Policy Tag: Emergency Care

Adopted by the 62nd WMA General Assembly, Montevideo, Uruguay, October 2011

In the last decade, the attention of the world has been drawn to a number of severe events which seriously tested and overwhelmed the capacity of local healthcare and emergency medical response systems. Armed conflicts, terrorist attacks and natural distasters such as earthquakes, floods and tsunamies in various parts of the world have not only affected the health of people living in these areas but have also drawn the support and response of the international community. Many National Medical Associations have sent groups to assist in such disaster situations.

According to the World Health Organization (WHO) Center for Research on the Epidemiology of Disasters (CRED), the frequency, magnitude, and toll of natural disasters and terrorism have increased throughout the world.  In the previous century, about 3.5 million people were killed worldwide as a result of natural disasters; about 200 million were killed as a result of human-caused disasters (e.g., wars, terrorism, genocides).  Each year, disasters cause hundreds of deaths and cost billions of dollars due to disruption of commerce and destruction of homes and critical infrastructure.

Population vulnerability (e.g., due to  increased population density, urbanization, aging) has increased the risk of disasters and public health emergencies.  Globalization, which connects countries through economic interdependencies, has led to increased international travel and commerce. Such activity has also led to increased population density in cities around the world and increased movement of people to coastal areas and other disaster-prone regions.  Increases in international travel may speed the rate at which an emerging infectious disease or bioterrorism agent spreads across the globe.  Climate change and terrorism have emerged as important global factors that can influence disaster trends and thus require continued monitoring and attention.

The emergence of infectious diseases, such as H1N1 influenza A and severe acute respiratory syndrome (SARS), and the recent arrival of West Nile virus and monkey pox in the Western hemisphere, reinforces the need for constant vigilance and planning to prepare for and respond to new and unexpected public health emergencies.

The growing likelihood of terrorist-related disasters affecting large civilian populations affects all nations.  Concern continues about the security of the worldwide arsenal of nuclear, chemical, and biological agents as well as the recruitment of people capable of manufacturing or deploying them. The potentially catastrophic nature of a “successful” terrorist attack configures an event that may demand a disproportionate amount of resources and healthcare professionals preparedness..  Natural disasters such as tornadoes, hurricanes, floods, and earthquakes, as well as industrial and transportation-related catastrophes, are far more common and can also severely stress existing medical, public health, and emergency response systems.

In light of recent world events, it is increasingly clear that all physicians need to become more proficient in the recognition, diagnosis, and treatment of mass casualties under an all-hazards approach to disaster management and response.  They must be able to recognize the general features of disasters and public health emergencies, and be knowledgeable about how to report them and where to get more information should the need arise.  Physicians are on the front lines when dealing with injury and disease-whether caused by microbes, environmental hazards, natural disasters, highway collisions, terrorism, or other calamities. Early detection and reporting are critical to minimize casualties through astute teamwork by public- and private-sector health and emergency response personnel.

The WMA, representing the doctors of the world, calls upon its members to advocate for the following:

  • To promote a standard competency set to ensure consistency among disaster training programs for physicians across all specialties. Many NMAs have disaster courses and previous experiences in disaster response. These NMAs can share this knowledge and advocate for the integration of some standardized level of training for all physicians, regardless of specialty or nationality.
  • To work with national and local governments to establish or update regional databases and geographic mapping of information on health system assets, capacities, capabilities, and logistics to assist medical response efforts, domestically and worldwide, when needed. This could include information on local response organizations, the condition of local hospitals and health system infrastructures, endemic and emerging diseases, and other important public health and clinical information to assist medical response in the event of a disaster. In addition, systems for communicating directly with physicians and other front line health care providers should be identified and strengthened.
  • To work with national and local governments to ensure the developing and testing of disaster management plans for clinical care and public health including the ethical basis for delivering such plans.
  • To encourage governments at national and local levels to work across normal departmental and other boundaries in developing the necessary planning.

The WMA could serve as a channel of communication for NMAs during such times of crisis, enabling them to coordinate activities and work together.

Adopted by the 46th WMA General Assembly, Stockholm, Sweden, September 1994
revised by the 57th WMA General Assembly, Pilanesberg, South Africa, October 2006
and by the 68th WMA General Assembly, Chicago, United States, October 2017
and rescinded and archived by the 74th WMA General Assembly, Kigali, Rwanda, October 2023

PREAMBLE

1.      According to International Federation of Red Cross and Red Crescent Societies (IFRC) a disaster is a sudden, calamitous event that seriously disrupts the functioning of a community or society and causes human, material, and economic or environmental losses that exceed the community’s or society’s ability to cope using its own resources. Though often caused by nature, disasters can have human origins.

This definition excludes situations arising from conflicts and wars, whether international or internal, which give rise to other problems in addition to those considered in this paper.

2.      Disasters often result in substantial material damage, considerable displacement of people, many victims and significant social disruptions. Adequate preparation would make major consequences less likely and less severe and protect people especially the most vulnerable.

This document will focus particularly on the medical aspects of disasters. From a medical standpoint, disaster situations are characterized by an acute and unforeseen imbalance between resources and the capacity of medical professionals, and the needs of survivors who are injured whose health is threatened, over a given period of time.

