faced by healthcare systems in LMICs. This happens both in acute and post-emergency phases of disasters. Communicable diseases include air-borne, vector-borne, water-borne, food-borne, and sexually transmitted diseases, some of which are vaccine-preventable (Connolly, 2004; Kondo et al., 2002; Lemonick, 2011; Najmeh, Armindokht, Mehrdad, & Amir, 2011; Swanson et al., 2015; WHO, 2006). According to the WHO, after disasters, the most common diseases that contribute to additional morbidity and mortality emerge from acute respiratory infections, measles, and vector-borne diseases (WHO, 2006). The risk of these diseases varies according to disaster types, population displacement and shelter conditions, immunization rates among the affected population, and measures taken for their early detection and prevention. The risk of water-borne diseases, for instance, is considerably high in floods and storms. In this case, the diseases transmitted through the fecal-oral pathway may amount to more than 40% of deaths in the acute phases of disasters as well as more than 80% of deaths in children under the age of 2 years (Connolly, 2004). In addition, the focus on certain events or diseases may lead to the neglect of others. An example is the previous and ongoing Ebola outbreaks both in West Africa and the Democratic Republic of Congo (Elston, Cartwright, Ndumbi, & Wright, 2017; Wilhelm & Helleringer, 2019). While Ebola requires attention, it should not overshadow other pertinent health issues such as the ongoing response to infectious diseases such as HIV, tuberculosis, and malaria, which kill nearly 10,000 people every day in many less developed countries. Indeed, this is far from the number of deaths caused by Ebola.

LMICs are disproportionately affected by outbreaks of communicable disease after disasters. The WHO reported that after the 2005 Pakistan earthquake, the risk of pneumonia, cholera and other diarrheal disease, tetanus, malaria, measles, HIV, and hepatitis C viruses was heightened. Some reasons for this were overcrowding and inadequate water and sanitation facilities for displaced people (WHO, 2005). Elsewhere, in Mozambique, the incidence of malaria and diarrhea increased following the 2000 floods. Kondo et al. (2002) attributed it to food shortages, poor temporary living conditions, and turbid degeneration of drinking water.

A wealth of evidence points at weak health systems, which are further disrupted by disasters; population displacement and overcrowding, inadequate medical supplies and infrastructure, lack of emergency preparedness and response systems, and malnutrition particularly contribute to the challenges of controlling communicable diseases in LMICs (Lemonick, 2011).

  • Population displacement due to loss of homes and overcrowding in temporary shelters that lack proper planning and site management can lead to an increased likelihood of air-borne infections such as measles through person-to-person contact. This is often facilitated by low baseline vaccination coverage rates. Moreover, population crowding in temporary shelters necessitates higher immunization coverage levels to prevent disease outbreaks than in the predisaster situation (WHO, 2006). While mass immunization against measles is generally recommended, the utility of other immunization campaigns depends on the baseline situation and population mobility (WHO, 2006). Vaccine-preventable disease programs may, however, be hampered by various challenges. These include inaccurate population data, lack of baseline data or data destruction, lack of information about population mobility in the aftermath of the disaster, shortages of drugs, absence of guidelines for administering specific vaccination programs, and inadequate logistics. According to Rouzier et al. (2013), population mobility, paucity of data on reactive vaccination campaigns, logistics, inadequate infrastructure, and human resources were some of the impediments faced during the Haitian cholera vaccination campaign in post-2010 earthquake recovery. In Fiji, following cyclone Toma, Scobie et al. (2014) pointed out that challenges were encountered during the typhoid vaccination due to the absence of specific recommendation for typhoid vaccination in postdisaster settings.

  • Population displacement, improper conditions in temporary shelters, and lack of social organization and appropriate site management may further pander to sexual violence (WHO, 2005). Accordingly, social disruption that is caused by disasters may lead to a lawless environment without adequate security and protection mechanisms, thus exposing vulnerable groups, especially children and women, to violence. For example, children are vulnerable to sexual violence in the form of rape, molestation, or unwanted touching in the absence of their parents or guardians who might have died or been separated from them during a disaster. Also, sexual violence can be enacted on the vulnerable populations simply because of the ways sheltering camps are constructed (e.g., without restricting forceful entry and often requiring people to travel some distance in order to access bathrooms and toilet facilities, food and water, and other basic services). In a six-week time period after the 2010 earthquake in Haiti, Kolbe et al. (2010) estimated that over 10,000 people were sexually assaulted—with the majority being female.

