Reports for humanitarian practitioners & policymakers
The following key findings emerged from the natural disasters sub-study:
- Participants described palliative care as a key component of comprehensive humanitarian healthcare involving companionship and psychosocial support for patients and their families, dignity in death and dying, and the management of pain and other distressing symptoms.
- Barriers to the provision of palliative care in natural disaster settings included damage to health structures; inadequate resources; disrupted supply chains; the invisibility of patients with palliative needs; differences in local cultural norms; the prioritization of acute needs; and challenges of mobility and access to care.
- Despite existing limitations, respondents agreed that humanitarian aid organizations have an ethical obligation to provide palliative care.
- Integration of palliative care may play a role in alleviating distress among disaster responders, particularly those from affected communities.
- Participants emphasized that palliative care must be integrated into disaster planning from the beginning; otherwise, it is likely to be neglected during a crisis.
- There was a clear consensus concerning the need for palliative care training and protocols to guide practice in natural disaster settings.
Overview: Focus on Natural Disasters Settings
According to the World Health Organization, a natural disaster is “an act of nature of such magnitude as to create a catastrophic situation in which the day-to-day patterns of life are suddenly disrupted and people are plunged into helplessness and suffering, and, as a result, need food, clothing, shelter, medical and nursing care and other necessities of life, and protection against unfavourable environmental actors and conditions.”  While we use the term “natural disasters” in this sub-study, it is widely recognized that the impacts of natural disasters such as earthquakes and tsunamis are shaped by human activity, degrees of vulnerability of certain communities, and action or inaction to mitigate natural hazards.  The annual death rate due to natural disasters is around 90,000 people worldwide, with approximately 160 million others also affected.  Over the last 10 years, 95% of the nearly two billion people affected by natural disasters were affected by a weather-related event. 
Like conflict settings and public health emergencies, natural disasters can overwhelm the capacity of health systems to meet the needs of the general population. This constitutes a humanitarian crisis, wherein the health and well-being of large groups of people are threatened due to factors such as lack of access to care, infrastructure damage, and resource scarcity. In recent years, many nations, including Haiti, Nepal, Pakistan, India, and Japan have experienced significant losses of life and devastation to infrastructure due to natural disasters.
Natural disasters, including famine, can exacerbate conditions in regions experiencing conflict, and are often a factor in the development or escalation of violence. Likewise, ongoing conflict in disaster-affected countries can further limit or hinder disaster response. This perpetuates a continuous cycle of poverty and instability for such countries and constrains the possibilities for disaster preparedness and response by local and international care providers.
Natural Disasters Sub-Study Objectives
- To develop evidence clarifying the ethical and practical possibilities, challenges, and consequences of palliative care needs following natural disasters.
- To inform realistic, context-sensitive guidance, education, and practices for the provision of palliative care during natural disaster response.
Summary of our Approach
In-depth, semi-structured interviews (N = 20) were conducted with international and local healthcare providers who had responded to a variety of natural disasters. For this sub-study, we included natural disasters that often strike without warning (earthquakes, landslides, and flash floods); those with a short warning time frame (tsunamis, hurricanes, typhoons and flooding); and protracted or foreseeable disasters (famine). The relationship between conflict and natural disasters was also explored.
Natural Disasters Team
Rachel Yantzi RN, MSN/MPH – PhD student in Health Research Methodology, McMaster University, Hamilton, Canada
Takhliq Amir, BHSc – MD student at the Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Canada
Matthew Hunt, PhD, PPT – Professor, School of Physical and Occupational Therapy, McGill University, Montreal, Canada
Lisa Schwartz,PhD – Professor & Arnold L. Johnson Chair in Healthcare Ethics, McMaster University, Hamilton Canada
Sonya de Laat, PhD – Academic Advisor & Global Health Scholar, Global Health Program, McMaster University, Hamilton, Canada
Carrie Bernard MD MPH CCFP FCFP – Assistant Professor, Department of Family and Community Medicine, University of Toronto, Toronto, Canada
Laurie Elit, MD – Professor of Obstetrics and Gynecology, McMaster University, Gynecologic Oncologist, Hamilton Health Sciences, Hamilton, Canada
Corinne Schuster-Wallace, PhD – Associate Professor, Faculty of Geography & Planning, University of Saskatchewan, Saskatoon, SK
Lynda Redwood-Campbell, MD, FCFP, DTM&H, MPH, Canadian Red Cross International Emergency Response Unit, Professor of Family Medicine, McMaster University, Hamilton, Canada
Conference Oral Presentations:
- Schwartz L, de Laat S, Yantzi R, Nouvet E, Bezanson K, Amir T, et al. Refugee experiences of palliative care in humanitarian settings: Views from conflict and disaster. 30th Annual Canadian Bioethics Society Conference; 2019 May 22-24; Banff, Canada.
- Yantzi R. Dying in the margins: Palliative care, humanitarian crises and the intersection of global and local health systems. Presented at: 16th Annual HEI Research Day, McMaster University; 2019 Mar 14; Hamilton, ON.
Conference Poster Presentations:
- Amir T, Yantzi R, Schwartz L. ‘Someone who was expected to die and didn’t’: Implications of the theme of reversibility of triage during humanitarian response to natural disasters. Creating Space 10 Conference; 2020 Apr 17-18; Vancouver, Canada. [Conference cancelled due to COVID-19 pandemic]. Abstract available from: https://static1.squarespace.com/static/5bc617272727be33bbf369d5/t/5e9f38bb4644dd371e01a200/1587493092725/Creating+Space+10+–+Conference+Abstract+Guide+FINAL.pdf
- Amir T. ‘And whom do you let go?’: Exploring the theme of reversibility of triage during humanitarian response to natural disasters. BHSc Poster Day, McMaster University; 2019 Apr 2; Hamilton, Canada. https://humanitarianhealthethics.net/2019/04/04/and-whom-do-you-let-go-a-poster-on-palliative-care-in-natural-disaster-settings/
- Amir T, Yantzi R, de Laat S, Hunt M, Nouvet E, Redwood-Campbell L, et al. ‘So that at the end, you have a gentle landing’: Exploring the role and ethical dimensions of palliative care during humanitarian response to natural disasters. 16th Annual HEI Research Day, McMaster University; 2019 Mar 14; Hamilton, Canada. Poster available from: https://humethnet.files.wordpress.com/2019/03/hei2019_poster_nd-array-final.pdf
- Assar, M. Guide to sanitation in natural disasters. World Health Organization. 1971. Available from: https://apps.who.int/iris/bitstream/handle/10665/41031/10678_eng.pdf;jsessionid =890EB054FAB45D038B5BC2F479F6E813?sequence=1
- World Health Organization. Definitions: emergencies. 2020. Available from: https://www.who.int/hac/about/definitions/en/
- World Health Organization. Environmental health in emergencies. 2020. Available from: https://www.who.int/environmental_health_emergencies/natural_events/en/
- International Federation of Red Cross and Red Crescent Societies. (2018). World disaster report: Leaving no one behind. Available from: https://media.ifrc.org/ifrc/world-disaster-report-2018/