Overview of Medical Rehabilitation in Natural Disasters in the Pacific Island Countries

  

    
Country 
    
Year 
    
Event 
    
Number affected 
    
Number displaced 
    
Number killed 
  
  

    
Kiribati 
    
March, 2015
    
Cyclone Pam passed over as a category 2 story

    
2,000
    
-
    
-
  
  

    
Tuvalu 
    
March, 2015
    
Cyclone Pam passed over as a category 2 story
    
4,600
    
350
    
-
  
  

    
Vanuatu 
    
March 10-13, 2015
    
Cyclone Pam passed over as a Category 5 system
    
189,000
    
4,000
    
11
  
  

    
Vanuatu 
    
March 10-13, 2014
    
Cyclone Lusi passed over as a Category 2 system
    
20,000
    
149
    
10
  
  

    
Federated States of Micronesia 
    
March 29 and April 1, 2015
    
Typhoon Maysak made landfall at Chuuk on Ulithi    and Yap
    
29,700
    
1,500
    
4
  
  

    
Palau 
    
November 7, 2013
    
Super Typhoon Haiyan passed directly over the    island of Kayangel
    
2,300
    
900
    

  
  

    
Solomon Islands 
    
April, 2014
    
Three days of heavy rain caused flash floods
    
52,000
    
10,000
    
22
  
  

    
Marshall Islands 
    
March 3, 2014
    
King tides inundated Majuro Atoll and some outer    islands
    
1,730
    
940
    

  
  

    
Tonga 
    
January 11, 2014
    
Cyclone Ian passed directly over the Ha'apai    Group as a Category 5 system
    
5,000
    
2,335
    
1
  
  

    
Source: Office for the Coordination of Humanitarian Affairs    (OCHA). 
      
 
  

Table 3:  Major natural disaster in Pacific region (2014 - 2015).

Key Regional Initiatives in Disaster Management

Although PICs have achieved progress in terms of life expectancy, infant mortality rates, and infectious disease control etc., the economic growth, however, has been well below global average. Overall, the regional disaster management capacities and collaboration have improved in recent years and the PICs recognise the importance for disaster planning and management initiatives [11]. In line with other countries in the Asia-Pacific, there is growing attention in the PICs on disaster prevention and preparedness, especially early warning systems, early evacuation and awareness. The United Nations (UN) regional arm the Economic and Social Commission for Asia and the Pacific (ESCAP) (1947) was established as an inter-governmental forum for all countries and territories of Asia and Pacific region, and currently has 53 members and 9 associate members covering more than 60% of the world’s population (4.1 billion people). Early in 1994, all PIC governments agreed on a common strategy for disaster reduction at the World Conference on Natural Disaster Reduction held in Yokohama, Japan [12]. In 1999, UN Office for the Coordination of Humanitarian Affairs (OCHA) established a Regional Office for the Pacific (ROP), with aim to mobilize and coordinate effective and principled humanitarian action in the region in partnership with national and international actors. In 2008, the OCHA ROP established the Pacific Humanitarian Team (PHT) to improve the timeliness, effectiveness and predictability of humanitarian response and coordination of humanitarian action using a regional cluster approach in the region, by bringing together humanitarian actors in the region to support governments. Currently, the OCHA ROP supports all 14 Pacific Island countries. Australia is the key funder of disability initiatives in the PICs under its “Development for All” strategy [2].

At the regional level, Pacific Forum Islands Leaders in 2005 approved the Pacific Disaster Risk Reduction and Disaster Management Framework for Action 2005 – 2015 (Madang Framework) [11]. The key activities under this framework to date include: Pacific Catastrophe Risk Financing Mechanism (under development); Regional Tsunami Exercise and Pacific Disaster Net (online virtual Center of Excellence) [13]. In 2006, to support capacity-building in disaster-risk management in the PICs, Pacific Disaster Risk Management (DRM) Partnership Network was established comprising more than 30 regional and international organizations [11,13]. This Partnership Network is assisting and supporting the PICs to develop and implement Strategic National Action Plans (SNAP) for disaster risk management with funding from major donors such as European Islands and Australian Aid (AusAID) [11]. Other key objective of this network is to sustain a regional network of development partners that work in the different areas of disaster management to improve regional cooperation, coordination and collaboration; strengthen thematic areas identified in the 2005-15 Pacific Framework for Action; monitor and evaluate national progress; reduce duplication of efforts and ensure assistance is built on the efforts and experiences of each other [13]. Many PICs currently have the SNAP, while in some countries processes are underway to develop this action plan.