  • Water, sanitation, and hygiene (WASH) are essential services needed by populations in both routine and emergency situations. WASH aims at providing safe water for drinking and supporting other domestic activities (like washing and bathing), safe removal of waste (toilets and waste disposal), and health promotion activities. WASH is not only underscored as a vital measure in reducing the burden of communicable diseases but also as a pathway for economic growth and sustainable development for LMICs (Raviglione & Maher, 2017; United Nations [UN], 2000; UNISDR, 2015). However, according to the WHO, worldwide around 1.1 billion people lack access to improved water sources and 2.4 billion have no basic sanitation, especially in Southeast Asia and Africa where diarrheal diseases are responsible for 8.5% and 7.7% of all deaths, respectively (Connolly, 2004; WHO, 2010). While diarrheal and other diseases due to infections from contaminated water are a major public health concern in lesser developed countries already in nondisaster situations, they may become even a greater threat in the aftermath of disasters (Najmeh et al., 2011). This is mainly due to the breakdown of water supply, the contamination of water with feces, poor sanitation in temporary shelters, and increased proximity to rodent populations. Run-off from farms or impact of water supplies can also cause issues for resistant infections. While water-borne diseases are mostly associated with floods, tsunamis, and storms, they may occur in any poorly conceived shelter due to the supply with safe drinking water not meeting demands and groundwater contamination. Incidents involving an increased acquisition of water-borne disease were reported (e.g., leptospirosis) in Salvador after hurricane Mitch (Sarkar et al., 2002); malaria, respiratory communicable diseases, and diarrhea after the 2000 floods in Mozambique (Kondo et al., 2002); and a severe cholera outbreak after the 1998 West Bengal floods in India (Najmeh et al., 2011). Whereas risk assessment and timely interventions such as chlorination of drinking water are vital and cost-effective to mitigate the health impacts of WASH problems triggered by natural disasters, they are often not implemented in LMICs due to lack of public awareness, simple implementation guidelines, and required logistics.

  • Although many vector-borne diseases are preventable through informed protective measures, they continue to account for more than 17% of all communicable diseases and cause more than 1 million deaths annually. Malaria, for example, is responsible for more than 400,000 deaths every year globally, of which the majority occurs in children under 5 years of age (WHO, 2017b). The incidence of vector-borne diseases can dramatically increase, particularly after meteorological events such as cyclones, hurricanes, and flooding. This is because these types of disasters enhance the availability of vector breeding sites and disease transmission due to standing water from the overflow of rivers or in artificial containers (e.g., unprotected drinking water) mostly associated with flooding, the interruption of vector control measures where they previously existed, and increased person-vector exposure due to crowding. As vector-borne disease outbreaks usually happen after several weeks, they are preventable through effective early-warning and alert systems and interventions. Implementation of this in LMICs may, however, be complicated by logistics, insufficient supplies (e.g., insecticide-treated nets), lack of public awareness about personal protection measures, and sociocultural behavioral factors. In Pakistan, where a number of preventable diseases are endemic (e.g., polio, hepatitis B, and others), Sumera, Nadir, and Savera (2016) noted that vaccination was commonly perceived by many people in rural areas and urban slums as making them infertile.

  • As noted before under the section about vulnerable populations, many medical facilities in the aftermath of disasters are confronted not only with newly injured patients but also those with existing health conditions. Amidst this situation, pertinent healthcare measures such as disinfection can easily be overlooked or superseded by other immediate needs, especially in LMICs, where many healthcare systems grapple with the challenge of adequate resources. Yet, significant risk of contagious infectious disease (e.g., influenza) can easily be spread with substantial clinical consequences both among the patients and healthcare workers. This is particularly so for patients who present with undifferentiated illnesses and variable acuity, ranging from the otherwise healthy to the critically ill (Casey, Hawley, Edwards, Cox-Ganser, & Cummings, 2017).

  • If communicable disease outbreaks cannot be prevented, the next best measure is to control them as early as possible. Difficulties in setting up surveillance systems for communicable disease control may, however, pose a significant challenge in LMICs. Kouadio, Aljunid, Kamigaki, Hammad, and Oshitani (2012) noted that, if surveillance systems and even basic facilities (clinical and laboratory) in developing countries are not functioning, an epidemic may go unnoticed. In particular, access to algorithms for rapid risk assessments based on existing information, appropriate sampling and screening techniques for on-site assessments, qualified health practitioners for performing differential diagnosis, laboratory support for diagnostic confirmation, supplies with effective medication, and strategies for monitoring the success of control measures and other interventions may be severely limited in lesser resourced countries (WHO, 2006).