3.      Disasters, irrespective of cause, share several common features:

3.1.     Their sudden and unexpected but often predictable occurrence, demanding prompt action;

3.2.     Material or natural damage making access to the survivors difficult and/or dangerous;

3.3.     Displacement or movement of often large numbers of people;

3.4.     Adverse effects on health due to various reasons such as physical injuries and high energy trauma, direct and indirect consequences of pollution, the risks of epidemics and emotional and psychological factors as well as factors such as reduced access to food, potable water, shelter, health care and other health determinants;

3.5.     A context of insecurity sometimes requiring police or military measures to maintain order; and

3.6.     Media coverage, and the use of social media.

4.      Disasters require multifaceted responses involving many different types of relief ranging from transportation and food supplies to medical services. Physicians are likely to be part of coordinated operations involving other responders such as law enforcement personnel. These operations require an effective and centralized authority to coordinate public and private efforts.

Rescue workers and physicians are confronted with exceptional circumstances, which require the continued need of a professional and ethical standard of care. This is to ensure that the treatment of disaster survivors conforms to basic ethical tenets and is not influenced by other motivations. Inadequate and/or disrupted medical resources on site and a large number of people injured in a short time present specific ethical challenges.

RECOMMENDATIONS

5.      Medical profession is at the service of the patients and society at all times and in all circumstances. Therefore, the physicians should be firmly committed to addressing the health consequences of disasters, without excuse or delay.

6.      The World Medical Association (WMA) reaffirms its Declaration of Montevideo on Disaster Preparedness and Medical Response (2011) recommending the development of adequate training of physicians, accurate mapping of information on health system assets and advocacy towards governments to ensure planning for clinical care.

7.      The WMA recalls the primary necessity to ensure the personal safety of physicians and other responders during the event of disasters (Declaration on the Protection of Health Care Workers in situation of Violence, 2014).

Physicians and other responders must have access to appropriate and functional equipment, both medical and protective.

8.      Furthermore, the WMA recommends the following ethical principles and procedures with regard to the physician’s role in disaster situations:

8.1    A system of triage may be necessary to determine treatment priorities. Despite triage often leading to some of the most seriously injured receiving only symptom control such as analgesia, such systems are ethical provided they adhere to normative standards.  Demonstrating care and compassion despite the need to allocate limited resources is an essential aspect of triage.

Ideally, triage should be entrusted to authorized, experienced physicians or to physician teams, assisted by a competent staff. Since cases may evolve and thus change category, it is essential that the official in charge of the triage regularly assesses the situation.

8.2     The following statements apply to treatment beyond emergency care:

8.2.1      It is ethical for a physician not to persist, at all costs, in treating individuals “beyond emergency care”, thereby wasting scarce resources needed else-where. The decision not to treat an injured person on account of priorities dictated by the disaster situation cannot be considered an ethical or medical failure to come to the assistance of a person in mortal danger. It is justified when it is intended to save the maximum number of individuals. However, the physician must show such patients compassion and respect for their dignity, for example by separating them from others and administering appropriate pain relief and sedatives, and if possible ask somebody to stay with the patient and not to leave him/her alone.

8.2.2      The physician must act according to the needs of patients and the resources available. He/she should attempt to set an order of priorities for treatment that will save the greatest number of lives and restrict morbidity to a minimum.

8.3    Relation with the patients

8.3.1      In selecting the patients who may be saved, the physician should consider only their medical status and predicted response to the treatment, and should exclude any other consideration based on non-medical criteria.

8.3.2      Survivors of a disaster are entitled to the same respect as other patients, and the most appropriate treatment available should be administered with the patient’s consent.

8.4    Aftermath of disaster

8.4.1      In the post-disaster period the needs of survivors must be considered. Many may have lost family members and may be suffering psychological distress. The dignity of survivors and their families must be respected.

8.4.2      The physician must make every effort to respect the customs, rites and religions of the patients and act in impartiality.

8.4.3      As far as possible, detailed records should be kept, including details of any difficulties encountered.  Identification of patients, including the deceased should be recorded.

8.5    Media and other third parties

Physicians should take into consideration that in any disaster media is present. The work of the media should be respected and facilitated as appropriate in the circumstances. If needed, physicians should be empowered to restrict the entrance of reporters and other media representatives to the medical premises. Appropriately trained personnel should handle media relations.

The physician has a duty to each patient to exercise discretion and to seek to ensure confidentiality when dealing with third parties. The physician must also exercise caution and objectivity and respect the often emotional and politicized atmosphere surrounding disaster situations. Any and all media especially filming must only occur with the explicit consent of each patient who is filmed. With regard to social media use, physicians must adhere to these same standards of discretion and respect for patient privacy.

8.6    Duties of paramedical personnel

The ethical principles that apply to physicians in disaster situations should also apply to other health care workers.

8.7    Training

The World Medical Association recommends that disaster medicine training be included in the curricula of university and post-graduate courses in medicine.

8.8    Responsibility

8.8.1      The World Medical Association calls upon governments and insurance companies to cover both civil liability and any personal damages to which physicians might be subject when working in disaster or emergency situations. This should also include life and disability coverage for physicians who die or are harmed in the line of duty.

8.8.2      The WMA requests that governments:

  • Ensure the preparedness of healthcare system to serve in disaster settings.
  • Share all information related to public health timely and accurately.
  • Accept the participation of demonstrably qualified foreign physicians, where needed, without discrimination on the basis of factors such as affiliation (e.g. Red Cross, Red Crescent, ICRC, and other qualified organizations), race, or religion.
  • Give priority to the rendering of medical services over anything else that might delay necessary treatment of patients.