In August 2010, the Pacific Platform for Disaster Risk Management (PPDRM) Framework for Action 2010–2015 was adopted, to enhance disaster risk management in the PICs. Currently, most counties in the region have some form of legal and regulatory frameworks for managing disaster risk [14]. Regional cooperation mechanisms developed include a range of activities, such as Pacific Risk Exposure Database, Regional Specialized Meteorological Center for Tropical Cyclone in Nadi, Pacific Tsunami Warning Center, Melanesian Volcanological Network and others [13]. Unfortunately, major disparities and gaps amongst the PICs exist, and those with high disaster risk tend to have low coping capacity [8,15]. People in these region are vulnerable to the future natural calamities as they live in more exposed areas and have weak livelihoods and few resources [8,15]. In recent international forum, at the third UN World Conference in Sendai, Japan (March 18, 2015), leaders and decision-makers across the region adopted a new global framework for disaster risk reduction - the ‘Sendai Framework for Disaster Risk Reduction 2015-2030’ [16]. The Sendai Framework is successor instrument to the ‘UN Hyogo Framework for Action 2005-2015: Building the Resilience of Nations and Communities to Disasters’ and was developed on elements which ensure continuity with the work done by States and other stakeholders under the ‘Hyogo Framework’ [16]. This new framework introduces innovations and emphasises on disaster risk management as opposed to disaster-management. Further, the Sendai Framework broadened disaster risk reduction significantly to focus on both natural and man-made hazards and related environmental, technological and biological hazards and risks; and provides a strong foundation for governments to take on a greater role at all levels [16]. Similar to the ‘Hyogo Framework’, the ‘Sendai Framework’ is also based on voluntary commitment of the member states. As many argue that the ‘Hyogo Framework’ was limited in its capacity to move certain actions forward [14], it is still unclear whether the ‘Sendai Framework’ will have similar difficulty.

Medical Rehabilitation in Disaster Settings

With advances in rescue and field management in disasters, survival rates have improved significantly worldwide [17]. However, rates of long-term physical disabilities, and mental and psychological disorders related to disasters are on the rise, requiring integrated interdisciplinary longer-term collaborative care from the acute phase of disaster to community reintegration [18,19]. There is a strong consensus amongst the disaster management authorities, that longterm rehabilitation planning is critical [19-21] and integral part of the comprehensive disaster management of victims [22]. The main aims of medical rehabilitation in disaster settings include: collaboration in the management of acute injury, optimization of functional capabilities (including cognitive, neuropsychological function) postacute care, and social re-integration [18,23]. The role of rehabilitation physician/team in disaster settings is extensive and has an array of activities such as: coordination and assessment of injury patterns and post-disaster rehabilitation needs; valuation of resource requirements (including long-term); establishment of patient triage, discharge, referral, and tracking systems; collaboration with other healthcare service providers (local and international); coordination with emergency response systems, host health system and government managers; data collection, management and analysis and others [17,18].

The medical rehabilitation process should be initiated immediately (early) during the emergency response phase, and should continue in the community over a longer-term [19,24]. There is strong evidence that early involvement of rehabilitation programs can reduce disability, improve participation and quality of life of disaster victims [17,18,21]. Further, studies conducted in previous disasters have demonstrated that involvement of rehabilitation physician in the disaster management, results in positive and improved disaster victims’ clinical outcomes, reduced length of hospital stay and fewer complications [25,26]. Despite the evidence, regrettably, often emergency responses and disaster management do not extend to include rehabilitation services [17]. In many disasters, the acute response and care protocols focusing on saving lives and treating acute injuries get utmost attention, and rehabilitative needs are often ignored [18,21,27].