  • Food is an inalienable human right. All people, at all times, should have uninterrupted access to food to meet their nutritional requirements and lead an active and healthy life. Food security and good nutrition are enablers for human development and socioeconomic well-being and are foundations for sustainable development (Balikuddembe, Hosseinzadeh-Attar, & Ardalan, 2016). However, the supply of safe food can be severely impeded by natural disasters. Although all natural disasters impact food security, droughts and floods, of which the burden is disproportionately borne by vulnerable populations in the poorest regions of the world, need to be particularly emphasized in this respect (McCarthy, 2001; Rodriguez-Llanes, Ranjan-Dash, Degomme, Mukhopadhyay, & Guhar-Sapir, 2011). Malnutrition is a serious risk factor for communicable diseases, which is in turn a risk factor for malnutrition.

    The relationship is synergistic; malnutrition compromises natural immunity leading to increased susceptibility to infection and more frequent and severe episodes of communicable diseases. Likewise, infection can aggravate or precipitate malnutrition through decreased appetite and intake, mal-absorption, nutrient loss or increased metabolic needs.

    (WHO, 2010)

  • It is further notable that food and nutrition programs in emergencies take up to 50% of the entire humanitarian budget (Saade & Burnham, 2000). The likely impact of this is the diversion of funds or budget cuts, which are instead used in financing the implementation of other healthcare interventions after disasters.

Mental Health

Mental disorders and substance abuse disorders are a major cause of years lived with disability and disability adjusted life years across the world (GBD 2017 DALYs and HALE Collaborators, 2018; GBD 2017 Disease and Injury Incidence and Prevalence Collaborators, 2017) with a considerable burden falling on LMICs where the mental health treatment gap (i.e., lack of access to mental healthcare by those in need) is also largest (Wainberg et al., 2017).

Disasters significantly contribute to this mental health burden, causing a range of physical, emotional, cognitive, and behavioral changes in the affected population. Mental health problems may manifest in fear, sadness, grief, anxiety, irritability and anger, disbelief and shock, apathy, confusion, frustration, and crying. Others exhibit distressing dreams; insomnia and nightmares; difficulty in concentrating or making decisions; trauma, headaches, back pain, and stomach problems; increased use of alcohol and dangerous substances; and violence (Reissman et al., 2009; WHO, 2017a).

Disasters cause psychological distress in those directly or indirectly affected because they are stressful life events entailing the experience of an uncontrollable threat; people may also witness adverse effects such death and destruction. Disasters moreover cause chronic strain because of social disorganization, grief due to loss of relatives and friends, displacement, the experience of injury and disability, and the loss of livelihood and predisaster social roles. Though less visible than death or injury, mental health problems due to disasters are often more widespread, geographically more dispersed, and longer lasting than physical health problems (Shultz, 2014). A systematic review and meta-analysis by Dai and colleagues (2016), for example, estimated the pooled prevalence of posttraumatic stress disorder (PTSD) from 46 studies of 16 earthquakes from 11 countries as 28.8% at 9 months or earlier and 19.5% at over 9 months after the respective event.

Immediately after disasters, acute stress syndrome and grief are important mental health problems that need to be addressed. Then, weeks after the event, attention needs to be paid to more severe mental conditions such as PTSD, depression, anxiety disorders, or prolonged grief disorder, which may develop and often last for years. Associated problems including substance abuse, sleeping problems, unexplained somatic complaints, and suicide attempts may also occur (Guo et al., 2017; Inter Agency Standing Committe, 2010). Moreover, volunteer or professional disaster responders may also be affected by emotional and mental health problems as their work is highly demanding while at the same time they are confronted with physical and psychological stressors such as seeing and handling dead bodies, coping with dying victims, exposure to individuals with serious injuries, dealing with distressed individuals and families, coping with deaths and serious injuries of children, and facing risks to their own safety (Benedek, Fullerton, & Ursano, 2007; Ehring, Razik, & Emmelkamp, 2011).

All of these pose challenges to the responding health system, in particular in lesser resourced settings.

