What's new in critical illness and injury science? The effect of concomitant natural and manmade disasters on chronic disease exacerbations: COVID-19, armed conflicts, refugee crises and research needs.

Disasters, both natural and man-made, may have a range of health effects that last for years, decades, or life.[123456] Apart from the obvious burden of wounds and injuries that may accompany acute events, many disasters promote infrastructure and resource disruption, population displacement, and impair access to medical and public health services resulting in communicable disease outbreaks as well as the development or decompensation of chronic and noncommunicable diseases.[137] It has long been recognized that armed conflicts may deteriorate into prolonged disaster scenarios, however, when they occur concomitantly with acute or protracted natural disasters (e.g. COVID-19, wildfires, etc.), the health effects may be challenging to predict or mitigate.

The COVID-19 pandemic has caused ripple effects across health care, commerce, manufacturing and politics.[8] However, one should remember that this current pandemic came on the back of the armed conflict in Syria with its resultant refugee crisis. Roughly 13.4 million Syrians were internally (6.7 million) or externally displaced.[9] As the conflict in Ukraine grows, Europe now faces its largest potential refugee crisis since World War II. Within weeks, millions have been internally displaced or fled to neighboring countries. Even the best-designed health-care system is not designed for this and may fail under such stresses. Moreover, with conflict now involving the immediate areas of the Zaporizhzhia nuclear power plant (supplies 20% of Ukraine's electricity) as well as the defunct Chernobyl nuclear facility (site of a major nuclear disaster in 1986), the prospects of layering yet another acute disaster with chronic consequences is becoming increasingly possible.[10]

Increasing attention is being focused on the needs of vulnerable populations during humanitarian emergency response. Vulnerable populations are those groups with increased susceptibility to poor health outcomes rendering them disproportionately affected by the event.[11] Such populations often include the elderly, children, women, and minority groups among others.[71112] In addition, those with chronic diseases may be among the most vulnerable.[3] The burden of chronic disease has been observed to be high, but variable, among refugees depending on the country of origin, with estimates as high as 50% among some Syrian refugee populations.[13] Traditionally, host health systems and research efforts have prioritized emergency needs, traumatic injuries, and infectious diseases to address immediate health needs.[13] Noncommunicable diseases have received less traction, perhaps because of the challenges of providing continuous care to a large population and the less urgent nature by which these conditions may be perceived.[1213] There are numerous reasons why a host health-care system may be insufficiently equipped to address the chronic disease burden of its refugee population in tandem with those of the host population in a manner that is sustained and equitable.

Since chronic conditions, such as diabetes and cardiovascular disease, require sustained care coordination and treatment, migrant populations may experience disruptions in treatment as they navigate access to a new health system. Lapses in treatment and delayed care may lead to poorly managed health conditions, potential complications, and increased morbidity and mortality. For those remaining in Ukraine, these events will strain (or may break) an already beleaguered health-care system that was struggling with reform.[141516] The barriers impacting health and wellness experienced by displaced persons and refugees are numerous. Age and mobility may be particularly impactful.[17] In addition, an increase in unhealthy lifestyles has been observed in such populations including sedentarism, poor food and water quality, and intoxicating substance use/misuse among others.[2] Postdisaster increases in mental and behavioral health comorbidities, obesity, hypertension, atrial fibrillation, cardio-cerebrovascular disease, respiratory problems, diabetes, gastrointestinal diseases, chronic kidney disease, eye disease, arthritis, and others have been observed.[2318192021]

Moreover, system operational and logistical barriers may significantly limit the access, efficacy, and adherence to treatment protocols.[1] Foremost among these is the legal status of the displaced or refugee population. Legal status is a fundamental determinant in defining how migrants can interact with the local health system. Similarly, patient identifiers and language barriers may be significant, as may be medication and treatment access and shortages. Migrants and refugees may find it difficult to navigate the host health-care system. Lack of access to records, prior results, and treatment responses may challenge the ability of providers to manage conditions with limited resources. In addition, systems established for refugees and displaced persons may not be designed or supported to provide longitudinal comprehensive assessment.[7] In addition, as migrants integrate into the host society, anti-immigrant sentiments may arise, further compounding refugees’ barriers to health-care access and prompting fears of adverse treatment. Finally, cost is an often-cited barrier, including medication, transportation, and other associated costs.[13]

These aspects of disaster medicine have long been recognized but to date have been understudied. To better serve the patients and health-care systems affected by such events, researchers and organizations may consider conducting longitudinal assessments of disasters on migrant populations. For those utilizing electronic medical records, working with clinical, administrative, public health, and information technology professionals to build tools to capture reliable and relevant data that may be integrated with existing systems and documentation tools may both improve understanding of known challenges and identify previously unrecognized ones that require further assessment and intervention.

Research quality and ethics statement

This report was exempt from the requirement of approval by the Institutional Review Board/Ethics Committee. The authors followed applicable EQUATOR Network (http://www.equator-network.org/) guidelines, however, no specific guideline is available for editorials.