Rehabilitation approach for disaster victims should include a wide spectrum of treatments and interventions [17,18]. The importance of rehabilitation services and need for inclusion of rehabilitation in response and planning for humanitarian catastrophes are well documented [24,28]. This review did not find any evidence of inclusion of rehabilitation professionals in emergency-response staffing configuration in any of disasters in the Pacific region. Similar to previous disasters worldwide, there are immense challenges for rehabilitation personnel, particularly, during the disaster settings in the PICs. These may include (but not limited to) [18,21,25,29]:

• Rehabilitation services do not exist and/or are in infancy stage in many PICs, and in many PICs these services are usually integrated within other health services in public hospitals (mainly in urban areas)
• Limited number of services specific for complex disasterrelated disabilities
• During disasters, existing host-healthcare infrastructure (including rehabilitation services) may be damaged and/or disrupted or overwhelmed by the influx of disaster victims
• Discharge from healthcare facilities/community reintegration can be challenging due to lack of appropriate, accessible housing
• Poor coordination amongst disaster management organisations (national and international)
• Limited number of skilled human resources locally-few or no rehabilitation professionals
• Inadequate community rehabilitation resources and facilities
• Limited provision of psychological support and cognitive rehabilitation
• Lack of reporting, assessment, measurement and data collection tools
• Deployment to the affected areas can be complicated by damaged and/or disrupted infrastructure, such as roads, transport, communications etc.
• Cultural beliefs and practice of the people affected about disability and the disaster itself
• Challenges posed by distance, diverse languages, cultural differences and geographic barriers
• Cost of access to rehabilitation services can be a barrier for victims due to lack or limited provision of disability support and government health plans

Identified Gaps for Action

Natural disasters potentially have significant consequences and serious economic implication for the PICs [11,14]. The challenges in disaster management are common for most developing countries, including PICs. Despite progress in surveillance and early warning systems and evacuations, overall Asia and Pacific region is still largely unprepared in disaster management [14]. Most importantly, some of the Pacific countries at greatest risk for natural disasters are those that are the least developed to manage these disaster-related risks [4,11]. The PICs recognise the immense challenges ahead for effective disaster risk management [11]. There is urgent need for investments in disaster risk reduction and disaster management in the Pacific region. This will not only improve physical and psychosocial disabilities of the disaster victims, but also result in significant economic benefit to the governments and community. For example, it is estimated that investment in reduction of coastal erosion in Kiribati can achieve net economic returns of a minimum of A$1.1 million [11,30]. The PICs seems to be heading in the right direction and are considering improving prospects for national development, through supporting investment in disaster risk reduction, climate change adaptation and disaster management [11]. Improved regional information exchange, strengthened regional cooperation for effective post-disaster management and joint coordination to address cross-border disasters are critical for disaster management [6,14,31].

• Leadership role of the central national healthcare ministry/ organisation to coordinate and provide cooperative effort in disaster management to enhance capacity (national and international health care organisations, NGOs and Emergency Medical Teams)
• Robust inter-disciplinary and inter-sectoral partnerships need to be stimulated for disaster management, preparedness, emergency response and long-term planning
• All national and international representative organisations (including NGOs, disability-related society) should be recognised as important stakeholder group and included in disaster management agenda and processes, especially rehabilitation
• Develop comprehensive disaster management system
• Building capacity in rehabilitation (including regional capacity) and improving collaboration between all health care services
• Person-centred interdisciplinary care which includes rehabilitation of all survivors
• Service provision (including funding) of assistive devices such as crutches, prostheses, wheelchairs etc., when appropriate
• Treatment goals must be non-discriminatory and require alignment with key international Human Rights and principles of the UN Convention of the Rights of Persons with Disabilities
• Improve communication (information gathering, sharing and disseminating), cost-effectiveness and proactive technologies
• Information needs to disseminate to relevant authorities for longer-term management
• Fostering knowledge exchange and greater access to information/data for future capacity building
• Increase public awareness and active participation/ inclusion of disaster survivors/family/community
• Leadership guidance from the governmental and other relevant authorities for training and empowerment and educational programs for healthcare professionals in regards to disasters and disability
• Rehabilitation capacity building at national health level and other relevant institutions for development of skilled workforces
• Access to information to enable active participation and contribution from treating teams
• Bilateral assistance for disaster victims: health security, financial, job creation, resources tailored to country characteristics
• Strengthen evidence-based information, data and knowledge
• Build grass root capacity for disasters preparedness
• Strengthen community-based rehabilitation