  • Given that available mental health services cannot meet the demands of the population in nondisaster situations, disasters are likely to considerably enlarge this treatment gap, in particular when the existing mental health facilities are destroyed and mental health workers displaced or killed (WHO, 2013).

  • Since mental health problems are less visible than physical problems, they are easily overlooked, especially if disaster response plans do not foresee systematic assessment of the mental health of the affected population and mental health services are generally underdeveloped and of low priority for local authorities (de Ville de Goyet et al., 2011).

  • Lack of training of disaster responders, including emergency medical personnel, in acute mental health interventions such as psychological first aid can lead to an increased incidence of mental health conditions, while limited diagnostic skills may contribute to lack of or inappropriate referral of persons experiencing mental health problems to respective services where they are available (WHO, 2011, 2015).

  • Limited knowledge and awareness about mental conditions in the affected population may lead to lack of recognition of mental health problems, somatization, and self-treatment through consumption of alcohol or drugs, which in turn can exacerbate the underlying problem. Stigma and discrimination against people with mental health conditions may further contribute to worsening the situation. To overcome this, Wainberg et al. (2017) emphasized the need for devising and evaluating respective culturally appropriate strategies to reduce stigmatization regarding mental health issues.

  • Absence of coordination between responding stakeholders may further lead to duplicate provision of some services for some populations and neglect of others. This may, for instance, lead to an overfocus on PTSD while ignoring other mental health concerns (WHO, 2013).

  • The mental health of disaster responders must not be neglected. Disaster responders need to be prepared for the psychological impact of dealing with the consequences of the event and be equipped with self-reflection, self-assessment, and coping skills. Moreover, disaster responders should be given the opportunity to speak about their experiences and seek psychological support and treatment where needed (Haugen, Evces, & Weiss, 2012).

  • People with existing mental health conditions might be at an increased risk of suffering physical injury due to the disaster or violence and sexual abuse in the aftermath (Kolbe et al., 2010). Their conditions may further be worsened to a life-threatening degree due to interruption of treatment and breakdown of supply of medicines. At the same time, those people can be displaced and difficult to identify (WHO, 2015).

Disability and Rehabilitation

Disability refers to impairments of body function and structures, limitations in activity, and/or restrictions of participation and occurs in interaction with environmental factors as well as resources of the person (WHO, 2001). According to the UN Convention on the Rights of People with Disabilities “disability results from the interaction between persons with impairments and attitudinal and environmental barriers that hinder their full and effective participation in the society on an equal basis with others” (UN, 2008). The 2011 WHO World Report on Disability estimates that more than 1 billion people or about 15% of the world population lives with disability, with an increased prevalence of disability in low-income countries (WHO & World Bank, 2011). While rehabilitation, which involves “a set of measures that assist individuals who experience, or are likely to experience disability to achieve and maintain optimal functioning in interaction with their environments” (WHO & World Bank, 2011), is a human right to persons with disabilities (UN, 2008; WHO & World Bank, 2011), many of their needs in this regard are largely unmet, particularly in LMICs. This is attested by a recent systematic review, which revealed that access to rehabilitation for persons with disabilities in LMICs ranged from 5% in India to 80% in Brazil (Bright, Wallace, & Kuper, 2018). Thus the baseline situation is, in low income regions of the world where most persons with disabilities live, the fewest rehabilitation services exist. Given that persons with disabilities are more vulnerable to disasters and disasters increase the numbers of people with long-term impairments such as spinal cord injury, amputation, and traumatic brain injury (Reinhardt et al., 2011), the situation in LMICs is alarming. Although it has been demonstrated that rehabilitation of disaster survivors with disabilities is effective in improving physical function (Zhang, Reinhardt, Gosney, & Li, 2013), mental health (Ni et al., 2013), and life satisfaction (Zhang et al., 2012), the provision of rehabilitation services after disasters still faces significant challenges in LMCIs (Amatya, Galea, Li, & Khan, 2017; Khan, Amatya, Gosney, Rathore, & Burkle, 2015; Reinhardt et al., 2011; World Confederation for Physical Therapy, 2016; WHO, 2016).

  • People with pre-existing disabilities are at an increased risk of exacerbation of their conditions due to loss of medicines and assistive technologies, loss of support, lack of appropriate evacuation strategies, and shelter construction that does not accommodate their needs (WHO, 2016).

