COVID-19 and Haiti Earthquakes: Catalysts to Improve Global Healthcare

Natural and man-made disasters are inevitable and can strike anywhere at any time. Although some mass casualty events are beyond human control, we can improve our response to these incidents by ensuring the right infrastructure is in place to build resilient global healthcare systems.

Two Recent Examples

The COVID-19 pandemic has resulted in nearly 935,000 deaths in the US and more than 6.5 million deaths worldwide, according to data available in early February from the Institute for Health Metrics and Evaluation.^1,2 As noted in the August 21, 2021, issue of The Economist, “Even if the next [pandemic] disaster cannot be predicted, having good infrastructure can make all the difference.”³The infrastructure for responding to a pandemic depends on both minimizing person-to-person contact and maximizing the capacity of the system providing care to patients who require hospitalization.

Indeed, infrastructure plays an important role in determining the impact on lives when any disaster strikes. Fortunately, because the epicenter of Haiti’s August 14, 2021, earthquake—the Tiburon Peninsula—is much less populated than Port-au-Prince, this quake was 1/100th as deadly as the 2010 Haiti earthquake: 2,200 deaths in 2021 versus more than 200,000 deaths in 2010.

An estimated 20,000 people died each day the first few days following the 2010 earthquake, many of whom could have been saved had basic surgical services been available in Port-au-Prince.^3,4 Long bone fractures, soft tissue wounds, and thoracoabdominal, brain, and spine trauma all are amenable to life- and disability-saving emergency surgery, but the infrastructure must be both resilient and immediately available.

How can we do better the next time a pandemic spreads around the world, an earthquake strikes Haiti, or a mass casualty disaster strikes anywhere?

A Recognized Solution

A mass casualty disaster can be either an acute event (earthquake) or a subacute to chronic event (pandemic). Mass casualty disasters include not only natural disasters (from earthquakes and volcanoes to hurricanes and floods), but also manmade disasters (from infrastructure and transportation accidents to terrorism and warfare).

Nearly a decade ago, the World Health Organization (WHO) recognized the benefit of local healthcare response for trauma in mass casualty disasters, stating that “…the most timely and cost-effective response to trauma is the one mobilised by the affected country itself.”⁵

The benefits of aligning mass casualty response and surgical systems recently have been documented.^6-8 Resilient surgical systems are essential to address not only mass casualty disasters, but also day-to-day conditions that require urgent or emergent surgical intervention, such as difficult childbirth and neonatal conditions (cesarean section, hydrocephalus), acute abdomen, cancer and cardiovascular emergencies, road traffic accidents, and other trauma. In many developing countries, the supply of electricity and/or clean water can be unreliable, making the availability of both routine and emergency care unpredictable.

Added Resilience through Established and Innovative Methods

The well-established trauma/stroke center model can be used to expand surgical resources for both day-to-day and mass casualty care.^7,8 A resilient trauma/stroke center includes (in addition to surgical services) the radiology, laboratory, and intensive care unit resources necessary to provide effective, full-service healthcare at all times. Such centers include battery-powered equipment (including computed tomography scanners), as well as resilient surgical and intensive care structures, transportable by ambulance or helicopter for a disaster at a remote site.

A critical component of resilient healthcare, made obvious by the COVID-19 pandemic, is telemedicine. Nationwide telemedicine programs have been developed and sustained for years in Cabo Verde and Albania.⁹ These initiatives have been shown to improve both routine patient care and emergency care by expediting the diagnosis of serious conditions that necessitate transfer to a higher level of care. Complementary to this is the savings in resources (and expense) by avoiding patient transfer when the teleconsultation indicates transfer is unnecessary.

The nationwide programs in Cabo Verde and Albania—developed by the International Virtual e-Hospital Foundation (IVeH) with support from the European Union through the Slovenian government and the US Agency for International Development (USAID)—can be replicated in other countries through the use of the Initiate-Build-Operate-Transfer (IBOT) strategy. IBOT calls for countries and healthcare leaders to commit to the project through all phases, from initiation through the building and operating phases until the government is in a position to operate and maintain the telemedicine program independently (transfer phase).

