CASE BOX 6.1 THE 2008 SICHUAN EARTHQUAKE

An earthquake with a magnitude measuring 7.9 on the Richter scale occurred on 12 May 2008 in Wenchuan County in Sichuan Province in southwestern China. The earthquake killed more than 87,000 and affected 45 million peo-ple. The death toll ranks eighth among all earthquakes recorded in history (Centre for Research on the Epidemiology of Disasters [CRED], 2013).

Although the complications associated with prolonged entrapment in col-lapsed buildings were expected to be high, the prevalence of crush syndrome was reported to be only around 1% among the physical trauma and injury cases (Zhang et al., 2012). Yet, timely medical response, especially carrying out surgery within the first week of the earthquake, was hindered by the prev-alence of chronic non- communicable diseases (NCDs) among the victims:

close to 38% of them required management of their pre- existing, unstable chronic medical conditions before surgery. In the second week, more than 50% of the injured victims required treatment for preventing the exacerbation of underlying conditions.

Technically, standard guidelines and medication are required for NCD management after disasters. The lack of an operational mandate, competing field priorities and a general lack of awareness and expertise for chronic medi-cal management were consistently reported by the responders. Although the patient- to- doctor ratio was 1:3 in many disaster response sites, 80% of the doctors were orthopaedic surgeons and there was a lack of general inter-nal medicine and primary care professiointer-nals to manage underlying common chronic medical conditions (Chan, 2008). There was also a resistance to treat-ing patients with chronic conditions because of a limited understandtreat-ing of the treatment implications and long- term financial constraints.

Even if there might be willingness to manage chronic disease post–natural disasters, there was another major concern about sustainability. Hung (2010;

Hung, Lam, Chan, & Graham, 2013) describes the dilemma that his team faced when diagnosing hypertension after the earthquake. His team ques-tioned that once the consultation drug supply was used up, the drugs were either too expensive or just not available to the patient to allow long- term treatment. They therefore questioned whether they should treat, or even look for raised blood pressures at all.

The recent literature on public health has suggested that chronic disease needs are still largely neglected post- disaster (Wells, 2005; Chan, 2008; Chan & Sondorp, 2008; Chan, 2009; Chan & Kim, 2011; Zhang, Liu, Liu, & Zhang, 2011). Case Box 6.1 discusses why NCDs continue to be ignored in major earthquake relief operations such as 2008 Wenchuan earthquake in Sichuan Province of China.

Why are chronic diseases still being forgotten?

Although typical natural disaster emergency health responses include emergency (often surgical) treatment for injuries, basic care for communicable diseases, such as diarrhoea and respiratory infections, surveillance of and response to communicable disease outbreaks, nutritional support and provision of water and sanitation (Landes-man, 2001; The Sphere Project, 2011), the management of non- communicable chronic disease remains neglected (Ford et al., 2006; Kwak, Shin, Kim, Kwon, & Suh, 2006; Guha- Sapir, van Panhuis, & Lagoutte, 2007; Chan, 2008; Chan & Griffi ths, 2009; Chan & Kim, 2010a, 2010b). Case Box 6.2 discusses some factors that lead to chronic diseases are still forgotten notwithstanding the evidence.

CASE BOX 6. 2 WHY ARE CHRONIC NON- COMMUNICABLE DISEASES FORGOTTEN?

The lack of an operational mandate and guidelines, the inflexible established practices and concern about sustaining the provision of chronic medica-tion after natural disasters remain the major challenges (Chan & Sondorp, 2007; Spiegel, Checchi, Colombo, & Paik, 2010). Minimum standards, with the exception of those of the Sphere Project (2011), are virtually non- existent (HelpAge International, 2005; Wells, 2005). There are multiple reasons for such neglect of chronic disease, some of which are listed in Table 6.3.

TABLE 6.3 Reasons why different responders often neglect chronic diseases after a disaster

Lack of awareness

Lack of operational mandate Not part of established practices

Lack of relevant skills and expertise to detect and manage chronic diseases in a post- disaster setting and resistance to external pressure to change among local health systems and stakeholders lacking understanding of the problem Lack of knowledge of local demographic and epidemiological characteristics among outside response organisations and alternative fi nancial incentives among local care providers

Lack of resources for managing chronic diseases in relief settings Lack of standardised protocols or guidelines for the management of chronic diseases in the post- disaster context Lack of cooperation/coordination

Issue of sustainability

Source: Adapted from Chan and Sondorp (2007).

Some progress is being made to raise the profi le of chronic diseases post- disaster.

The most recent version of the Sphere standards says that people should “have access to essential therapies to reduce morbidity and mortality due to acute complications or exacerbation of their chronic health condition” and that “people who were previously on anti- retroviral therapy continue to receive treatment.” Key indicators, such as “all primary health care facilities have clear standard operating procedures for referrals of patients with NCDs to secondary and tertiary care facilities,” are also proposed (The Sphere Project, 2011, pp. 336, 329, 337). Evidence- based clinical guidelines are now being developed. For example, for hypertension, some technical groups recommend frequent home blood pressure measurement, good sleep quality, hydration and physical activity (Kario, Shimada, & Takaku, 2005). Continued advo-cacy in the published literature will raise awareness of the issue but chronic medical conditions are becoming too signifi cant a disaster disease burden to be ignored in the coming decades.

Primary care approach in disaster medical and public health responses

Field studies have indicated that the most common medical treatments required in a post–natural disaster clinic were antibiotics (20.2%), analgesia (17.1%), teta-nus vaccine (15.5%) and wound care (14.2%) (Nufer, Wilson- Ramirez, Shah, Hughes, & Crandall, 2006). The health infrastructure and systems with disaster- resilience features (protection of essential equipment and stockpiling of essential medicines) can maintain the continuity of care for a population with chronic disease needs. Not only can the primary care approach tackle these immedi-ate needs, non- communicable disease management needs may also be addressed through primary care service approach, which deals with the range of service needs across the pathway of care (see Chapter 2 ) from prevention, diagnosis and treatment to rehabilitation and palliative care. A primary care unit, with its underlying knowledge and information of the prevalence of pre- emergency NCD patterns, NCD treatment protocols and guidelines in emergencies, clinical assessment and audit tools to monitor diseases as well as the availability of relevant equipment and medication for NCD management are all important elements to ensure the success of a programme. Active health education and promotion activities may also be conducted during the relief phase to raise awareness of these issues among the public, including the appropriate diet and family support for target groups.

Threats to mental health

The World Health Organization defi nes mental health as “a state of well- being in which every individual realises his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribu-tion to her or his community” (WHO, 2014). In ordinary circumstances, people

generally make three fundamental assumptions about the world, that: (1) the world is essentially a good place, (2) life and events have meaning and purpose; and (3) they are valuable and worthy (Janoff- Bulman, 1992).

Not all distress is abnormal and a large portion of distress is a normal human reaction in times of critical incidents (Williams & Alexander, 2009). However, in disasters, traumatic experiences challenge individuals’ perception about the world and themselves and such stressors are known risk factors for mental health problems, the impact of which could be far-reaching (see Knowledge Box 6.4).

Normal reaction after disasters

After the occurrence of a disaster (i.e. impact), it is normal for an affected popula-tion to experience distress. Such distress usually peaks within the fi rst week of the incident and then the level gradually drops as the post- disaster time passes. Figure 6.1

KNOWLEDGE BOX 6.4 GLOBAL PATTERN OF MENTAL