  • While the importance of an early start of rehabilitation and the importance of consultation of the surgeon with a rehabilitation specialist (e.g., about the optimal location of an amputation in order to fit a prosthesis) is undoubted in the rehabilitation community (Rathore et al., 2012), responding emergency medical teams may lack knowledge about disability and rehabilitation and understand rehabilitation as something that is, if at all delivered, administered late in the care delivery process.

  • The lack of existing rehabilitation services infrastructure and personnel can make it more difficult for external rehabilitation teams—should they be requested by local authorities—to integrate into the service delivery system.

  • Assistive devices and rehabilitation equipment must further be compatible with the technological standards and physical environment of the host country, a necessity often ignored by donators and foreign medical teams. People must, for instance, be able to repair a wheelchair with available and affordable means (WHO, 2008).

  • Within the humanitarian response framework, multiple agencies are concerned with disability, leading to disability issues being at an increased risk for inefficient communication, coordination, and resource allocation (Reinhardt et al., 2011).

  • Lack of awareness and knowledge of rehabilitation among local authorities may entail that rehabilitation services are considered a cost instead of an investment and thus given a low priority. Rehabilitation service delivery after disasters thus must include appropriate strategies for raising awareness in policy- and decision-makers and convince them of the benefits of rehabilitation (Reinhardt et al., 2011).

  • Cultural beliefs about disability may further limit delivery and impact of rehabilitative services. This is particularly so in many low-resourced countries where it is believed, for instance, that persons with permanent impairments such as spinal cord injury will depend on their families and need to be cared for during their entire life (Reinhardt et al., 2011).

  • Passive attitude of patients and families, like lack of understanding of the patient contribution through home exercise, can further pose a considerable obstacle. It is therefore important to include family members early in the rehabilitation process and devise acquisition strategies to enhance the education of patients and families (Reinhardt et al., 2011).

  • Even if delivered, the main focus may be on hospital-based rehabilitation and tangible rehabilitation technology, neglecting strategies for community follow-up as well as educational, vocational, and sexual rehabilitation.

Building Back Health Systems

In spite of the destruction of infrastructure and the loss of health workers, the disaster recovery phase following the response phase also provides opportunities to “build back better” by integrating disaster risk reduction into development measures, as outlined in the Sendai Framework for Disaster Risk Reduction (World Bank, 2017). However, this should be based on effective planning, damage assessment, and trained professionals if the immediate resumption of activities and service delivery at affected health facilities is to be ensured. Depending on the nature of the disaster and its impact, the concept of building back should help in the recovery of critical infrastructure, workforce development, provision and extending of health and human services, and restoration of the care delivery systems. However, building better healthcare systems in less-resourced settings after disasters remains a challenge due to technical and financial limitations as well as political interests and corruption.

Ideally, after disasters large investments and financial resources are required to rebuild and extend new hospitals, clinics, and infrastructure; recruitment and remuneration of workers; capacity building; procurement of medicines and new equipment; and funding short- and long-term health programs. Without sufficient assistance from external funding sources and donors, many LIMCs lack the financial and technical capacity needed to rebuild their health systems. A worthy example is Afghanistan, which for a long time has been plunged into a protracted state of political emergency and aggravated by natural disasters such as earthquakes, floods, and prolonged drought. Dalil et al. (2014) argued that Afghanistan has been fortunate to have many donors and partners—bilateral and multilateral agencies—to assist it financially and technically in rebuilding the health system. Nonetheless, rebuilding effective healthcare systems is still a serious challenge in disaster-prone settings such as Afghanistan. This is because the interests of donors and politicians in visible assets like hospitals and technologies lead to investments being mostly concentrated in the big cities, with little interest in funding community-based programs and those for the rural settings.

Although disasters momentarily unify the population, political agendas of powerful interest groups have yet to play a role in the long run. Rono-Bett (2018) cautioned how disaster recovery might be marred by political uncertainty along with other factors. He noted that decisions on preparedness actions and the subsequent allocation of resources are often driven by the political economy—the institutions and individuals where power lies. This is aggravated by challenges of lack of effective mechanisms and structures to prioritize the postdisaster assistance, which should also focus on rebuilding back better the healthcare systems. In fact, Cohen and Werker (2008) asserted that in the course of recovery, disaster assistance can instead be distorted and manipulated in poor countries with self-interested leaders. As a result, this can compromise the allocation of resources and even weaken the local health system’s ability to effectively respond to the healthcare needs of populations in disaster-affected areas.