For developing countries, such a strategy is particularly helpful in that developed country input is readily available during the initial phases. Collaboration between developing and developed countries has proven successful in improving surgical services in many under-resourced nations. It can benefit implementation of the mass casualty center model as well.⁷

Telemedicine plays an essential role in acute mass casualty disaster response. A prime example is the North Atlantic Treaty Organization (NATO) Multinational Telemedicine System (MnTS) for disaster response.¹⁰ The NATO MnTS, begun in 2013, has brought together telemedicine experts in three disciplines: governance, information technology, and clinical/medical support. A multinational telemedicine disaster response requires not only the infrastructure (requisite hardware and software) and personnel (medical and technological support), but also resolution of issues—notably legal—that arise with cross-border collaboration. Crucial aspects in systems like MnTS for disaster response include redundancy in both communication capabilities and mobile power sources. Once an MnTS has been established for a region, telemedicine coordination in an acute mass casualty event can be implemented in less than 30 minutes.¹¹ Combining a robust telemedicine mass casualty disaster response system with robots and drones (equipped with high-resolution imaging capabilities) affords real-time triage of precious disaster response resources by a coordinator equipped with smart glasses that provide continuous observation (visual, thermal) of the disaster scene.⁸

Humanitarian and Economic Benefits of Resilient Local Healthcare

An article published recently in JAMA Health Forum called for expansion of surgical care globally as one method to achieve the United Nations (UN) Sustainable Development Goal #3 for 2030 (Ensure Healthy Lives).¹² An important part of such expansion is the implementation of resilient surgical resources that can be mobilized in response to a mass casualty disaster in minutes to hours, rather than the days to weeks of the current disaster response by external organizations, such as the UN, WHO, and Red Cross.

Climate change appears certain to increase the frequency and severity of weather-related mass casualty disasters. Geological mass casualty disasters (earthquakes, volcanoes) will persist. Man-made mass casualty disasters are unlikely to lessen in the future. Mass casualty disasters such as the Haiti earthquakes foster a collaborative humanitarian response that is frequently lacking for other crises because of ideological, religious, or social differences among countries and organizations.⁷

Mass casualty disasters (both natural and manmade) in many years result in hundreds of thousands of deaths, with an economic toll of more than $500 billion.⁷ Lack of surgical care in low- and middle-income countries, the cause of one-third of all deaths worldwide, has been predicted to cost more than $1 trillion (US) annually in lost gross domestic product by 2030.¹² Establishing robust and resilient surgical systems now is an investment many times over in terms of decreased morbidity and mortality from both day-to-day conditions and mass casualty disasters.⁹

If we learn nothing from the lessons of the COVID-19 pandemic and the Haiti earthquakes in 2010 and 2021, we are condemned to the same disastrous outcomes (both humanitarian and economic) somewhere, sometime, and likely all too soon.

References

1. Institute for Health Metrics and Evaluation. COVID-19 Projections: USA. Available at: https://covid19.healthdata.org/united-states-of-america?view=cumulative-deaths&tab=trend. Accessed February 9, 2022.
2. Institute for Health Metrics and Evaluation. COVID-19 Projections: Global. Available at: https://covid19.healthdata.org/global?view=cumulative-deaths&tab=trend. Accessed February 9, 2022.
3. Author unknown. Policymakers weigh up the future of Britain’s pandemic state. The Economist. Available at: https://www.economist.com/britain/2021/08/21/policymakers-weigh-up-the-future-of-britains-pandemic-state (subscription required). Accessed February 9, 2022.
4. Smith M. Haiti earthquake slams local hospitals. ABC News. January 13, 2010. Available at: https://abcnews.go.com/Health/HaitiEarthquake/haiti-earthquake-slams-local-hospitals-struggling/story?id=9554083. Accessed February 15, 2022.
5. Norton I, von Schreeb J, Aitken P, et al. Classification and Minimum Standards for Foreign Medical Teams in Sudden Onset Disasters. Geneva: World Health Organization Press; 2013.
6. Pyda J, Patterson RH, Caddell L, et al. Towards resilient health systems: Opportunities to align surgical and disaster planning. BMJ Glob Health. 2019;4(3):e001493.
7. Khan T, Quintana L, Aguilera S, et al. Global health, global surgery and mass casualties. I. Rationale for integrated mass casualty centres. BMJ Glob Health. 2019;4(6):e001943.
8. Aguilera S, Quintana L, Khan T, et al. Global health, global surgery and mass casualties: II. Mass casualty centre resources, equipment and implementation. BMJ Glob Health. 2020;5(1):e001945.
9. Latifi R, Azevedo V, Boci A, Parsikia A, Latifi F, Merrell RC. Telemedicine consultation as an indicator of local telemedicine champions’ contributions, health care systems needs, or both: Tales from two continents. Telemed J E Health. 2021;27(2):200-206.
10. Doarn CR, Latifi R, Poropatich RK, et al. Development and validation of telemedicine for disaster response: The North Atlantic Treaty Organization multinational system. Telemed J E Health. 2018;24(10):1-12.
11. Meara JG, Leather AJM, Hagander L, et al. Global surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. Lancet 2015;386:569-624.
12. Andrews RJ, Rosenfeld JV, Crisp N. The importance of surgical care to achieve the United Nations Sustainable Development Goal for healthy lives by 2030. JAMA Health Forum. 2021;2(6):e211213.