Discussion

Natural disasters (and related human-suffering) are escalating worldwide due to many factors, including: emerging effects of climate change, population growth, rapid urbanization, development patterns and poverty. Pacific region remains one of the most susceptible and exposed to natural disasters. The region is diverse geographically, economically, culturally and politically, which impede disaster risk reduction and effective management. Sustained disaster management progress in the region will require long-term cooperation by international partners and donors to provide lifesaving response and recovery assistance to victims when disasters strike. More broadly, greater economic integration, public awareness and education, more equitable resource, more innovative methods and adaptation to climate change will be needed for long-term management of future disasters in the PICs.

Long-term health consequences and disability affect many disasters victims, their family/carers, society and the overall health system. The National Action Plan for disaster management for PICs should include comprehensive long-term rehabilitation inclusive management approach. The ‘Sendai Framework for Disaster Risk Reduction 2015-2030’, sets up an agenda for all government and sectors of society for collaborative effort for successful future disaster planning and management. The PICs are formulating their National Action Plans and other initiatives for disaster management and risk reduction. At national level, the capacity building approach needs to include the development of integrated disaster risk management and emergency response management plan, with inter-sectoral and interdisciplinary partnership amongst governmental, private, national and international sectors. The disaster management plan should consist long-term care and rehabilitation of the victims, which will require strengthening of community based organizations and more involvement of disaster victims and their families in planning.

Natural disaster management is acquiring a global attention. A futuristic perspective would have to look into the outlines of previous disaster experiences and come up with a systematic disaster rehabilitation strategy. The UN and WHO are key global actors with relevance to shaping disaster vulnerability and management in the PICs. Explicitly, the WHO Disability and Rehabilitation (DAR) Team works to support Member States to develop appropriate, effective and sustainable rehabilitation programs for persons with disabilities arising from all causes and has a number of collaborating partners and networks of rehabilitation experts [34]. The role of the WHO Liaison Sub-Committee on Rehabilitation Disaster Relief (CRDR) of the International Society of Physical and Rehabilitation Medicine (ISPRM) is vital in future disasters to facilitate coordination among major rehabilitation providers responding to the many needs in disasters, to minimize delay and duplication in the deployment and to deliver timely and effective rehabilitative care to the victims [19]. Many recent developments and initiatives could be regarded as the much needed steps, this includes the drafting of the ‘Emergency Medical Teams: Minimum Standards for Rehabilitation’ (in Printpersonal communication), which define standards for rehabilitation in emergencies acknowledging that variations in type and patterns of injury, disease and subsequent long-term disability that arise in different scenarios. In consonance with the new perspective, coordination and collaboration with other organisations (both national and international) in the field of disaster relief, rehabilitation and recovery, is crucial for future. Further, in post-natural disaster recovery phase, is important that the government ensures that investments in healthcare and health infrastructure are designed for long-term sustainability and is innovative. The government planning should also emphasise successful community reintegration of disaster victims, revitalizing the culture of community resiliency.

Conclusion

Natural disasters result in significant numbers of severely injured who require comprehensive and protracted rehabilitation. Management of survivors in future disasters will require diverse forms of multi-stakeholder partnerships, including partnership with governmental bodies, local health care institutions, NGOs and INGOs, civil society organizations related to persons with disabilities, EMTs, community organisations and private sector. The successful and effective future disaster management will depend on the capacity and willingness of the PICs to embrace and disseminate effective methods of disaster risk governance and preparedness, and develop appropriate policies, regulations and legislations. The challenges ahead are developing a comprehensive, targeted and integrated approach to disaster risk management. Furthermore, there is a need for long-term rehabilitation inclusive post-disaster management strategies, stretching across all government and non-governmental sectors and jurisdictions, and vulnerable communities.

Acknowledgement

We thank the Committee on Rehabilitation Disaster Relief (CRDR) of the International Society of Physical and Rehabilitation Medicine (ISPRM) for their support.

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