Epidemiological Research in Disasters

Disaster epidemiology may be defined as the study of the distribution, determinants, and effects of health states or events in the populations affected by disasters. It also involves the application of results of this study to prevent, mitigate, and control the adverse health effects of disasters and optimize the health of disaster-affected populations in the long run (Leaning & Guha-Sapir, 2013; Malilay et al., 2014; Noji, 1992).

According to Noji (1992), tasks of disaster epidemiology can be divided into pre-impact, during impact, and post-impact tasks.

In the pre-impact phase, disaster epidemiology should be concerned with vulnerability analysis in disaster-prone areas, including assessment of preparedness at community and household levels, assessment of infrastructure resilience and warning systems, identification of vulnerable communities and subpopulations, and consultation on as well as evaluation of measures to reduce vulnerabilities (Du, Ding, Li, & Cao, 2015; Leaning & Guha-Sapir, 2013).

During disaster impact, disaster epidemiology is ideally applied concurrently and links the collection of data about health effects and needs of the affected population with an immediate evidence-based decision algorithm in order to provide a basis for allocating available resources to needs, mitigate adverse health impact, and monitor and evaluate intervention programs. Disaster epidemiology is furthermore concerned with setting up or adopting existing surveillance systems, recommending and evaluation of health strategies for defined populations, assessment of the distribution and usage of health services, and ensuring standardized data collection and appropriate documentation including data storage (Leaning & Guha-Sapir, 2013; Noji, 1992).

Important tasks of disaster epidemiology in the post-impact or long-term phase (Malilay et al., 2014; Noji, 1992) comprise etiological studies on morbidity and mortality and underlying mechanisms, long-term epidemiological studies on the health of affected populations including evaluation and comparison of long-term effects of different intervention programs, assessment of the reconstruction of health services, and evaluation of epidemiological methods used including challenges faced and resulting limitations. This serves the planning for future disasters and improving the long-term situation of affected populations.

In short, disaster epidemiology is the science that provides the evidence base for the prevention of adverse health effects and optimal healthcare delivery after disasters. Understood like this, disaster epidemiology is as important as the actual healthcare delivery (Miller et al., 2016). The rigorous application of epidemiological methods to disaster situation, however, faces many challenges in lesser-developed settings:

  • Data must be collected rapidly under adverse and often chaotic environmental conditions within which priority is given to medical intervention and data collection is considered secondary. Critical information needed to improve future prevention and response (e.g., extrication methods used, time to arrival of emergency medical teams) cannot, however, be reconstructed if it is not collected concurrently (Noji, 1992). In addition, standardized data collection procedures used in nondisaster situations may be difficult to apply due to time constraints or needed assessor training (Leaning & Guha-Sapir, 2013).

  • At the same time, the timely mobilization of research funding may be difficult as the usual peer-review process in competitive grant application may involve protracted procedures. Also, access of research teams to the disaster areas may be limited due to safety and political concerns (Miller et al., 2016).

  • Population displacement because of referral to potentially remote hospitals and accommodation in temporary shelters makes it difficult to implement random sampling, even where population lists exist, and alternative strategies such as cluster random sampling may also have limitations (Leaning & Guha-Sapir, 2013). Another problem is related to problems in retrospectively obtaining data on initial diagnosis and treatment.

  • As population-level baseline data are often lacking in LMICs, background risk (i.e., risk before the event based on incidence and prevalence of health conditions as well as secular trends in disease and mental health) is often difficult to determine. This is, however, relevant to estimate excess morbidity and mortality due to the disaster, particularly in communicable disease, noncommunicable disease including malnutrition, and mental health (Aung & Whittaker, 2013; Leaning & Guha-Sapir, 2013; Noji, 1992).

  • Moreover, individual baseline data on medical history are often lacking or interventions are commenced without baseline assessments. This makes it impossible to disentangle intervention effects from time effects such as due to spontaneous recovery. Appropriate controls, that is, those not exposed to the disaster, are also difficult to identify because specifics of the communities that posed the population at an increased risk of impact may also specifically affect health outcomes.

  • Identification of populations at risk may also be difficult due to lack of recent censuses, population growth, and migration, as well as inconsistent definitions of affected populations. Information on the population initially at risk is, however, needed for denominators for the calculation of rates such as incidence rates. This leads to difficulties in data interpretation when comparing countries and when monitoring their progress in terms of investment in disaster risk reduction strategies over time (Guha-Sapir & Hoyois, 2015).

  • Another serious challenge relates to the lack of standardized protocols and minimal collaboration between different disciplines and research groups (Noji, 1992). This may lead to duplication of data collection in some respects and neglect in others, increased burden on victims, and poor research designs that are unable to answer underlying research questions. Lack of or unawareness about ethical standards for research involving humans may further lead to violations of the rights of research subjects (Tansey et al., 2017).

Conclusion and Future Directions

Given that disasters are events that exceed the adjustment capacity of the affected community, they pose challenges in every setting, be it high- or low-resourced. When a disaster occurs, all health systems have to deal with excess mortality, injury, morbidity, mental health problems, and disability. The key to preventing disasters and mitigating their adverse effects on human health does not solely lie in financial means and other tangible resources that can be mobilized by a health system but also in the way it is organized and tailored to the specific sociocultural structures and values of the population in need. Many challenges LMICs face with regard to healthcare delivery after disasters such as the organization of mortality management, triage and treatment of the injured, or the delivery of rehabilitative and mental health care cannot be reduced to the lack of baseline resources in terms of health infrastructure, technology, and personnel but are related to the absence of proper planning for future disaster scenarios including implementation strategies and simulation exercises. This not only encompasses the formal drafting of disaster preparedness and response plans, contingency planning of hospitals, and the provision of disaster-related training to health personnel but in particular the identification and involvement of the potentially and traditionally affected communities and especially vulnerable groups in all the process of disaster risk reduction (Hoffman, 2009; UNISDR, 2015). What works in high-income settings does not necessarily work in a lower-resourced setting, and more evidence is needed on how to overcome respective challenges. That said, there is a growing number of studies on community-based strategies for healthcare delivery in low-resourced settings that can possibly be applied in the context of disasters. One example is integrated mental health care delivery (e.g., based on the collaborative care model). This includes the integration of mental health services into primary care and community-based service delivery models based on paramedics or trained lay personnel, including families that assist psychiatrists’ assessment and monitoring of treatments of those with mental disorders in the community (Wainberg et al., 2017). Wainberg et al., however, also remarked that more implementation research is needed “so that evidence-based mental health programs are adopted and scaled-up within existing country health, educational, and other public systems” (p. 10).

What holds true for disaster preparedness and response within LMICs holds equally true for the response of the international community. An international response that is uncoordinated and poorly adapted to social and cultural conditions of the affected country is likely to be counterproductive. The recent WHO Emergency Medical Team (EMT) initiative therefore defines minimum technical standards and recommendations for different types of emergency medical teams. This WHO EMT initiative moreover involves setting up a registry within which different types of EMTs ranging from specialized cells to field hospitals that fulfill these minimum standards according to scrutiny by WHO can preregister and afterwards be deployed pending the demand of disaster-affected countries. A central focus is thus on enabling LMICs to develop their own EMT response capacity so that external assistance is not required (WHO, 2016).

While the focus of this article was on outlining challenges associated with healthcare delivery in disasters within LMICs, a next step is to match those challenges with evidence on cost-effective interventions suitable for lower-resourced settings as well as on strategies on how to adopt them to local needs under the consideration of all stakeholders.

Further Reading

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Cordner, S. M., Coninx, R., Kim, H.-J., Van Alphen, D., & Tidball-Binz, M. (Eds.). (2016). Management of dead bodies after disasters: A field manual for first responders. Geneva, Switzerland: Pan American Health Organization.Find this resource:

Inter-Agency Standing Committee. (2010). Mental health and psychosocial support in humanitarian emergencies: What should humanitarian health actors know? (Vol. 978-9953-0-2558-2). Geneva, Switzerland: Author.Find this resource:

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Leaning, J., & Guha-Sapir, D. (2013). Natural disasters, armed conflict, and public health. The New England Journal of Medicine, 7369(19), 1836–1842. Find this resource:

United Nations Office for Disaster Risk Reduction. (2015). Sendai framework for disaster risk reduction 2015–2030. Geneva, Switzerland: Author.Find this resource:

Wallemacq, P. (2018). Economic losses, poverty & disasters 1998–2017. Brussels, Belgium: Centre for Research on the Epidemiology of Disasters.Find this resource:

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